Headache Managment

Headaches can usually be well controlled with a combination of lifestyle adjustments, drugs, and complementary therapies. Treatment is most successful when it is tailored to each person's individual needs and when a person actively participates in therapy. It is therefore important to learn as much as you can about your headaches, to discuss the treatment options carefully with your doctor, and to take an active role in your treatment. This discussion of treatment will focus upon the three major types of non-life threatening headaches: migraine, tension, and cluster headaches. In most people, the frequency and severity of attacks can be well controlled with an individualized combination of lifestyle adjustments, drug treatment, and complementary therapies. LIFESTYLE ADJUSTMENTS – Some simple lifestyle adjustments may reduce the frequency of headache attacks. These include adhering to a routine schedule, exercising regularly, learning stress-management skills, and avoiding known headache triggers whenever possible (see below). Patients with cluster headaches should avoid smoking and alcohol. Headache triggers – Many potential triggers can start a headache attack or worsen a preexisting headache. The specific factors that trigger attacks differ from person to person. Most of these triggers have been noted in people with migraine headache; their role in other headache types is less clear. In particular, food triggers are much more common in people with migraines than in people with tension headaches. Your headache triggers, if any, can sometimes be determined by keeping a headache diary. If you can discover certain things that trigger your headaches and avoid them, you can prevent future headaches. Some triggers are unavoidable; for example, migraines occur about three times more often in women than in men. Hormones have a variable effect on migraines. Some women who take oral contraceptives or estrogen experience worsening headaches, while others improve. Similarly, some women have an increasing headache pattern during pregnancy, while others have diminished headache intensity. Headaches may increase in some women in the days before the menstrual period. When a medication is triggering a headache, talk with your doctor to see if there are any alternatives. DRUG TREATMENT – Doctors usually tailor drug treatment to the frequency, severity, and features of each person's headache attacks. Other factors that will affect the choice of drugs include each person's response to various drugs, side effects, and the presence of other medical conditions. Abortive treatment refers to the use of drugs to halt or lessen the severity of an attack; prophylactic treatment refers to the daily use of drugs to reduce the frequency and severity of headache attacks. Migraine headache – Most people with migraines benefit from treatment with one of the many drugs known to reduce the frequency and severity of these attacks. These drugs are now available in several easy-to-use forms, giving people with migraines greater control over their own symptoms. Abortive treatment of migraines alone is appropriate for people who have infrequent headaches (fewer than four headaches per month) that last less than 12 hours. Prophylactic treatment is usually recommended for people who have more frequent headaches, infrequent but disabling headaches, or long-lasting headaches. Abortive treatment – Abortive treatment is most effective when the drugs are taken at the first indication of an attack (eg, at the onset of aura if one occurs, or at the onset of pain). Mild analgesics (painkilling drugs) are usually sufficient for mild attacks; more severe attacks may require migraine-specific drugs. When migraine headaches are accompanied by marked nausea and vomiting, several drugs can be given by non-oral routes (by injection, rectal suppositories, or intravenous administration). Alternately, antimigraine drugs may be given in combination with drugs that alleviate the gastrointestinal symptoms of migraine (such as metoclopramide, also known as Reglan). It is generally felt that patients who tend to respond to mild analgesics should continue taking these with each attack, as long as they are not being used more than once or at most twice per week. Patients who do not typically respond to analgesics, however, should find the migraine-specific drug that works best for them and stick with it for future attacks [1]. • Mild analgesics are painkilling drugs that are often available over the counter. These drugs include aspirin, acetaminophen, and nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen , indomethacin, and naproxen . Indomethacin comes in a rectal suppository, which makes it particularly effective for patients who experience nausea during their headaches. Mild analgesics are also available in combination with caffeine, which enhances their antimigraine effect; as an example, Excedrin contains a combination of acetaminophen, aspirin, and caffeine. Mild analgesics are often recommended first for mild to moderate migraine attacks. However, they should not be used regularly because overuse can readily lead to rebound headaches (chronic, daily headaches caused by the medications themselves). If the judicious use of mild analgesics does not effectively control migraines, your doctor will likely recommend other drugs. People with gastritis (inflammation of the stomach), ulcers, kidney disease, and bleeding conditions should not take products containing aspirin or NSAIDs. • Moderate and strong analgesics provide greater pain relief than mild analgesics; some of these drugs also have a sedative effect.. • Ergotamine drugs are migraine-specific drugs that promote constriction of blood vessels. These drugs are often combined with caffeine (Cafergot, Wigraine). Nevertheless, compared with newer antimigraine drugs, ergotamine drugs are often less effective and more likely to produce side