Approach To Migraine Headaches

The Migraine And Headache Program

Migraine Headaches Holistic Medicine

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Headaches are an extremely common complaint in primary care, urgent care, and emergency settings. The vast majority of adults have at least one headache each year, although most do not present for medical care. The role of the practitioner is to attempt to accurately diagnose the cause of the headache, rule out secondary causes of headaches ("red flags") that may signify a serious underlying pathology, provide appropriate acute management, and assist with headache prevention when needed.

The medical history in a patient with headaches should focus on several important areas. The quality and characteristics of the headache and its specific location and radiation should be identified. The presence of associated symptoms. especially neurologic symptoms that may suggest the presence of a focal neurologic lesion or increased intracranial pressure, must be documented. The age at which the patient first developed the headaches, the frequency and duration of the headaches, and the amount of disability and distress that is caused to the patient should be explored. It is also important to note what the patient has done to try to treat the headaches in the past, including as much detail as possible regarding medication usage (both prescription and over-the-counter |OTC|).

The examination should include both a general examination and a detailed neurologic examination. A funduscopic examination revealing papilledema may be supportive of the presence of increased intracranial pressure. Identifying a focal neurologic deficit increases the likelihood of finding a significant CNS pathology as the cause of the headache.

A patient with symptoms and signs consistent with migraine and who does not have any "red flag" findings (Table 34-1) does not require any further testing prior to instituting treatment. Neuroimaging should be performed if there is an unexplained neurologic abnormality on examination or if the headache syndrome is not typical of either migraines or some other primary headache disorder. The presence of rapidly increasing headache frequency or a history of either lack of coordination, focal neurologic symptom, or headache awakening the patient from sleep, raises the likelihood of finding an abnormality on an imaging test. Magnetic resonance imaging (MRI) may be more sensitive than computed tomography (CT) scanning for the identification of abnormalities, but it may not be more sensitive at identifying significant abnormalities. Other testing (e.g., blood tests, electroencephalogram |EEG]) should only be performed for diagnostic purposes if there is a suspicion based on the history or physical examination.

The treatment of headache is best individualized based on a thorough history, physical examination, and the interpretation of any additional study results. Nonpharmacologic measures and cognitive-behavioral therapy are worth considering in most patients with primary headache disorders. The U.S. Headache Consortium lists the following general management guidelines for the treatment of migraine headaches:

Table 34-1


Table 34-1





Sudden-onset headache

Subarachnoid hemorrhage, pituitary apoplexy, hemorrhage into a mass lesion or vascular malformation, mass lesion

Neuroimaging first: lumbar puncture if neuroimaging negative

Headaches increasing in severity and frequency

Mass lesion, subdural hematoma, medication overuse

Neuroimaging, drug screen

Headache beginning after age 50 years

Temporal arteritis, mass lesion

Neuroimaging, Erythrocyte sedimentation rate level

New-onset headache in patient with risk factors for HIV infection or cancer

Meningitis, brain abscess (including toxoplasmosis), metastasis

Neuroimaging first: lumbar puncture if neuroimaging negative

Headache with signs of systemic illness (fever, stiff neck, rash)

Meningitis, encephalitis, Lyme disease, systemic infection, collagen vascular disease

Neuroimaging. lumbar puncture, serology

Focal neurologic signs or symptoms of disease (other than typical aura)

Mass lesion, vascular malformation, stroke, collagen vascular disease

Neuroimaging. collagen vascular evaluation (including antiphospholipid antibodies)


Mass lesion, pseudotumor cerebri, meningitis

Neuroimaging. lumbar puncture

Headache subsequent to head trauma

Intracranial hemorrhage, subdural hematoma, epidural hematoma, posttraumatic headache

Neuroimaging of brain, skull, and cervical spine

Adapted from South-Paul JE. Matheny SC. Lewis EL. el al. Current diagnosis and treatment in family medicine. New York: McGraw-Hill, 2004:330.

