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Headache Pain
Researchers/reviewers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD.
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Headache: Pediatric Perspective From: eMedicine by WebMD. Authors: J. Ivan Lopez, MD; John F. Rothrock, MD. 10 pages. Updated June 2008. Access checked 1/17/09.
How Clinicians Can Detect, Prevent and Treat Medication Overuse Headache By: Dodick DW, Silberstein SD. Cephalalgia. 2008;28(11):1207-1217. Access checked 1/18/09.
Medication overuse headache (MOH) — also referred to as analgesic-rebound or drug-induced headache — occurs in patients with chronic daily headache (defined as 15 days or more per month for 3 consecutive months) who overuse drug therapy for acute headache attacks. They commonly occur after 3 months of frequent drug therapy and can be a source of considerable disability in affected patients. The authors of this article present evidence of a growing awareness of MOH and they review the recent proposal to revise ICHD (International Classification of Headache Disorders) MOH diagnostic criteria. Additionally, a discussion of medications frequently associated with MOH, including potential factors that increase patient tendencies to overuse these drugs, leads to an examination of the evidence for effective treatment and prevention of MOH.
Migraine-Preventive Medications: Ensuring Their Appropriate Use From: American Pharmacists Association (APA); Wenzel RG. Pharmacy Today. 2008;14(8):34-51; 14 page monograph; 2008. Access checked 1/11/10.
Go to article within PDF of journal issue. This continuing education monograph from the APA was written for pharmacists but includes a thorough review of preventive migraine drugs. The authors focus on the evidence of under-diagnosis of migraine and the under-utilization of migraine-preventive medications suggesting that improved understanding of preventive therapy could reduce disability and improve the quality of life in migraineurs. Data from several studies was reviewed to identify patient perceptions of migraine that result in barriers to care and strategies are provided to improve patient education in these areas. Recommendations for evaluating levels of disability and the initiation of appropriate preventive-therapy are presented in a way that is useful to all healthcare professionals. A table of commonly used prophylactic drugs includes the mechanism of action, dosing instructions, adverse effects, and the drugs effectiveness in comorbid conditions.
Practice Guideline for Diagnosis and Management of Migraine Headaches in Children and Adolescents From: Gunner KB, Smith HD, Ferguson LE. Medscape. 2007-2008. 10 pages each. Access checked 1/17/09.
Articles were also published as: Part 1) Gunner KB, Smith HD. J Pediatr Health Care. 2007(Sep-Oct);21(5)327-332; Part 2) Gunner KB, Smith HD, Ferguson LE. J Pediatr Health Care. 2008(Jan-Feb);22(1):52-59.
Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache From: British Association for the Study of Headache (BASH); 2007; 52 pages. Access checked 1/16/09.
This easy-to-read 3rd edition guideline was developed by a team of headache specialists, members of BASH and the Association of British Neurologists, for use by all healthcare disciplines. Existing evidence demonstrating improved outcomes in headache management was evaluated and recommendations were developed for all headache types, including multiple coexistent headache disorders and medication-overuse headache. These guidelines use criteria from the 2003 International Classification of Headache Disorders (ICHD-II) and include a discussion of signs and symptoms suggestive of secondary headache due to more serious pathology. A brief 6-part patient questionnaire is provided as a tool for assessment.
Migraine – Special Edition, The Pain Practitioner From: American Academy of Pain Management. 2007 [Spring];17(1):86 pages. Access checked 1/17/09.
Mind-Body Therapies For Headache From: Sierpina V, Astin J, Giordano J. American Family Physician. 2007;76(10):1518-1522. Access checked 1/15/09.
This article, written for physicians in family practice, examines the multi-faceted pathophysiology of headache as evidence for the potential of mind-body interactions to reduce or relieve headache episodes. Efficacy data for 6 different therapeutic approaches for migraine and tension-type headaches are presented in an easy-to-read format. The authors suggest several potential reasons for the underuse of mind-body therapies by headache specialists, despite low adverse effects associated with these modalities. A table provides recommended resources for further information on mind-body therapies.
The Differential Diagnosis of Chronic Daily Headaches: An Algorithm-Based Approach By: Bigal ME, Lipton RB. J Headache Pain. 2007;8(5):263-272. Access checked 1/15/09.
A patient complaint of chronic daily headaches (CDHs) can result in a diagnostic challenge unless the differential diagnosis is approached systematically. A section on techniques for identifying the potential “red flags” of concern for secondary headaches includes a table listing disorders that can mimic benign CDH. A detailed discussion and several algorithms are provided to aid the identification of headache type by duration and frequency. Variations in the clinical presentation of headache types, including transformation migraines and medication-overuse headaches, are discussed and the ICHD (International Classification of Headache Disorders) diagnostic criteria for primary chronic daily headaches is reviewed.
Head Pain – Special Edition, The Pain Practitioner From: American Academy of Pain Management. 2006 [Fall];16(3):88 pages. Access checked 1/17/09.
