Managing the Pain of Headache

INTRODUCTION

In any given 12-month period, approximately 90-95% of the US adult population will suffer from a headache according to the American Council for Headache Education (AsCHE). That’s well over 200 million people. The National Institute for Neurological Disorder and Stroke (NINDS) reports that as many as 45 million of them will suffer from chronic headaches accompanied by pain so severe it is disabling.⁷⁵ Headaches account for more than 8 million doctor visits a year and the financial impact due to lost work varies anywhere from $5 billion to $6.5 billion per year in the US.

Children also suffer from headache but the estimates of the exact incidence vary too widely to establish reliable statistics.

The word “headache” is somewhat a misnomer since there are no pain-sensitive nerve fibers in the bones of the skull and the tissues of the brain so there is no pain there.⁷⁶ What actually hurts can be

• a network of nerves that extends over the scalp.
• certain nerves in the face, mouth and throat.
• muscles of the head.
• blood vessels found along the surface and at the base of the brain that contain delicate nerve fibers.

TYPES OF HEADACHE

There are many different kinds of headache, all of which fall within two main categories: Primary, in which the headache is the disease; and Secondary, in which the headache is a symptom or result of an underlying disease or disorder. Headache can be further divided into sub-categories:

• Primary
  • Vascular
    • Migraine
    • Cluster
  • Muscular Contraction
    • Tension-type
• Secondary (there are over 300, only some of the most common are given)
  • Sinus
  • Abnormalities of the neck muscles
  • Temporomandibular Joint Dysfunction (TMJ)
  • Glaucoma
  • “Warning”⁷⁷

Warning headaches are those that can signal a very serious underlying disorder, and should be immediately referred for further diagnosis. In the Summer 2000 issue of its Newsletter, the American Headache Council for Education (ACHE) published a list of some of the warning headaches (see figure 9.) that should not be ignored.

Figure 9: Warning Headaches

The “thunderclap” headache was a term introduced in 1986⁷⁸ because it presents very suddenly with extreme pain at the onset. The thunderclap headache seems to be an occasional precursor to a subarachnoid hemorrhage, although how often this occurs is a point of controversy that is widely debated. What is not a subject of debate is that a patient reporting a thunderclap-type headache should be seen by a physician immediately.

Only about 10% of headaches fall into the Secondary category. The overwhelming majority are in the Primary category.

Primary Headaches - Tension-type Headache
The most common of the primary headaches is the tension-type. Characteristics of the tension-type headache include:

• Often experienced in the forehead, temples, and/or the back of the head and neck
• Commonly described as a “tight” feeling
• Soreness in the shoulders or neck
• Sometimes accompanied by depression, anxiety and sleeping problems
• Some sensitivity to light (not the intense sensitivity common to migraine)

Tension-type headaches are further classified as episodic or chronic.

Episodic headache is described by the National Headache Foundation as occurring randomly and “…usually triggered by temporary stress, anxiety, fatigue or anger…” These are also commonly referred to as “stress headaches.” Figure 10. is the International Headache Society (IHS) diagnostic criteria for episodic tension-type headache.

Figure 10: IHS Diagnostic Criteria for Episodic Tension-type Headache

Chronic headache, or chronic daily headache (CDH), is defined by the International Headache Society (IHS) as any benign headache—including tension-type—that is not associated with an underlying serious disorder and occurs more than 15 days a month. Figure 11. is the IHS diagnostic criteria for chronic tension-type headache.

Figure 11: IHS Diagnostic Criteria for Chronic Tension-type Headache

MANAGING TENSION-TYPE HEADACHES

Few people seek medical help for managing tension-type headaches. Many minor headaches simply go away on their own and if treatment is required, over-the-counter pain medications are usually successful.

Chronic tension-type headaches often require on-going treatment that includes medication—but sometimes the medication contributes to the headache. This is called a “rebound” headache and occurs because of medication overuse. Any type of treatment that offers fast headache relief can cause a rebound headache.⁷⁹ These include:

• Aspirin, acetaminophen and ibuprofen, especially if taken in higher than recommended daily dosages
• Mixed analgesics
• Migraine-specific medications
• Opiates

Caffeine, a common ingredient in many over-the-counter drugs, can also be a culprit in rebound headaches.

Sometimes it is necessary to prescribe medication. According to the National Headache Foundation one primary drug of choice for chronic tension-type headache is amitriptyline or some of the other tricyclic antidepressants. The use of propranolol is sometimes helpful as a singular drug, particularly when there is a mild chronic anxiety state.⁸⁰

Biofeedback techniques can also be helpful in treating tension-type headaches as can:

• cognitive behavioral therapies like relaxation and stress-reduction techniques.
• physical therapy.
• acupuncture.

