RENEW OR SUBSCRIBE TO PPM
Subscription is FREE for qualified healthcare professionals in the US.
4 Articles in Volume 3, Issue #6
Coexistent Headache and Chronic Pain
Laser-Accelerated Inflammation/Pain Reduction and Healing
Referred Pain vs.Origin of Pain Pathology
TENS in the Treatment of Primary Dysmenorrhea

Coexistent Headache and Chronic Pain

The combination of headache and chronic pain in a patient presents challenges to both headache and pain management clinicians due to the lack of overlap between the two specialties.

Patients presenting with both headache and chronic pain may find that their condition provides a complexity that neither the clinical management of headache nor general management of pain is equipped to handle alone. The practical reality of today’s medicine is that there is little overlap between the two specialties. As a result, the patient may find great difficulty in finding a practice that will commit to the patient’s medical management. On the one hand, a headache specialist/neurology office may lack knowledge about pain literature or common pain complaints, may be uncomfortable with the demand/need of opiates for chronic pain, or may lack the procedures or time for frequent office calls and interactions that a typical pain patient requires. On the other hand, the pain management office may not be knowledgeable about unique headache/ migraine considerations in prescribing medications or find that initial evaluations for chronic pain are complicated by the overlay of headache.

Other concerns include the potential for misdiagnosis when, in actuality, brain disease is present. Yet despite the trepidation that these practitioners may have, patients with coexistent headache and chronic pain are common in the medical office and may be successfully managed. The following discussion provides insights into the variation of presentation and potential treatment modalities.

Chronic Intractable Headache

Every headache clinic has a small percentage of patients who are essentially intractable and are often referred to basic pain management with chronic narcotics as the primary form of treatment. This may include patients with chronic migraine, post-craniotomy patients, trigeminal neuralgia and other more obscure conditions. These are patients who have failed all the usual and customary forms of headache treatment. There is general agreement in the headache literature that opioids rarely conquer the problem of chronic headache entirely as tolerance and analgesic rebound issues intervene. Further, severe headaches may come through baseline chronic analgesic medications and these patients often require some breakthrough medication such as another opioid or a triptan.

There are major differences in opinion regarding the utility of chronic narcotics in these patients. On the downside, for example, Dr. Joel Saper, Director of the Michigan Headache Center, concluded in his long term study of 385 patients on chronic opiates for headache that only 26% had significant benefit after 3-5 years of therapy. About 50% of the 385 patients voluntarily discontinued the medications because of adverse effect or failure to benefit. These numbers, however, don’t negate what benefits the patients might have experienced for some period of time — 1-2 years, perhaps, or even six months. At times, all that physicians can do is offer solace and temporary relief of symptoms no matter what the eventual outcome may be.

On a more favorable note, Dr. Lawrence Robins has described his experience with 67 patients with refractory chronic daily headaches treated with Kadian, a 24 hour morphine preparation, and interviewed after 6 months of therapy with 40 mg a day dosing. 50% of these patients reported moderate to excellent relief after 6 months of therapy, a shorter treatment course than reported by Dr. Saper’s group, but nonetheless a significant patient benefit. Other studies employing methadone and controlled release oxycodone have shown moderate success.

A review of the major textbooks on headache in this area further demonstrates the reluctance by headache clinicians to utilize opioids in the headache patient. This reluctance, however, often fails to differentiate between headache sub-types and may deal with migraine and intractable chronic headache pain on an equal basis. There should be, for example, a completely different attitude toward treatment of the intractable headache following cervical surgery versus the typical common migraine sufferer. It has been recently noted that analgesic rebound — the principal concern over use of opioids — occurs in the migraine population but should not be considered a hazard of other headache types with the possible exception of ‘tension’ headache patients which are commonly comorbid with migraine. Addiction is also prominently mentioned in the majority of headache resources as a major hazard of opioid use when, in fact, that is not a frequent issue in the headache population.

