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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.
Researchers/reviewers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD.
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Chronic Headache: Stop the Pain Before it Starts
By: Latimer KM. Journal of Family Practice. 2013(Mar);62(3):126-133. Access checked 5/16/13.
PDF available here: http://www.chronicpainperspectives.com/PDF/CHPP/Mayf1.pdf
Written for the family practice physician, this article focuses on the challenges of treating patients with chronic headache and addresses the risks associated with medication overuse and the importance of prophylactic therapy. The author provides a review of the assessment components necessary for an accurate diagnosis, the known risk factors for chronic headache, and a comparison of the characteristics of chronic migraine versus other primary headache disorders. A helpful summary table presents the diagnostic criteria and first-line treatment for 5 chronic headache conditions. Additional monograph features include a list of headache red flags and a patient case example to show the importance of identifying and appropriately managing medication overuse headache. The evidence for prophylactic migraine therapy includes guidance on agent selection for each patient based on comorbidity as well as individual drug benefits and adverse effects when considering the therapeutic options.
Treatment of Headache in the Elderly
By: Hershey LA, Bednarczyk EM. Current Treatment Options in Neurology. 2013(Feb);15(1):56-62. Access checked 2/21/13.
PDF available here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3553408/pdf/11940_2012_Article_205.pdf
Headache symptoms in elderly patients can present in ways that differ from those of younger adults and contributing factors can be more diverse and complex. Migraines in older adults can begin with visual or sensory phenomena before headache pain is apparent. While primary headaches tend to decline as people age, secondary headaches can become more common and include a wide variety of causes from sleep apnea to intracerebral hemorrhage. Hypnic headaches occur only in the elderly during sleep but can awaken the victim with dull or throbbing pain that can last between 15 minutes and 3 hours. The authors review the common types of later-life headaches and provide prevalence data as well as typical and atypical symptom characteristics. A list of oral and intravenous agents for acute and prophylactic headache therapy includes information on the action of the agent, standard dosage, contraindications, and the most common adverse effects.
Loosening the Grip of Migraine Attacks
By: Wenzel R, Aurora SK. Pharmacy Today. 2012(Jan);(18)1:61-72. Access checked 11/12/12.
PDF available here: http://elearning.pharmacist.com/Portal/Files/LearningProducts/...article.pdf
This educational monograph addresses migraine assessment — including a determination of migraine-related disability and those patients who are self-treating but should be referred for physician evaluation. The authors emphasize opportunities to educate patients on the best use of over-the-counter products, the importance of therapy timing, and drug dosing information. A review of migraine treatment stresses that 'stratified care' is the therapeutic approach recommended by the U.S. Headache Consortium and should replace 'step care.' A discussion of abortive and prophylactic therapies includes brief information on the status of investigational drugs and the evidence for alternative treatment and nonpharmacologic strategies. (Note: isometheptene combination products referenced in one of the graphics are no longer on the market.)
Biofeedback in Headache: An Overview of Approaches and Evidence
By: Andrasik F. Cleveland Clinic Journal of Medicine. 2010(Jul);77(Suppl 3):S72-S76. Access checked 12/04/10.
PDF available for download: http://www.ccjm.org/content/77/Suppl_3/S72.full.pdf+html
Biofeedback techniques have been used for decades to relieve the painful symptoms of migraine and chronic headache. An expanded number of techniques in recent years have resulted in improved outcomes for many patients. This article reviews the efficacy criteria developed by the U.S. Headache Consortium as well as existing evidence for using general biofeedback techniques and headache-specific therapy. The results of evidence-based studies and meta-analyses on electromyographic (EMG) and thermal biofeedback, with and without relaxation training, are summarized. Based on the cumulative findings, the author concludes that some forms of biofeedback provide effective relief for many patients with migraine and tension-type headache and, in some cases, provides relief equal to that of medication alone. An additional number of patients find improved relief with combined biofeedback and medication therapy. The research on electroencephalographic (EEG) biofeedback is also reviewed.
Breaking the Cycle of Medication Overuse Headache
By: Tepper SJ, Tepper DE. Cleveland Clinic Journal. 2010(April);77(4):236-242. Access checked 9/11/10.
PDF available for download: http://www.ccjm.org/content/77/4/236.full.pdf
Migraine treatment can become complicated when frequent attacks result in increased medication use and cause a rebound effect. A condition called medication overuse headache (MOH) can occur and further complicate migraine therapy. This monograph defines chronic daily headache and the transformation to MOH in terms of headache days per month and drug consumption. The authors review the symptoms of MOH and discuss the use of prophylactic agents that can reduce overall drug usage to help prevent this negative cycle. Two approaches are presented for weaning a patient from all current headache medications and subsequently beginning an alternate well-defined drug regimen. Clinicians are reminded that relapse is common and patients must be followed regularly.
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.
HTML document available at: http://www.emedicine.com/neuro/topic528.htm
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.
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.
PDF available for download: http://www3.interscience.wiley.com/cgi-bin/fulltext/121432412/PDFSTART (321 KB)
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.
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.
Part 1 – See HTML article at: http://www.medscape.com/viewarticle/562981_print
Part 2 – See HTML article at:: http://www.medscape.com/viewarticle/569475_print
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.
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 (2010 Update); 52 pages. Access checked 12/13/10.
PDF available for download: http://18.104.22.168/upload/NS_BASH/2010_BASH_Guidelines.pdf (467 KB)
This easy-to-read 3rd edition guideline (updated in 2010) 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.
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.
PDF available for download: http://www.aafp.org/afp/20071115/1518.pdf (120 KB)
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.
PDF available for download: http://www.springerlink.com/content/6126x3pp05713t83/fulltext.pdf (525.7 KB)
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.
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.
PDF available for download: http://www.jaoa.org/cgi/reprint/105/4_suppl/16S (120 KB)
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.
PDF available for download: http://www.aafp.org/afp/20041215/2299.pdf (198 KB)
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.
PDF available for download: http://www.ninds.nih.gov/doctors/OP129A_Clinician_fa.pdf (314 KB)
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.
Information for Healthcare Professionals [19 Headache Fact Sheets]
From: American Headache Society. Various authors, undated. Access checked and updated 12/4/11.
HTML list of all fact sheets, which can be downloaded, is available at:
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:
- Is migraine a progressive disorder?
- Is a hemicranial headache always a migraine?
- Does sinus headache exist?
[Note: The fact sheets list reference sources, but are otherwise undated.]
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