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9 Articles in Volume 13, Issue #5
Elvis Presley: Head Trauma, Autoimmunity, Pain, and Early Death
Traumatic Brain Injury: Treatment of Post-traumatic Headaches
Advances in Pharmacologic Pain Management of Juvenile Idiopathic Arthritis
Integrative Treatment Approaches for Juvenile Idiopathic Arthritis
How Changing Hydrocodone Scheduling Will Affect Pain Management
Editor's Memo: Interpreting Indications For Electromagnetic Therapy
Specimen Validity Testing
Can a Buprenorphine Transdermal System (Butrans) Be Used to Treat OUD?
Letters to the Editor: Testosterone, Ultra-high Dose Opioids

Traumatic Brain Injury: Treatment of Post-traumatic Headaches

Part 1 of this series described the biomechanics and pathophysiology of traumatic brain injuries, as well as their symptoms: post-concussion syndrome, post-traumatic headache, and migraine. This month, our author tackles treatment of TBI headaches.

Increased attention to traumatic brain injury (TBI) has raised renewed interest in one of its consequences—post-traumatic headaches (PTH). Most often these have the characteristics of migraines, migrainous headaches, and mixed tension-type headaches (TTH) and migraines, as was discussed in Part 1 of this series.1 There have been a number of recent articles in medical journals that have renewed the debate about TBI, including an article by Robbins and Conidi on sports-related injuries. According to Seifert, there are approximately 3.8 million sports-related concussions occurring each year, providing unique treatment challenges for medical personnel.3 The presence of new onset or persistent headache following an injury often complicates return-to-play decisions.

The second part of this series specifically addresses the treatment of PTH and does not claim to be comprehensive. It consists of three parts: Acute treatment of post-TBI headaches using migraine-specific therapy, prophylactic therapy to suppress post-TBI headaches, and interventional treatments used in our outpatient headache clinic. Part 3 of the series will discuss evaluation, treatment, and rehabilitation.

Acute Therapy

Quite frankly, the "classic" migraine-specific abortive medications used for treatment of acute migraines and migrainous headaches—for example, dihydroergotamine (DHE-45) and triptans—are FDA indicated for moderate to severe migraines. A reformulated diclofenac potassium preparation (Cambia), with very rapid absorption kinetics, is also FDA indicated for mild to moderate migraine. The spectrum of abortive medications is covered extremely well in some of the comprehensive textbooks about headaches and migraines, including the role of opioids.4-6 A selective list of FDA-approved agents are highlighted in Table 1.

Migraine-specific abortive therapy centers on the triptan family of compounds. Theses agents primarily decrease neural activity in trigeminovascular afferent nerves that are sending signals from dural nerve endings to the trigeminal nucleus caudalis in the brainstem. They also have vasoconstrictive properties on blood vessels in this system, but the main effect is on neural firing. Triptans act specifically on serotonin (5HT)-1B and 1D receptors. They should be used for disabling migraines that are moderate to severe in intensity. If migraines are present >2 to 3 times per week, it may be wise to consider a suppressive or prophylactic medication (see next section).

Triptans can be used in conjunction with antiemetics (metoclopramide [Reglan], ondansetron [Zofran], promethazine [Phenergan], etc), and perhaps anti-inflammatory compounds. They are indicated for moderate to severe migraines, but early intervention in the migraine process is always desirable. Some of the triptans are available in faster delivery systems like injectable and nasal spray.

Nausea should always be treated alongside the migraine. Our preference is for the prescription of the more potent antiemetics, including ondansetron or metoclopramide. In the author's practice, we successfully have used these, as well as droperidol intravenously (IV) in the clinic (in small doses).

Preventative Therapy

When TBI migraines become disabling to one's lifestyle and occur more frequently than 3 times per week despite successful treatment with triptans or other migraine-specific therapies, it may be time to think about suppressive or prophylactic therapy. Only four medications are FDA approved for this indication: topiramate (Topamax), valproate sodium, propranolol, and timolol (the last of which is available as an optic solution primarily, and is very hard to find in tablet form). In addition, Botox is currently the only medication approved for prophylactic treatment of chronic migraine (Table 2).

