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Practical Headache Pearls
Lawrence Robbins, MD
Posted June 2002

Practical Headache Pearls

  • Migraine tends to be underdiagnosed. Chronic sinus headaches often are, in actuality, migraine. One recent study indicated that over 95% of patients with a history of chronic sinus headaches are actually experiencing migraine. While the sinus medications may be of benefit in migraine patients, the migraine-specific medications usually are more effective.

  • Legitimize the headache problem as a physical illness. Statements such as "Headaches are just like asthma, diabetes or hypertension -- a physical medical condition" -- go a long way toward establishing trust between the patient and physician. When we mention that it is a medical condition, often times inherited, and that there is too little serotonin in the brain in people with headaches, patients are extremely receptive. Once we have established receptivity, the patients are much more amenable to addressing such comorbidities as anxiety and depression, with therapy or other means. However, if we focus on the patientís stress, anxiety, depression, and psychological comorbidities, patients are often turned off to the clinician unless we do state that we are treating the headaches as a legitimate medical illness.

  • We must try to achieve a balance between medication and headache; I tell the patients that we are trying to improve the headaches 50%-90%, while minimizing medications.

  • The initial history and physical is the best time to consider a list of medications; at that point we have a good grasp of the patientís comorbidities. If we list in the chart the therapeutic alternatives (in case our initial medications do not work), later we (or our partners) do not have to reconstruct the entire history with the patient.

  • Outside of medication, patients often benefit from 20 minutes (or more) of exercise on a daily basis. I usually recommend low-level exercise programs, such as treadmill, stationary bike and walking. For those who are not big on exercise, we push the "chunks of time" method of exercising: 10-20 minutes at a time, once or twice daily. In addition to exercise, yoga may be very helpful. Many patients with headache have associated neck pain and tightness in neck muscles, and yoga may help to relieve stress and improve neck or back pain.

  • In choosing preventives, assess other conditions, particularly anxiety, depression, insomnia, gastritis, GERD, IBS, constipation, hypertension, asthma, and sensitivities or allergies to other drugs. These often determine which therapeutic option to pursue.

  • Keep track of sensitivities and allergies to medications in a prominent place in the chart. If the patient has had severe reactions to two SSRIís, a third is not a good choice. However, those reactions may not be readily apparent in the chart. If they are extremely fatigued on one Ŗ-blocker, a second will probably not prove helpful in the long term.

  • It helps to view chronic headache as a continuum or spectrum. The "in between" headaches may not fall neatly into the current tension-type or migraine categories. Whether these are severe tension-type or milder migraines, they often respond to the same medications.

  • Start with low doses of medication, particularly with antidepressants and other preventives. Headache patients tend to be fairly somatic, and there is no need to push medicine very quickly. One exception to this is in patients with severe "new onset daily persistent headache"; these patients may be less patient.

  • Keep a drug medication flow chart. Headache patients are constantly having medications stopped and re-started, and over 10 years, a patient may have been on 50 different medications. It is impossible to piece through 40 progress notes trying to determine what the next best course of action is. A drug medication flow chart from the beginning helps immensely.

  • When we place patients on antidepressants, we need to make it clear that we are trying to help their headache directly by increasing serotonin. We also state that we certainly hope this helps anxiety and depression. Patients are often confused as to the reason why they are given an antidepressant. It helps if we make it clear that we are NOT trying to treat their headache by treating depression.

  • While most natural treatments do not benefit the patients, a few have proven safe and effective in double-blind studies. Feverfew is a very good herb, relatively safe, that may help to prevent migraines in certain patients. In addition, magnesium as a supplement has been utilized as a natural preventative. Many parents do not want their adolescents on daily medication, but are willing to start with feverfew as a milder alternative.

  • Watch for soft bipolar signs in headache patients who have anxiety and depression. Bipolar disorder tends to be underdiagnosed, and the clinical stakes for missing it are enormous. Bipolar disorder, primarily mild and soft (Bipolar II or III), is seen in as many as 6% to 7% of migraineurs. While many of these patients will do well on an antidepressant, it is often necessary to add a mood stabilizer (Depakote, lithium, Tegretol, Neurontin).