The Resources section, Appendix P, lists organizations that can provide the most-up-to date information on tension-type headaches.

MANAGING VASCULAR HEADACHE

There are two types of vascular headache, migraine and cluster headache. Migraine is much more common, and a very serious problem. In the United States about 10% of the population, more than 28 million people suffer from migraine, 75% of them women.⁸¹ Globally migraine is such a problem that in 2001 the World Health Organization (WHO) classified migraine as one of the top 20 disabling diseases worldwide.⁸²

Migraine
Migraine can present in many different forms, which makes it difficult to diagnose. For this reason, a person can go years before a correct diagnosis is made. An example of this is tennis champion Monica Seles. For years, beginning when she was about 15 or 16, she suffered from headaches that were dismissed as being caused by stress or nerves. In a 2004 article in USA Today⁸³ Seles said, “As a teenager I didn't know what was wrong really so I went undiagnosed for about seven years. There's nothing worse. If you haven't had a migraine, I don't think you understand how bad they are. … The headaches would come when I was playing a tournament or meeting friends for dinner. They can be around my cycle. I never knew why one would start. If I got one, I just couldn't do anything. I couldn't go out with my friends. Nothing. . . in 1996 I had to withdraw from tournaments twice.”

Finally in 1997, when she was in her early twenties, Seles was properly diagnosed and began treatment with triptans. In her case, they provided incredible relief.

Migraine also has a huge financial impact. The U.S. economic burden of migraines is enormous, 14.5 billion dollars annually. Only 8% of the economic cost reflects physician visits and prescription medication; the other 92% stems from missed workdays and lost productivity.⁸⁴

Other migraine facts

• Approximately 18% of women and 6% of men have one or more migraine headaches per year.⁸⁵
• Migraine affects people of all ages and races.⁸⁶
• Migraine in children usually does not occur before the age of seven; by ten years of age, 5% of all children have experienced a migraine.⁸⁷
• About half of people with migraine as adults experienced them during their childhood or adolescence.
• Migraine prevalence is greatest between the ages of 25 and 55 and declines thereafter.

In 1999, the National Headache Foundation conducted the American Migraine Study II, a survey of 30,000 individuals who selectively represented the U.S. population in terms of age, geographic region, household size and socioeconomic status. Individuals who met the IHS criteria for migraine were asked to provide information about diagnosis, treatment, health care utilization, and disease burden. Key findings included the following:⁸⁸

• Forty-eight percent experienced severe headaches for 1 to 4 days of any given three-month period; 20% had migraines for 5 to 10 days; 13% had migraines for 10 to 19 days; and 10% had attacks for more than 20 days.
• 53% of respondents experienced functional impairment, requiring bed rest.
• About one-third of migraine sufferers said they had never consulted a physician for the problem.
• Only 48% of participants who met the clinical definition of migraine had been diagnosed by a physician.
• 46% of diagnosed respondents reported migraine pain as extremely severe.
• 57% were managing their pain with OTC medications exclusively.
• Diagnosed patients generally had more severe migraines and reported more symptoms than the undiagnosed, but a high level of suffering was documented for both groups:
  • Throbbing Pain - 85% diagnosed/85% undiagnosed
  • Sensitivity to light – 89% diagnosed/72% undiagnosed
  • Nausea – 80% diagnosed/66% undiagnosed
• The data compiled from the American Migraine Study II was compared to a methodologically identical study conducted in 1989 (American Migraine Study I) in order to identify pertinent trends. They learned that in the 10 year span:⁸⁹
  • The number of patients who sought medical attention for migraine did increase significantly.
  • There was a modest rise in the number of patients who received a diagnosis of migraine – from 38% to 48%.
  • There was only a very small increase in the use of prescription pain drugs.

While there has been some progress over the past decade in diagnosis and management of migraine pain, many challenges remain. Only half of the people suffering from migraines actually know their headaches are migraines; the other half are misdiagnosed or not receiving any treatment at all. Typically, people who have been diagnosed with migraine headaches have struggled through a long line of doctors before receiving a correct diagnosis and proper pain treatment.

On the health care system side, barriers to diagnosis may stem from knowledge deficiencies or failure to recognize migraine as a legitimate medical disorder. Gender bias may also be a factor, as women are three times more likely to suffer migraine than men.

For migraineurs—the term used for migraine sufferers— erroneous beliefs may present obstacles to optimal care. They might assume that their headaches are related to a sinus infection or menstruation. They may be in denial or embarrassed. Based on relatives who endured migraines for years without help, they may think that there is no effective treatment and that they must simply live with the pain.

