Headache is one of the most common disorders seen in the primary care and neurology clinics. By far, the most common primary headache disorder in the general population is episodic tension-type headache (TTH), which affects 40% of the population each year. The lifetime prevalence in the general population ranges in different studies form 30 to 78%. It is the least studied of the primary headache disorders, despite the fact that it has the highest socio-economic impact. TTH is a bilateral headache in mild to moderate pain degree, and majority of the patients thus will not visit the doctors. They usually self administer over-the-count medications like Tylenol, Ibuprofen. Recent publication from Drs. Zhao and Stillman has thoroughly reviewed the TTH (Zhao C & Stillman MJ. Expert Opin Pharmacother. 2003;4(12):2229-37). Migraine is the second commonest primary headache disorder affecting 18% of women and 6% of men every year. There exist 28 million migraine sufferers in US in 1999. One out of four households had at least one member with migraine. The prevalence is highest in the 25-55 age groups. The direct cost of migraine is 2.5 billion dollars and indirect cost 13.5 billion dollars each year. Fifty-one percent of women miss the equivalent of 6 or more days of work per year due to migraine, which accounts for 93% of all work lost due to migraine. Thirty-eight percent of men lose that same amount of time (6 days), accounting for 85% of work loss because of migraine. Frequent headaches occur > 15 days per month and affect 5% of women and 2.8% of men. The two most common frequent headaches are chronic tension-type headache (CTTH) and transformed/chronic migraine. This group of headache is most difficult to treat. Medication overuse is probably the most common reason leading to the chronic headache. Migraine is the most common headache disorder seen by doctors. Close to 70% of the migraine are treated by primary care physicians and 20% by neurologists including headache specialists. However, by 1999, only 48% of the migraine sufferers have received correct diagnosis and more than half of the patients are not diagnosed. Therefore, there is urgent need to educate the headache practitioners to improve their skill to recognize the migraine before delivering the best care to the patients. The Headache Classification Subcommittee of the International Headache Society (IHS) has proposed the first edition of diagnostic criteria for head and facial pain in 1988 and the 2nd revised edition will be published in January 2004. This gives a comprehensive guideline for the practitioners to make the diagnosis, even though some practitioners argue this guideline may not be very practical at least in USA. Unfortunately, few practitioners have known this guideline. This may be one of the reasons that headaches including migraine and chronic headache are still one of the most difficult neurological disorders being treated successfully.
Headache – Do you receive an appropriated diagnosis?
Failure of the headache treatment is commonly due to the inaccurate diagnosis. As a patient, you have the right to know what the exact problem is. The following is the classification of head and facial pain proposed by the IHS in 2004. Dr. Zhao comments briefly on the management of each group of them. Interested patients or physicians are encouraged to contact this center for more detail information.
Comment: The treatment of migraine includes acute abortive therapy and chronic preventive therapy. Current abortive treatment options include triptans, non-steroidal anti-inflammatory drugs (NSAIDS), Intravenous therapy of dihydroergotamine (DHE 45) and antiemetics. Triptans provide 55-75% of 2 hour response rate (pain is reduced from moderate-severe to free-mild degree at 2 hour after administration). A patient with attack frequency more than 3-5 times per month or fewer attacks but very disabling should consider the preventive therapy. Typical preventive treatment options include anticonvulsants, tricyclic antidepressants, herbal or supplemental agents. The efficacy of them ranges from 40-60% in different controlled studies. The following lists the most common and effective treatment agents/options for migraine; they are supported by clinical experience and/or research evidence.
Comment: The treatment of Cluster headache includes acute abortive, transitional prevention, and longterm prevention therapies. Because the short duration and severity of painful attack, acute abortive treatment should be given right at the time of the attack onset. Transitional preventive therapy buys time for the longterm therapy to become effective. The longterm preventive therapy usually last weeks to month, depending on the length of the cluster cycle. The following list the common drugs used in the cluster headache management.
Comment: The key for treatment is to find out the underlying etiologies and eliminate them if possible. Neuroimaging studies such head and neck CT, MRI, MRA, CTangiogram and special lab tests like PT/PTT/Platelet count will be extremely helpful in assisting in diagnosis. The possible treatment options include anticonvulsants, muscle relaxants, NSAIDS, acetaminophen, antidepressants, trigger point injection, nerve block, facet block, acupuncture, physical therapy and pain psychotherapy. Patients or physicians can call this center for more information.
