The following headache topics are discussed:
Treatment of headache after age 50
Occipital nerve injections for neuralgia and unilateral headache syndromes
Indomethacin responsive unilateral headaches (chronic paroxysmal hemicrania and hemicrania continua)
SUNCT (short lasting, unilateral, neuralgiform headache with conjunctival injection and tearing) syndrome
Exertional and sexual headache
Lumbar puncture headache
HEADACHE AFTER AGE 50
Although it is true that the incidence of migraine, cluster, and tension headache decreases after age 50, headache continues to be a major problem for many people. The vast majority of patients with headaches after age 50 have had preexisting migraine, tension, or cluster headache, but a significant number of people begin suffering from headache in their 50s or 60s.
When headache begins de novo in adults, a workup is usually indicated, and this is particularly true with advancing age. Intracranial pathology, giant cell arteritis, thrombotic cerebrovascular disease, meningitis, and hypertension need to be excluded. In addition, cervical spine disorders may play a role in producing headache in this population. Systemic disease, such as chronic renal disease, anemia, and respiratory disorders, contribute to headache. The effect of various medications needs to be considered.
The presence of focal neurologic symptoms requires investigation. A workup is indicated when preexisting headache patterns change dramatically; It is a very difficult situation in patients with a long history of migraine who have had an MRI scan in the past, and now develop new intracranial pathology. The pathology may go undetected because we do not usually continue to scan headache patients every year.
Cervical spine disease may contribute to headache. However, this is generally overdiagnosed, as cervical radiologic changes are very common after age 50. Headache of cervical origin is usually occipital in location and is often described as a dull ache. However, tension headache may occur in this location, and it may be difficult to differentiate between the two conditions. Unfortunately, treatment directed at the cervical spine usually leads to less than satisfactory results. Although physical therapy and anti-inflammatories may help, they are often disappointing.
Patients may experience migraine aura without the headache. These auras need to be distinguished from transient ischemic attacks. Depression may exacerbate headache, and the antidepressants often decrease both the headache and depression. However, the mechanism of action of antidepressants for headache is often independent of the antidepressant effect.
The primary headache types after age 50 or 60 are the same as in younger ages: migraine, tension, and cluster. The principles of treatment remain the same; however, in an older population, our medication choices are somewhat limited. Anti-inflammatories are used less often because of increased renal and GI toxicity. The COX-2 inhibitors (Celebrex, Vioxx, etc.) may be less of a problem. Triptans are used sparingly, and only in those with minimal cardiac risk factors. Vioxx (rofecoxib) is a COX-2 inhibitor with much lower risk of GI bleeding. Vioxx is available in 12.5 and 25 mg. tablets. Vioxx is officially indicated for acute pain, and it has been utilized for tension or migraine headache. Studies have not been done yet to determine the efficacy in headache. However, the lack of GI side effects gives this newer anti-inflammatory a distinct advantage over traditional NSAIDs. The addition of caffeine may render Vioxx more effective for an acute headache.
The usual dose of Vioxx for acute pain is 25 to 50 mg. (50 mg. in a day at most); if used daily, doses would be limited to 25 mg. For once or twice per week headaches, 25 to 50 mg. will most likely be the optimum dose for most patients. While GI side effects are much less with this newer class of NSAIDs, they still may occur, particularly in susceptible individuals. Vioxx is suitable for patients allergic to sulfa drugs, unlike Celebrex, and Vioxx is also indicated for acute pain, which at present Celebrex is not. Because Vioxx is metabolized hepatically, occasional lab tests for liver and kidney functions, as we do with all NSAIDs utilized on a daily basis, should be done. While low-dose aspirin has been utilized with Vioxx, it will increase the possibility of GI ulcerations. Vioxx is in pregnancy category C.
Migraine Headache After Age 50
The general principles for utilizing migraine preventives and abortives are the same in this age range as for younger patients, as discussed in earlier chapters. Nonmedication instructions such as diet, maintaining regular sleeping patterns, placing ice to the area of pain, etc., remain valid, but biofeedback or relaxation techniques are significantly less useful in older patients. Lower doses of most medications are used with advancing age.
First Line Migraine Prevention Medication After Age 50
The first line preventive medications are similar to those in younger age ranges, with one exception: naproxen is utilized less often in older patients. For abortive therapy, the anti-inflammatories are helpful at all ages, but I attempt to avoid the daily use of anti-inflammatories in older patients. Amitriptyline, propranolol, Depakote and verapamil are the first line migraine preventives. Antidepressants other than amitriptyline may be helpful. These include, among others, nortriptyline (Pamelor, Aventyl) and SSRIs. Antidepressants are particularly beneficial for daily headaches. SSRIs are generally well tolerated. In addition to propranolol, many other beta blockers are useful, such as nadolol, atenolol, or metoprolol. The above medications are discussed at length in Chapters 3 and 7. In choosing a preventive medication, comorbidities are crucial to consider. These include anxiety, depression, insomnia, gastritis or reflux, irritable bowel syndrome (IBS), arthritis, hypertension (HTN), asthma, etc.
Second and Third Line Migraine Preventive Strategies
Second line therapies include polypharmacy (combining two of the first line medications) and Neurontin. Methysergide (Sansert) is a helpful second line medication in younger age ranges, but is not usually utilized after age 50.
Third line strategies include MAO inhibitors, such as phenelzine, and repetitive IV DHE injections. Both of these are used with great caution in older patients. In addition, NSAIDs are considered a third line approach in this age range. These medications are discussed at length in Chapter 3. Long-acting opioids (see chapters 3 and 7) are also a consideration.
