Headache Management

Headache is one of the most common reasons patients consult a physician. There are many varieties which require specific treatment, thus accurate diagnosis is the first step in management. This involves diagnosis of the headache syndrome, contributing psychosocial factors, substance abuse issues, if present, and lifestyle factors. (exercise, diet, etc.).

Tension headache is the most common type. Patients present with unilateral or bilateral aching or pressure, which ranges from brief and intermittent to constant. For abortive therapy (treatment of individual attacks), most patients respond to OTC analgesics or physical modalities (hot or cold packs, rest, etc.) Prophylactic therapy, for prevention of headaches, relies on tricyclic antidepressants,and lifestyle modifications, such as diet, exercise, and stress management.

Migraine is also very common. Underlying disorders need to first be excluded. Abortive therapy consists of OTC analgesics, Midrin, ergot derivatives, NSAID's, and the serotinergic agents, such as sumatriptan and zolmatriptan. The most important principal of abortive therapy is that many patients do not adequately absorb the orally administered agents during an acute attack, but may respond well to suppositories, injectable agents, nasal medications, or co-administration of oral medications with metaclopramide. Prophylactic therapy relies on beta blockers, tricyclic antidepressants, calcium channel blockers, valproic acid, or methysergide. Lifestyle modifications are also very important, with the identification of any triggering factors an important first step. Any syndrome of intermitttent headaches may progress to become constant, chronic daily headaches. The most common reason for this is analgesic overuse, wherein patients who progress todaily use of abortive agents, develop headaches as a consequence of their analgesic use. Furthermore, prophylactic medications are not effective concominant with daily analgesic uae. Psychological factors are common. These patients usually require analgesic detoxification, sometimes as an inpatient, and multidisciplinary pain management.

Cervicogenic headache is an underdiagnosed problem wherein headaches are referred from neck pathology. These patients benefit from physical therapy or injection therapy (trigger point, facet, or epidural steroid injections).