A panel of experts for the National Headache Foundation, created a list of “Ten Steps for Better Communication,” that patients can follow in order to be more proactive in their treatment. (see figure 12.) These steps will help migraineurs to communicate more effectively with healthcare providers in order to facilitate a successful treatment program.⁹⁰ The full document can be found on the National Headache Foundation Website. There is a link to this site in Appendix P.

There are two types of migraines, classic and common.

Classic migraines begin 10 to 30 minutes before the arrival of the actual headache with a phenomenon known as an aura. Difficulty speaking, visual disturbances (e.g., flashing lights, bright spots, loss of a part of the visual field), and muscle weakness are symptoms of an aura.

Common migraines create an aura, and may also create fatigue, moodiness, food cravings and unusual retention of fluids prior to an episode.

Common to both is intense pulsating pain, usually on one side of the head. This pain is often accompanied by sensitivity to light, diarrhea, increased urination, dizziness, nausea and vomiting. Psychological comorbidities frequently include depression and anxiety. Recent studies point to a possible association between migraine, depression and suicide attempts.⁹¹

Previously it was thought that migraines were caused by blood flow changes to the brain. Dr. Stephen Silberstein, director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia believes that blood flow changes do occur during a migraine, but the migraine itself is not a disorder caused by blood flow. The mechanisms of migraine headache continue to elude scientists. Several theories exist, but more research is needed to clearly understand the pathophysiology or abnormalities in the body that cause migraines. The two theories that have the most scientific support are:

1. The neurovascular theory – an abnormal inflammatory response in the trigeminovascular system (nerves and blood vessels outside of the brain) results in a series of events ultimately causing migraine.
2. The vascular-supraspinal myogenic theory – several abnormal reactions interact to cause migraine, including changes in blood vessels, changes in the central nervous system (brain, serotonin, and stress), and myofascial triggers (spasm of deep muscles in the neck and shoulders).⁹²

Migraine headache is thought to be a genetically inherited disorder. 90% percent of people with migraine have a close relative who also experiences them. Hormones also play a role. The occurrence of migraine in women around the time of their menstrual cycle as well as at the start of menopause has been associated with fluctuations in estrogen and progesterone levels.⁹³ What is frustrating is that one cannot make any hard and fast conclusions about the influence of female hormones on migraine. For example:

• Only half of women with migraine experience a marked improvement in their headaches during pregnancy;
• Following natural menopause, two thirds of women report a decrease in migraine symptoms; only one third of women with migraine who undergo surgically induced menopause report a similar improvement;
• Women who take hormone replacement therapy following menopause are equally likely to have symptoms that improve vs. symptoms that worsen.⁹⁴

There are several known “triggers” for migraine headaches. ACHE has prepared a list of the most common (see figure 13. below)⁹⁵ A full-sized copy of the chart is included as Appendix N.

In a study conducted over a two-year period by headache specialists at The New England Center for Headache in Stamford, CT, 51% of patients with migraines were affected by weather. Changes in temperature, humidity, and barometric pressure were cited in the study as factors contributing to migraine onset.⁹⁶

Figure 13: Most Common Migraine Triggers

Diagnosing Migraines
The most effective tool for diagnosing migraine is the patient self-report of symptoms and medical history. The neurological examination is usually normal. In 1988 the International Headache Society established the following criteria for diagnosing migraine through a description of patient symptoms:

1. At least 5 attacks that fulfill the criteria below (items 2-4)
2. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
3. Headache has at least two of the following four characteristics:
• Unilateral location
• Pulsating quality
• Moderate or severe intensity (inhibits or prohibits daily activities)
• Made worse by walking up stairs or similar routine physical activity
4. During headache, at least one of the following occurs:
• Nausea and/or vomiting
• Photophobia (sensitivity to light) and phonophobia (sensitivity to sound)
5. History, physical and neurologic examination do not suggest a brain tumor, infection, or blood vessel abnormality (all very rare)

A migraine with aura is further diagnosed as follows:

1. At least two attacks that fulfill the criteria below (item 2)
2. Headache has at least three of the following four characteristics:
• One or more fully reversible aura symptoms indicating focal cerebral cortical and/or brain stem dysfunction
• At least one aura symptom develops gradually over more than 4 minutes, or two or more symptoms occur in succession
• No aura symptom lasts more than 60 minutes; if more than one aura symptom is present, accepted duration is proportionally increased
• Headache follows aura with a free interval of less than 60 minutes (it may also begin before or simultaneously with the aura)
3. History, physical and neurologic examination do not suggest a brain tumor, infection, or blood vessel abnormality (all very rare)

A simple, three-question survey developed by a team of American migraine experts to help identify people with migraines was recently tested.⁹⁷ Answering “yes” to two of the three questions was the criteria used to identify migraine sufferers. The three questions are:

1. Has a headache limited your activities for a day or more in the last three months?
2. Are you nauseated or sick to your stomach when you have a headache?
3. Does light bother you when you have a headache?