Migraine Abortive Medication After Age 50
Cold packs about the head, a dark and quiet room, and sleep remain mainstays of abortive therapy for migraine. However, patients usually require medication. The choice of abortive medication depends on many factors, such as concurrent medical conditions, cardiac risk factors, the presence of nausea, and addiction potential of the patient. The usual abortive medications are discussed extensively in Chapter 2. With older patients we rely more on pain medication than in younger patients because the triptans and DHE are used sparingly. Excedrin Migraine and the anti-inflammatories (naproxen) are often utilized, but they have increased GI side effect risks. The COX-2 inhibitors (Celebrex, Vioxx, etc.) may be useful for migraine or tension headache. (See section above for a discussion of Vioxx). If significant cardiac risk factors do not exist, we utilize small amounts of Triptans. For instance, initially we would use a half tablet of Imitrex, Amerge, Maxalt, or Zomig. If chest pain occurs, we would discontinue the triptan altogether. While chest pain overwhelmingly tends not to be cardiac with the triptans, we tend to be more cautious with older patients. Occasionally, stress tests and cardiac evaluation are utilized in an attempt to determine safety of triptans.
Midrin (if hypertension is not present), butalbital compounds (Fiorinal, Fioricet, Esgic, Phrenilin, Fiorinal with codeine, Fioricet with codeine), narcotics such as hydrocodone or codeine, and Norgesic Forte (one tablet or a half tablet) are utilized in limited amounts. Occasionally, sedatives such as benzodiazepines may be helpful. Antiemetic medications are very helpful for many patients.
Migranal nasal spray (DHE nasal spray) is primarily a venoconstrictor. DHE has had relatively few serious side effects since its introduction in 1945. Migranal may be a relatively safe alternative in those patients over the age of 50 who do have minimal cardiac risk factors. However, with more than minimal risk factors, we would tend to avoid even the use of Migranal. With a few exceptions, we tend not to utilize the ergotamines such as Ergomar and Cafergot in older patients. After age 70 or 75, the milder narcotic preparations are utilized more than the others because of their relative safety. Certain butalbital compounds may be useful in this age range, such as Phrenilin, which contains only butalbital and acetaminophen without the aspirin or caffeine.
Quick Reference Guide: Migraine Preventive Therapy After Age
First Line Therapy:
Amitriptyline: Effective, inexpensive, also helpful for daily headaches and insomnia. Use in very low doses, all at night. Sedation, weight gain, dry mouth, constipation, and tachycardia are common. Initial dose is 10 mg., which may even be cut in half to 5 mg., working up to 25 or 50 mg., may be pushed to 100 or 150 mg. Others are also used (tricyclics or SSRIs).
Propranolol: Effective; long acting capsules may be dosed once a day. Occasionally useful for daily headaches. Sedation, diarrhea, GI upset, and weight gain are common. Very useful in combination with amitriptyline. Begin with the long acting 60 mg. capsule once per day. Average dose is 60 to 120 mg. per day (dose may be increased in younger age ranges).
Verapamil: Reasonably effective for migraine, convenient once per day dosing with the slow release (SR) tablets). Usually nonsedating, and weight gain is uncommon. Occasionally helpful for daily headaches. May be combined with other first line medications, particularly amitriptyline. Constipation is common. Starting dose is one half of a 180 or 240 mg. SR pill, increasing quickly to one per day. May be pushed to 240 mg. twice a day, or decreased to as little as one half of a 180 mg. SR tablet each day.
Valproate (Depakote): This seizure medication is popular for migraine prevention. Liver functions need to be monitored in the beginning of treatment. Side effects include lethargy, GI upset, cognitive effects, weight gain, and alopecia. Dosage varies from 250 to 2,000 mg. per day, in divided doses. The average dose is 750 mg. to 1,000 mg. per day. On the higher doses, levels need to be checked for
Second Line Therapy:
Polypharmacy: The combination of two preventives is often more effective than one drug. Amitriptyline may be combined with propranolol, particularly if the tachycardia of the amitriptyline needs to be offset by a beta blocker. This combination is the most commonly used one for mixed headaches (migraine plus CDH).
Neurontin (gabapentin): Neurontin has been an excellent and safe medication. Originally indicated for epilepsy it is now being widely used for pain and headaches. Neurontin has some efficacy for migraine and chronic daily headache. Side effects include sedation and dizziness. Neurontin does not irritate the liver, as it is cleared renally. The doses vary widely, from 300 to 2,000 mg. or more per day. We usually begin with very low doses, 300 mg. once or twice per day.
Third Line Therapy:
Phenelzine (Nardil): An MAO inhibitor, phenelzine is a powerful migraine and daily headache preventive medication. Phenelzine may be used alone, or in combination with amitriptyline, verapamil, or propranolol. Phenelzine is very helpful for depression, anxiety and panic attacks. The risk of a hypertensive crises is small but is a major drawback to this type of medication. Dietary restrictions render MAO inhibitors difficult for the patient. Side effects include insomnia, weight gain, dry mouth, and constipation. The usual dose is 30 mg. each night (2 of the 15 mg. tablets). This can be adjusted up or down, and the average range is from one to 4 tablets per day.
Repetitive IV DHE therapy: DHE should be used with caution in patients over the age of 50, as coronary artery spasm, although very rare, may occur. Helpful for patients with frequent or status migraine, this therapy often provides weeks or months of headache improvement. IV DHE can be done in the office or hospital. Side effects include nausea, a feeling of warmth about the head, leg cramps, or diarrhea. In the office, the protocol consists of a pill of metoclopramide (10 mg.), followed in ½ hour by the DHE. For the first dose, ½ mg. is given, and, if well tolerated, the subsequent doses are 1 mg. Three or four doses are given in the office, and up to nine doses in the hospital. After the IV DHE, migraine prevention medication is usually instituted. This protocol is discussed in Chapter 3.
