Abstract
The headache problem with its debilitation and pain has been noted throughout medical history. It is one of the most common outpatient complaints and affects more than 45 million Americans. The lost days to work and family and the immeasurable suffering of patients can be lessened with the understanding and knowledge of a caring physician. Osteopathic physicians with expertise in holistic and musculoskeletal concepts are particularly well prepared to help.
The establishment of an accurate diagnosis through a careful history and physical examination is essential before the physician can develop an effective treatment plan. Treatment can be abortive, prophylactic, or symptomatic, or a combination. Abortive treatment is geared to reverse the headache once begun; prophylactic treatment usually involves the use of daily medications to prevent, decrease frequency, or lessen severity of attacks; and symptomatic treatment is for relief of pain or accompanying symptoms.
Most headaches experienced are of the tension type, whereas most debilitating headaches are of the migraine type. Cluster headache, though experienced by a small percentage of sufferers, is especially severe, and is useful in differential diagnosis.
Headaches with attendant pain and debilitation have been noted throughout recorded medical history. Early etiologic theories included curses of the gods, evil spirits, imbalance of humours, and many other equally imaginable ideas. Treatment often was bizarre and could range from rituals and spells to trepanning and bleeding. Today, though headaches are still not completely understood, scientific progress has enabled physicians to effectively treat most headache sufferers.
Headache is one of the most common outpatient pain conditions encountered in both physician offices and emergency departments. The National Headache Foundation estimates that more than 45 million Americans suffer, with the vast majority presenting with migraine or tension-type headache (TTH).
1 The countless lost days to work and family and the immeasurable suffering of patients can be significantly lessened with the understanding and knowledge of a caring physician. Especially well prepared and able to evaluate and treat headache patients is the osteopathic physician, with expertise in holistic medicine in addition to the musculoskeletal system. This system is increasingly being recognized as an important component of both migraine headache and TTH.
2
Establishment of an accurate diagnosis, accomplished only by a thorough history followed by a physical examination, is critical before treatment can be initiated. Important to the history are pertinent details of the headache, including onset, frequency, duration, characteristics of the pain (ie, sharp, dull, or throbbing), and associated symptoms. In most patients, a headache will match one of the more frequently encountered headache types. If it does not, or physical examination reveals positive neurologic signs, consultation and more diagnostic testing may be necessary.
Treatment for patients with headache can be abortive, prophylactic, or symptomatic, or a combination. Abortive therapy is geared to reverse a headache process once it has begun. Prophylactic management usually involves daily medication and is instituted to prevent and/or decrease the frequency and/or severity of attacks. Symptomatic treatment is for relief of symptoms of attacks that are occurring or do not fully respond to abortive treatment. These therapeutic modalities are not mutually exclusive, and combinations of modalities are appropriate.
As with any prescription, when pharmacotherapy is included for headache treatment, physicians should familiarize themselves with appropriate dosages, potential adverse events, drug interactions, and the overall safety of recommended drugs.
Migraine Headache
Every primary care physician should have a basic understanding of migraine headache. The burden of migraine headache is tremendous for sufferers, the healthcare system, and the economy.
3 Many patients are not satisfied with their treatment, stop seeing physicians in the belief that there is no help, and therefore do not receive the latest in migraine treatment.
4 Various reasons have been offered, some of which include inadequate education of physicians, limited public awareness, and low medical priority because migraine does not kill, maim, or cripple.
Migraine, one of the most frequent pain-related diseases encountered in the office setting, is thought to be a progressive inflammatory neurovascular disorder associated with considerable disability and impairement of quality of life.
5 Six percent of males and 18% of females are afflicted during adulthood
6; however, in childhood, adolescence, and senior years, the male-to-female ratio is equivalent. This difference is thought to be due to estrogen fluctuations, common in the fertile years of women.