Called “ID Migraine,” the study included 443 patients, all with headaches that interfered with work, study or quality of life. They were referred to one of 12 headache specialty centers, where experts diagnosed them without knowing how the participants had answered the three-question survey. Of the patients who answered “yes” to two of the three questions, 93 percent received a migraine diagnosis from one of the headache specialty centers. It is hoped that use of this kind of screening tool will identify migraine sufferers more quickly, and will enable clinicians to initiate an effective treatment program.

Migraine Medications
There are many effective drug therapies for migraine, with or without aura. Drugs for headache are divided into two types:

1. Abortive/symptomatic medications
2. Prophylactic (preventive) medications

Abortive/symptomatic medications - are drugs taken at the onset of or during a migraine attack to stop the headache or lessen its symptoms. When prescribing these medications, it is important to keep the following in mind:

• Not every patient will respond the same way to medication; some patients will respond more favorably than others.
• Excessive use of these drugs may result in the development of Rebound Headache Syndrome. Some patients may be tempted to take these medications daily in an attempt to prevent migraine or minimize its symptoms. Over time, the body can become accustomed to these drugs, and headaches return a little bit stronger than when they started.

Abortive/symptomatic headache medications include:

• Over-the-counter analgesics
• Prescription non-steroidal anti-inflammatory drugs
• Barbiturates
• Ergots
• Antiemetics
• Opioids
• Triptans

Because of the episodic nature of migraines, treatment options must be fast and effective, much like the medications used for cancer breakthrough pain. A survey of migraine patients indicated that they would like a medication that delivers rapid, sustained pain relief and also averts or minimizes future attacks.⁹⁸

Triptans can be very effective for delivering quick relief. Triptans bind to serotonin receptors in the brain and blood vessels, effectively disrupting the transmission of information between nerve cells and altering the perception of pain.

Injectable pain medication appears to be effective in aborting a migraine, but many patients resist self-injection. Oral medication is the more convenient administration route. This can be impractical, however, if the patient has nausea and vomiting. Absorption may also be impaired because of the high prevalence of gastroparesis during a migraine attack.⁹⁹

Recently approved intranasal migraine medications offer two key advantages: they don’t require injection and they by-pass the need for gastric absorption. In placebo-controlled clinical studies, intranasal forms were effective in relieving migraine pain.¹⁰⁰ Clinicians interested in this kind of medication for migraine patients should ask the specific drug companies for published clinical data comparing intranasal medications with current abortive therapies.

Clinicians prescribing opioids for migraine pain can protect themselves from liability through careful adherence to current guidelines for legitimate medical use of opioids. Appendix B is a copy of the “Model Policy for the Use of Controlled Substances for the Treatment of Pain” adopted by the Federation of State Medical Boards in May 2003.

Prophylactic Medications
Some patients, because of the severity of attacks, require preventive medication, and commonly must take it for months, and sometimes years. Preventive migraine medications include beta-blockers, antidepressants, anticonvulsants, calcium channel blockers, nonsteroidal agents (NSAIDs), and serotonin antagonists. Side effects, such as fatigue, dizziness, depression and insomnia, can outweigh the benefits, particularly for those people that only have migraine episodes every once in a while. For some patients, who have no insurance and/or the financial means, the cost of these medications can be prohibitive.

Criteria for determining whether a patient would benefit from preventive migraine medication include:

• Frequency and severity of migraine attacks.
• Efficacy of abortive agents when migraine episodes occur.
• Patient’s general health and any conditions that might contraindicate use of preventive medication.
• Degree of reduction in headache frequency or severity needed to significantly improve the patient’s quality of life.
• Patient understanding of potential side effects and acceptance of them.
• Patient willingness to be compliant with treatment instructions and return for periodic evaluations.

The correct dosage for preventive medications should be determined on a case by case basis, with guidance from the manufacturer. Starting with a lower dose and titrating upward as needed is recommended. To assess efficacy, preventive medications should be tried for at least two months.

Clinicians are urged to review current clinical data regarding the use of preventive medications to reduce the frequency and severity of attacks. Realistic expectations should be established with patients to avoid potential misunderstandings and frustration. Preventive medications do not cure migraines. Referral to a headache specialist may be prudent if a patient continues to experience intolerable pain, despite preventive and abortive therapies.

