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12 Articles in Volume 16, Issue #10
2016 Practical Clinical Advances: Ketamine and Metformin
Case Challenge: Amniotic Allograft Reduces Joint and Soft Tissue Pain
Challenges of Treating Young Patients With a Terminal Prognosis
Defining Palliative Care
Discussing Benefits of Palliative Care
Evaluation of Antiemetic Pharmacotherapy in the Setting of Opioid Withdrawal
Fibromyalgia, Chronic Fatigue, and Chronic Fatigue Syndrome
Gabapentin Dosing for Neuropathic Pain
IV Acetaminophen Reduces Need for Opioids in Burn Patients
Opioid-Induced Constipation: New and Emerging Therapies—Update 2016
Osteopathic Treatment Considerations For Head, Neck, and Facial Pain
Tips From the Field: Deconstructing the Art of Headache Medicine

Tips From the Field: Deconstructing the Art of Headache Medicine

The author presents 7 tables and commentary for taking a medical history and determining the best strategy for headache management.

Severe headaches, including migraines, affect nearly 15% of American adults.1 Migraine headaches are considered to be among the most debilitating physical ailments, responsible for roughly 1.2 million visits to the emergency department (ED) each year and some $13 billion a year in lost productivity.2

Despite the prevalence of headache disorders and their physical and economic toll, the treatment of these conditions remains largely individualized. More often than not, treating someone with recurrent headaches boils down to a combination of artful clinical care and a thorough knowledge of the patient’s personal history. It tends to be more art than science. Every headache patient is unique and many factors should be considered when choosing the best treatment option for any 1 patient.

This article attempts to deconstruct the thought process that is involved in determining the best strategy for treating headache patients and presents a number of tips for taking a careful medical history of these patients. Of course, it will not always be feasible to obtain the entire history as listed in the tables of this article. However, the more of this information is collected, the better your treatment decisions will be for that patient.

Table 1: History, Headache Characteristic, Frequency

We treat patients very differently at age 15, 30, 60, or 80. With advancing age, for example, our medication options dwindle. Not enough has been written about headache treatment in the elderly, where our medication choices are limited.

When taking the history of a patient with recurrent headaches, the logical place to start is with the simple question: When did the headaches begin? New onset daily persistent headache (NDPH) and post-traumatic headaches are more difficult to treat than are transformed migraines. How recently the headaches began, and how they have evolved, drives therapy. Some patients are not bothered by their chronic daily headache (CDH) and want to focus instead on the severe migraines. Others may state, “My migraines are well controlled, it is the CDH that is the main problem.”

The type of headache (migraine, tension, cluster) is important, as is the severity—about 60% of patients report pain isolated to one side of the head, and for 15% of patients, the headaches occur only on that side.3

Aura occurs in approximately 25% to 30% of patients with migraines, although most of these patients also experience migraines without aura.3 The presence of an aura, and how severe and prolonged the neurologic symptoms may be, affects treatment.

Other factors that influence treatment choices include the presence of nausea or vomiting, and how severe these may be; how quickly the headache escalates; and the degree of disability. When (and if) the patient can tell if the headache is becoming severe is a determining factor. The frequency of moderate-to-severe headaches drives treatment. Prolonged (2 days or longer) headaches may require a different strategy. Because treating patients with headaches is so complex, we need to inquire about what has helped, or has not been effective, for the longer headaches.

Table 2: Refractory, Triggers, Special Situations, Past and Current History

Refractory migraines are defined as headaches that fail to respond to an adequate course (typically 2 months or more) of at least 2 of 4 classes of preventive medication.4 The prevalence of refractory migraines remains unknown, but the condition affects a small subset of people with chronic migraines. “Refractory” does not necessarily imply severe; some patients experience moderate or mild headaches that nevertheless do not resolve with treatment.  

Does the person have “difficult to treat” refractory headaches? If so, how refractory? Mild, moderate, or severe? Determining this involves the number of years of severe headaches, medical and psychiatric comorbidities, number of days per month with severe head pain, and other factors.