7
Migraine is a disease accompanied not only by characteristic throbbing pain, but also by associated symptoms and disability. Pain is more often unilateral and can be associated with a multitude of symptoms such as nausea, vomiting, photophobia, phonophobia, fluid retention, irritability, personality changes, paresthesias, or muscle tightness of scalp and neck. Attacks can occur at anytime of the day, develop gradually, or be present on awakening, with a 1- to 3-day duration.
Increasingly, experts have recognized that there is a muscular tension component to most migraine attacks.
2,8 In some patients, neck symptoms precede the pain, while in others, these symptoms develop simultaneously with the pain. The association of neck symptoms and migraine tends to increase with advancing age. For this reason, special attention should be given to muscles of the neck and scalp in both the evaluation and treatment of sufferers.
Migraine headache frequently is preceded by a prodrome lasting from hours to days or an aura lasting approximately 15 to 30 minutes. This prodrome is nonspecific, as if the patient is broadcasting an impending attack, with symptoms such as mood change, fluid retention, fatigue, yawning, food cravings, or a sense of well-being. The aura of migraine is a clearly defined neurologic deficit, most often visual in nature, such as scotomas or visual field changes. Migraine preceded by prodrome is classified as migraine without aura (previously termed common migraine) and migraine preceded by aura is classified as migraine with aura (previously termed classic migraine).
It is thought that various risk factors or triggers are involved in precipitating migraine attacks. Although many physicians take these factors into consideration when developing patient treatment plans, others question their importance. It is this author's view that since the importance of trigger and risk factors varies from patient to patient, a trial-and-error approach is best. When possible, avoiding many triggers can play an important role in comprehensive management of migraine (
Figure 1).
Migraine Headache Treatment
For migraine sufferers who have only occasional attacks, abortive and back-up pain medication may be all that is needed. However, a more comprehensive plan is recommended for those patients who have more frequent or regular attacks. This plan may include pharmacologic, behavioral, personal, physical, or dietary measures singly or in combination. In general, the more frequent the headache, the more comprehensive the treatment plan that will be needed. Avoiding certain foods (
Figure 2), fasting, caffeinated beverages, alcohol, and other known triggers, as well as having adequate rest, exercise, stretching, and schedule regulation can be part of this treatment plan. Physicians should familiarize themselves with potential adverse events, drug interactions, and the overall safety of any recommended drugs.
▪
Triptans—Triptans, or 5HT
1 (5-hydroxytryptamine) agonists, have become the norm for migraine abortive treatment. At present, there are seven available triptans, all of which have similar degrees of efficacy in clinical trials.
9 Individual triptans, however, differ in onset and duration of action, recurrence rates, adverse event profiles, and routes of administration.
Sumatriptan succinate, zolmitriptan, naratriptan hydrochloride, rizatriptan benzoate, almotriptan malate, frovatriptan succinate, and eletriptan hydrobromide are available and approved by the US Food and Drug Administration. It is helpful for physicians to be familiar with more than one triptan, affording their patients more options. Although triptans have similar efficacy, it is clear that each migraineur is an individual and that the pharmacologic and physiologic actions and efficacy can vary. Each triptan does not affect all migraineurs in the same way, and what is effective for one patient may not be for another (
Table).
Triptans are arbitrarily categorized as short-, intermediate-, and longer-acting drugs for ease of understanding. This categorization may help the physician in deciding which drug to recommend for a specific patient; eg, patients with longer menstrually related migraine attacks may benefit from a longer-acting triptan, whereas a patient who has a rapid-onset attack may benefit from a shorter-acting triptan. All triptans, however, have demonstrated efficacy in virtually all types of migraine. These agents should be avoided in patients with cardiovascular and cerebrovascular disease.
