Headache can be either primary or secondary. Primary headache includes migraine, tension headache and cluster-type headache. Secondary headache can be related to other disturbances such as stroke, infection, with meningitis, brain abscess or encephalitis the most worrisome concerns, brain tumor, the consequences of trauma, such as a subdural hematoma, sinus infection or inflammation, or medication effect such as medications which can dilate the circulation such as nitroglycerin for angina. Up to 10% of the population has migraine and people tend to have their own perspective of what constitutes migraine. It is typically viewed as a “sick headache” accompanied by nausea and malaise and might often put the person to bed. There is often a unilateral pattern to migraine along with a significant throbbing component to the pain. Light, sound and smell sensitivity are common as is nausea and some patients can have pronounced vomiting. Those that have warning preceding the headache, termed an aura, have what is termed migraine with aura or “classic” migraine. Most do not have such an aura and this is termed migraine without aura or “common” migraine. Auras can consist of visual distortion with seeing either bright or dark spots and the bright ones can sparkle in a zigzag-type pattern often referred to as a “picket fence” pattern or fortification spectra. Such visual phenomenon can accompany the headache as well as precede it. There can be actual visual loss as well. Of note, some patients will have the visual symptom without the headache and this has been termed “retinal migraine”. It is not uncommon to have sensory symptoms, such as numbness or tingling on one side, as part of the migraine and there is the potential to have significant weakness associated with the migraine termed “hemiplegic migraine”. Other manifestations can include confusion, speech disturbance and loss of eye movement termed “ophthalmoplegic migraine”. Migraine can look like a stroke and there is particular concern when there are stroke like symptoms in older patients who are on birth control pills as well as older patients with risk factors for stroke including smoking. Migraine can actually progress to an ischemic stroke, but, fortunately, this is not commonly seen.
The evaluation for migraine is a good history is careful exam including both physical and neurological exam. For example, some patients have headaches related to poor blood pressure control. There are medical conditions that are associated with headache either directly, such as connective tissue disorders, such as systemic lupus erythematosus (SLE), as well as the potential for certain medications prescribed for a medical condition, such as the combination of aspirin and dipyridamole for stroke prevention, to be associated with headache. Migraine can be relatively mild, moderate or severe. There is always concern when the headache is “the worse headache” of one’s life or if the headache begins after age 35 years of age in a person who never experienced migraine-type headache in the past. Most typical migraine patients do not need to have the performance of a brain scan unless there is something atypical in the presentation, something abnormal found on the exam, or the pattern starts to change with no obvious explanation.
There are three approaches to treating migraine. The first is to address possible triggering factors such as menstrual periods, oral contraceptives or other hormonal issues in women such as menopause. Certain patients have their migraine either set off or aggravated by oral contraceptives containing estrogen and this may lead to discontinuation or at least acknowledgment that this might be a factor that has to be discussed. Some patients actually have improvement in their migraine pattern with estrogen-containing oral contraceptives. Certain foods and beverages can trigger migraine in certain patients. More common culprits include certain cheeses, chocolate, red wine, citric acid and use of MSG as a preservative. Cigarette smoke can promote migraine as can certain fragrances. It is generally a good idea for everyone to refrain from smoking and this is particularly an issue for migraineurs. Weather changes can promote migraine especially low barometric fronts coming in. Emotional stress can set off migraine and there can be an overlap between migraine and both tension headache as well as so-called “sinus” headache. Dealing effectively with triggering factors for migraine can be a very worthwhile non-pharmacological approach.
One the two main additional approaches toward headache management, is abortive, i.e. as necessary medication for the headache when it occurs. This can include simple over the counter agents such as aspirin, acetaminophen, naproxen or ibuprofen or there are combination pills including caffeine which tends to facilitate the response. Prescribed abortive agents include triptans such as sumatriptan available either by injection, tablet or by nasal spray as well as dihydroergotamine available as a nasal spray. Butalbital, a barbiturate, in combination with caffeine and either acetaminophen or aspirin, can be quite effective but recurrent use of this combination is very much of concern in light of the potential to evolve into a chronic daily headache pattern. This has been termed “rebound”-type headache or medication overuse headache and it tends to develop when a particular abortive agent, including triptans, is used to regularly. It is generally advisable to avoid any particular abortive agent more than twice a week as increasing frequent use can evolve into a pattern of “quick fix” of the headache with the particular agent being overused and then a return of the headache on a recurrent basis.
There are a number of preventive agents for migraine that can be quite effective. These are generally reserved for patients susceptible to severe recurrent headache that does not adequately respond to periodic use of abortive therapy. A negative impact on the quality of life is a good rule of thumb for consideration of such preventive therapy and some formulations which can be quite benign and not expensive include riboflavin and magnesium supplement. Prescribed preventive agents include topiramate which is quite popular as it tends to work well, is available as a generic, is generally well tolerated and can be associated with weight loss which a number of patients find particularly attractive. This medication is not right for everyone and there is concern about the risk for both glaucoma and renal stones. In addition, this agent should best be avoided if there is a risk of pregnancy in a woman of child bearing potential with migraine. Alternative prescribed medications for migraine can include tricyclics such as amitriptyline, beta-blockers such as propranolol and calcium channel-blockers such as verapamil. Valproic acid can also be quite effective for patients who are not susceptible to side effects such as weight gain, hair loss, an effect on the liver and the potential to lower the platelet count. Alternative non-prescription formulations can include coenzyme Q-10 as well as the herbal formulations feverfew and butterbur.
Not every migraine patient responds effectively to presently available formulations. More recently available for such an intractable migraine picture is botulinum toxin (Botox) injections which are necessary every three months and can be costly. There is now more readily available insurance coverage for Botox but it must be determined that it is being prescribed for patients who are not having an adequate response to more standard approaches to migraine management. There might also be some benefit to relaxation techniques such as yoga, transcendental meditation, aerobics, etc. Some patients report response to biofeedback or acupuncture. A certain percentage of patients require chronic pain management with narcotic medications to make their quality of life manageable.
While migraine is most common in young women, cluster headache is most common in middle-age white men who are chronic heavy smokers. Despite, the incredible severity of head and periorbital pain that cluster-type headache can be associated with, such patients tend to be very reluctant to quit smoking. It is important to recognize cluster headache as it tends to be quite treatable, but the severity, if left untreated, could lead to suicide. There tends to be a very significant response to breathing 100% oxygen with the proviso that the person not be smoking during such therapy. Triptan formulations and dihydroergotamine can also be quite effective as abortive therapy as can a course of steroid therapy. Preventive therapy, outside of making every effort to discontinue smoking, can include verapamil, valproic acid or tricyclic agents while beta-blockers don’t tend to be as effective for preventing cluster type headache.
Tulane Department of Neurology has a very accommodating service in the realm of Headache Management. Dr. Roger Kelley has an active headache practice and there are a number of patients under the care of Drs. Patricia Colon, Angela Traylor and Morteza Shamsnia. Dr. Shamsnia is well recognized for his expertise in chronic pain management. Dr. Shamsnia sees patients at the Tulane-Lakeside campus in Metairie, while Dr. Kelley sees patients at Tulane-Lakeside, Tulane Clinic at Uptown Square and in a Covington Clinic on the North Shore.
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