NSAIDs: Anti-inflammatories, such as naproxen, ibuprofen, and flurbiprofen, are discussed in Chapters 2, 3 and 6. I utilize these in older patients only as a third line approach because of increased GI and renal effects. However, in certain patients the NSAIDs are effective for migraine and daily headache. When utilized daily, frequent blood tests need to be performed. The Cox-2 inhibitors (Celebrex, Vioxx, etc.) generally do not irritate the GI tract, and may be useful for headaches. (See previous section on these medications).
Tension Headache After Age 50
Tension headache is common in all ages, and is extensively discussed in Chapters 6 and 7. Tension headache is an unfortunate choice of terms because it implies that tension in the patients life is at the root of the headache; stress and tension may exacerbate an underlying primary headache disorder, but are not usually their cause. The vast majority of patients with daily headache also suffer from migraine. After age 50, migraines often diminish, leaving a chronic daily headache (CDH).
There are two primary categories of tension headache: episodic tension headache and chronic tension headache. The as needed abortive therapy is essentially the same for the two types. When chronic daily tension-type headache is moderate or severe, the preventive medication approach becomes very important. It is possible that tension-type headache has an underlying pathophysiology similar to migraine, and that we are observing different parts of a spectrum. It is clear that people are predisposed to these headaches, and they are not a psychological problem. Stress does affect tension headaches, as it does most illnesses. Strategies for coping with psychological factors in headache patients are discussed in Chapter 1. Cervical arthritis is a consideration in this age range.
The decision to utilize preventive medication depends upon whether the daily headaches are mild, moderate, or severe. Daily pain medications need to be kept to a minimum, to avoid the rebound headache situation.
For patients with episodic tension headaches, the abortive medication approach is usually all that is necessary. However, if patients overuse analgesic medication, preventive therapy may be beneficial. For abortive treatment of episodic tension headaches, see Chapter 6
Chronic Daily Headache:
When tension headaches are daily or almost daily, analgesics are often consumed in excessive amounts, thus creating rebound headaches. Many patients take large number of OTC medications, resulting in increased headaches.
For CDH that is moderate or severe and interferes with the quality of life, the preventive medication approach is utilized. Stress management, psychological counseling, or relaxation strategies do have a role to play in certain patients, and should be offered as a treatment option. Most patients experiencing moderate or severe daily headaches will benefit from a preventive medication approach.
First Line Preventive Therapy for CDH:
The antidepressants are the mainstay of therapy for daily headaches. They are often effective whether or not the patient is depressed, and the reason that they benefit headaches may be independent of antidepressant action. The choice of antidepressant depends upon many factors, including the anxiety level of the patient, presence of a sleep disturbance, weight, age of the patient, and other medical conditions. If the patient has a tendency toward constipation, that also will influence our choice.
There are many antidepressants from which to choose, and not all are effective for headaches. The tricyclic antidepressants have been the most widely utilized. Fluoxetine (Prozac) is gaining acceptance as a first line daily headache preventive. Sertraline (Zoloft) and Paroxetine (Paxil) are serotonin reuptake inhibitors similar to Prozac. These are well tolerated and effective for certain patients. The most commonly used medication for daily headaches is amitriptyline. In the elderly population, nortriptyline (Pamelor) is generally preferred over amitriptyline because of the milder anticholinergic and sedative effects. However, nortriptyline is less effective. SSRIs are often a good choice, as is desipramine (Norpramin), because of decreased side effects. For a complete discuss of the above, see Chapters 3 and 7.
Second line daily preventive medications include valproate (Depakote), beta
blockers such as propranolol, Neurontin, and calcium blockers (verapamil). The NSAIDs are not a first or second line preventive therapy after age 50 or 60, because of increased renal and GI toxicity. Third line prevention therapy includes MAO inhibitors (phenelzine), NSAIDs, or polypharmacy combining, for instance, an antidepressant and a beta blocker). All of the above are discussed in detail in Chapters 3 and 7. The COX-2 inhibitors (Celebrex, etc.), with minimal GI side effects may prove to be useful for headache. Long-acting opioids are an end-of-the-line approach (see chapters 3 and 7).
Cluster Headache After Age 50:
The treatment of cluster headache after age 50 is, in most respects, the same as the treatment of cluster in younger patients. Most patients have episodic cluster headaches and do not need medication except when they are in a cluster series. Chronic cluster sufferers, of course, require constant therapy. With most cluster patients, there is a need for daily preventive medication and abortive medicine. Cluster headaches are also discussed in Chapters 9, 10, and 11.
Preventive Therapy for Cluster Headache:
The primary preventive medications remain the same: verapamil (Calan, Isoptin), lithium, and corticosteroids. Corticosteroids should be minimized, and generally used in low doses, saving them for the peak of the cluster period. Episodic cluster periods often slowly increase in intensity over days to weeks, and they then peak in intensity. With chronic cluster, patients also experience peaks throughout the year, and small amounts of corticosteroids may be utilized at these times. Verapamil and/or lithium remain the standard cluster preventives, and these are usually well tolerated in the older patient. Sansert, which is only minimally helpful in most cluster patients, should not usually be employed in this age range.
Valproate (Depakote) is a good addition to the armamentarium. Valproate should be considered after corticosteroids, lithium, and verapamil. It is usually well tolerated, but blood tests need to be monitored. IV DHE is a strong consideration as a second line preventive medication and may be administered in the office as a course of four injections over 2 days. The IV DHE will often help for a period of time until the preventive medication takes effect. Occipital injections of corticosteroids, such as betamethasone or Depo-Medrol, are effective and well tolerated. These injections usually give 1 to 2 weeks of relief. In patients with refractive chronic cluster, radiofrequency gangliorhizolysis or the gamma knife is a reasonable alternative to medication. For a complete discussion of cluster preventive therapy, see Chapter 10.