▪
Ergotamine Tartrate—Ergotamine tartrate has been used with considerable efficacy by migraineurs for more than 75 years. It is available in 1-mg tablets in combination with caffeine), 2-mg suppositories in combination with caffeine, and 2 mg sublingual tablets. The usual dose of ergotamine tartrate is 1 mg or 2 mg at onset of pain and repeated in 1- to 2-hour intervals as needed to a maximum of 6 mg. The suppository form is rapidly absorbed, and patients frequently report relief with only a partial suppository. Most patients do not need to use the maximum ergotamine dose. Nausea is the most common side effect and sometimes requires medication. Although effective, ergotamine has a prolonged half-life, is slowly absorbed when taken orally, and should be used no more frequently than every 4 days to avoid ergotamine rebound headache.
10 It should be prescribed only for patients free of cardiovascular, peripheral vascular, and cerebrovascular disease.
▪
Dihydroergotamine—Dihydroergotamine (DHE), a derivative of ergotamine, has been available for more than 60 years. It is better tolerated than ergotamine and is available in parenteral and inhalation forms. The injection form of DHE is helpful for particularly difficult migraine attacks and, in addition to self-administration, is frequently administered in emergency departments. The nasal spray form is more convenient and when administered correctly, has a favorable efficacy, safety, and recurrence profile.
11 Dihydroergotamine is not absorbed through the gastrointestinal tract and any medication swallowed is wasted Absorption via nasal mucosa is rapid over minutes.
▪ Isometheptene Mucate—Isometheptene mucate (65 mg), available in a formulation combined with acetaminophen (325 mg) and dichloralphenazone (100 mg), is a mild vasoconstrictor and can be effective in migraine, especially in patients who have slower onset attacks. Two capsules (130 mg isometheptene mucate) are administered early in the attack and another one each subsequent hour, as needed, to a maximum of five. This combination product can also be helpful in patients with TTH and those with an anxiety or vascular component.
▪
Nonsteroidal Anti-Inflammatory Drugs— Certain non-steroidal anti-inflammatory drugs (NSAIDs), ie, ibuprofen and a combination of aspirin, caffeine, and acetaminophen carry FDA indications for migraine. Taken early in attacks, they have been shown to be effective in many migraine sufferers.
12,13 Other NSAIDs such naproxen sodium also can be helpful.
▪
Analgesics—Symptomatic treatment with analgesics is recommended for attacks that do not respond to abortive treatment or in patients who cannot take vasoconstrictors. A multitude of medications is available, but it is essential to limit their use because of analgesic rebounding.
14 Some of these include NSAIDs, butalbital combinations, opioids, and muscle relaxants. It is recommended that only small amounts of these medications be prescribed to avoid either daily or near-daily use, and possible rebound headache.
▪ Prophylactic Medications—Prophylactic medications are an important component of a comprehensive treatment plan. The goal of prophylaxis is to limit the frequency or severity of attacks, or both. A decision as to which medication to use depends on the patients' comorbidities and concomitant medications and potential side effects. For example, nonspecifc β-blockers could be prescribed for migraine patients with hypertension or anxiety, but they would be contraindicated in those with asthma. Drugs currently approved by the FDA for migraine prevention include propranolol hydrochloride, timolol maleate, divalproex sodium, and topiramate.
Propranolol is a nonspecific β-adrenergic blocking drug that can reduce migraine attacks by more than 50%.
15 It is administered in doses from 60 mg/d to 240 mg/d and is available in a long-acting capsule. Although this drug is generally well tolerated, fatigue and lethargy are common side effects. An alternative is timolol maleate, administered in doses of 10 mg/d to 30 mg/d; side effects are similar to those of propranolol.
16Divalproex and topiramate are anti-convulsant drugs particularly useful in migraineurs with a history of seizures and bipolar disorders.
17,18 Divalproex sodium, available in an extended-release form, is administered in doses from 500 mg/d to 1000 mg/d. Common side effects are tiredness, weight gain, and hair thinning. The daily dose of topiramate is 50 mg to 200 mg; common side effects include dizziness and paresthesias; patients frequently report decreased appetite and consequent weight loss.
