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There is a vast array of information on the Internet and from various support groups such as the British Association for the Study of Headache, the American Association for the Study of Headache, the Migraine Trust, Migraine Action and the International Headache Society, all of which cover the treatment of headache disorders. What I thought I would do in this very much personalised article is try and add my own perceptions on the assessment and management of benign, that is primary, headache based on years of experience and seeing literally thousands of people with headache disorders over that time.
The word benign means that there is no sinister or malignant underlying process. The opposite of benign in medical terms is malignant. That does not necessarily mean cancer but it may do. There are a range of other conditions such as bleeding from an aneurysm called a subarachnoid haemorrhage, or meningitis that represents secondary causes of headache that can by virtue of the outcome be more “malignant”.
In this article, I am only considering those people who have primary headache. What I mean by this is that the individuals have normal MRI brain scans and no suggestion that there is any other sinister or significant pathology that is causing the headache disorder.
94-96% of the whole world will suffer headache at some stage in their life. These headaches may be tension type headache, migraine or a range of other benign diagnoses. About 4% of current headache sufferers will have chronic daily headache. This means that the individual will have headache on more than 150 days in a year. Within this group, a number will have chronic migraine, chronic tension type headache and also chronic analgesic overuse or medication overuse headache. In this situation, individuals generate more headache by virtue of the fact that they are taking regular analgesic preparations to try and help the headache. This is not a criticism of the individuals involved. It was commonsense for them and their managing clinicians and pharmacists to recommend painkilling tablets when headaches became a problem. In this group, the headaches do not cease as is usually the case but they persist with the analgesia then becoming an absolute need in their life. The individuals become dependent on the painkilling tablets. If they do not take the medication, the headaches get worse.
The International Headache Society has worked very hard over many years in order to prepare a definition and classification of headache disorders. The whole headache classification is again easily accessible on the Internet. Many of these definitions are contained in my article on headache on this website.
What is often poorly understood is the fact that the diagnosis of headache is made by Neurologists according to the descriptive history of the headache disorder given by the patient. Some Neurologists perceive that most, if not all, benign headache falls within the same continuum, that is benign headache is a spectral disorder. I have some sympathy for this view as most of the headache disorders seem to respond to very similar treatments. Whatever the right answer, it does appear that the trigemino-cervical neurovascular pathway in the brain stem is responsible for generating head pain. When this pathway activates, then an individual will get headache.
There is no such thing as a cause of primary headache. It is always multi-factorial. There will be a significant genetic factor. A small number of individuals never get headache and many will not have headaches throughout their lives. When there is a powerful family history of headache, then other members of the family will be more likely to suffer with headache disorders.
The trigemino-cervical neurovascular pathway stimulates the nerves that go to the face, head and neck. When this pathway is activated whatever the cause, the brain perceives that there will be pain in whatever part of the head and neck it identifies, albeit wrongly, as giving off abnormal signals. The pain itself is actually appreciated in the thalamus with the misery of the pain effectively arising from the front of the brain or the frontal lobe.
Over the years, I have heard specialists in many different fields saying that most headache is caused from the sinuses, the eyes, the teeth, the jaw joints, the neck, the spine or in fact any other part of the body. It is not so much that all these specialists are wrong, it is just that they have not quite fully grasped what is going on. Each of them is in fact correct in their own way. If there is a headache pathway, then quite simply any abnormality throughout the body will be responsible for generating more headache. These are triggers or risk factors and they modulate the firing of the trigemino-cervical pathway.
Over the years without too much evidence to support, I have used the analogy that if this pathway fires off …, you get tension headache. If it fires off ---, you get migraine and if it fires off .-.-, then you get a mixture of tension headache and migraine etc.
The key point for the management of all primary or benign headache is that the sufferer or person with the pain feels that they are working on the same team as the managing clinician. This is vitally important. Sometimes patients feel that they are on a different team and rarely on a different playing field altogether. If they are not on the same team as the managing clinician, then the management must fail. If the individual perceives that they have to persuade their clinician how badly they are being affected by their headaches, then they are not on the same team but they are on perhaps a different team on the same playing field. If there is a constant discussion about what treatment can be used with a perception that they as patients are not getting the best that is on offer, then quite simply they are on a different playing field altogether.
Hopefully in the case of the different team same playing field, it should be possible for the clinician to work with the patient to get them on to the same team. When however there is a repeated feeling that the patient is on a different playing field, then it is better for the patient to seek alternative opinion.
The headache diary is a fundamental “piece of investigation”. The headache diary should record the amount of pain, when the pain occurs, how long it lasts and what the individual does about it.
The diary should represent four sections of the day, namely morning, afternoon, evening and night.
The pain can be monitored in two different ways. Either it can be
0 = 0
1 = mild (that is just get on with it)
2 = moderate (wish that painkillers worked)
3 = severe (unable to lead a qualitative functional existence such as going to bed or not being able to work)
The alternative way of measuring pain of any type is the so-called visual analogue scale as follows:
This involves a linear or straight line. 0 at one end = 0, 10 at the other end represents the worst possible pain imaginable.
