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.
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).
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, 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.