The first two medications were originally approved as anticonvulsants, but were found to be effective in managing migraine, chronic daily headaches, and cluster headaches. Sedation and cognitive side effects, such as confusion or memory problems, however, may limit the use of topiramate. Valproate sodium has been a popular migraine preventive. The agent is usually well tolerated in the lower doses used for headaches; however, the FDA recently issued a warning that valproate sodium can cause decreased IQ scores in children whose mothers took the medication during pregnancy. The agency now reports that these agents are contraindicated in pregnant women for the prevention of migraine headaches.7 The β-blocker propranolol is often tried as initial prophylaxis therapy. Originally, it was noted serendipitously to help migraine headaches when it was being used for management of blood pressure and cardiac rhythm disorders.

When we think of preventative therapy, it is wise to think about co-morbid post-concussion symptoms. This might include anxiety, depression, bipolar-like symptoms, seizures, high blood pressure, irritability, poor sleep, and mood swings. Besides these FDA-approved medications, virtually all of the anticonvulsants (we much prefer the phrase "neuronal stabilizing agents") have been tried in small trials, which are usually open label in nature. For example, the author published the first data on migraine and neuropathic pain management treated with oxcarbazepine, levetiracetam, and zonisamide8-10 soon after they were officially released as seizure medications. Other agents in this large group were also studied for migraines, chronic daily headaches, and neuropathic pain by the same author.11 Unfortunately, in the vast majority of these studies the industry chose not to study the medication formally in a double-blind, placebo-controlled fashion.

Similarly, many agents that are approved for other uses have been used off-label for their abilities to help migraine patterns. Post-TBI migraines, when accompanied by cognitive difficulties, have been shown to respond to the treatment memantine (Namenda), officially on the market only for management of dementia.12,13 However, many studies, primarily from Europe, have used this agent for various pain conditions off label, and we have used it as an agent to help with cognition after TBI.14

Antidepressants, particularly the serotonin-norepinephrine reuptake inhibitors, can help depression and anxiety, but they can also reduce pain and migraines post-TBI. The author has used venlafaxine (Effexor), duloxetine (Cymbalta), and milnacipran (Savella) off-label in his clinical practice. Medication in other categories (so-called antipsychotic agents) have also been used to suppress migraines (eg, ziprasidone) and can be very useful in post-concussion headaches accompanied by irritability, mood instability, and sleep disorders.15

The bottom line on preventative therapy for post-TBI headaches and migraines is to look for comorbidities that are present along with the headaches and to treat with an agent that can reduce the migraine frequency and severity and the comorbid clinical state. Off-label use of medication is perfectly legitimate as long as the clinician explains that to the patient. We always have a patient acknowledge this for any treatment, oral or IV, and document this in their chart and on paper.

Interventions for Refractory Migraines

Headaches and migraines that occur after a TBI can be treated in any number of ways by healthcare practitioners. This part of the article attempts to describe more aggressive and definitive treatments available in the outpatient headache clinic setting.

The author's clinic compiled a track record in treating refractory headache and pain patients using IV medication therapy. More than 95% of our clinic patients fared exceedingly well as far as their headache and pain symptoms were concerned.16 We arbitrarily defined success as a greater than 50% reduction in the headache, based on a 0 out of 10 visual analog scale (VAS) from baseline. Very few of the patients had to be retreated. This suggested that we were not only clinically efficient but, on a cost basis, an aggressive clinic treatment of headache was less expensive than treatment in the emergency department (ED) as well. It has been estimated that the direct medical costs and indirect costs, such as lost productivity, of TBI totaled an estimated $76.5 billion in the United States in 2000.17,18

In my opinion, the ideal headache clinic would offer a large number of IV services and be staffed by nurses trained in IV therapy and monitoring with pulse oximetry. I strongly suggest that advanced cardiovascular life support–trained staff and a crash cart with oxygen and medications are in the clinic treatment area.

I have listed all of the IV treatments to be described in the following sections in Table 3, which are based on my clinical experience.