It has been the author’s impression that many headache specialists will refuse to treat if the headache becomes intractable and, instead, send the patient to a pain specialist or pain clinic, where they will inevitably be treated with an opioid. The unwillingness to treat the intractable headache patient does not justify a lack of treatment for the pain patient nor negate the utility or necessity of treating these difficult, intractable patients with opioids.

Cervicogenic Headache

The next most frequent disorder where headache and chronic pain intersect is the cervicogenic headache1 or headaches resulting from some variety of cervical pathology. These headaches are often traumatic or arthritic in origin. The basic cervicogenic headache tends to be posterior, usually one-sided, and triggered by movement or neck positioning with migrainous features being infrequent or minimal. Diagnostic blocks in the cervical region would be another helpful diagnostic clue. As with any variety of headache disorder, however, wide variations in features may occur.

One of the important variations on this theme would be cervical pain-induced migraine or the circumstance in which neck pain acts as the migraine trigger. Traumatic events may produce chronic pain and headache, depending on the pathology involved. Cervical pain and cervicogenic headaches are frequent as are ‘post-traumatic headache’ in general.2 Couch reported 37% of head injuries with cerebral injury and 52% of those with skull fracture developed ongoing headache disorders. Headaches developing in the context of head trauma are as variable as the injuries and the patients. They may take the form of migraine, ‘muscle contraction’, TMJ syndrome or cervicogenic headache. They may be brief or outlast all other apparent injuries. They may persist more than a year and run through all available treatments offered by neurology and headache specialists and yet be unimproved.

The next most frequent disorder where headache and chronic pain intersect is the cervicogenic headache1 or headaches resulting from some variety of cervical pathology.

Recent literature3 has confirmed the author’s observations that this is a common occurrence. Kaniecki reported neck pain as a frequent occurrence with migraine and often relieved along with the migraine pain using sumatriptan. It is a common occurrence in a typical headache practice to see post-traumatic headache patients with migraine features, responsive to migraine medications, or to see previous migraine disorders worsened by trauma.4 One likely explanation for the ability of cervical pain to trigger migraine is the extension of the nucleus caudalis of the trigeminal nerve, a major relay in the genesis of migraine, down to C2-4 in the cervical spine. Thus neck pain may charge up the migraine generators in the brain stem.

The result of these factors is that neck-injured or neck-pain patient may have headaches of several varieties — not easily treatable with either traditional cervical treatments or migraine therapy and, indeed, may require both.

Headache and Generalized Pain

The classic disorder in this category is fibromyalgia in which headache is reported in 75% of cases along with numerous diffuse symptoms. The headache features in fibromyalgia5,6,7,8 are not specific in type, degree, or disability. Some authors have suggested that the process of central sensitization (CS) may be responsible for the development of chronic daily headache out of periodic headache and also may be responsible for the development of fibromyalgia. CS presumably results from the continuing chronic pain assault on the brain and spinal cord neurons. Oversensitivity results from this over-stimulation, in some regard like learned behavior in the nervous system.

Other more specific rheumatological disorders such as systemic lupus erythematosus and giant cell arteritis may also be associated with headache and body pain, specifically arthralgias. These conditions have other manifestations that may aid in diagnosis. For example, giant cell arteritis is specifically suggested by age of onset, sedimentation rate, physical examination and general bodily symptoms.9

Triptans
Midrin
Cycloxygenase-2 (Cox-2)
inhibitors/Non-steroidal anti-
inflamatory drugs (NSAIDs)
Tricyclics
Anti Epileptic Drugs (AEDs)
(gabapentin, topirimate,
valproic acid)
Beta-blockers
Calcium Channel Blockers
Angiotensin II Receptor Blockers
(ARBs)

Headache Medications

Virtually all headache medications, most specifically migraine drugs, can be used in the chronic pain patient (see Table 1). That has been a subject of some confusion in the treatment of pain. Patients with migraine on chronic pain programs frequently continue to suffer migraine as a separate issue and report that the severe spiking headache cuts right through the opiates. This requires them to take breakthrough medications, either more opiates or migraine treatments. When any specific combination of medications is used, it is recommended that there should be consideration of possible interactions.

