1. Legitimize the headache problem as a physical illness.  When we mention that it is a medical condition, primarily inherited, and that there is too little serotonin in the brain in people with headaches, patients respond exceedingly well to this.  Once we have established this, the patients are much more amenable to addressing anxiety, depression, etc. with therapy or other means.

2. In choosing preventives, look at comorbidities, particularly: anxiety, depression, insomnia, gastritis, GERD, IBS, constipation, hypertension, asthma, and sensitivities or allergies to other drugs.  These often determine which way to proceed with medication.

3. It helps to view chronic headaches as a continuum or spectrum.  The “in between” headaches may not fall neatly into the current tension or migraine categories.  Additionally, patients need to accept with chronic daily headaches that it is not a black and white situation.  If a headache is reduced from severe to moderate, then the situation is improved and we should not feel inclined to change all the medication.

4. Preventives do not work for everyone; only 50% (at most) of patients achieve long-term relief with daily preventitive medications.  To see the possible full beneficial effects of preventitives, however, the medication must be used consistently for a minimum of four weeks.

5. It can “take a village to help a person with severe pain”.  Get other “villagers” involved , such as psychotherapy, massage, physical therapy, pain specialists or acupuncture.  We cannot promise patients that their headaches will improve with psychotherapy alone, but coping with headaches and the stresses that headaches produce is often improved with therapy.  Biofeedback is underutilized, and should be offered more often.

6. Learn about and recognize personality disorders.  Additionally, watch for soft bipolar signs in headache patients who have anxiety and depression.  Bipolar disorder tends to be underdiagnosed, and is seen in as many as 6% to 8% of migraineurs, primarily in the mild and soft forms (Bipolar II or III).

7. Heed red flags in your patients on opioids; while pervasive behaviors help to determine addiction, even one red flag early in treatment should be seriously considered.  In using opioids, you must be willing to say NO and set LIMITS.

8. Acceptance of the chronic illness (headache) is a helpful state of mind for patients to achieve and helps to ease anxiety.  When patients feel they can actively help their headaches (“self-efficacy”) by medication or biofeedback or other means, it improves their sense of well-being and enhances positive outcomes.

9. Pain is what the patient says it is, and it’s as bad as what the patient says it is.  Be aware of cultural and ethnic differences in the perception and experience of pain.  Additionally, the “level of pain” is not an accurate predictor of disability in chronic pain patients.  Accurate predictors are active coping, such as therapy, exercise, working, socializing, etc.

10. When we place patients on antidepressants, we need to make it clear that we are trying to directly help their headache by increasing serotonin, and also state that we certainly hope this medication helps with anxiety, depression, etc.  Additionally, for depression to improve, it is important to control pain and, likewise, to help pain, we must treat depression.

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