Suggested IV Interventions

MgSO4

In many ways, IV magnesium sulfate (MgSO4) is sort of an "opening shot" for intractable headaches, both TBI migraines and not. It can be given alone, or combined with either antiemetics or IV corticosteroids. There is substantial literature on the use of IV magnesium for migraines and cluster headaches.19-22 The original studies by Mauskop and colleagues studied ion-sensitive Mg++ electrodes to measure ionized magnesium, a technique not commonly available. Magnesium has primary effects as a physiologic antagonist to calcium. It also blocks N-methyl-D-aspartic acid (NMDA)–type glutamate excitatory amino acid activity, and nitric oxide synthesis and release—all of which are factors in migraine pathophysiology or maintenance. In addition, magnesium augments serotonin, which may be a direct means of blocking migraines. Multiple types of headaches, including migraines, migrainous headaches, TTH, and cluster headaches responded to IV magnesium therapy.19 The headache sufferers with the best and longest response to this treatment also had the lowest ionized Mg++ levels, both for migraines as well as for cluster headaches.20 One study has summarized clinical data with IV MgSO4 using doses of 0.5 to 1 g.23 In general, the author uses higher doses than that, and typically uses 2.5 to 3 g.21,22

Antiemetics

Antiemetics have been used along with acute opioid therapy for headaches and for pain treatment. This is based on the notion that the use of both agents was somehow synergistic. Animal experiments seemed to support this idea, but human studies are not at all conclusive on this point.24 I've looked for evidence of this, but it is almost non-existent; nausea is a prominent symptom accompanying headache. Nevertheless, traditional ED treatment of headaches often uses a combination of opioids and antiemetics. In the past, promethazine was the most frequently used antiemetic.25 However, our preference is to use either ondansetron or metoclopramide, both IV and intramuscular (IM), as a firstline antiemetic in the clinic. This is based on a study of 202 migraine patients. The study found that IV metoclopramide 20 mg was more effective than sumatriptan 6 mg subcutaneously at reducing pain intensity scores (reduction of 7.2 vs 6.2, respectively) and pain-free rates (59% vs 35%, respectively).26

There is a growing body of evidence that a blockade of central dopamine receptor systems can enhance anti-nociception or the pain-relieving analgesic properties of opioids.27-29 One study of neuropathic pain suggested that bupropion might decrease neuropathic pain via an effect on presynaptic reuptake of dopamine.30 These properties might explain the ability of dopamine blockers, like metoclopramide or droperidol, to reduce migraine headaches—an effect we and others have noted in the clinic setting in the treatment of migraines.

One of the initial studies using IV droperidol used quite high doses (mean 16.6 mg) and reported nearly all of their patients being sedated and more than 50% having extrapyramidal symptoms 24 hours after treatment.31 We repeated the study in our clinic using from one fifth to one quarter of the dose of IV droperidol with only 3% side effects and well over 50% success rate in reducing or eliminating refractory migraines.32 A double-blind trial of IM droperidol,33 again using high doses of the medication, showed efficacy; the placebo response rate was 57% vs 84% for droperidol. Once again, anxiety, akathisia, and somnolence were rated as severe in 30% of patients, presumably due to the high doses employed. Thus, keeping doses quite low (around 2 mg total) can be very effective and I have quite a number of patients who use IM droperidol at home as rescue medication for their migraines—either with migraine-specific therapy or to avoid a trip to the ED. The starting dose is 0.625 mg of IM droperidol, repeated after 20 to 30 minutes, and once again if needed.

An older ED study using IM prochlorperazine compared with metoclopramide found the former to be more reliable in reducing headache to the endpoint of the study (1 hour). Yet both groups required additional rescue treatment with analgesics (57%-79%) after initial treatment with an antiemetic.34 Another ED study compared the efficacy of IV MgSO4 with prochlorperazine in acute headache patients. This small study (36 patients) found prochlorperazine to be statistically more effective at reducing pain than magnesium (90% vs 56%, respectively) with fewer side effects.35 One comment is that the dose of the MgSO4 was rather low at 1 g compared to our clinic IV doses of 2 g or greater.

Ondansetron, a 5-hydroxytriptamine type 3 receptor antagonist, is a very powerful antiemetic often used in the management of chemotherapy-induced nausea and vomiting. The agent has been used successfully in the clinical setting as an adjunctive medication for intractable vomiting associated with prolonged migraines (dosage: 2-4 mg IV). A search of the literature surprisingly revealed very little data to support its use in the treatment of acute or refractory migraines. Indeed, one small study involving 6 children described the development of severe daily migraine-like headaches during cancer treatment.36 All patients had received daily doses of ondansetron and had a personal or family history of migraines, which may have placed them at risk of developing ondansetron-associated migraine-type headaches. The authors noted that all the children responded to stopping the medication and starting treatment with standard anti-migraine therapy.

