Chronic Headache Management: Outpatient Strategies
When we assess patients who seek medical treatment for headache pain, they usually suffer from migraine, tension, or chronic migraine. Only about 5% of patients fall outside of that realm. Chronic daily headache, the majority of which are chronic migraine, occurs in 3% to 4% of adults in the United States,1 and often results in a markedly decreased quality of life.2 There are numerous medications for episodic migraine but fewer options that are effective for chronic migraine. The following discussion reviews what we know about migraine types, comorbidities that commonly occur in patients with migraines, as well as migraine triggers, and treatments.
It is estimated that between 25 to 28 million people in the United States suffer from migraines, making it one of the most common illnesses—this includes a prevalence of 18% among women and 6% among men.3 Many migraine patients successfully alleviate their headaches with over-the-counter (OTC) medications, but most are disabled to some degree during their migraines.
Migraine is an inherited, chronic illness characterized by moderate to severe pain that often is unilateral but can be bilateral. Migraine usually is accompanied by features such as nausea, dizziness, photophobia, sonophobia, or osmophobia. Exacerbation of the headache from bending or other movement is common, as is neck pain. Aura is fairly common; up to 25% of migraineurs experience an aura but not with every headache. Prodromal and/or postdromal fatigue and mood changes are common.
Migraine may begin at any age, and it is surprisingly common in children and adolescents. At least 1% of 6-year-olds and 4% of 10-year-olds suffer from episodic migraine. Until age 12, boys and girls suffer from migraine in equal numbers. During puberty, the familiar female-to-male ratio of 3:1 is reached, and that ratio is maintained throughout the rest of life.4
When diagnosing migraine, it helps to look at consistent triggers, such as menses, weather, and insufficient sleep. If weather changes bring on migraine, it can be confusing because the migraineur often is told (and feels) that they have a sinus headache. To further confuse the picture, OTC sinus medications often help all types of headache. However, several large studies have indicated that 95% of people presenting with chronic sinus headaches actually have migraines, so one must think “migraine first” when patients present with pain in the sinus area.5
With a new-onset headache—especially in a patient in middle or later life—more extensive work-up is needed. This also is true for new neurological symptoms such as numbness, a change in mental status, or visual problems. The patient with chronic daily headaches warrants an MRI more often than the patient with sporadic migraines. Children with migraine may not need an MRI. If a 12-year old presents with a history of 2 migraines per month since age 6, an MRI is not absolutely necessary. However, if patients continue to have migraines and are followed until college age, they are likely to have a headache that warrants MRI scanning at some point.
Most headache patients should undergo routine hematologic exams, primarily to assess liver and kidney function. Patients often take OTC medicines that they don’t tell their physicians about. Either they don’t remember or don’t have a sense of how many OTCs they take for pain relief. It is not unusual for headache sufferers to consume 8 to 10 or acetaminophen-caffeine (Excedrin, others) or ibuprofen (Advil, Motrin, others) a daily basis, putting their liver or kidneys at risk.
One of the primary things pain practitioners can do for their patients with headache is educate them about triggers. Certain triggers cannot be controlled, but when a patient has a headache every time the weather changes, or the first day of every menstrual period, clinicians can prescribe medication to be taken the day or night before as a preventive.
The top triggers tend to be stress (daily hassles), menses, and weather. When they occur simultaneously, patients get the worst, most prolonged migraines. Of course, missing meals, under- or over-sleeping, bright lights, and certain foods also contribute, but the role of foods tends to be overemphasized.
Many books concentrate on diet and foods, but these are low on the list of important triggers. Caffeine, however, is a major trigger. We need to limit the patient’s intake, although the limit varies from person to person. Some people can consume 800 mg of caffeine a day and not have rebound headaches or withdrawal. Other people get headaches from a small amount of caffeine in their diet.
Caffeine is an adjunct for pain relief because in small amounts it helps enhance the effect of analgesics. But, patients should be advised to watch out for the specialty coffeehouse effect. For example, Starbucks coffee has approximately 23 mg of caffeine per ounce. In an oversized cup of Starbucks, a patient can ingest 400 mg of caffeine (twice the daily maximum recommended), or more. Most home-brewed coffees have manageable doses. For example, Folgers or Hills Brothers brewed coffees have about 150 mg per cup, whereas instant coffee has half that amount. Tea, if it has caffeine, will generally have 30 to 60 mg per cup. Cola drinks have 40 to 60 mg and Mountain Dew has a little more. The new energy drinks may have 200 mg in 12 ounces. Patients should be advised to watch for accumulated caffeine from these sources and OTC medications. Each tablet of the acetaminophen-caffeine combination analgesic has 65 mg of caffeine, whereas the aspirin-caffeine combination product has 33 mg. I attempt to limit a patient’s daily caffeine intake to 150 mg, with 200 mg as the maximum.6
A word on disability. One might think that pain level is the major predictor of disability. It has been shown, in well-done studies, that other factors probably are more important. Catastrophizing, such as thinking one’s headache is always a 14 on a scale of 1 to 10, is one of these factors. Part of the pain practitioner’s job is to turn down the volume and limit the drama. We can talk to people about catastrophizing and try to reduce the fear that underlies it.
Catastrophizing by proxy also happens, such as when a parent thinks his child has the worst headaches on the planet. Fear of pain also plays a role in disability. Some people have more fear and anticipation of pain than others and, as with catastrophizing, fear of pain may be lessened through psychotherapy.
When a patient comes into the pain practitioner’s office, we are not looking at a just a headache, we are assessing the whole person. By concurrently managing the patient’s comorbidities, we can help them achieve a better quality of life.