The following sections present a discussion of some special issues that occur with the use of headache medications in chronic pain patients.

Triptans. One problem with triptans in chronic pain patients is their lack of efficacy in the circumstances of analgesic rebound. This may occur in patients on chronic opiate therapy but it is, by no means, absolute. Triptans may be very effective even in the presence of high dose daily opiate use.

NSAIDs/Cox-2 inhibitors. As analgesics these medications are less potent than opiates but, in special circumstances, might be indicated along with them. These medications may have a greater role in the headache patient. Recent studies have shown efficacy in conjunction with triptans or in higher dosing for acute pain. Many patients with chronic pain have gastrointestinal issues relating to years of excessive analgesic use. This could limit the use of these type of medications.

Headache medications and weight gain. Several ‘headache’ medications may promote significant weight gain in a population that already is at risk for that problem. This would include, most particularly, valproic acid or Depakote and tricyclic antidepressants. Less commonly used medications might include cyproheptidine and the atypical antipsychotics such as olanzapine. Medications such as topirimate would be more likely to promote a weight loss and might be a better choice.

Beta-blockers. The primary negative issues with this category include hypotension and exercise intolerance which may reinforce a problem that is already an issue in the typical pain patient.

Stimulants. Stimulants may be used in chronic pain patients to promote wakefulness, such as Provigil (modafinil) and Ritalin. These can definitely produce headache in 7-10% of patients.

Antidepressants. Antidepressants in the SSRI category are frequently employed in the chronic pain patient, but have never been shown to have any consistent beneficial effect in headache patients. They certainly can increase headache, however. Anecdotal reports in this area abound. Effexor may improve headache; Zoloft is more likely to worsen them.

Analgesic rebound headache11 can be a significant issue in the migraine population if analgesics are used on a regular basis. This would be another way that migraine could be worsened in association with chronic pain and the treatment thereof.

Steroids. Steroids are frequently used in both chronic pain and headache. In headache disorders, they are used in cluster headache and in the management of severe prolonged headache and rebound headache. In chronic pain, they may be used with inflammatory disorders, acute radiculopathy or arthritic pain. The blood level of steroids may be reduced in the presence of barbiturates by the enhancement of enzymatic metabolic activity. This might reduce their effect in the presence of such headache medications containing butalbital such as Fiorinal or Esgic. Other anticonvulsants may behave similarly, including phentyoin and carbamazapine.

Steroids would not be recommended in conjunction with NSAIDs nor in patients who’ve already traumatized their GI tract with the over-use of over-the-counter medications.

Medications reducing the efficacy of opiates. Inhibitors of CYD2D6 (a gene family that encodes enzymes for the metabolism of psychoactive drugs) prevent the conversion of codeine and hydrocodone to the active byproduct morphine. These inhibitors include a number of different medications which could be used in the headache or pain patient. This list includes tagamet, fluoxetine, and paroxetine. Thus a chronic pain patient treated for depression with Prozac may find that suddenly pain medication doesn’t work as well anymore.

Migraine coexisting with chronic pain. Migraine, a common disorder effecting 12% of Americans or around 30 million patients, may coexist with any other variety of pain syndrome.10 In women that number is 16% with higher percentages in younger women. Given these numbers, the probability of migraine being correlated with some other variety of chronic pain — such as lumber radicular syndrome — particularly in a younger female, is quite high. In the case of cervical pain or cranial pain, the migraine may be induced by the pain, whereas that triggering effect has not been described with other areas of pain. Put another way, a pain in the neck is likely to trigger a migraine, but a low back pain is not.

Analgesic rebound headache11 can be a significant issue in the migraine population if analgesics are used on a regular basis. This would be another way that migraine could be worsened in association with chronic pain and the treatment thereof. There is no evidence that analgesic rebound occurs in non-migraine populations, therefore it would not be expected that headaches would result from analgesic or narcotic use in the non-migrainous patient.

The comorbidity of migraine,12 the associated disorders that occur with migraine, may complicate any case in these patients. These include mitral valve prolapse, irritable bowel syndrome, epilepsy, and multiple psychiatric syndromes including bipolar disease.