Comment:. The key for treatment is to find out the underlying etiologies and eliminate them if possible. Neuroimaging studies such MRI, MRA, MRV, CTangiogram and special lab tests like ESR, CRP will be extremely helpful in assisting in diagnosis. The possible treatment options include muscle relaxants, acetaminophen, antidepressants, trigger point injection and nerve block, acupuncture and pain psychotherapy. An experienced Stroke specialist may be needed to work with the headache specialist for a complete treatment plan.
Description: Headaches in this category are mainly secondary to the changes in intracranial pressure, non-infectious inflammatory diseases, intracranial neoplasia, seizures, and rare conditions such as intrathecal injections and Chiari malformation type I, and other non-vascular intracranial disorders.
acetaminophen, antidepressants, diuretics, lumbar puncture, trigger point injection and nerve block, acupuncture and pain psychotherapy.
Comment: Frequent headaches occur > 15 days per month and affect 5% of women and 2.8% of men. The two most common frequent headaches are chronic tension-type headache and transformed/chronic migraine. Chronic headache is very commonly caused by medication overuse or withdrawal, and often requires comprehensive management. Such treatment will at least include detoxification or elimination of the overused medications, and symptomatic/comforting/soothing therapies. Most of the treatment can be completed in the headache and only occasionally hospitalization is needed. Patients and primary care doctors are encouraged to consult the headache specialists or experienced neurologists for accurate diagnosis and comprehensive treatment plan.
Comment: The key is to find out the etiology. Necessary tests include infectious workup, brain MRI / CT with contrast, PCR, etc. Antibiotic probably is the most important treatment. Cooperation with infectious specialist is greatly encouraged.
Description: This group of headache is caused or associated with significant disturbances in arterial pressure, myocardial ischemia, altered arterial blood gases, volume disturbances as in dialysis and disorders of endocrine function, fasting.
Comment: Elimination of the causes is the final treatment option. Cooperation from specialists in relevant to the etiology is necessary to prepare a comprehensive treatment plan.
Comment: As the other secondary headaches, elimination of the causes is generally the final resolution. However, it may not be easy or practical to do that in this group of disorders. Thorough physical, neurological and other specialized exams are often needed to find out the accurate diagnosis and warrant the treatment success. Comprehensive management is highly recommended due to the complexity of the causes. Team approaches include physical therapy, muscle relaxants, NSAIDS / Cox-2 inhibitors, anticonvulsants, antidepressants, trigger point injection, nerve block, acupuncture, pain psychotherapy and even invasive anesthetic invasive procedures. Patients are encouraged to contact this center for more useful diagnostic and therapeutic information.
Description: The studies on association between headache and psychiatric disorders are very limited. Headache can be one of the complaints associated with some psychiatric disorders such as major depressive disorder, panic disorder, generalized anxiety disorder, somatoform disorder, and psychotic disorder (delusion).
Comment: Organic etiologies must be ruled out before diagnosis of psychiatric disorder is made. Polypsychopharmacotherapy and psychotherapy play a very important role in the treatment. The cooperation of psychiatrists and headache specialists is needed to maximize the treatment outcome.
Comment: Understanding of neuroanatomy is fundamental toward the diagnosis. Because few diagnostic tests can be helpful in assisting the diagnosis of neuropathic pain, therefore, a detail headache or pain history and comprehensive physical/neurological exam are required to make the accurate diagnosis. Anticonvulsant, antidepressant and office procedures are extremely useful in management.
Description: This category is intended for those head and facial pain which do not fulfill the above diagnostic criteria.
Comment: There are little evidences for the treatment of this group of headache. The recommendation includes ruling out the primary and secondary causes, and then symptomatic management.
The author recommends the key points towards the successful management of headache.
1. Allow enough times to communicate with the patients. The placebo effect in headache studies typically accounts for 30-40 % of the treatment outcome.
3. Complete the thorough physical and neurological exams. Some special tests applied in orofacial pain, orthopedics can be very useful to rule out the secondary causes.
4. Establish broad differential diagnosis. The headache may be due to the structural from the face and neck, or a mixture of different types of headache.
5. Always rule out the secondary before conclude the patients have primary headache disorder. Up to 7-10 % of the chronic headache can be caused by cerebral venous sinuses thrombosis reported by some studies.
6. Propose a comprehensive treatment plan for the patients. The most powerful management should include behavioral modification, oral and intravenous polypharmacotherapy, pain procedures, physical therapy, acupuncture and pain psychology.
Comment: Acupuncture becomes more and more popular in USA. Most of the controlled studies favor or in the trend of favor the use of acupuncture in migraine management. The recent publication from Dr. Zhao and colleagues comprehensively reviews the mechanism and clinical profile on the use of acupuncture in headache (Zhao C et al. Medlink Neurology, 2003).