TOC | Neurology
HEADACHE - See Migraine | Headache Rx (KP Intranet only)
Types of Headaches:
A. No structural disease (pathophysiology poorly understood)
1. Tension muscular type headache
2. MIGRAINE vascular type headache
B. Structural disorders
1. Intracranial structural disorder
2. Extracranial structural disorders
C. Toxic, metabolic, & systemic illnesses
1. Headache associated with fever or systemic infections
2. Headache associated with hypoxia, ischemia, dialysis
3. Headache associated with substances or their withdrawal
D. Cranial neuralgias
REF: Harrison's Med Text 1994
Management of Primary Headache - Cleveland Clinic J Of Med Nov. 2001
Sexual aspects of headache
How sexual function relates to headaches and their causes and treatment
Jerome Goldstein, MD
VOL 109 / NO 1 / JANUARY 2001 / POSTGRADUATE MEDICINE
What's New in Medicine
from WebMD Scientific American® Medicine
Randolph W. Evans, MD
Prevention of Migraines
A number of factors may justify daily preventive medication for patients with migraines [see Table 1]. Indications for preventive treatment are as follows: the headaches significantly interfere with the patient's daily routine, despite acute treatment; acute medications are contraindicated, ineffective, or overused or have intolerable side effects; frequent migraines (two or more attacks a week); uncommon migraine types (hemiplegic, basilar, prolonged aura, or migrainous infarction); the cost of acute medications is significantly greater than the cost of preventive medication; and patient preference (i.e., the patient is willing to risk the possibility of side effects from the preventive medication to reduce the frequency of headaches).
Several general principles apply to the use of preventive medications:
The clinician should start with a low dose of medication and increase it slowly, depending on the response and whether side effects occur.
Each medication should be given a trial of 2 to 3 months at an adequate dose.
Overused medications that may be causing rebound headache and that may decrease the efficacy of preventive treatment should be discontinued or tapered (depending on the drug).
The patient should keep a headache diary to monitor his or her headaches.
The clinician should educate the patient about the rationale for treatment and possible side effects and should address the patient's expectations for treatment.
In the treatment of suspected rebound headache, the medications acetaminophen, aspirin, NSAIDs with short half-lives, and triptans can be stopped abruptly. Caffeine use should be tapered to avoid withdrawal symptoms. Opiates and butalbital should be tapered because of the risk of a serious withdrawal syndrome. If butalbital is abruptly discontinued, phenobarbital can be substituted to prevent withdrawal; the phenobarbital is tapered down from 60 mg to 15 mg at night over 1 week. After medication withdrawal, the duration of rebound headaches from triptans is about 4 days, and from other analgesics, it is about 9 days. A migraine preventive medication can also be started, but it may not be effective when patients are overusing symptomatic medications.
Two outpatient transitional strategies have been suggested to reduce the headaches during the withdrawal period. One approach is the use of prednisone: 60 mg a day for 2 days, 40 mg for 2 days, and then 20 mg for 2 days. Alternatively, the combination of tizanidine and an NSAID (e.g., piroxicam, rofecoxib, naproxyn, sustained-release ketoprofen, or celecoxib) may be effective.
Cluster Headache Treatment
For acute attacks of cluster headache, inhalation of 100% oxygen at a rate of 7 to 10 L/min for 15 to 20 minutes with a loosely applied face mask is effective in about 70% of cases. Sumatriptan, 6 mg subcutaneously, is effective in 90% of patients for 90% of their attacks, with no tachyphylaxis or rebound effect. Intranasal sumatriptan or oral triptans are less efficacious. Intravenous dihydroergotamine (DHE), 1 mg, may provide relief in less than 10 minutes; intramuscular or intranasal administration results in slower onset. Triptans and DHE should not be used within 24 hours of each other. Ergotamine may also be effective. Topical lidocaine 4%, administered as nosedrops, may be effective. To administer the drops, the patient lies supine with the head tilted backward 30° and turned to the side of the headache. A nasal dropper may be used. The dose (1 ml) may be repeated once after 15 minutes. Butorphanol nasal spray may be tried if other treatments are not effective or are contraindicated, but this medication has a significant potential for habituation and addiction.