Corticosteroids

There is very little literature on the use of corticosteroids to treat migraines. More data are available for the treatment of cluster headaches, status migrainosus, or analgesic rebound headaches.37 We frequently use dexamethasone (2-4 mg every 8-12 hours, as needed) for severe, refractory migraines along with IV MgSO4. Both agents are compatible in the same IV bag (unpublished observations). Other authors have published results from their own clinics, showing that dexamethasone was indeed effective in their migraine and status migraine populations.38,39 This is not necessarily followed by an oral taper. Long-term use of steroids has its own side effect profile.

Dihydroergotamine

Before triptans, the gold standard for treating intractable migraines was DHE, a compound similar to, but pharmacologically very different from, ergotamine. Many people forget that the pharmacologic profile of DHE is predominantly that of a venoconstrictor, as well as a relatively mild arterial constrictor. Ergotamine is a pure arterial vasoconstrictor. Also, ergotamine is fraught with the possibility of rebound migraines and headaches (now termed "medication overuse headache"), whereas DHE does not have this property. DHE can be given IV or IM and has a 10- to 14-hour half-life. The original IV DHE protocol to treat refractory migraine headaches was introduced in 1986 by Professor Raskin and it became the mainstay of inpatient and in-clinic treatments.40 Typically, DHE (1 mg) is given every 8 hours with IV metoclopramide 10 mg for 2 to 3 days. Comparisons of this protocol against "typical" treatment with meperidine (75 mg) and promethazine (25 mg) showed similar efficacy with significantly fewer side effects in the DHE/metoclopramide group,41 making it very useful for office-based treatment of migraines. Another small study evaluated the same protocol in a headache clinic against IV ketorolac and found the DHE protocol to result in a greater degree of pain improvement (P=0.31) and better function clinically (P=0.057).42 Various IV protocols available for clinic use were subsequently summarized by the same author.43

Valproate

Divalproex sodium (Depakote), as an enteric-coated preparation, was approved in 1994 for oral use in the prophylaxis of migraines in the United States. It was the first anticonvulsant molecule to be found useful in treating migraines in a prophylactic manner.44-46 An IV version of valproate sodium (Depacon) was developed and was used for treatment of seizures. In our search for additional IV agents to use in the clinic for intractable migraines, we turned to this compound and presented an initial open-label study in poster form.47 Our results showed an impressive reduction in migraine severity, both in this initial trial and in subsequent studies. Soon thereafter, other open-label studies, including our own, began to show up in the literature48-50 documenting efficacy of valproate sodium IV in treating migraines.

Our study included 85 intractable migraineurs. We reported an 88% reduction in severity of migraine, based on patient-rated VAS, in the IV valproate sodium group. The average dose of valproate was 720 mg, given IV over about 50 minutes (100-200 mg every 5-10 minutes).47 Another study investigated the use of valproate sodium (loading dose 15 mg/kg, followed by 5 mg/kg every 8 hours) in initial treatment of chronic daily headache, transformed migraine, and analgesic overuse headaches.51 The authors stated that headache improvement was reported by 80% of the patients treated with IV valproate sodium, especially if other agents were not effective.

A third study, however, found that valproate sodium was significantly less useful than prochlorperazine (Compazine) in the ED for headache pain (9 mm vs 64.5 mm, respectively) and nausea symptoms (35.5 mm vs 2 mm, P<0.001).52 A different study treated mostly chronic daily headaches, chronic TTH, and unclassifiable chronic headaches (67%), with just over 30% episodic migraines. More than half of the patients (57%) responded to valproate sodium treatment and the lower efficacy may be due to the nature of the chronic headache population treated in this study.53

We went over our initial study data and extracted 23 cases of bona fide status migrainosus from our initial published study sample treated with IV valproate sodium in the headache clinic.50 This very difficult-to-treat migraine population responded similarly as the refractory migraineurs, but needed a higher dose of valproate sodium (1,017 mg) and a longer treatment time (73 min vs 50 min). Thirteen of the 23 patients (57%) rated their migraines as 0 out of 10 in severity after treatment.54