Additional head-pain topics include:
Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies From: Biondi DM. Journal of the American Osteopathic Association. 2005;105(4Suppl2):S16-S22. Access checked 1/16/09.
Cervicogenic headache — pain referred from soft tissues or bony structures of the neck — is frequently unrecognized and can be resistant to conventional headache therapies. A checklist of criteria to identify headaches as manifestations of neck disorders addresses typical indicators identified in diagnostic reports, postural characteristics, and treatment failures with specific drug therapies. Evidence-based treatments for cervicogenic headache are explored in detail and include pharmacologic, nonpharmacologic, interventional, and surgical modalities.
The Patient With Daily Headaches By: Maizels M. American Family Physician. 2004;70(12):2299-2306. Access checked 1/15/09.
Challenges in the diagnosis and treatment of chronic daily headache (CDH) can be compounded by inconsistent or atypical symptoms. The author states that patient referrals to headache specialists have doubled in recent history and, further, provides a brief guide to the types of patient concerns that suggest the need for specialist consultation. The elements of a comprehensive patient assessment are reviewed, with emphasis on the need to rule out secondary causes of headache. A table of preventive therapies for CDH includes dosing instructions and common adverse effects; a separate protocol guides the treatment of medication-overuse headache. Treatment recommendations stress the need for patients to reduce headache triggers and use preventive medications.
21st Century Prevention and Management of Migraine Headaches From: National Institute of Neurological Disorders and Stroke (NINDS); 2001; 35 pages. Access checked 1/16/09.
Information for Healthcare Professionals [19 Headache Fact Sheets] From: American Headache Society. Various authors, undated. Access checked 1/18/09.
These 2 to 3-page fact sheets each contain an overview of the headache topic, a discussion of specific concerns or relevant data, and a conclusion with recommendations for management or incidence reduction. Several topics address treatment recommendations, including pediatric/adolescent migraine, prophylactic therapy, cluster headache, medication-overuse headache, and neutraceutical therapy. Specific issues that relate to diagnosis, exacerbation, and comorbidity include depression, photosensitivity, sleep disorders, and oral contraceptive use in women. Additionally, 3 of the fact sheets address the following questions:
[Note: The fact sheets list reference sources, but are otherwise undated.]
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Headache affects nearly everyone at some point in their lives. It is one of the most frequent reasons for physician outpatient visits and specialty consultations, and headache takes an immense toll in human suffering and socioeconomic consequences. Its various forms include migraine, tension-type, cluster, drug-overuse, sinus-related, and dental-related headache. Causes of headache may be relatively minor – due to infections, hangovers, or nutritional deficiencies – or very serious, such as brain tumor or stroke. Causes often are not secondary to some other disorder, but are biological ailments of the nervous system, as with migraine or cluster headaches. Documents in this section focus on the various types of headache pain, including their diagnosis and symptom management via approaches incorporating pharmacologic, nonpharmacologic, and/or complementary therapies, as well as other components of a comprehensive pain management program.
For additional and more specific headache pain documents, see the following sections….
HTML document available at: 
This eMedicine topic review begins with a brief discussion of the prevalence and classification of pediatric headache. Because migraine headache is the most common headache seen by the pediatric neurologist, a more detailed examination of the diagnostic criteria for migraine is presented. Secondary causes of headache and the rationale for neuroimaging in cases when an underlying structural pathology is suspected are discussed briefly. Recommendations are made for pharmacologic (abortive and prophylactic) and nonpharmacologic treatment of primary headache in children.
PDF available for download: 
Part 1 of the guidelines from University of Texas pediatric practitioners includes assessment and history considerations, diagnostic criteria for headache classification, and findings relevant to differential diagnosis in children and adolescents. Part 2 briefly reviews migraine pathophysiology and provides pharmacologic and nonpharmacologic recommendations for the management of the acute attack and prophylactic therapy. Behavioral guidance related to sleep, nutrition, stressors, and physical activity for this population is also presented.
This special issue of The Pain Practitioner journal is the last of a 2-part series on head pain (see part one entitled “Head Pain” below) and focuses on a wide variety of issues related to the diagnosis and treatment of migraine. As a disorder that affects millions of people, an awareness of current knowledge on migraine management is important for practitioners in all disciplines. Article topics include a thorough review of migraine pathophysiology, migraine-specific therapy for acute episodes and prevention, special issues in women with migraine, intravenous drug interventions for refractory headache, and the impact of headache disability. A special section explores the complex relationship between emotions, physiology, mood disorders, and the need for behavioral medicine and complementary therapies in chronic headache management.
This older document from the National Institutes of Health is a report covering state-of-the-art information presented at a conference in June 2000. This appears to be the most current report from NINDS on migraine headaches and is included here because it provides good information on migraine pathophysiology, migraine comorbidities, and management considerations in special populations. Treatment topics include acute and preventive drug choices for chronic migraine and cluster headache. Additionally, two convenient tables show evidence-based U.S. Headache Consortium rankings for acute and preventive medications.