effects. These drugs are usually recommended for people with very long headaches (greater than 48 hours) or those who have headaches that frequently recur. People with hypertension, vascular disease, and kidney or liver disease should not take ergotamines. • The triptans are a newer class of migraine-specific drugs. These drugs include sumatriptan (Imitrex), zolmitriptan (Zomig), naratriptan (Amerge), and rizatriptan (Maxalt). The triptans can be easily used at home or at work. Sumatriptan, in particular, is available in many different formulas, including tablet, nasal spray, and injectable formulas. Over 70 percent of people experience headache relief within one hour of a subcutaneous (under the skin) injection of sumatriptan; by two hours, 90 percent of people notice improvement [4]. The injection may be repeated after 60 minutes if symptoms improve with the first injection but do not completely resolve. However, a second injection is not helpful if there has been no improvement in headache symptoms after the first hour. Common side effects of the injection include redness around the injection site, chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, a feeling of warmth, and tingling in the extremities. Most of these reactions occur soon after the injection and resolve spontaneously within 30 minutes. There have been rare serious side effects associated with injection of triptans, but generally these drugs are considered safe in appropriate patients. The oral form of sumatriptan is also safe and effective. Intranasal sumatriptan has a faster onset of action that the oral drug and fewer side effects than the injectable drug. The most common side effect of intranasal sumatriptan is an unpleasant taste. Headaches return within 48 hours in about half of all people who take sumatriptan by injection. Older adults and people with hypertension, vascular disease (including coronary artery disease), and kidney or liver disease should not take triptans. Prophylactic treatment – Prophylactic treatment effectively controls migraines in most people, although the benefits of this treatment may not be evident for three to four weeks. In some cases, both abortive treatment and prophylactic treatment are necessary to adequately control migraines. The choice of drug should be tailored to each individual, and is often based upon side effects and other medical illnesses. • Calcium channel blockers are very effective for controlling migraines. They are vasodilators normally used in patients with heart disease and are hypertension. They are safe drugs with few side effects. The calcium channel blockers include the drugs verapamil, nifedipine, and nimodipine. Calcium channel blockers may lose their effectiveness against migraines over time, but this can be remedied by taking a higher dose of the drug or switching to another drug in the same class. • Beta blockers reduce the frequency of migraine attacks in 60 to 80 percent of people [5,6]. These drugs are often used in patients with cardiovascular disease. Commonly used beta blockers include propranolol, nadolol, timolol, atenolol, and metoprolol. Beta-blockers may cause depression or impotence in some people. Those who have asthma, diabetes, depression, and certain types of heart disease should not take beta-blockers. • Other drugs that may be helpful in preventing migraines include the tricyclic antidepressants, serotonin reuptake inhibitors (SSRIs), cyproheptadine, methysergide, phenelzine, valproate, nonsteroidal anti-inflammatory drugs (NSAIDs), the blood pressure medication lisinopril, and riboflavin. With most of these drugs, it can be expected that approximately one-half of people will notice a reduction in migraine frequency. • Herbal therapies have been studied for the treatment of migraine headache; feverfew has been the most widely studied herbal remedy. Some studies have found it to be effective for migraine prevention, although most literature reviews suggest that any possible benefits are still unproven [7]. Avoiding overuse of antimigraine drugs – It is essential to use antimigraine drugs according to the prescription and your doctor's instructions. Overuse of these drugs, including over-the-counter drugs such as acetaminophen or NSAIDs, can lead to rebound headaches and a pattern of daily headaches that require increasing quantities of drugs for relief. Rebound headaches occur in people who have persistent headaches that cause them to overuse headache medication. A vicious cycle occurs whereby frequent headaches cause people to chronically take medications, which then cause rebound headaches as the medications wear off, causing more medication use, and so on. Let your doctor know if a treatment is not adequately relieving your migraines or is producing unpleasant side effects. He or she may recommend switching to another drug or switching from abortive treatment to prophylactic treatment. Tension headache Abortive treatment – Abortive treatment of tension headaches consists of the judicious use of analgesics (painkilling drugs) to control the pain of headaches. These drugs include aspirin, acetaminophen (Tylenol), and nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (eg, Motrin or Advil), indomethacin, and naproxen (eg, Naprosyn or Aleve). People with tension headaches should avoid analgesics that also contain caffeine (such as Excedrin) because frequent use of these drugs can worsen this headache condition. Analgesics should not be used regularly; overuse can lead to rebound headaches (chronic, daily headaches). If the judicious use of analgesics does not effectively control your tension headaches, your doctor will likely recommend other drugs. People with gastritis (inflammation of the stomach), ulcers, kidney disease, and bleeding conditions should not take NSAIDs. Prophylactic treatment – Prophylactic treatment of tension headaches is usually recommended for people who have frequent headaches despite the