Propofol

Sometimes, interesting results are stumbled upon serendipitously, as occurred in the case of the pre-anesthetic agent propofol. We have used this agent routinely in the clinic as a mild sedative prior to epidural steroid and facet nerve blocks in a conscious sedation manner. It was noted that some patients who had migraines at the time of their blocks would comment on eradication of the migraine before the block was performed, but after propofol was given. After researching the literature, we found no mention of this agent in the treatment of migraines. We undertook a formal open-label study in the headache clinic to treat refractory migraines unresponsive to usual abortive approaches. A cohort of 77 patients were treated and the results were dramatic.55 Propofol was the most effective IV agent that we had ever employed, with a 95% success rate in reducing ongoing migraine headaches. The total dose (subanesthetic) was only 120 mg, given slowly by IV push 20 mg at a time. The specific pharmacologic effect of propofol, with sole effects on subtypes of the gamma-aminobutyric acid type A (GABA-A) receptor, is a unique mechanism of action. It caused speculation as to the role this receptor might play in migraines. Since then, topiramate (Topamax) has been approved for migraine prophylaxis and one of its mechanisms of action is on GABA-A receptors. We have also anecdotally looked at small numbers of patients with painful disorders like trigeminal neuralgia, complex regional pain syndrome (CRPS), and other pain flare-ups and they seem to also respond to propofol (unpublished data).

Lidocaine

Lidocaine is an indiscriminate blocker of sodium (Na+) channels. Blockade of this system has definite implications for reducing neuropathic pain disorders. Many of the neuronal stabilizing agents include this mechanism of action. All of the same agents have also been shown, at least in open-label trials, to reduce migraines and other headaches.56

I have used IV lidocaine, with pulse oximetry monitoring, in the clinic for many years for the treatment of migraine, headache, and pain flare-ups. The paradigm is to treat very slowly, so as to saturate the Na+ channels and obtain the best possible blockade. Often, the response is short-lived (12-48 h), which buys time for other treatments to be put in place. Formal trials of IV lidocaine to treat acute migraine headache were published some time ago. Two studies found poorer outcome in the lidocaine-treated patients than with DHE, chlorpromazine treatment IV,57 or against placebo.58 The response to IV lidocaine was better in chronic daily headache in two retrospective studies.59,60 We have re-explored IV lidocaine for treatment of refractory migraines and have shown some promising data.61,62 However, this was an off-label use of lidocaine and, due to its ability to block neuropathic pain, it may play a roll in the treatment of refractory migraine post TBI. More studies are in progress.

Ketamine

Some headache and pain physicians think that neuropathic pain, chronic daily headaches, and migraines are, underneath it all, very similar in their biochemical underpinnings with respect to cellular mechanisms. The fields of pain and headache management use common terminologies to describe these processes. Nociceptive pain, peripheral and central sensitization, windup, long-term potentiation, and neuroplasticity are concepts basic to the expression and maintenance of these disorders. Common neurocellular and neurotransmitter pathways may explain the clinical expression of both neuropathic pain and migraine and associated hyperalgesia and central sensitization.63 On the treatment side of things, why is it that medications with completely different structures but similar mechanisms of action (propofol and topiramate, each of which act on GABA-A receptors) both reduce migraines, other headaches, and pain?

Considering the evidence that excitatory amino acids like glutamate are the "bad guys" in promoting nociception in general—and hyperalgesia and possibly allodynia—it is not surprising that agents, which antagonize this system might have utility in reducing pain and headache symptoms. Compounds that block the NMDA sub-family of glutamate receptors either have low potency (dextromethorphan or memantine) or they have higher potency and a narrow therapeutic index (ketamine).64

Ketamine, an agent specifically active against NMDA-type glutamate receptors in subanesthetic doses, has been little studied thus far, but may have theoretical implications for preventing chronic migraines. One study administered ketamine intranasally to migraine patients who had pronounced and disabling aura. Fewer than 50% had successful resolution with ketamine.65 In this study the dose of ketamine was low, but more work needs to be done with this specific blocker of NMDA glutamate receptor subtypes. A poster described increased cerebrospinal fluid glutamate levels in chronic migraineurs compared to non-migraine controls.66 Patients with migraines and fibromyalgia had higher levels than patients without chronic pain.

Glutamate, with its subtypes of receptor families, will be an active area of research and, hopefully, treatment. As we have used IV ketamine in the clinic for more than 12 years, we have presented our data for IV ketamine for treating refractory headaches and pain several times.67,68 This is an ongoing study, which includes post-TBI migraines and headaches (with and without pain) and may be the largest database for migraine, cluster, chronic daily headache, and rare subtypes like paroxysmal hemicrania, hemicrania continua, and trigeminal neuralgia with migraines.69,70

Levetiracetam

Clinical data with the oral form of this neuronal stabilizing agent were the first available anywhere in the treatment of refractory migraine headaches,71 and this agent has a unique mechanism of action that effectively blocks high-voltage calcium channels—another major activity of many neuronal stabilizing agents.