Abortive Therapy for Cluster Headache:
The abortive approach differs slightly for older age ranges, as we use less
ergotamines (except DHE). Oxygen remains a mainstay of therapy, and should be tried in all patients. Ice packs are utilized directly where the pain is most severe. Pain medications have relatively little use, for by the time they may take effect, most cluster episodes have ceased. However, the pain of cluster is often so severe that the anticipation of the cluster becomes a major problem; patients find comfort knowing that they possess an analgesic that may dampen the intense pain. Lidocaine nose spray may help to a small degree, and is very well tolerated. The most effective treatment for cluster headaches has been Imitrex. While the tablets are occasionally useful for long cluster headaches, the nasal spray and injections have been the standard. With cluster headaches, we need rapid onset of action. Imitrex has been remarkably successful in aborting cluster headaches within minutes. However, after age 50, the issue of coronary artery disease and risk of the triptans is extremely important. (See chapters 2 and 9). Risk factors that need to be assessed include hypertension, hypercholesterolemia, diabetes, family history of CAD, and smoking history. The other triptans, available in tablet form, are occasionally useful for cluster headache. However, the slow onset of action is detrimental when treating clusters. The standard older ergotamines, except for DHE, are rarely utilized after age 50.
DHE, primarily in the form of Migranal nasal spray, is occasionally
utilized. DHE, as discussed in previous chapters, is primarily a
venoconstrictor and is relatively safe for the coronary arteries. The
nasal spray may cause nasal stuffiness, which is present to begin with in
cluster headache. Occasionally we utilize the injections of DHE in
aborting cluster headache.
Pain medications include butalbital compounds (Fiorinal, Fiorinal with codeine, Fioricet, Esgic, Phrenilin), and narcotics or sedatives. These are helpful for lengthy clusters. In general, analgesics are not extremely effective for cluster headache, but it is often helpful for patients to know that an analgesic is available. In the emergency room, as a last resort for a long, severe cluster headache, intramuscular narcotics are occasionally useful. This situation occurs during the peak of the cluster period. Overuse of narcotics and possible addiction, is a potential problem with cluster patients, primarily because of the intense, horrible pain. For a complete discussion of abortive therapy for cluster headache, see Chapter 9.
The post-traumatic headache syndrome is a very common sequelae following injuries to the head or neck, and often occurs after rear-end auto accidents. The headaches are usually self-limited and resolve quickly, within days to several weeks. The vast majority of patients with post-traumatic headaches simply want their pain to be improved and their disrupted life back to normal. Surprisingly few are malingering or exaggerating their symptoms.
In many patients, particularly those with more severe trauma, headaches may be a problem for months, years, or a lifetime. If the headaches develop within 2 weeks of the event, and persist for more than several months, we would consider this to be the chronic phase of the post-traumatic headache syndrome. Very rarely, patients develop post-traumatic migraines months following the injury, but headaches usually begin within hours or days of the accident. The International Headache Society (HIS) has set 2 weeks as an arbitrary limit.
Predicting which patients will continue to suffer chronic, unremitting
post-traumatic pain is a difficult undertaking. In general, patients with a preexisting headache or migraine problem are at increased risk. Women have a 1.9-fold increased risk. Patients with a strong family history of migraine may be at increased risk for developing chronic headaches. Severity of trauma may also aid in predicting outcome, but many patients endure months or years of severe headaches after trivial head trauma. Rear-end auto collisions, without head trauma, commonly produce severe headaches and cervical pain. Factors such as the angle of impact, where the patient was sitting in the car, and what happened to the brain within the skull are key elements in producing the headaches. The post-traumatic headaches occur more often with increasing age.
Many patients have associated neck and posterior occipital pain. The neck pain tends to be independent of the headaches, and the cervical pain and headaches may resolve at different times. Physical therapy is a key element in treating the associated neck pain and tenderness, and physical therapy may also decrease the headaches.
The headaches are usually of two types: (1) tension-type headache that may be daily or episodic, and (2) migraine headaches that are usually more severe. In some patients, the post-traumatic migraine headaches are the major problem, with a periodic severe headache lasting hours to days. In other patients, the tension-type headache is the predominant problem. Many post-traumatic patients have mixed headaches, with both CDH and migraines. The occipital aching pain, so often associated with the neck pain, is usually considered to be of muscular origin. However, the occipital pain may respond to therapies for cervical pain, and at other times the occipital pain improves with the standard tension headache medications.
Medical work-up for post-traumatic headaches includes, if necessary a CAT or an MRI scan to rule out an intracranial hemorrhage. There is also consideration for performing an EEG. The work-up usually limited and is done according to the physicians clinical judgement. Most patients with mild post-traumatic headaches do not need to undergo extensive testing other than a neurologic exam. Occasionally a second CAT scan or MRI is necessary to completely rule out a hematoma. With prominent neck pain, x-rays to rule out fracture or dislocation may be necessary. Cervical MRI occasionally is helpful, but usually does not influence therapy.
There are many other symptoms that often accompany the post-traumatic headache syndrome. These tend to be similar in most patients. They include some or all of the following: poor concentration, becoming easily angered, sensitivity to noise or bright lights, depression, dizziness or vertigo, tinnitus, memory problems, fatigue, insomnia, lack of motivation, decreased libido, nervousness or anxiety, irritability, becoming easily frustrated, and decreased ability to comprehend complex issues. Neuropsychological testing is often abnormal early in the course of post-traumatic headache but slowly returns to normal. Concentration and attention seem to be the first to return to normal, usually within 6 weeks. Analytic capacity, imagination, and visual memory take somewhat longer, but resolve by the end of 3 months. The last to recover are the speed at which the patient processes information, cognitive selectivity, and verbal memory abstraction. While attention and concentration often improve over the first 4 to 6 weeks, memory and information processing speed may take considerably longer.
