Headache Management

By Bernard M. Abrams, MD

Abstract

Headache Management

The diagnosis and management of headaches rests on the international classification of headache disorders (2004), which divides headaches into primary and secondary. A primary disorder is not due to another condition, and a secondary headache is due to a definable condition such as a brain tumor. There are 4 primary headache categories, and 8 secondary headache categories.

The primary headache disorders are:

• Migraine

• Tension-type headache

• Cluster and other trigeminal autonomic cephalgias

• Other primary headaches

The goal of any headache evaluation is distinction between primary and secondary headaches. Warning signs suggesting possible secondary headaches are:

• Sudden onset headache

• Subacute headaches, with increasing frequency or severity

• Headache, with systemic illness

• Chronic, daily headache

• Focal neurological signs other than typical visual or sensory aura

• Headache always on the same side

• Papilledema, cognitive impairment, personality change, or seizures.

Migraine is a highly prevalent medical disorder with most individuals suffering severe pain. There are clear IHS criteria for the diagnosis of migraine. Migraine must be viewed as a process and steps taken to ensure that it does not proceed to chronic daily headaches. The most consistent migraine symptoms are nausea, disability and photophobia.

Migraine is a phasic disorder with a prodrome, aura (20%), and headache, and post headache phases. There are numerous comorbidities with migraine, including stroke, epilepsy patent Foramen ovale, and mitral prolapse. There are also significant psychiatric comorbidities.
Treatment of migraine includes removal of known triggers, abortive treatments, and prophylactic treatment. Stratified care is more effective than step care and relies on the MIDAS questionnaire. Abortive treatments may include simple and combination analgesics, anti-emetics, narcotics, and triptans. There are numerous triptans which vary in onset times and duration of action. They also vary in that they may be administered parenterally, orally, by nasal spray or by orally disintegrating tablets. Nausea may dictate the route of administration. Limiting factors with triptans may be side effects and contraindications. Too frequent use of abortive medication may produce analgesic withdrawal headaches. Prophylactic medications used for migraine therapy include beta-blockers, valproate, and topiramate, anti-convulsants, and tricyclic antidepressants. Currently, propanolol, valproate, and topiramate are FDA approved for this use. Comorbidities with migraine produce therapeutic opportunities, and contraindications.

Tension-type headaches have different characteristics than migraine, and are additionally included in the IHS criteria for diagnosis. No FDA approved medications are currently used for tension-type headaches.

A special class of headaches is indomethacin responsive headache, which includes hemicrania continua, paroxysmal hemicrania, ice pick, headache, sexual headache, and benign cough headache.

Cluster headache is the most frequent example of a trigeminal autonomic cephalgia, which also includes paroxysmal hemicrania, SUNCT syndrome, and hemicrania continua. There are also IHS criteria for the diagnosis of cluster headache. Cluster headaches cluster both in time by occurring frequently within a given time period and also at given times of the year (spring and fall). There is a severe, unilateral, and orbital, suborbital or temporal pain, lasting 15 minutes to 3 hours, untreated. There are autonomic features of the headache. Abortive therapy consists of 100% oxygen, sumatriptan, hand, DH E. or intranasal lidocaine. Prophylactic treatment includes calcium channel blockers, steroids methysergide or lithium. There are a variety of neurosurgical procedures, but recently, occipital nerve stimulation has become the procedure of choice.

Primary chronic daily headache is a headache lasting more than 15 days a month and not related to structural or systemic disease. It has an incidence of 4 to 5% of the population. Short duration, less than 4 hours, includes chronic cluster, chronic paroxysmal hemicrania, and hip, neck, headaches. Long duration, includes chronic tension-type headache, new persistent daily, headache, hemicrania continua, and chronic migraine headache. Risk factors include high headache, frequency, female gender, obesity, snoring, stressful life events, high caffeine consumption, acute medication overuse, depression, head trauma, a history of migraine and less than a high school education. Over 70% of patients with chronic daily headache began as patients with migraine headaches. Commonly use medications and procedures include tricyclic antidepressants, beta blockers, calcium channel blockers, valproate, topiramate, gabapentin, antidepressants, muscle relaxants, occipital nerve blocks, and botulinum toxin type A. No medications are currently approved by the FDA for treatment of this entity and prevention is the most desirable alternative to treatment.