Our knowledge of headache disorders continues to expand as new research reveals more and more information. The medical community is developing new treatment protocols for chronic headaches and patients are learning to reduce headache severity, frequency and/or duration through diet, exercise and other physical means. There was a time when headaches were considered either migraine or non-migraine. Unfortunately, this led to a common misunderstanding. Most people now use the word "migraine" to signify a "bad headache" but the term migraine was originally used to describe a specific neurological syndrome. Partly because of the common misunderstanding about the term "migraine" and partly because of newer research into headache types, many physicians now believe in a continuum of headache disorders and no longer separate a specific patient's headache into either a "migraine" or "non-migraine" category.

A headache event involves many changes in the nervous system. There are fluctuations in the blood vessels that affect the blood supply to the brain, inflammatory cells causing a release of their inflammatory actions, neurotransmitters sending signals from nerves as those nerves slowly fire one after another in a depolarizing wave, moving over the brain, and, yes, much more. It is because of the many actions involved in a headache that there are so many treatment options: some focusing on the blood supply, some on inflammation, some on nerve stabilization, and some on the brain neurotransmitters.

Please feel free to click on one of the links to the right to access additional information. 

 

Making the diagnosis
Non-medication treatment considerations
Medication treatment considerations
Headache links

 

 

 

Making the diagnosis: in most cases, the diagnosis of the various chronic headache syndromes is made by the history and physical examination. There are guidelines produced by the American Academy of Neurology in regards to the need for additional studies, such as MRI. For those patients whose presentation requires further testing, the following are some procedures that may be performed:

• Lumbar puncture - CSF analysis

This study involves taking a sample of spinal fluid for analysis. Because the spinal fluid is separate from blood, when there is a question of infection or inflammation in the central nervous system, this study can help determine whether a problem exists, and if so, what the problem may be. Click here to read a basic review of lumbar puncture at another website.

• MRI - magnetic resonance imaging

This study involves using magnetic pulses to create a very detailed image of the body part being investigated. A neurologist typically orders MRIs of the brain or spine, although many body parts can be imaged. The Wikipedia entry on MRI provides a good overview of the procedure and its purposes.

• CT - computed tomography

This study involves computer manipulation of regular X-rays. The CT scanner contains an X-ray machine. The machine takes several X-rays in a row and the computer helps assemble them into a very detailed picture. In neurology, a CT scan is important because it is very rapid and can show serious and life threatening brain events such as brain hemorrhage. The Wikipedia website has a good overview of CT.

• EEG - electroencephalography

This study shows brain activity as it happens, just like an EKG shows heart activity. This study is important when questions arise as to the function of the brain. EEGs are performed for many conditions from seizures to memory loss. Additional information about the various findings in EEG can be found at the eMedicine website.

 

 

Treatment considerations: treatments are evolving. Currently, it is believed that daily pain-killer use may actually worsen headache or maintain it. In fact, recent studies have been consistent in their conclusion: daily pain medications can and do cause a rebound headache. Recent studies show that using a pain killer just eight times in one month doubles the risk of the headache turning into a chronic daily headache! Yet, for those patients who have failed lesser means, the use of daily pain medication is within the standard of care. It is not clear yet whether the analgesically-mediated headache results from just the short-acting drugs or whether it results from long-acting drugs or both as well. Current treatments involve prophylactic medication, rare use of pain killers (unless other modalities have failed), and other modalities from exercise to stress reduction. Botox also can be helpful for headache disorders but currently is off label for that purpose. 

Treatments vary, but the following NON-medication treatments are quite commonly prescribed.

• Physical therapy techniques

Physical therapy encompasses various types of treatment. Although physical therapy itself is fairly specific, we typically think of various other physical modalities as being a part of physical therapy. In fact, many physical therapists employ other techniques, such as Feldenkrais, Pilates and the like, along with standard physical therapy. The American Physical Therapy Association has additional information for patients.

It is important to emphasize that all physical modalities are potential treatments. Although some treatments carry more risk than others, and although some treatments may be appropriate for some but not others, many patients benefit from yoga, meditation, exercise, swimming, Feldenkrais, Pilates, and a host of other physical modalities.