Triggers

Some (but not all) triggers may affect our treatment choices. These include menses, stress, and exercise. If stress is a trigger, addressing the underlying cause of stress and ways to address stress through therapy, meditation, exercise, or medications may help.

Special Migraine Situations: Preventive Therapies

For patients who have a known history of migraines centered around a specific event, it may be possible to prescribe preventive therapies for those occasions—these medications can be taken in advance of the event and then stopped afterward. For example, if a woman suffers from prolonged menstrual migraines, we may choose to use preventive medications prior to and after the expected onset of the pain. Prolonged headache may necessitate a different approach (particularly with regard to the use of low-dose cortisone). Exertional or sexual headaches may be amenable to preventive medications taken just prior to the activity. Altitude headache is often relieved by acetazolamide and/or dexamethasone.

Past Medications

What worked and did not work needs to be explored. Efficacy and side effects of over-the-counter (OTC) medications are important to evaluate, as well as prescription medications and supplements. Outside of the medications, it is helpful to know whether the patient has had any experience with onabotulinumtoxinA (Botox) and nerve blocks, and what the outcomes were.

Current Medications

When first seeing a patient with refractory headaches, we do not want to change all of the patient’s medications during the first visit. Rather, we ask: Are the current preventives helping? And has the patient been on an adequate dose? Side effects are crucial to list. We may not discontinue a particular medication, but we might state in the chart “cannot increase the medication due to (this) side effect.” If preventives are helping with psychiatric or medical comorbidities, we may continue the medication, even if it is not helping the head pain.

Table 3: Family History, Emergency Department, Herbs and Vitamins, Nonpharmacological, Patient Input

A close family member’s response to medications may influence our treatment. For instance, an 18-year-old patient comes in with her mother, and we mention topiramate (Topamax), which is approved for the prevention of migraines in people 12 years and older. When the mom states, “Topiramate almost killed me, I crashed my car on it,” we probably should not prescribe topiramate for the daughter. This is partly due to genetic polymorphisms that affect medication response in mother and daughter. But also there is the “nocebo by proxy” effect: The mom had a terrible experience, and the daughter knows that; therefore, she is unlikely to have a positive experience. By contrast, if the mom had an excellent experience with topiramate, we may encounter the “placebo (positive) by proxy” response.

Emergency Department Treatment

It is helpful to know how often, if ever, the person goes to the ED. We need to ask what treatments did work, and which did not (or caused side effects). This will influence what medications we prescribe as end-of-the-line therapy: what to take when nothing is helping. In addition, the physician should note if drug-seeking behavior is suspected.

Herbs, Vitamins, and Non-Prescription Treatments

Feverfew, Petadolex (butterbur), and magnesium oxide have all proven effective as migraine preventives in double-blind studies. Of these, Petadolex has been the most effective. Petadolex, a purified form of the herb butterbur, is made of extracted plant. The patient should be asked whether he or she has tried Petadolex or the parent compound butterbur. Occasionally the other “natural” compounds may help: feverfew, vitamin B2, and magnesium. We attempt to ensure that all patients are on adequate doses of vitamin D. Some patients ingest large quantities of “natural” herbs and vitamins. We need to know what types of herbs and vitamins they are consuming. Most of the time, we will discontinue all vitamins (except D) and most herbs.

Has the patient been trying to actively cope with headache pain, or has he or she been relying solely on medicine? Many chronic pain patients lack coping skills, but developing coping skills may be key to improving a patient’s quality of life. The various active coping strategies include, among others, exercise, and mindful meditation. In addition, physicians should ask whether physical therapy (PT), biofeedback, acupuncture, massage, or chiropractic adjustments have been helpful. Depending upon the location, type of pain, and comorbidities, we may suggest one or more of these modalities. The biggest barrier to the use of nonpharmacologic treatment, however, is access and financial coverage.

The Patient’s Input

The patient is a full partner, so physicians need to be flexible and listen to their patients. Many patients do not want to be on daily medications, Botox, or nerve blocks. Some patients are unwilling to use nasal sprays, injections, or suppositories. Many will not take any medication that may cause weight gain. If the person only requests “natural” remedies, we will go that route.