A grade 10 pain is beyond coping. It would require immediate medical attention. If you get severe headache but can go to work, breath, eat or even talk, then you do not have a grade 10 pain.
On the scale, 1,2,3 = mild, 4,5,6 = moderate and 7,8,9 and 10 = severe. No headache specialist is going to keep any patient with pain above 4 on a regular basis. This is what I mean by being on the same team. If a patient says that their pain is a grade 11, then they do not understand the process. In my experience, if this has to be pointed out more than once, then the patient is on a different playing field and should be invited to see another specialist. The reason I say this is that the individual is having to persuade the clinician that the pain is so bad and that they really do not understand how bad it is which means there cannot possibly be a trust in the managing clinician.
Over the years, I have identified that people particularly with migraine like to have full control in their lives. Stress in fact is defined by me as a situation when there is inadequate or no control of the living process. That can be anything. Each person can have their own stress or lack of control and the managing clinician, if on the same team, will never judge what that represents in their own life compared to what is the significance for the individual patient.
It is essential that the chronic headache sufferer monitors every aspect of the living process and writes down on a daily basis those times when control is not there.
That lack of control may be a problem with spouse, employer, employee, friends, work colleagues, neighbours and in fact anyone. It may be difficulties with money, bills, household chattels and chores or just be in the emotional state generally. Every single aspect of the living process may lead to a feeling that control is not complete and that in turn will lead to more headache for the migraine sufferer.
Once all of these difficulties have been identified, then work can be put in in order to correct them. Sometimes a specialist psychiatrist or clinical psychologist can be involved to help unravel the problems with great benefit on the headache.
Often for many of my patients, the identification of the problems means that there can be worked on by the brain with much better strategies invoked.
One of the most potent mechanisms I have found over the years that generates more headache in people is the so-called anger/guilt conflict. What do I mean by this?
The simplest example is the elderly parent who tragically has developed Alzheimer’s or some other degenerative disease. They are not able to look after themselves. They need total care and input from usually a loved child. Multiple phone calls during the night, the need to visit often on a daily basis, the chaos of their financial administration and everything else that is part of dependent existence will inflict on those who are trying to provide care. When this is for instance shared by one person as opposed to the whole family, then the conflict is even greater.
The anger is of course the fact that the parent is taking up so much time and emotional energy. They are waking at night. They are leading to a depressed and emotional state. The guilt the fact that the individual has felt angry over this when they are of course still a loved mother or father who has brought the child up so well, only for the child now to have negative thoughts about them.
This anger/guilt conflict leads to not just headaches. It will lead to more irritable bowel syndrome in people with gut disorders. There will be more chest pains and shortness of breath generally. Asthma sufferers will have more asthma. Skin sufferers will have more dermatitis and psoriasis as well as the obvious psychological disturbances.
Most specialists in medicine see such people but rarely have I seen the anger/guilt conflict discussed openly as a mechanism by which symptoms and syndromes are not actually caused but modulated by the situation.
The identifying of environmental and social trigger factors is important. Other factors are also important. Over the years, there has been a lot of discussion about food substances. I do not perceive that this is an allergic phenomenon. Some food substances clearly do trigger more migraines.
By the time an individual sees a neurologist, in my experience they have already identified what modulates the headache and so rarely is a new food intolerance detected. It is still worth thinking about particularly if someone is not aware that they are drinking 10-20 cups of coffee every day, not sleeping properly, eating a lot of cheese and chocolate and drinking red wine without realising it or similar. It is an interesting reflection that in France, it is perceived that it is white wine that causes headache whereas in England, it is red wine.
A colleague of mine did a study some years ago looking at this phenomenon. He adulterated white wine with spices adding those to red wine as well. The white wine and red wine became unidentifiable to those who were in the trial. All of them thought that red wine caused the headaches. When the trial finally unravelled, it was apparent that there was no difference between white wine and red wine in the generation of headache. A lot of food intolerance is in fact perception rather than reality. As long as the diet does not become too crazy, then there is no problem with the individual restricting themselves in some way. The problem I have seen however is that some organisations put people on to what can only be described as ludicrous diets, withdrawing enormous numbers of food substances and then insisting that a large number of vitamins, minerals and other food supplements needed to be added because the diet is so perverse.
I suspect that this does lead to improvement in headache but mainly because so much or life is taken up with worrying about diet and taking pills that there is not much time left to do anything else.
As I have already mentioned, anything around the neck and head will lead to more headache. Refractive errors rarely lead to headache but if there is a refractive problem, then a trip to the optician and correcting the glasses prescription will not do any harm.
Sinus disease is regularly mis-diagnosed when the true diagnosis is migraine or tension headache but in the region of the face or the frontal sinuses. I have seen so many people over the years who have been on literally dozens of courses of antibiotics for their sinuses when the diagnosis is in fact migraine with a predominant involvement of the face.
If however there is a tendency towards hay fever or chronic sinus disease, then appropriate sinus management will reduce the total headache load. It will not cure it.
Exactly the same comment applies to poor dentition with poor bite and the need for a bite-raising appliance. Tooth grinding at night and jaw clenching, known as bruxism, also need to be considered if there are symptoms in keeping.