• Acupuncture

People often think of acupuncture as "alternative." However, acupuncture is scientifically proven and performed by many mainstream practitioners. In fact, the US Government provides a background about acupuncture. The National Institutes of Health maintains a "complementary" medicine section and provides quite a bit of information about acupuncture.

• Psychology - including pain psychology

Psychology is often thought of one-dimensionally: a person to talk to. In fact, psychology is much, much more. In addition to the counseling aspect of psychology, we rely on psychologists for memory testing in cases of dementia or brain trauma. We rely on pain psychologists to assist with imagery and coping skills with chronic pain. We have noted that patients who have a psychologist involved in their care typically show a better quality of life. Psychology Today is a common web portal that may provide additional information.

• Botulinum toxin (Botox) injections for pain and neurological purposes

Botulinum toxin (Botox and Myobloc) is thought of as a cosmetic treatment. However, it's original use was neurological. Botox can reduce muscle tension and spasm and therefore reduce pain. It is commonly used for cervicogenic (muscle-related) headache, writer's cramp, blepharospasm, and other muscle conditions. Although not FDA-approved for many of the uses, it has been used successfully and safely in many more conditions. Recent studies reported by the American Academy of Neurology suggest that Botox may more efficacious for muscle disorders than for migraine.

• Injections - epidural, facet, joint

Injections are a common form of treatment for various conditions. The underlying idea is simple: a medication is injected in a specific region, intended to provide improvement in the condition. In a joint, the medication may be a lubricant to compensate for worn out cartilage; in a trigger point, the medication may be a numbing agent to reduce pain; in the spine, the medication may be a steroid to reduce spontaneous nerve firing and to reduce pain; in the muscle, the medication may be botulinum toxin (Botox or Myobloc) to reduce abnormal muscle tension. Depending on the purpose and location, these procedures may be performed in an office setting or in a radiology suite with X-ray guidance.

There are medication treatments as well.

Almost everyone has a headache here and there. Some have regular headaches. Those patients typically are offered various treatments for the recurrent headaches. Sometimes those treatments involve medication. Current research shows that there is a limit to the use of abortive therapies (like triptans or opioids). If a patient uses an abortive medication more than 8 days per month, there is a significantly increased risk of the headache transforming into a chronic daily headache rather than just an intermittent headache. Although long suspected, the research was presented at the American Academy of Neurology meeting in April 2008. For patients who have more than 8 days' of headaches per month, the use of prophylactic medication (medication that helps prevent headaches) is an important consideration.

• Preventing headaches: PROPHYLACTIC medication

There are many medications used to help prevent headaches from happening in the first place. Actually, these medications may do any or all of the following three things to headaches: reduce the frequency, reduce the severity, and/or reduce the duration. Currently, topiramate and a form of valproic acid are FDA-approved to be advertised for headache prevention. The neurological community employs several other medications that were intended originally to treat other conditions. Examples include some blood pressure medications, a specific antihistamine, a few specific older antidepressants, a specific memory loss medication, and more.

If headaches are occurring very frequently, then the patient should consider using a medication to reduce the frequency, in addition to the various options for stopping the headaches when they do come.

• Stopping the current episode: ABORTIVE medication

There are several categories of medication to help stop a headache when the headache occurs. A true migraine might be aborted with a triptan medication. NSAIDs, opioids and even nausea medications have been shown helpful in stopping headaches. In some cases, infusions of ergotamine and caffeine have been used.

Successful headache treatment typically requires avoidance of triggers (if known), good sleep habits, and for those with very frequent headaches, a combination of a preventative medication along with very judicious use of an abortive medication.

 

 

Headache links: These sites are solely responsible for their content. 

• American Academy of Neurology
  The American Academy of Neurology is the society of neurologists.


• Neuroscience Institute at California Pacific Medical Center, (please note that this office is a part of the Neuroscience Institute)
  
• National Headache Foundation: a society for headache investigation and treatment
  
• National Institutes of Health, headache information
  
• The American Headache Society and the AHS website for Headache Education

 

 

 

HEADACHE

 

Headaches and headache disorders fit into both the neurology and the pain management categories. Because of the complexity of headaches, however, a separate category is required.

 

Introduction to headache

Making the diagnosis

Treatment concepts

Headache help & links