Table 4: Psychiatric, Addiction, Personality, Psychiatric Medications

Patients with migraines experience a great deal of disability related to their chronic headaches, including anxiety, depression, bipolar spectrum, personality disorders (PDs), somatization, and post-traumatic stress disorder. Significant abuse in childhood, whether sexual, physical, or emotional, may predispose a person to the development of central sensitization syndromes, such as chronic migraine, fibromyalgia (FM), irritable bowel syndrome (IBS), chronic pelvic pain, and temporomandibular disorder (TMD). Therefore, in my opinion, these are the most important comorbidities to explore.

If there is a history of depression, a number of crucial questions must be asked, such as:

  • When did the depression begin?
  • Do you have a family history of depression?
  • How severe and frequent is your depression, or is it dysthymia (examine further to rule out bipolar disorder)?
  • Has psychotherapy been helpful?
  • Have you had a positive response to medications; if so, which ones?
  • Have you had suicidal thoughts?

The most important questions to ask are those to determine whether the person fits into the bipolar spectrum. The more severe end (bipolar 1) is not often missed; it is the milder end that is often overlooked. Asking a significant other (spouse, partner, parent, caregiver) about the patient is crucial. The clinical stakes for missing bipolarity are enormous.  

After inquiring about depression, the physician needs to diagnose anxiety; separating into mild, moderate, and severe is clinically useful. Determining whether the patient has generalized anxiety disorder, social anxiety, and/or obsessive-compulsive disorder (OCD) may drive treatment choices.

Approximately 5% of chronic headache patients have a moderate or severe PD.  There is no easy screening procedure for PD traits. It may take the clinician many months to determine if the patient has a PD. Family history may help. PD is often a spectrum, with patients exhibiting characteristics from several categories (borderline, antisocial, narcissistic, etc). It is vital to be on the lookout for PD characteristics in order to help and protect the patient. In addition, people with a moderate or severe PD may be dangerous to the clinician and staff (legally, emotionally, and [occasionally] physically).  

Determining whether the patient has attention deficit hyperactivity disorder (ADHD) is vital, as our treatment options may change. ADHD is encountered in 4.7% of adults and is often undertreated.  

In addition to psychological disorders, it is also helpful to note if the patient has a hard-driving, Type A personality (common among migraineurs). The most common PD traits are avoidant and dependent; these traits may affect our therapy.

Psychiatric Medications

As noted in the depression questionnaire above, assessing efficacy and side effects of psychiatric medications must be done prior to outlining a logical medication plan. Patients often relate their response to antidepressants as “mind racing, up all night, I felt crazy.” That reaction is a solid indication for bipolarity. Family history of response to psychiatric medications also drives treatment. Some patients are unwilling to take antidepressants, and this input must be taken into consideration.

History of Addiction

Knowing the addiction potential of the patient may influence treatment. Smokers have a higher potential for addiction. In addition, if someone is still smoking, we may work with that patient on picking a cessation program and quitting. If someone drinks more than minimal alcohol, this may steer us away from certain medications. Family history of addiction should be taken into consideration, and patients should be screened for risk factors.

Resilience, Catastrophizing, Acceptance

The level of the person’s resilience is important. How resilient the patient is may influence our goals for that patient as well as drive us in certain directions (such as psychotherapy). Catastrophizing is a major contributor to disability. We can work on “turning down the catastrophizing dial.” “Catastrophizing by proxy” is also encountered among parents of adolescents with severe headaches. Acceptance is an important construct to assess. The road to acceptance often is paved with many stops in various clinics. By increasing the level of acceptance, we alleviate some of the angst that accompanies chronic pain.

Table 5: Medical Comorbidities, GI, Weight, Sleep, and Fatigue

Patients with migraines often have more than 1 medical condition. As noted, chronic pain that has become centralized (central sensitization) often includes a myriad of problems: IBS, chronic fatigue, and fibromyalgia. With fibromyalgia, we may utilize medications, PT, exercise, injections, etc. For patients with TMD, the presence of clenching and bruxism influences treatment choices. For the jaw pain, PT, medications, and Botox are considerations. In addition, patients with various immune disorders (lupus, rheumatoid arthritis, Sjögren’s syndrome) often suffer from severe, refractory headache.