Prophylactic medications generally are continued for at least 4 to 6 weeks before discontinuing for lack of efficacy. It is common for effectiveness to increase over time. Other medication alternatives, not specifically indicated by the FDA but which have shown efficacy in migraine prevention, are calcium channel blockers, tricyclic antidepressants (TCAs), and NSAIDs.
19How long effective prophylactic medications should be taken is the treating physician's determination, but most specialists continue prophylactic medications for 4 to 12 months before considering discontinuation.
▪
Nonpharmacologic Therapy—Physical measures can be helpful in a comprehensive treatment program. Osteopathic manipulative treatment (OMT) with both soft tissue and more active techniques, geared at restoring normalcy of muscle tone and range of motion, can be helpful in reducing attacks. During acute migraine attacks, many migraineurs have allodynia or throbbing, and active or passive manipulation of the head can aggravate the attack. Therefore, gentle technique to the lower cervical regions as well as the thoracic and lumbar regions can be helpful. Other physical modalities such as stretching, massage, or physical therapy have been reported by some to be effective.
20
Table
Triptans Currently Available for Treatment of Patients With Migraine
Triptan*
|
Half-life, h
|
Administration
|
|---|
| ▪ Shorter Acting | | |
| □ Sumatriptan succinate | 1.75 | Subcutaneous, oral, nasal spray |
| ▪ Intermediate Acting | | |
| □ Zolmitriptan | 2.5—3.0 | Oral, dissolve on tongue, nasal spray |
| □ Rizatriptan benzoate | 2.0—3.0 | Oral, dissolve on tongue |
| □ Almotriptan malate | 3.0—3.8 | Oral |
| □ Eletriptan hydrobromide | 4.0 | Oral |
| ▪ Longer Acting | | |
| □ Naratriptan hydrochloride | 5.0—6.0 | Oral |
| □ Frovatriptan succinate | 26.0 | Oral |
Table
Triptans Currently Available for Treatment of Patients With Migraine
Triptan*
|
Half-life, h
|
Administration
|
|---|
| ▪ Shorter Acting | | |
| □ Sumatriptan succinate | 1.75 | Subcutaneous, oral, nasal spray |
| ▪ Intermediate Acting | | |
| □ Zolmitriptan | 2.5—3.0 | Oral, dissolve on tongue, nasal spray |
| □ Rizatriptan benzoate | 2.0—3.0 | Oral, dissolve on tongue |
| □ Almotriptan malate | 3.0—3.8 | Oral |
| □ Eletriptan hydrobromide | 4.0 | Oral |
| ▪ Longer Acting | | |
| □ Naratriptan hydrochloride | 5.0—6.0 | Oral |
| □ Frovatriptan succinate | 26.0 | Oral |
×
Tension-type Headache
Tension-type headache, previously known as
muscle contraction headache, was thought to be caused by sustained muscle contraction of the neck and shoulders as a result of psychogenic or arthritic disturbances. However, it has been learned that sustained muscle contraction associated with TTH may occur as an epiphenomenon to neurologic central disturbances similar to migraine. Regardless of the cause, TTH is the most common of headaches. In fact, most people in the United States have had TTH at one time or another.
21,22
Patients with TTH have intermittent or persisting bilateral pain, often described as a “squeezing” or “band-like” pressure around the head. The location of symptoms can vary and more commonly are reported in the temporal or occipital regions. Associated tightness of the neck and shoulders are frequent accompaniments; nausea or vomiting are rare. Tension-type headache can last from hours to days, and commonly occur during periods of stress and emotional upset.
The neck is most often involved with TTH, especially with increasing age and degenerative joint disease. Some refer to headaches associated with the neck as
cervicogenic headache. The International Headache Society classifies this type only in those patients who demonstrate radiologic evidence of cervical abnormalities.
23 Regardless, most physicians do not differentiate and consider these headaches to be of the tension type.
Tension-type Headache Treatment
Successful treatment of patients with TTH can include various modalities such as behavior modification, OMT, physical therapy, nerve blocks, exercise, stretching, and medication.
