|
|||||||||||||
|
|
||||||||||||
|
|
|||||||||||||||||||||||||
|
|
Headaches
It is estimated that up to 40 million people in the United States suffer from chronic headaches. Most of these people do not consult doctors because they consider the problem to be too trivial or they think that no treatment is available. Patients who do consult a physician are usually those whose headaches significantly disrupt their lives. Educating the public about available treatments through the media and practicing physicians has increased but more needs to be done.
Diagnosis of Headache Type Most of the information leading to the diagnosis of the headache type is obtained from the patient's history. 1. Frequency and duration : Increasing frequency or duration of headaches indicates the need for a re-evaluation of the patient. Daily headaches are often the result of caffeine or medication overuse. Very brief, but intense and frequent (several times a day) headaches in women suggest the diagnosis of chronic paroxysmal hemicrania which almost always responds to indomethacin. 2. Time patterns : A patient who wakes up with a headache which quickly resolves without medications may be suspected of having a brain tumor or another space occupying lesion. Tension-type headaches tend to worsen as the day progresses but it is not unusual to have a headache upon awakening as well. Cluster headaches tend to be very regular in their time of occurrence. Typically these headaches wake the patient up from sleep in early morning hours. 3. Character and location of pain : Burning occipital pain suggests a focal neuropathy. Unilateral and pulsatile pain is most common in migraine and cluster headaches. 4. Precipitating factors : Alteration of sleep patterns, tyramine-rich foods, alcohol, chocolate and other foods can provoke a migraine attack. Overexertion and emotional stress is one of the most common precipitating factors for both tension-type and migraine headaches. Strong sensory stimuli such as loud noise, strong odors, bright and flashing lights can induce a headache in a susceptible individual. Changes in barometric pressure such as with weather changes, flying or climbing a mountain can provoke a headache. 5. Preceding and accompanying symptoms : Migraine headaches are often preceded by a visual and other types of aura. Nausea, sensitivity to light, noise and movement are typical accompaniments to migraine headaches. Agitation, unilateral nasal congestion and tearing frequently occur with an attack of cluster headache. Dizziness can occur with migraine and cervicogenic headaches. A general medical examination is necessary to detect many of the systemic conditions that can lead to headaches. After a detailed history a neurologic examination is the most important diagnostic step. This examination should be normal for the types of headaches described below with few exceptions. Patients with cluster headaches often have Horner's syndrome that can transiently persist for some time after the attack. Benign intracranial hypertension is accompanied by papilledema and can lead to visual field defects and cranial nerve palsies, especially of the sixth nerve. If the history or physical examination raises any doubt about benign etiology of headaches an imaging procedure such as CAT scan or, preferably, MRI scan should be performed. Concern over a possible brain tumor or another serious condition often makes the headache worse. Negative CAT or MRI scan reassures the patient and can reduce headaches. A CAT or MRI scan of the brain is routinely performed to exclude a subdural hematoma which in the elderly may develop from a trivial head injury suffered many weeks or months earlier. Up to 40% of elderly patients with a chronic subdural hematoma give no history of a head injury. Conditions such as, metastatic brain tumor and cerebro-vascular disease are also more common in the elderly than in a younger persons. Laboratory tests on patients who have not had any screening blood tests in many months should include a complete blood count, thyroid function tests and a standard battery of chemistry tests. These tests may detect anemia, systemic infections, renal insufficiency, hypothyroidism and other conditions that may cause headaches. An erythrocyte sedimentation rate (ESR) must always be obtained in a patient over 60 years of age with a recent onset of headaches. If the ESR is high a temporal artery biopsy is necessary to confirm the diagnosis of giant cell arteritis. Electroencephalography has traditionally been considered unnecessary in patients with headaches and is still not a part of a standard headache work up. In patients with severe intractable headaches, however, an abnormal EEG may prompt a trial of divalproex sodium (Depakote) or another anticonvulsant. This type of headache is described as pressing or tightening in quality, of mild or moderate intensity, bilateral in location, without associated nausea, photophobia or phonophobia. It is not made worse by routine physical activity as may be the case with migraine headaches. Tension headaches are the most common type of headache and have many precipitating factors. Removal of identifiable causes and precipitating factors is the ideal way to treat this type of headache. Although the most common precipitating factor - stress - is often difficult to alleviate, reducing the physical effects of stress can be achieved through both non-pharmacological and pharmacological methods. A. Non-pharmacological treatment Biofeedback is one of the most effective treatments for both tension and migraine headaches. Meditation, yoga and other mental exercises can help but biofeedback is a more direct approach aimed at eliminating headaches. Well-trained staff and patient compliance with home exercises are essential for achieving a high success rate. Follow-up studies indicate up to 80-90% improvement 5 years after completion of a biofeedback training course. This course usually consists of 30-60 minute sessions every week for 6 to 15 weeks. Children can learn to rid themselves of headaches in as few as three to four sessions. Transcutaneous electrical nerve stimulation (TENS) and acupuncture can provide fast relief for tension headaches. These methods have a solid scientific basis, but lack clinical studies proving their efficacy. Acupuncture can stop an acute headache or with a series of treatments relieve a chronic one. Regular physical exercise is an excellent way to reduce adverse effects of stress on the body. B. Pharmacological treatment Abortive therapy - Sporadic attacks of severe tension-type headaches may respond to analgesics.