A patient’s medical history of comorbidities often determines which medications are used. If a patient has hypertension, for example, we may choose between beta blockers, calcium channel antagonists, or angiotensin II receptor blockers (ARBs). When patients concurrently suffer with anxiety or depression, various antidepressants are utilized to manage the headache and mood disorder. We want to minimize medications, and treating 2 conditions with 1 medication is ideal.

The medication choices often depend upon comorbidities such as weight gain and fatigue. Weight often drives where we head with medicine.

Neck Pain, Back Pain, and Arthritis

These 3 conditions are commonly encountered in headache patients. We may utilize muscle relaxants and nonsteroidal anti-inflammatory drugs (NSAIDS) to manage pain from both conditions. Physical therapy, exercise, yoga, and Pilates are often recommended.

Sleep Disorders

Insomnia greatly influences treatment. Outside of recommending psychotherapy and sleep hygiene (setting consistent bedtime and waketime, etc), using a medication that helps both sleep and headaches is ideal. Side effects to OTC and prescription sleep medications may limit use. Assessing for sleep apnea is also important. Many chronic headache patients have sleep apnea, periodic limb movements, or restless legs syndrome.

GI Issues

Many patients with chronic headaches have a sensitive gastrointestinal (GI) system. IBS is common. If the patient has IBS-diarrhea (IBS-D), certain medications such as tricyclic antidepressants and verapamil may help both the headaches and diarrhea. With IBS-constipation (IBS-C), we want to avoid constipating medications. Other GI conditions (Crohn’s disease, bypass surgery, etc) also influence our choice of medications.

Weight Gain

Weight issues greatly affect our choices. We may want to limit medications that have a potential for weight gain, or eliminate them altogether. Less commonly, patients who are underweight may benefit from certain headache medications that help increase their appetite and weight.

Fatigue

The most common comorbidity among chronic headache sufferers is fatigue. Patients do not want medications that exacerbate their tiredness. A few of our headache medications, particularly the stimulants, may help the condition. Chronic fatigue greatly affects quality of life. At times, we will treat the fatigue separately with medications that are approved for sleep disorders and may not help the head pain (such as modafinil [Provigil] or armodafinil [Nuvigil]). With the presence of chronic fatigue, we will investigate other factors that may contribute, such as insomnia, medications that disrupt the sleep cycle, sleep hygiene, etc.

Table 6: Functioning, Social, Finances, Significant Other’s Input

Knowing about the person’s living and family situation may help. Whether he/she has a support system and friends is important. Job or school requirements may affect treatment. For instance, if a patient is an accountant, we may not want to utilize topiramate, which often causes thinking problems. If someone needs to be sharp early in the morning, limiting sedating medications at night is important. The perspective of a family member often provides valuable information. Their input on the characteristics of the patient’s headaches, functioning, moods, etc is helpful. This is particularly important when assessing for the mild end of the bipolar spectrum.

The patient’s finances and insurance situation may influence treatment. We may avoid medications that the patient cannot afford. Utilizing discount sites and cards such as GoodRx.com is very helpful. If a patient cannot afford certain treatments (Botox, PT, etc), it may mean going in another direction. In an ideal world, finances would not matter, but this is a consideration for many headache patients.

Table 7: Your Gestalt, Treatment Recommendations, Follow-up Visits

With each return visit, we want to assess whether the preventives we have prescribed have been effective. In addition, an evaluation of side effects is important. If efficacy is insufficient, we can push to increase the dose or discontinue the drug. If the preventive is not helpful for the headaches but is effective for comorbidities, it may be worthwhile to continue the medication. The logical medication choices should be listed in the chart from the previous visits.

As with the preventives, we need to evaluate efficacy and side effects of abortives and nonpharmacological treatments. If efficacy is lacking, we can change the form, change the dose, or discontinue the drug. With most return visits, we want to reassess whether appropriate referrals are necessary. Exercise should always be discussed. It truly can take a village to raise a pain patient.

Last updated on: June 12, 2017
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2016 Practical Clinical Advances: Ketamine and Metformin

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