Stress-reduction exercises, situational stress avoidance, counseling, and biofeedback relaxation training can be used to diminish precipitating causes, promote relaxation, and lessen the frequency of headaches. However, the addition of physical modalities, especially OMT, usually enhances treatment whether it be abortive or preventive.
24 Appropriate active and passive forms can be equally effective, depending on the philosophy and skill of the physician. No specific medications carry FDA approval for the prevention of TTH; however, muscle relaxants such as cyclobenzaprene hydrochloride, NSAIDs, low-dose TCAs (eg, nortriptyline hydrochloride 10 mg to 25 mg), and selective serotonin reuptake inhibitors have been used with varying degrees of success.
It is extremely important that patients having frequent TTH be free of the daily or near-daily use of analgesics, especially those containing caffeine or opioids. Patients with analgesic rebound headache rarely respond to appropriate preventive therapy, whether medicinal or physical.
25 Unfortunately, some patients with daily or near-daily headaches take analgesics for relief and unknowingly become physiologically dependent, thus perpetuating their headache problem.
From an abortive or symptomatic perspective, appropriate OMT can be extremely effective, especially when there is involvement of the paracervical and upper thoracic musculature. When this treatment is not available or practical, warm compresses, relaxation, or medication can be used. Medication alone can provide relief in most cases, though with a somewhat slower onset; they include NSAIDs, combination aspirin-acetaminophen and aspirin-caffeine, other over-the-counter products such as ibuprofen or naproxen sodium and muscle relaxants such as metaxalone or orphenadrine. The combination butalbital preparations and opioid drugs are recommended for severe attacks but only on a limited basis to avoid analgesic rebound.
Cluster Headache
Cluster headache, previously termed histamine cephalalgia, is an infrequently encountered condition, often mistakenly assigned to patients suffering with migraine or other less-common forms of chronic headache. The hallmark of cluster headache is its severe, excruciating pain and characteristic brief duration. Pain is always unilateral, frequently around the eye, and often described as “burning,” “boring,” or “sharp” and “deep.” Associated with the pain can be ipsilateral lacrimation, rhinorrhea, ptosis, or schleral injection.
Men have cluster headache more frequently than women (6:1); it can begin in the fourth or fifth decade and repeatedly occurs on a daily basis for weeks to months.
26 Attacks generally are self-limiting, lasting 30 to 45 minutes; they occur multiple times daily and mysteriously disappear for months to years, only to recur at a later time.
Because of the rarity of cluster headache, most primary care physicians will encounter a sufferer only on limited occasion. Treatment most often is focused on prophylaxis because of the brief and frequent occurrence of attacks. There are no FDA-approved medications for management of cluster headache at the present time; however, corticosteroids (eg, dexamethazone or prednisone), calcium channel blockers (eg, verapamil), lithium, ergotamine, and the judicious use of triptans have had varying degrees of success.
27
Inhalation oxygen by facial mask at 7 L is effective to abort an attack in most sufferers, but it is not practical because of the cumbersome apparatus.
28 Judicious use of DHE nasal spray or injection, the faster-acting triptans by injection or nasal spray, and sublingual ergotamine also have been recommended with varying degrees of success. Analgesics (eg, NSAIDs, opioids) are rarely recommended because of their slow onset of action and the brief duration of the headache. Also, the risk for physiologic dependence is high because of the frequency of attacks.
Comment
Chronic headache sufferers present a significant challenge to physicians. Millions of suffering patients throughout the United States have recurring headache attacks and are in need of help. Osteopathic physicians are particularly well prepared, with expertise in the diagnosis and treatment of the musculoskeletal system, to help these patients. It is important that all primary care physicians have a basic understanding of headache diagnosis and musculoskeletal components and keep current with evidence-based best-practice treatment modalities.
This continuing medical education publication supported by an unrestricted educational grant from Purdue Pharma LP
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