Prophylactic therapy
Migraine Headaches A. Non-pharmacological treatment Dietary changes can occasionally completely stop migraine headaches, but in many patients they only reduce the frequency of attacks. Some of the foods that can provoke migraine headaches include yogurt, bananas, dried fruit, beans, aged cheese, pickled and marinated foods and buttermilk. Monosodium glutamate and aspartame should be avoided. Among the alcoholic beverages, red wine and beer are more likely to induce a migraine headache than vodka. Biofeedback, relaxation techniques and regular aerobic exercise are as effective for prevention of migraine headaches as they are for tension headaches. B. Pharmacological treatment Abortive therapy is used when the attacks are not very frequent. Non-steroidal anti-inflammatory agents mentioned above can be effective for migraine headaches as well. Rapid onset of action can be achieved by using an effervescent form of aspirin (Alka-Seltzer). Combination medications listed in the section on tension headaches can be very effective. Addition of codeine to some of the combinations (Fiorinal with codeine and Fioricet with codeine) improves their efficacy for severe headaches. Ergots alone (Ergostat, sublingual) and with caffeine (Cafergot, tablets and suppositories, Wigraine, tablets) are limited in their utility by a relatively high incidence of nausea. Reducing the dose, particularly of Cafergot suppositories to one quarter or one half of a suppository can avoid nausea and provide effective and rapid relief. Ergots are contra-indicated in patients with cardiac or peripheral ischemia and pregnant women. Dihydroergotamine (DHE-45) is effective for abortive treatment of migraines. This ergot derivative is available only in a parenteral form and can be given subcutaneously, intramuscularly or intravenously. A dose of 1 mg is sufficient for most patients but some may require 2 or 3 mg. The starting dose should be 0.5 mg repeated in 45 minutes if necessary. Once a total effective dose is established for a patient, that amount is given for future attacks. If the headache is accompanied by nausea an injection of an antiemetic such as prochlorperazine (Compazine) or metoclopramide (Reglan) 10 mg IM can be effective. These medications can be given with DHE-45. Sumatriptan (Imitrex) is a "designer" drug specifically developed to bind to 5HT-1D serotonin receptor which is operational in the pathogenesis of migraine headaches. Sumatriptan relieves both the pain and the nausea and allows the patient to return to normal functioning within 10-20 minutes. Sumatriptan is available in an injection which can be self-administered by the patient using an auto-injector. Tablet form of sumatriptan should become available in the United States in the near future. Common side effects include a flushed sensation, paresthesias and injection site pain. Sumatriptan is contraindicated in patients with uncontrolled hypertension, ischemic heart disease and complicated migraines (migraines that are accompanied by a transient neurological deficit). Sumatriptan and ergots should not be given on the same day. C. Prophylactic therapy Tricyclic and other antidepressants can be as effective for migraine headaches as they are for tension-type ones. Propranolol, nadolol and other beta blockers are good prophylactic drugs. The effective dose for propranolol can be as low as 40 mg daily but is usually 80 to 240 mg. Long acting preparation of propranolol (Inderal LA) facilitates its use. Contraindications for the use of beta blockers include bronchial asthma, sinus bradicardia, greater than first degree block, congestive heart failure, and diabetes. In some patients who do not respond to either a TCA or a beta blocker alone, use of these two drugs together may stop the headaches. No clinical trials have been published, however, to prove the efficacy of this combination. Divalproex sodium (Depakote) can relieve migraine headaches in patients who do not respond to beta blockers or antidepressants. The starting dose is usually 250 mg a day with a gradual increase up to 2000 mg in a divided dose. Potential side effects include nausea, drowsiness and weight gain. Calcium channel blockers are sometimes effective for migraines, but are more likely to benefit a patient with cluster headaches. NSAIDs can be given prophylactically with good results. A. Elderly patients Cervicogenic headaches are very common in elderly patients due to arthritic changes in the cervical spine. Pain described as radiating from the neck or occipital in location suggests this diagnosis. Pain of cervical spine origin, however, can sometimes be felt in the front of the head. Loss of sensation over the occipital area, often on one side can accompany occipital neuralgia. Neck muscles are tender, frequently in spasm, and their movement can aggravate the pain. [ Treatment ]
B. Whiplash injuries Another frequent cause of cervicogenic headaches is a whiplash injury commonly sustained in car accidents. [ Treatment ]
In many patients post-traumatic headaches will subside in a few weeks or months without any treatment. Chronic post-traumatic headaches in many patients, however, are notoriously hard to treat regardless of the presence or absence of litigation. [ Treatment ]
Cluster headaches are the most intense headaches of all, leading some patient to thoughts of suicide. Symptoms Headaches occur in clusters, frequently during the same season each year, with each episode lasting for several weeks or months. The pain often wakes the patient from sleep - sometimes at the same time - every night and usually lasts for 30 to 90 minutes. Such regular occurrence, however, is not always present. The pain is described as retro-orbital, unilateral and is associated with agitation, nasal congestion, conjunctival injection and lacrimation. Cluster headaches can be affected by external factors although not to the extent that migraine or tension-type headaches are:
Abortive treatment Treatment of cluster headaches begins with measures designed to reduce pain of each attack while prophylactic drugs take effect. The most benign and frequently effective treatment is
inhalation of oxygen. It is done through
a mask (not nasal prongs) using 100% oxygen at 8-10 liters per minute.