use of analgesics. Several different classes of drugs are used for prophylaxis. • Tricyclic antidepressants are the drugs most commonly used for the prophylaxis of tension headaches. The tricyclic antidepressants include the drugs nortriptyline, amitriptyline, and clomipramine. Tricyclic antidepressants can cause weight gain and other side effects in some people. People who have glaucoma, certain types of heart disease, or difficulty urinating should not take tricyclic antidepressants. • Beta blockers can effectively control tension headaches, and they may be particularly effective in people who also have symptoms of migraine headache. The beta blockers include propranolol, nadolol, timolol, atenolol, and metoprolol. Beta blockers produce substantial side effects in some people (see above under migraine). • Calcium channel blockers are also effective for controlling tension headaches and, similar to beta blockers, may be particularly effective in people who also have symptoms of migraine headache. Compared with beta-blockers, calcium channel blockers have fewer side effects. The calcium channel blockers include the drugs verapamil, nifedipine, and nimodipine. • Several new antidepressants may be effective for the prophylaxis of tension headaches. These drugs include the selective serotonin reuptake inhibitors (SSRIs) fluoxetine, paroxetine, and sertraline, as well as the drug bupropion. • Serotonin antagonists have been used to treat headaches for many years. These drugs include cyproheptadine and methysergide (Sansert). The serotonin antagonists may cause sedation and weight gain in some people. Furthermore, people who take methysergide must periodically stop taking the drug to prevent the more serious side effects associated with long-term use. • Anticonvulsants (drugs primarily used to treat seizures) are also effective for the prophylaxis of tension headaches. The anticonvulsants include valproate, phenytoin, carbamazepine, and gabapentin. Anticonvulsants can have several side effects, including cosmetic side effects (such as hair growth with phenytoin) and liver damage (carbamazepine). Because valproate can cause birth defects, this drug may be inappropriate for women of child-bearing age. Cluster headache – Most patients who suffer with cluster headaches will need to take both an abortive and prophylactic medication. Abortive therapy – Abortive therapy may include the following: • The majority of people obtain relief by inhaling 100 percent oxygen by mask. • Sumatriptan (and also possibly zolmitriptan) can stop an acute cluster attack, often within 10 to 15 minutes. Sumatriptan can also be combined with oxygen therapy. • Cafergot, DHE 45, and probably the nonsteroidal antiinflammatory drugs (such as indomethacin) are also effective in aborting cluster headaches. Prophylactic treatment – Prophylactic therapy is usually started at the onset of a new cluster. A number of drugs may be useful: • Verapamil is effective and has few side effects, although there may be a delay of four to six weeks before headache frequency diminishes. • The steroid drug prednisone is very effective prophylactic therapy, but should not be used long-term because of side effects. • Lithium appears to be particularly effective for the chronic form of cluster headaches. • Ergotamine, methysergide, cyproheptadine, and indomethacin have also been shown to be effective. Prophylactic medications can be gradually stopped after the expected duration of the cluster has passed. The drugs can be restarted if symptoms recur. COMPLEMENTARY THERAPIES – Several therapies can complement the lifestyle adjustments and drug treatment in people with headaches. The choice among these therapies depends upon personal preferences and on the presence and underlying cause of other types of headaches. Physical therapy – People with frequent tension headaches (more than 10 headache days per month), frequent mixed migraine and tension headaches, and chronic daily headaches (more than 15 headache days per month) may benefit from a physical therapist with special interest in headache and cervical spine dysfunction. These techniques should be used in people in whom medications either fail or achieve only partial or transient success or in whom medications can't be used (eg, pregnancy and breast feeding). Massage therapy – Massage therapies may help relax tense muscles and relieve ongoing headaches. These therapies include basic massage, manipulation, and ultrasound. Ice massage can help relieve migraine attacks. Nerve blocks or injections – People with chronic headaches that are associated with significant muscular pain and do not respond to a combination of pharmacologic treatments and physical therapy may benefit from injections or nerve blocks. These can range from simple injection of pain relieving medication into muscle tissues (trigger point injection), to injecting medication into the fluid space around the spine (epidural injection). Behavioral therapy – Headache conditions can be worsened by stress, anxiety, depression, and other psychological factors. Behavioral therapy that addresses these factors is often a component of a well-rounded headache treatment plan. There are many different types of behavioral therapy, including psychotherapy, relaxation techniques (meditation, progressive muscle relaxation, and self-hypnosis), biofeedback, and group skill-building exercises. The choice among these therapies is a matter of personal preference. The American Academy of Neurology recommends that relaxation training, biofeedback, and cognitive-behavioral therapy be considered for migraine prevention [8]. Homeopathic remedies – A number of homeopathic remedies have anecdotally been shown to relieve or prevent headaches. The precise effects of certain homeopathic remedies on the frequency and severity of migraine attacks are still being studied. At this time, homeopathic remedies do not have any proven benefits.