Make the Proper Diagnosis—Take a detailed headache history of the patient, including all prescription and OTC medications used and the frequency of their use.
Cheryl's headache diagnosis is migraine without aura, in addition to probable medication overuse headache. She has a long history of typical migraines. However, the character of her headaches has changed. They have become more frequent and more difficult to manage, requiring additional medications. These changes may indicate the need for further testing, such as brain MRI, though there are certain known reasons for escalation of Cheryl's headaches.
She is overusing caffeine and analgesics, substances that may cause, worsen, or maintain her daily headache pattern. She is also perimenopausal, with hormonal fluctuations and sleep disturbance. Thus, it may be reasonable to withdraw the overused agents with close follow-up before conducting further testing.
Educate the Patient About Nonpharmacologic Management— Cheryl should understand that her diagnosis is migraine, that there are no objective markers for this disorder, and that it is usually inherited, chronic, and biochemical in nature.
There is no single definitive cause of migraine or definitive treatment for patients with migraine. However, the disorder can be successfully managed. It is important for the patient to stay regimented in her daily schedule, including meals and sleep. Fluid intake should be maintained, because dehydration is a trigger for migraine. Any identified food triggers for migraine should be avoided, though food may not consistently trigger headaches and may be additive with other stimuli.
The patient should be especially careful to avoid migraine triggers during her most vulnerable time for headaches (ie, during menses). Regular exercise may have beneficial effects on headaches. Relaxation activities, including biofeedback training, listening to relaxation tapes, and performing yoga, may also be beneficial. Furthermore, OMT for paravertebral cervical spasm associated with headaches may be beneficial—though some patients have cutaneous allodynia during acute migraine and may prefer not to be touched at such times.
Educate the Patient About Pharmacologic Management— Use of all analgesics and caffeine was terminated. Cheryl was warned that she would probably have more intense headaches while withdrawing from these substances and that any prescribed abortive medications may not work as effectively as a caffeine product for the next few weeks.
Removal of offending agents alone may markedly improve headaches, but most patients still require prophylactic therapy. Treatment with prophylactic medications was initiated immediately, and Cheryl was made aware that medication doses are started low and gradually increased, depending on observed efficacy and adverse effects. It may take 3 months for prophylactic medications to achieve complete benefit at the full therapeutic doses. In the past, this patient did not achieve effective doses of prophylactic medications or did not use these medications long enough. In addition, she had been overusing caffeine and abortive medications during prophylactic medication trials, rendering the medications ineffective.
Initiate Treatment— Cheryl was educated; weaned off caffeine and an OTC proprietary acetaminophen-acetylsalicylic acid (ASA)-caffeine formulation; started on an alternative triptan for first-line acute treatment; and given a second-line abortive medication (a phenothiazine) for nausea and/or rescue pain when the triptan did not provide complete relief.
Rescue therapy is often sedating, but the goal of rescue therapy is alleviation of pain and associated symptoms rather than restoring full function.
Cheryl was encouraged to not take any OTC medications for her daily milder headaches, but she was given an NSAID as needed for up to 2 days per week. A daily regimen of low-dose amitriptyline (10 mg/d for 1 wk; then 20 mg/d) at bedtime was started for headache prevention; this medication also helped Cheryl sleep. She was provided with detailed written instructions on her treatment and a diary to keep track of her headache frequency, severity, and medications.
Have the Patient Follow Up— Headaches change with time, and secondary headaches may develop in patients who have had life-long headaches. In addition, abortive and prophylactic medications need to be continually assessed and adjusted to achieve maximal benefit. Physicians should review headache diaries, any medication adverse effects, and any changes in medical condition that may warrant changes in therapy. Generally, prophylactic medications are continued for approximately 6 months if a beneficial response is achieved, then attempts are made to wean the patient away from the medications.
Prophylactic medications may be stopped with continued observed benefits, or headaches may worsen. If headaches worsen, the lowest dose that adequately controls headache should be maintained.
Cheryl had severe headaches during the first week she was off caffeine and the acetaminophen-ASA-caffeine formulation. She then noticed a lessening of headache intensity, with some headache-free days by the third week of therapy. At her next visit, 1 month later, amitriptyline was increased to 40 mg/d. Two months after her second visit, Cheryl had only one migraine with menses per month. The use of her triptan during these episodes provided complete pain relief within 2 hours. Recurrence of headache 24 hours later was again relieved with her triptan. After 2 months, Cheryl rarely had mild tension-type headaches and did not require abortive treatment for such headaches.