The presence of headaches, neck pain and the symptoms in the above paragraph often lead physicians, coworkers, and family members to conclude that the patient is exaggerating the complaints. However, in the vast majority of post-traumatic patients, every complaint is real, not exaggerated, and these people simply wish to feel better. The post-traumatic headache syndrome ranges from mild to severe and is often disabling to a persons life. Most patients have some degree of difficulty with their home or work life because of the headaches, anxiety, insomnia, and concentration difficulties. It then becomes a vicious cycle, with more psychological stress being placed on the patient because of the difficulties at work and at home. Unfortunately, our legal and insurance processes are not entirely fair to many of these patients, because objective testing does not reveal deficits in the vast majority of these injured patients. They are often unfairly viewed as functional or malingering. Studies have conflicted as to what percentage of patients are exaggerating or malingering. One study suggested that in countries where there are very few legal or insurance disability remedies, post-traumatic situations rarely exist at all. However, after secondary-gain issues (litigation, disability, workers compensation) have been settled, most patients continue having the same degree of post-traumatic symptoms.
As mentioned above, accompanying the post-traumatic headache problem is the very frequent neck pain. This is usually secondary to soft tissue damage to ligaments and muscles, but may involve disc damage and, occasionally, nerve root compression as well. Sensitivity over the occipital nerve area is very common and occipital neuralgia may accompany the post-traumatic headaches. We frequently find trigger points in the trapezius, posterior cervical, and occipital areas, with muscle spasm in these areas being very common. It is not infrequent to find such severe spasm that patients have almost zero range of motion of their cervical spine, and the neck muscles feel extremely tight upon palpation.
Treatment of the post-traumatic syndrome involves one or several of the following: medication, physical therapy, psychological counseling, and relaxation training/ biofeedback. Most patients do not need all of the modalities of therapy, and treatment programs need to be individualized. First and foremost, reassurance that this condition will improve is important, as in the vast majority of cases, the headaches and neck pain progressively lessen over time. While most patients do recover over time, a small (but important) percentage continue to suffer for months, years, or a lifetime.
Medication for Post-Traumatic Headaches:
For the headache, medication is the cornerstone of treatment, as it is consistently the most effective therapeutic modality. We have available both abortive and/or preventive medication. In the first three weeks of the headaches, we usually only utilize abortive medication. If the headaches persist beyond this point, and remain moderate or severe, preventive medicine should be instituted. Physical therapy is the primary treatment for the associated neck pain. Unfortunately, post-traumatic headaches are often poorly responsive to all treatments.
The choice of abortive therapy depends upon the type of headache that is being treated. The principle medications for treating post-traumatic tension-type headaches are the same as those outlined in Chapter 6. I often utilize the anti-inflammatories in the post-traumatic situation, so as to aid the accompanying cervical or back pain. Muscle relaxants are more helpful than in routine tension headaches, because of cervical muscle spasm. We do not want to use addicting medication on a daily basis for more than 1 or 2 weeks. If patients require excessive amounts of abortive medication, we need to consider the use of preventive medication. We do not want to create the rebound headache situation.
Typical anti-inflammatories include aspirin, ibuprofen, and naproxen.
Muscle relaxants such as Flexeril or Robaxin are often helpful, but fatigue
is always a problem with this class of medication. For a complete
discussion of abortive medications, see Chapters 2 and 6.
Abortive therapy for post-traumatic migraine headaches follows the same
guidelines as for routine migraine headaches, as outlined in Chapter 2.
Antiemetic medications are helpful for any patients. The primary migraine
abortives are as follows: Triptans, Extra Strength Excedrin (Excedrin
Migraine), Aspirin Free Excedrin, naproxen (Naprosyn, Aleve or Anaprox),
ibuprofen (Motrin), ketorolac (Toradol), Midrin, Norgesic Forte, butalbital
compounds (such as Fiorinal, Fioricet, Esgic, Fiorinal with codeine,
and Phrenilin), corticosteroids, narcotics, and sedatives. For a discussion of these, see Chapter 2.
Most patients with migraine, and the majority of patients with post-traumatic migraine, simply require abortive medications for their headaches. However, if the migraines are frequent and/or severe, we need to progress to daily preventive therapy. The decision as to when to progress to daily preventive therapy is a difficult one, but most patients with severe post-traumatic migraines also suffer from daily headaches, and they usually benefit from preventive medication.
Preventive Medication for Post-Traumatic Headaches:
During the first 2 to 3 weeks of the post-trauma period, abortive medications such as anti-inflammatories are usually employed. Most patients do not need daily preventive medication, and the post-traumatic headaches decrease steadily over time. However, after the initial period, if the migraine-type headaches remain frequent (at least one or two per week) or the CDH is moderate or severe, patients may benefit from prophylactic medication.
The most commonly employed preventives for the post-traumatic headaches are the antidepressants, particularly amitriptyline (Elavil) or nortriptyline (Pamelor), and SSRIs. The anti-inflammatories often serve a dual purpose,
functioning as both abortives and preventives. The antidepressants that are sedating, particularly amitriptyline, often decrease the daily headaches, migraines, and the associated insomnia. The selection of preventive medication differs depending upon whether there is associated insomnia, GI problems, etc., and which headache type is predominant. Chapters 3 and 7 discuss antidepressants and SSRIs for migraine and tension headache.
Although the first choices for prevention medication in the post-traumatic situation are usually antidepressants, alternative medications may be utilized. Calcium blockers (verapamil) or beta blockers are used for migraines as a first line therapy. Valproate (Depakote) is often a good choice. Methysergide (Sansert) and MAO inhibitors (phenelzine) are employed if initial approaches have not been successful. IV DHE, used repetitively in the office or in the hospital, is very useful with severe post-traumatic headaches. I use IV DHE relatively early in the patients course, often after 1 or 2 months, if the headaches are very severe. Concurrently, daily preventive medication is employed in these patients. See Chapters 3 and 7 for discussions of preventive medication.