  • Many patients are frustrated by the lack of efficacy and/or side effects of daily preventives. Tell them that only 50% (at most) of patients achieve long-term relief with preventives. This helps them to realize therapeutic failure is not their fault.

  • We need to stick with preventive medications for at least four weeks (or longer); if we abandon them too quickly, we may not see the beneficial effect. However, few patients are willing to wait months for positive benefits from a medication.

  • We cannot promise patients that their headaches will improve with psychotherapy (as it often does not), but coping with headaches and the stresses that headaches produce is often improved with therapy. Unfortunately, because of stigma, time and money, only a small minority of patients will actually go to a therapist. However those that do go will usually benefit.

  • Patients with chronic daily headache may view the headache situation in black and white terms; they will come back for a return visit and state, "Well, I still have a headache everyday." They need to accept that if we have gone from moderate-to-severe headaches (7 on a scale of 1-10) to mild-to- moderate (4 on a scale of 1-10), that the situation is improved and we should not change all the medication. If the patients keep a headache chart or calendar, this may help. Patients need to be willing to accept 50-90% improvement in frequency and/or severity.

  • While most patients are honest about analgesic use, some are embarrassed to tell us how much they are utilizing. Between OTC analgesics and herbal preparations, many patients are consuming larger quantities of medications than we realize.

  • Weight gain is a major issue; even though a drug may be more effective, choosing one that avoids weight gain (in those prone to it) is more likely to lead to long-term success. Fatigue is another major reason for patients abandoning a preventive medication.

  • When we treat headache patients, we are also treating families. Spouses are usually watching what their husband or wife is ingesting, and kids observe mom taking medication. We do want to minimize medication and not overmedicate. While many patients with headache have 3 or 4 abortive medications at home, they usually are not overusing the medication. However, spouses often will say "my wife is taking too much medicine, she has 5 bottles of headache pills in our cabinet."

  • Do not confuse addiction with dependency. When treating chronic daily headache, dependency has to be accepted. Unfortunately, DSM-IV is inadequate in addressing prescription abuse.

  • What to do when nothing works: Before "giving up" on a patient with severe, refractive chronic daily headache, consider "end of the line" strategies such as: MAOIís, daily long-acting opioids (e.g., methadone, Kadian, Oxycontin, MS-Contin), stimulants (e.g., dextroamphetamine, methylphenidate, phentermine), IV DHE, daily triptans in limited amounts, daily IM DHE (or nasal), or combinations of approaches.

  • For those refractory patients, occasionally it will be necessary to use more than the recommended amount of triptans. Many patients have discovered that the only medication that helps is a triptan, but they end up utilizing these on a daily basis. While there is no evidence that long-term use is harmful, we have no evidence to prove that these are safe. There have been several small studies on frequent or long-term use of triptans, but the class of drugs is too new to guarantee long-term safety.

  • Using a medication to establish a diagnosis may NOT be accurate. For instance, DHE or triptans may mitigate the pain of subarachnoid hemorrhage or even tumors.

  • Very many children and adolescents have headache; headache is a major health problem in these years. While we do not want to overmedicate in this age range, the triptans have been very well received in the 12-18 year old age range. As with adults, adolescents also like the feeling when the headache completely lifts away with a triptan, as opposed to only partial relief from analgesics.

  • When children or adolescents have severe chronic daily headaches or frequent migraines that prevent them from going to school, we need to have a good psychotherapist involved. If we simply use medication in these patients, we are usually unsuccessful. Particularly in those who miss at least 20-25 days of school yearly, it is extremely important to address underlying psychological comorbidities such as school phobia, anxiety, depression, etc.

  • Acceptance of the chronic illness (headache) is a helpful state of mind for the patient. Acceptance is different than resignation. Acceptance helps to ease anxiety ("Isnít there a cure; these must be curable".)

  • When patients feel that they can actively help their headaches ("self-efficacy"), by medication, biofeedback or other means, it improves their sense of well-being.