Non-Pharmacologic Therapies
There are a number of non-pharmacologic therapies that can be recommended to migraine patients as a way to augment drug therapy and encourage self-management of their condition. It is incumbent on physicians to become knowledgeable about these therapies and include them in discussions about possible pain relief measures. Each patient’s personal belief systems, their likes and dislikes, will likely influence what they choose in managing migraine beyond the pill.

Some of the more common non-drug therapies utilized in the treatment of migraine include biofeedback, relaxation training, exercise, physical therapy, hypnosis, guided imagery, meditation and yoga. Some patients take advantage of acupuncture, chiropractic treatments and massage, all of which may relieve muscle tension and promote an improved sense of well being. Migraine support groups, on the Internet or within a patient’s local community, can provide immeasurable benefits in terms of a patient’s motivation to take positive action based on testimony from fellow sufferers who have found relief.

Headache Diaries and Patient Education
Headache diaries are an invaluable source of information for developing competent, patient-specific treatment programs. Headache diaries ask patients to document the relevant details of their migraine experience: how long the episodes last, the severity, what may have triggered them, what medications they took, any side effects, relieving factors they used, what worked and what didn’t, and how the attack affected work and home life. Recording headache information serves a number of purposes.

1. It inherently forces a patient to take stock of the many factors contributing to migraine, encouraging them to adopt preventive measures. Indirectly, performing this activity may restore a patient’s sense of control over their condition.
2. It provides the physician with the quantitative and qualitative information needed to assess and, if necessary, adjust the treatment program.
3. It establishes a focal point of communication between a physician and a patient, ensuring that all aspects of a patient’s migraine suffering is regularly discussed.

The National Headache Society offers an excellent example of a headache diary, which is included as Appendix O.

While physicians cannot take responsibility for those people who simply don’t seek help, it is imperative that they educate patients who do consult them about their headaches. Patients should understand what is known about the cause of migraines, environmental triggers, the pros and cons of migraine medication, and non-pharmacologic therapies that have been used successfully by other patients. They should be given written information or referred to Internet sources. All of the major headache organizations (American Council for Headache Education, American Headache Society and the National Headache Foundation) provide comprehensive migraine information written specifically for people who suffer from them. Links for all of these Websites are included in the Resources section.

Cluster Headache
The other form of vascular headache is the cluster headache. This is a very rare form of headache that occurs in less than 1% of the population, and about 80% of cluster headache sufferers are male. In men the peak age of onset is the early thirties, but in women there are two peak ages of onset, one in the twenties, and the other in the fifties. They rarely occur in childhood.¹⁰¹

These headaches occur over a period of several days, usually at the same time every day, which is why they are called “cluster” headaches. They present very suddenly, with extreme pain. There are two types of cluster headache—episodic and chronic. Episodic is most common, occurring in about 90% of patients. The only difference in episodic and chronic cluster headaches is that the episodic headache disappears for over 14 days after less than one year of repeated attacks—the chronic cluster headache remits for less than 14 days and/or does not remit for a year or more. Figure 14. is the IHS criteria for cluster headache.

Cluster Headache Medications
Treating cluster headache primarily involves acute treatment and preventive treatments.¹⁰³ Key acute treatments include:

• Inhalation of 100% oxygen
• Triptans
• DHE
• Topical 4% lidocaine given as nose drops
• Butorphanol nasal spray

There is potential for addiction to butorphanol, so the clinician is advised to use this medication with caution, following all safety and legal protocols. Key preventive treatments include:

• Verapamil
• Methysergide
• Divalproex sodium
• Lithium carbonate
• Topirimate
• Baclofen

Research is constantly being conducted to find new ways to treat cluster headache, so it is critical to remain up-to-date on treatment guidelines. Appendix P, Resources, offers links to various groups— government and private—that offer the ongoing changes in treatment options.

Lifestyle modification is also a key element in treating cluster headache. Cluster headache sufferers are advised to avoid the following:

• alcohol.
• foods containing nitrates or nitrites (such as smoked meats). No other dietary factors appear to play a role, for good or ill, in this disease.
• medications containing nitrates (such as nitroglycerin).
• smoking. Smokers who can't quit should at least stop smoking at the first sign of an attack and not smoke throughout a cycle.

As with migraine, there is no cure for cluster headache, but most patients can be successfully treated.

SUMMARY

Chronic headaches are a major health problem. The pain can be debilitating and demoralizing. They diminish quality of life, and the pain can be so severe it drives some individuals to attempt suicide. Enhanced awareness of the many types of headache and patient education and involvement will enable physicians to improve headache treatment and the quality of life of their patients.

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