OCCIPITAL NERVE INJECTIONS FOR NEURALGIA AND
UNILATERAL HEADACHE SYNDROMES
Many patients with migraine (almost 20%) suffer intermittently from occipital neuralgia. Tenderness about the occipital nerve area is seen in many different headache syndromes. Injections in the occipital area with corticosteroids. and/or lidocaine are often helpful for these patients. In addition to benefitting occipital neuralgia, occipital nerve blockade is helpful for cluster headache and cluster variants, such as chronic paroxysmal hemicrania.
The first several segments of the spinal cord are important in generating posterior occipital pain, with the dorsal ramus of C2 continuing on to the scalp as the occipital nerve. Occipital neuralgia is usually sharp, ice-pick, or lancinating pain. The pain may be severe, and at times is referred to the periorbital area. Tenderness about the occipital nerve is usually elicited with palpation. Hypesthesia is present in the greater occipital nerve dermatome. The occipital nerve may be injured with trauma (as in the whiplash type of injury), it may be involved in herpes zoster (shingles), in cervical pathology, or it may simply be irritated in migraineurs through unknown mechanisms. Although medications such as antidepressants, anti-inflammatories, or antiepileptics may be needed, many patients with occipital neuralgia respond to injections. (see Characteristics of Occipital Neuralgia) at the end of this section.
The most commonly used antiepileptics include carbamazepine (Tegretol), Depakote, and gabapentin (Neurontin).
Injection Technique for Greater Occipital Nerve Block:
The same technique is used whether we are treating occipital neuralgia, cluster headache, or posterior occipital pain.
There is one greater and one lesser occipital nerve on each side. I occasionally block the lesser occipital nerve that pierces the sternocleidomastoid below the ear. The greater occipital nerve is involved in pain much more frequently than the lesser occipital nerve. Many patients are tender over the nerve, and injecting at the point of tenderness is effective. The nerve runs along the half-way point between the occipital protuberance and the superior nuchal line. Palpating for the arterial pulse may be helpful.
Swab the area with alcohol, and ask the patient where tenderness is maximal; this is usually a good place to inject. However, with certain conditions, such as cluster headache, there often is no tenderness. Using a 25 gauge syringe with a 5/8 inch needle, I usually mix 2% lidocaine, 1 or 1.5 cc, with betamethasone, 4 or 6 mg. Alternatively, Depo-Medrol may be used, from 40 to 80 mg. Marcaine, 0.25%, may be used as the anesthetic. I usually inject both the anesthetic and steroid, but at times one or the other may be just as effective. Some patients do better with the anesthetic, and others with the cortisone. The advantage of using only an anesthetic agent for nerve blocks or trigger point injections is that repeated injections may be performed, where as steroid injections need to be limited. However, the steroid usually provides longer term relief.
The short needle helps to insure that we will not be entering the subarachnoid space. Feeling the bony resistance of the occipital bone also aids in telling us that we are not in the subarachnoid space. I inject ½ cc at this point, and then withdraw the needle to just below the skin; ½ cc is then injected medially and ½ cc laterally, about the tender area over the occipital nerve. The area is then massaged for 1 or 2 minutes. Side effects from occipital area injections are rare, and primarily involve the very unlikely possibility of infection. Dimpling or discoloration of the skin may occur with corticosteroids, and that is the reason why I limit steroid injections.
If patients require repeated injections, I usually use pure lidocaine or
Marcaine, without cortisone. All injections in the occipital area should be limited, however, to prevent repeated trauma to the occipital nerve.
In addition to injections for the occipital neuralgia, Marcaine or lidocaine injections into tender cervical areas may be helpful. Many headache patients concurrently have neck pain with trigger points, and trigger-point injections are helpful at times. While some patients only experience hours or days of relief, others may have 3 or 4 good weeks after the injection. The technique is similar to that for the occipital nerve block, but we rarely use steroids.
Characteristics of Occipital Neuralgia:
- Common in migraineurs (almost 1/5 of migraineurs experience occipital neuralgia)
- Trauma is frequently a cause
- The pain is often burning, or may be stabbing or lancinating
- Hypethesia is found in the greater occipital nerve dermatome
- Cortisone and/or marcaine blocks are often helpful
- NSAIDs, antidepressants, and antiepileptics may decrease the pain
CHRONIC PAROXYSMAL HEMICRANIA (CPH)
CPH may be a variation on chronic cluster headache, but this remains unclear. CPH has a female-to-male ratio of 3:1, with a typical onset from age 25 to 35. The pain is usually about the ophthalmic division of the trigeminal nerve, concentrated around the eye, temple, and forehead. However, pain may occur in the occiput or periaural areas. While almost exclusively unilateral, there have been rare instances of bilateral pain. The attacks last from 2 to 45 minutes, with a frequency of 5 to 20 or more per day. The usual attack lasts from 10 to 15 minutes. Occasionally, head movement or mechanical stimulation may precipitate the pain. The pain is associated with at least one of the following: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, ptosis or eyelid edema. Except for the ptosis, these are mediated by parasympathic nerves. The pain tends to be very severe, and is usually stabbing or severely aching. However, at the beginning of the headache it may be throbbing. There is no clear increase at one particular time of day, and CPH may awaken patients from sleep. In the unusual situation where there is a break of at least a few months (or possibly years), we would term it episodic paroxysmal hemicrania.
Since CPH is rare, a workup to exclude secondary causes may be appropriate. These would include tumors, collagen vascular disease, cerebrovascular disease, and an aneurysm. MRI and MRA, along with routine lab tests including the sedimentation rate, would be prudent. If extremely high doses of medication are required, we think about secondary causes of CPH. With bilateral CPH, intracranial hypertension may need to be excluded by a lumbar puncture (LP). In very rare circumstances, a chest x-ray may be necessary to discover a Pancoast tumor as the cause of the CPH. Arteriovenous malformations (AVMs) have been reported to be a secondary cause of CPH.