Adapted from South-Paul JE. Matheny SC. Lewis EL. el al. Current diagnosis and treatment in family medicine. New York: McGraw-Hill, 2004:330.

• Educate migraine patients about their condition and its treatment, and educate them to participate in their own management.

• Use migraine-specific agents (e.g., triptans, dihydroergotamine, ergotamine)

in patients with more severe migraines, and in those whose headaches respond poorly to treatment with nonsteroidal antiinflammatory drugs (NSAIDs) or combination analgesics, such as aspirin plus acetaminophen plus caffeine.

• Select a nonoral route of administration for patients whose migraines present early with nausea or vomiting as a significant component of the symptom complex.

• Consider using a self-administered rescue medication for patients with severe migraine who do not respond well to other treatments.

• Guard against medication-overuse or rebound headaches. Patients who require acute treatment on two or more occasions per week should probably be on prophylactic treatment.

The goal of therapy in migraine prophylaxis is a reduction in the severity and frequency of headache by 50% or more. The strongest evidence supports the use of amitriptyline. propranolol, timolol, and divalproex sodium for migraine headache prevention.

Other Headache Syndromes Tension-type Headache

Tension headache is the most prevalent form of primary headache disorder, typically presenting with pericranial muscle tenderness and a description of a bilateral bandlike distribution of the pain. Headaches can last from 30 minutes to 7 days and there is no aggravation by walking stairs or similar routine physical activity. There is no associated nausea or vomiting. Photophobia and phonophobia are both absent, or one. but not the other, is present. They can be either episodic (less than 180 days per year) or chronic (greater than 180 days per year).

Initial medical therapy of episodic tension-type headache includes aspirin, acetaminophen, and NSAIDs. Because of the significant risk of developing drug dependency or medication-overuse headache, avoiding caffeine-containing over-the-counter or prescription drugs and codeine- or ergotamine-containing preparations (including combination products) is recommended. The general management principles for the treatment of migraine headaches can also be applied to the treatment of chronic tension-type headaches. In frequent headache sufferers, the combination of antidepressant medications and stress management therapy reduces headache activity significantly. Other prophylactic treatments of chronic tension-type headaches include calcium channel blockers and [^-blockers.

Cluster Headache

Cluster headache is strictly unilateral in location and can be located in the orbital, supraorbital, or temporal region. It is generally described as a deep, excruciating pain lasting from 15 minutes to 3 hours. The frequency can vary from one every other day to eight attacks per day. Cluster headaches are associated with ipsi-lateral autonomic signs and symptoms, and have a much greater prevalence in men. Compared to migraine sufferers who often desire sleep and a quiet, dark environment during their headache, individuals with cluster headache pace around, unable to find a comfortable position. The acute treatment of cluster headache involves 100% oxygen at 6 L/min. dihydroergotamine and the triptans. Verapamil, lithium, divalproex sodium, methysergide, and prednisone may be used for prophylactic treatment. Because of side effects related to chronic use, methysergide and prednisone need to be used with caution.

Chronic Medical Conditions

Patients with certain underlying medical conditions have a greater incidence of having an organic cause of their headache. Patients with cancer may develop headaches as a consequence of metastases. Someone with uncontrolled hypertension (with diastolic pressures >110 mm Hg) may present with the chief complaint of headache. Patients with HIV infection or AIDS may present with central nervous system metastases, lymphoma, toxoplasmosis, or meningitis as the cause of their headache.

Medication-Related Headache

Numerous medications have headache as a reported adverse effect. Medication-overuse headache (formerly drug-induced or "rebound" headache) may occur following frequent use of any analgesic or headache medication. This includes both nonprescription (e.g.. acetaminophen. NSAIDs) and prescription medications. Caffeine use, whether as a component of an analgesic or a beverage, is another culprit in this category. The duration and severity of the withdrawal headache following discontinuation of the medication vary depending on the medication(s) involved.

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