Treatment Protocols

The selection of treatment protocols is dependent on the relative significance/ severity of the headache versus chronic pain in any particular patient. Whether the problem is primarily severe chronic headache — often chronic migraine or ‘chronic daily headache’ — or primarily chronic pain, has a bearing on the approach chosen. The following describes the three possible combinations and the associated treatment approach.

Alternative treatment programs might include biofeedback, massage, Botox, or upper facet injections. These patients rarely require procedures or local injection beyond simple trigger points. Treatment of migraine comorbidity is another complicating factor, particularly depression and bipolar disease. It has been the author’s experience that patients often influence this course of treatment by the specialists they elect to see. Those with predominating headache end up moving from the chronic pain specialist’s office to the headache specialist. If their pain predominated and the headache doctor refused to use analgesics, the patient would move on to another physician willing to use narcotics.

  1. Headache is the primary issue. The possible treatment of a primarily headache patient is a very long list of medicinal and non-medicinal therapies. The primary diagnosis of the severe headache patient is most often migraine, chronic migraine and chronic daily headache. These patients may also be suffering from analgesic rebound headache. Treatment should include abolition of the triggers of the condition — such as hormonal factors — dietary manipulation, crisis management or abortive medications and prophylaxis medications. Great care must be given to avoid over-use of analgesics due to the potiential for analgesic rebound. Utilization of analgesics in headache patients is generally recommended at no more than two days a week to avoid the rebound scenario. However, there is no definite or defined data on this. It isn’t known, for example, if low doses of NSAID used on a daily basis cause rebound or whether cox-2 inhibitors are less likely to cause rebound.
  2. Chronic pain is the primary issue. Migraine triggers play little role in these patients. Traditional specific migraine medications, both abortive and prophylaxis, have little value except for several anti-convulsants, gabapentin in particular, and antidepressants such as amitriptyline. Physical therapy and massage may be important. Narcotic therapy is often required along with intermediate analgesics, such as tramadol. Procedures and local injections play an important role. Where non-headache pain is the primary issue, the issue of analgesic rebound is of less significance since the possibility of headache exacerbation is overshadowed by the necessity to treat the pain disorder.
  3. Equal headache and chronic pain. These patients often require dual therapy or some variety of a compromise program (see Table 2). Avoidance of headache triggers is important along with the use of any treatment with dual potential effect — physical therapy, massage, acupuncture, biofeedback, dietary treatment. Traditional abortive migraine meds and preventer meds may be required. Medications with dual effect such as gabapentin or tricyclic antidepressants may be useful. Recent studies have suggested utility for a diverse group of medications including tizanidine, tiagabine, lamotrigine, and trileptal. Local injections such as facet blocks or epidural injections are reasonable. The use of narcotic or analgesics in general could be problematic with the possibility of analgesic rebound but, in the worst pain scenarios, the physician will implement pain treatment despite this possibility, utilizing whatever is required for effective pain treatment. Every headache clinic and pain clinic will have some percentage of these patients in whom narcotics are required for the pain itself whether analgesic rebound is suspected or not. Use of psychotropic medications may add further complexity to these programs.
Stress management/psychiatric evaluation
Physical therapy
Massage
Acupuncture
Improvement in sleep disorder
Certain prophylaxis medications (such as gabapentin,
and tinazidine).
Tricyclic antidepressants
New medicinal applications for treatment of both
conditions: gabatril, trileptal, zonisamide, topirimate
Analgesic of all kinds ( considering the possibility of
analgesic rebound)
Botox
Cervical facet injections, occipital nerve blocks.

Summary

There are a number of challenges encountered in the treatment of patients suffering both chronic pain and headaches. Specialized programs of treatment may be required for both, and the extent to which one is emphasized will depend upon the magnitude of each. Many of the available treatments for headache may be inappropriate for chronic pain and vice versa. Often, compromise programs are established for the best possible outcome in these complex patients. n

Last updated on: January 28, 2012
close X
SHOW MAIN MENU
SHOW SUB MENU