Medication Treatment of CPH:
CPH is almost always relieved by indomethacin (Indocin). If indomethacin does not help, the diagnosis of CPH is in doubt (although it still could be CPH). The dose of indomethacin varies greatly, with some patients requiring as little as 25 mg. per day and others needing 250 mg. or more. Although the Indocin SR 75 mg. renders dosing more convenient, the 25 or 50 mg. capsules, taken throughout the day, may be more effective. Patients may titrate their own dose, for at times the attacks may decrease in severity. Usually, when Indocin is tapered or stopped, the attacks resume, but long term remissions may occur. Indomethacin should be taken with food, as GI upset is very common. Although headache may occur as a side effect of indomethacin, it is not common in patients with preexisting headaches. Cognitive side effects, such as fatigue, lightheadedness, and mood swings, may be a problem with indomethacin. Retinal or corneal problems have been reported with long term use of indomethacin. As with all of the anti-inflammatories, renal and hepatic functions need to be monitored through blood tests. Tachyphylaxis does not usually occur with indomethacin.
Corticosteroids, naproxen, and calcium blockers (verapamil) may provide some benefit, but these have limited usefulness in CPH. Acetazolamide may be of benefit in some patients. The triptans do not appear to be particularly effective for CPH.
Hemicrania continua occurs in men and women at all ages. These patients have moderate unilateral dull pain, with icepick pains intermittently during the day, and three-fifths of the patients have focal, intense pain lasting minutes. The pain may be increased with alcohol or physical exertion. Typical migrainous features may be present, such as sensitivity to light and accompanying nausea. There are many patients who do not fulfill all of these criteria, but who have unilateral dull or throbbing pain on a daily basis, with migraine features. They usually also experience intermittent icepick-type jabbing pains. Autonomic features may accompany flare-ups.
Indomethacin, as outlined in the above section on CPH, is the drug of choice with hemicrania continua. Patients who fit some but not all of the criteria for hemicrania continua also may respond to indomethacin. If indomethacin is not able to be used, or is not helpful, then proceeding along migraine prevention lines is required. Amitriptyline, naproxen, and calcium blockers may be helpful (see list below). Triptans may be useful in occasional patients.
Clinical Characteristics of Hemicrania Continua:
- Unilateral severe pain lasting 5-60 minutes, usually pulsating or throbbing, occurs in 60% of patients
- Nausea or photophobia may be present with the severe pain
- Attacks occur 3-5 times per 24 hours (in 60% of patients)
- Underlying unilateral aching, dull pain in all patients
- Patients may be awakened from sleep with the severe pain
- Icepick stabbing pain throughout the day
- Physical exertion increases the pain in some patients
- Alcohol may increase the pain
- Indomethacin is effective in 4/5 of patients
- Ergots, NSAIDs, tricyclics, or verapamil are effective for some patients
- The painful flare-ups may be associated with autonomic features, such as conjunctival injection, eye tearing, nasal stuffiness, etc.
SUNCT syndrome (short-lasting unilateral neuralgiform headache with conjunctival injection and tearing) is a rare unilateral headache syndrome that may be related to hemicrania continua, paroxysmal hemicrania, and cluster headache. The male to female ratio is 17:2. Patients usually experience five to seven attacks, lasting 5 seconds to 4 minutes, in the typical hour. Twenty to 30 attacks per day may be typical, but it may be less or more. Conjunctival injection may be very prominent. Other autonomic signs, such as forehead sweating, rhinorrhea, and tearing, may be present. Movements of the neck may trigger SUNCT. In patients with SUNCT, MRI should be done to rule out the extremely rare cases of tumor or other pathology. The pain usually occurs about the eye or temple and is typically stabbing or throbbing in nature. Unfortunately, treatment has not yielded promising results. The usual medications, such as steroids, triptans, ergotamines, and Indocin, have been failures. I have had moderate success in two patients with SUNCT syndrome utilizing long-term opioids (in these patients the opioid was methadone). One patient twice underwent gamma knife radiation but it was only mildly helpful.
EXERTIONAL AND SEXUAL HEADACHES
Exertional headaches are subdivided into benign exertional headache and headache associated with sexual activity. In addition, a third classification exists called benign cough headache. Benign exertional headache is brought on specifically by a physical exercise. It is usually bilateral and throbbing, but may develop migrainous features. The headache lasts for 5 minutes to 24 hours, and it does not have intracranial pathology. Hot weather and high altitude may render it more likely to occur, and avoidance of excessive exertion is recommended.
Headache associated with sexual activity begins bilaterally, is precipitated by sexual excitement, and may be stopped by ceasing sexual activity immediately. The first type is a dull ache about the head or neck that increases as sexual excitement escalates. A second explosive type is very severe and occurs at orgasm, and a third postural headache develops after sexual activity and is similar to that of low cerebrospinal fluid (CSF) pressure. Benign cough headache is usually of sudden onset, lasts less than 1 minute, and is bilateral. Structural lesions must be excluded.
The age of onset of the various exertional headaches varies widely. Benign exertional headache generally occurs in younger patients in their
20s and 30s, sexual headache usually occurs in middle age (approximately age 40), and cough headache typically presents in the 60s. There is a male predominance to all of these exertional headaches.
ORGANIC PATHOLOGY IN EXERTIONAL HEADACHES
With the exertional headaches, organic pathology must be excluded. Posterior fossa lesions and supratentorial space-occupying lesions are relatively easily identified on MRI. Trauma or craniotomy may predispose to exertional headaches. Basilar impression/platybasia or syrinx needs to be excluded. Subarachnoid hemorrhage, particularly with sexual headache, is a consideration with new-onset exertional headaches. Chiari type I malformation has been associated with cough headache in rare circumstances. Occasionally other pathologies such as sinusitis or brain metastasis have been identified. Whether to and how completely to work up patients depends on the clinical presentation, such as explosiveness of the headache, age of the patient, and how long the symptoms have been present with exertion. As with all headaches, new-onset exertional headaches are more worrisome than those of long-standing origin. Besides MRI, skull films, blood tests, and lumbar puncture may be necessary. MRA is helpful in identifying intracranial aneurysms.