We developed an IV form of the same agent (with a compounding pharmacy) and evaluated levetiracetam IV in the treatment of refractory migraines. Cluster headache flare-ups and pain flare-ups like trigeminal neuralgia and CRPS have also been treated in the clinic.72,73 This is a powerful, non-toxic form of treatment for many difficult pain and headache flare-ups. The manufacturer subsequently released an IV preparation for commercial use to treat only seizures, but our data preceded that formulation by several years. It is important to note that the author uses this preparation only in extremely refractory cases and very infrequently.

Opioids: Tramadol

Tramadol has been available in the United States for a number of years and has been used in Europe for more than 30 years. About 2 billion people worldwide have been treated for pain with this agent, which is a µ opioid receptor agonist, as well as weak presynaptic reuptake inhibition of norepinephrine and serotonin (like venlafaxine, duloxetine, or milnacipran).

I formulated a sterile IV preparation to treat headaches and pain. An IV form is available in Europe. I had originally published data with the oral form of the medication in treating headaches74 and was impressed by its ability to treat chronic headaches and migraines. The IV preparation of tramadol turned out to be very efficacious, very well tolerated, rapidly treated refractory migraines and mixed headaches, and gave me another tool to use in the clinic when other agents failed.75 Our most recent accumulated data were presented this year. In our study, we treated 79 patients with IV tramadol. The average dose was 423 mg (range: 250-1,100 mg), given over 95 minutes in our clinic. The results showed an average reduction in pain severity after treatment from 7.46 on the visual analogue scale (VAS) to 2.81 (P<.001).76

Methocarbamol

Although methocarbamol is an older muscle relaxant preparation with uncertain pharmacologic mechanism(s) of action, it is one of the very few available in an IV form and, for this reason, I sometimes use it in the clinic to treat migraines and other headaches—especially if accompanied by a lot of neck spasms. I know of no published studies looking at this medication in this setting. Therefore, all my information is anecdotal and I rarely use it alone but, instead, often use it after other agents. I have had about 200 patients over the last 15 years for whom the addition of methocarbamol (range: 300-500 mg) was a positive element in their overall headache relief.

Baclofen

Baclofen is a GABA-B receptor agonist, a unique mechanism of action. I use it in an intrathecal sterile form (Gablofen) for epidural and facet blocks, but a commercially available IV form is not available in the United States. Therefore, we have a compounding pharmacy make up a sterile, neutral pH solution for use in the headache and pain clinic. Our initial data with migraines77 have since grown in numbers and types of migraines treated78,79 and these include post-TBI migraines with severe muscle spasms. Our study examined 63 patients with migraine, and muscle spasm and pain who were given 5 to 10 mg of IV baclofen at intervals of 10 to 15 minutes. Muscle spasm and pain as distinguished from migraines were rated by patients using a VAS every 15 minutes. Results showed that headache severity diminished from 7.9 on VAS to 3.2 (P<.001). At the end of treatment, migraines were absent in 24 patients.79

Conclusion

The future of aggressive pain and headache treatment of TBI-related headaches will reside in the sphere of the specialist's clinic. This is a cost- and time-effective mode of treating intractable pain and headaches. Compared with the treatments commonly available in the ED, the outpatient clinic can offer a wider variety of effective and definitive treatments and, thus, offer patients a maximum degree of success for control of their intractable pain symptoms.

There are so many different combinations of pain presentations (eg, refractory post-TBI migraines/headaches with pain and with nausea, or accompanying muscle spasms, burning). It seems as if virtually every combination of IV medications at our disposal has been tried or given in our clinic at one time or another. Of course, we make every effort to use one medication at a time and to carefully document the percentage of pain reduction of that single agent. As you can imagine, agents that have worked successfully, perhaps many times before, might not work in the next particular situation and so we always have a "game plan" for the next agent. The key is to have a wide and varied repertoire of interventions to address each unique patient's pain presentation.

Post-traumatic headaches, often considered to be extremely difficult to treat, are actually easier to treat than most people realize if you pay attention to the parameters outlined in this article. In the future, we will undoubtedly have more unique pharmacologic agents to treat post-TBI migraines more effectively.

Last updated on: February 19, 2015
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