It should be used for patients who get most of their attacks at home.
If headaches occur during the day, patients can store another Ergotamine (Cafergot, Wigraine, Ergostat) can abort a cluster headache in up to 75% of patients. It is best given by a suppository or sublingually to provide rapid onset of action. Dihydroergotamine (DHE-45) is given only by injection and can be self-administered by the patient. Sumatriptan (Imitrex) injection is very effective in most patients and has few side effects. It can also be self-administered by the patient using an auto-injector. Prophylactic treatment A short course of prednisone will frequently stop the cluster. Dosage is started at 60-80 mg daily and then is tapered down over a period of two weeks. Calcium channel blockers are suggested for patients not responding to a course of prednisone.
Methysergide (Sansert) in a dosage of 2 mg three or four times a day is recommended for patients who fail prednisone and calcium channel blockers. Fibrotic complications should not occur because clusters rarely lasts for more than a few months. However, some reports suggest that this complication is more likely to be idiosyncratic rather than dose-related. Divalproex sodium (Depakote) 750-2000 mg daily in divided doses can provide relief for some patients. Lithium carbonate, 300 mg taken two to four times a day is effective within 1-2 weeks of therapy. It can work for both episodic and chronic forms of cluster headaches sometimes transforming chronic into episodic. Adding 2-4 mg of Ergotamine a day to lithium may produce remission in patients who do not respond to lithium alone. Ergotamine in a dose of 2 mg can provide good relief if taken 2 hours before the expected attack. Regular intake of 1-2 mg of Ergotamine three times a day has been reported to be effective in some patients. Headaches Associated With Substances OR Their Withdrawal [ Causes ] Many prescription medications can cause headaches. The most common offenders are nitrates, appetite suppressants, oral contraceptives, estrogens and anti-hypertensive medications. Foods can also cause headaches - specifically, those containing nitrites, monosodium glutamate, tyramine and aspartame. Other factors that can lead to headaches include excessive intake of caffeine, analgesics, benzodiazepines, barbiturates and ergot preparations. [ Treatment ] Eliminating offending foods and drugs can occasionally relieve all of a patient's headaches, or reduce their frequency and intensity. The treatment of a patient who is dependent on analgesics, caffeine, or ergot preparations can be very difficult.
Benign Intracranial Hypertension (Pseudotumor Cerebri) [ Causes ] This condition should be first treated by removing possible causes such as vitamin A, tetracycline, nalidixic acid and by reducing excessive weight. Acetazolamide (Diamox) is an effective drug in many patients and is available in a sustained release preparation. The dose ranges between 250 mg and 1500 mg daily. For patients with severe persistent headaches lumbar punctures can be performed while other treatments are being tried. These can also be performed during pregnancy. In pregnant women this condition often subsides after the delivery. Beta blockers and TCAs can sometimes provide relief of headache. Prednisone is useful in reducing intracranial pressure from a brain tumor, but its efficacy in Pseudo- -tumor cerebri remains controversial. Regular visual field testing is paramount in the management of benign intracranial hypertension. Patients with progressive visual loss should undergo optic nerve sheath fenestration. This operation is the treatment of choice for patients with visual impairment but it is not consistently effective for the relief of headaches. A lumbar-peritoneal shunt is more appropriate for patients with intractable headaches but it should be used as a last resort because of the potential for complications. The use of a thin or conical spinal needle reduces the incidence of post-lumbar puncture headaches. Contrary to popular belief, bed rest following a lumbar puncture does not prevent these headaches. When a patient does develop headaches, bed rest, good hydration and analgesics will provide relief. Most patients improve within a few days of this regimen. Those who do not improve should receive a blood patch. This procedure involves withdrawing 15-20 cc of patient's venous blood and injecting it into the epidural space at the same level where the lumbar puncture was performed. This stops the leakage of cerebrospinal fluid which caused the headache. Lance, JW. Mechanism and Management of Headache (5th ed). London: Butterworth, 1993. Olesen J, Tfelt-Hansen P, Welch KMA (eds). The Headaches. New York: Raven Press, 1993. Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain. Cephalalgia. Vol. 8, Suppl. 7, 1988. Table 1
Table 2
|
||||||||||||||||||||||||
Back
to Top| NYU Langone Medical Center | NYU School of Medicine | Research at NYU | Administration | NYU Hospital
for Joint Diseases | Giving & Support © 2005 NYU Medical Center | For Trustees | Ethics | Disclaimer | Privacy Policy | Sitemap |
Contact Webmaster
|