Treatment of Exertional Headaches:
If possible, avoiding the precipitating exercise may be useful, but for patients not willing or able to do this, the primary treatment usually is an anti-inflammatory.
The anti-inflammatories indomethacin (Indocin) and naproxen (Naprosyn, Aleve, Anaprox) have been the most commonly used medications. Ibuprofen (Motrin) or flurbiprofen (Ansaid) are also effective for some patients. The anti-inflammatory is usually given ½ to 2 hours prior to the activity. The effective dose varies widely, but the usual dosages are as follows: indomethacin, 50 to 75 mg; Naprosyn, 500 mg., or Aleve, 2 tabs, or Anaprox D.S., one tablet (550 mg); ibuprofen, 600 to 800 mg.; flurbiprofen (Ansaid), one or two of the 100 mg. tablets. Triptans may be effective, but decreased coronary blood flow is an issue.
Abortive treatment of the headache follows the usual therapy for tension or migraine headaches. Therapy consists of the application of ice to the head, lying down in a dark room, and taking medication. For a discussion of the abortive treatment of migraine and tension headache, please see Chapters 2 and 6.
LUMBAR PUNCTURE HEADACHE
Headache after a lumbar puncture (LP) is a major problem, occurring in 15% to 32% of patients. Post-LP headache may occur in any person, but women with a previous history of headache seem particularly prone to developing this problem. Younger patients, particularly those with lower body mass, are more susceptible. The position of the patient after the LP, experience of the person performing the procedure, and amount of CSF taken during the LP do not appear to increase the risk of developing the headache. Psychological factors play a lesser role than was once thought. Smaller LP needles are an important factor in avoiding the headache. New LP needles have been developed that may decrease the incidence of post LP headache.
The headache will usually be present within several days, but a delay may occur of up to 2 weeks. The pain may be frontal, occipital, or in the cervical and shoulder regions. The headache is positional in nature, with increased pain sitting or standing, and relief with the supine position. The pain may be throbbing, pounding, or simply a severe ache.
Patients may report symptoms typical for migraine, such as nausea, visual symptoms, photophobia, dizziness, and vertigo. In addition, cervical pain and spasm are often present, and nuchal rigity. This may confuse the situation, as meningitis becomes a consideration. Meningitis following LP is exceedingly rare, usually presenting a problem only in immunocompromised patients with sepsis (see chart at the end of this section).
LP headache is almost always self limited, resolving in days to weeks. Chronic headache may persist for months, or, rarely, years. The mechanism of the headache is questionable. Leakage through the dura is certainly an obvious answer, but vascular or serotonergic factors may be important as well.
Treatment of Lumbar Puncture Headache:
With most patients, the headaches do resolve quickly, within days, and simple analgesics are all that are necessary. Oral caffeine may help, but 300 mg. per dose may be necessary.
When the headache persists for more than 2 days, caffeine sodium benzoate may be given intravenously or intramuscularly. The IV caffeine is more likely to produce lasting relief. One dose of IV 500 mg. caffeine is given, and this may be repeated, if necessary, in 6 hours. Caffeine and sodium benzoate is available in 2 ml. amps of 250 mg. caffeine per ml. This may be given IM, 250 mg. every 3 to 6 hours, as needed. Patients may learn to do this at home for a number of days. With these large doses of caffeine, CNS side effects may occur, as well as tachycardia. Along with caffeine, analgesics provide a small amount of relief. Hydration is helpful to a small extent, and patients are encouraged to drink at least six glasses of liquid per day. Limited amounts of steroids may help.
If the headache is severe and not improving, an epidural blood patch should be given. This is usually done several days to 1 week after the LP. Epidural injections of the patients blood at the site of the LP are extremely effective in terminating the headache. The blood does track up and down the spinal area, thus helping the headache even if the blood is injected above or below the involved site. Twelve cc of blood are usually utilized. Pain at the injection site or radicular pain may occur with the blood patch, but rarely do these complications last more than days to weeks. Occasionally, there is a need for a second blood patch, or even a third. If the epidural blood patches fail to alleviate the symptoms, the patient is treated with standard headache prevention medications. In addition, epidural saline may be injected. This will occasionally help even when the blood patch has failed.
Features of Lumbar Puncture Headache:
- Headache is more common in younger women with lower body mass
- Headache is greatly increased sitting, decreased supine
- Shaking the head increases the pain
- Onset is usually within 48 hours
- Nausea is common
- Pain is aching but may be pulsating
- Location may be frontal, occipital, or both
- Visual blurring may occur, as may photophobia
- Low back pain may be present
- IV or IM caffeine is beneficial; oral caffeine, in high doses, may be helpful
- Epidural blood patch is highly effective
- Standard analgesics are only mildly effective
- Steroids may be useful
Controversy exists as to whether cervicogenic headache is a distinct entity or is a subset of migraine and tension headache. Cervicogenic headache consists of unilateral occipital or suboccipital pain, usually accompanied by neck tension and muscle spasm. Movement of the neck or other neck triggers often brings on the pain. This may be associated with migraine features such as blurred vision and nausea. Other symptoms that may be present include arm pain, lacrimation, difficulty swallowing, numbness, and tinnitus. The sensory abnormalities are in the distribution of the high cervical roots.
Imaging (MRI, x-ray) does not reveal an increased incidence of pathology over age-related controls. Treatment would mirror that of migraine or tension headache. Trigger-point injections may be helpful.
The above section is excerpted from Dr. Lawrence Robbins' book, "Management of Headache and Headache Medications." All references in the above text to specific chapter numbers refer to chapters in the book.