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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.
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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.


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.

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

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