The same comment also applies with regard to snoring when correction of the sleep pattern with appropriate treatment such as weight loss will be beneficial.
Finally similar comments apply to the neck. Mild cervical spondylosis is just so common. This does lead to neck spasm. Where there is neck spasm, there will often be more headache. There is a condition known as cervico-genic headache. This however is again only one facet of the headache disorder. Appropriate physical and medical treatments need to be introduced if the neck is identified as being a significant player in the totality of headache generation.
It is difficult to be dogmatic about who to investigate and when. To some extent, it depends on the nature of the presentation, the extent of the functional handicap and the pattern of the headache. Family history may be important.
The main investigation that worries primary care physicians referring patients and people themselves is whether or not MRI brain scanning ought to be undertaken.
It is my very solid opinion that CT brain scanning has absolutely no place whatsoever in the investigation of benign headache. CT brain scanning involves x-irradiation. It is much less sensitive in picking up any structural abnormality than MRI brain scanning. Migraine sufferers for instance can be found to have what are known as high signal lesions on MRI brain scanning which in turn may need further consideration and possible more extensive investigation. Those lesions would not be seen on CT brain scanning although in most people, in themselves they may not mean very much.
Usually it is necessary to undertake a full blood picture to check for anaemia particularly in women. Checking iron levels even with a normal haemoglobin can also be most informative. Other investigation might include assessment of thyroid function, a glucose level and also auto-immune studies, the extent of which are probably beyond the scope of this discussion.
The treatment of headache can be divided simply into non-drug and drug measures.
The non-drug measures involve the identifying of trigger factors and removal or treatment of them. It also involves the use of ice-packs, local heat, vibration, massage, acupuncture, physiotherapy, manipulation and transcutaneous electrical nerve stimulation to name just a few. All of these treatments, perhaps with the exception of acupuncture, have a success rate that is about 30%. This is the same as placebo responses in people with any headache disorder who enter the clinical trials programme testing drugs. I do not laugh at the 30% placebo response. I have noted for instance in my clinical practice that at least one-third of people coming to see me with a chronic headache disorder who receive appropriate investigation, full discussion and diarising of their symptoms, will get significant benefit from their headache just during the time that they are being assessed.
Why is this?
Our brain consists of one billion neurones, each of which has 10,000 connections. A whole stack of these fire in order to give us headache.
At no time in our lives does our brain stop working unless perhaps we are under very heavy anaesthesia.
At night, our brain continues to mull over everything that has gone on over the day. Information is sifted and stored. This process impacts on who we are as people.
How often do we try and think about something such as a name or a place we have visited. We cannot remember. Some three or four hours later, it suddenly comes to the surface of our minds. What has happened here? Simply our brain has continued working on the problem since we thought about what we wanted to remember. It has taken hours to sift the information and the answer arises.
As an aside, this is the very reason why all students taking exams must read the whole paper first. Even though a single question would be answered first, the brain will be working on all the other questions during the time that the first question is actually being answered.
I have never known any school to actually advise children that this is the case and it is about time they did so.
It is similar thinking that leads to headache resolution. A full discussion of the mechanism by which headache occur, the reassurance that there is nothing sinister taking place and the diarising of pain and the mechanisms that may be modulating it leads the brain to sort this out. In so doing, it switches off the pain generating pathway and headache is much relieved.
On this basis, I almost never introduce pharmacotherapy at the first visit but allow individuals to diarise their pain and then see how they get on at the next visit. Fortunately in the private sector where I practice now, that next visit will always be within one or two weeks whatever tests we do and it is interesting to see people whose headaches are much improved at that stage, not then requiring any kind of medication.
I have already mentioned physical treatments in the non-drug management of headache. There are a large range of therapists, many of whom are not medically qualified who claim benefit for migraine and other headache syndromes. Everyone is entitled to make a living and on the whole provided manipulation treatment is not too aggressive, there are few side-effects. Many people get benefit and of course one-third will get benefit because of the skills of the therapist in talking through the problem which in turn leads to the brain sifting a problem and then generating improvement. This does however lead two-thirds of headache sufferers still in trouble and they may well need pharmacotherapy or treatment with medications.
I find that most people have a natural hesitancy with regard to taking medications in order to block their headache. This is both reasonable and rational. Benign headache, as I always point out, is not going to kill people. What it does however is often cause a great deal of misery in life. I have heard myself saying so many times over the years “life is too short for headache!”. I think all my patients agree with me. If they have done everything they can to get risk factors under control and to deal with the anger conflict phenomenon as well as adopting a “you are quite right!” philosophy (explained later), then they may well need drug therapy to help them.
All drugs have side-effects but usually in headache work, the drugs used are low dose treatment regimes and side-effects usually reverse on withdrawal of the drug.
Perhaps I have been extremely lucky in my career that with all the thousands of patients I have seen with headache disorders, I have never yet witnessed a serious side-effect in any of my patients. This is not saying that side-effects do not occur but when they do, they are minor. They reverse very rapidly on cessation of the treatment and the introduction of something else.
If there was just one totally effective headache drug, then there would be one very rich drug company. As it is, there is no one drug that affects everybody beneficially. The benefit is about 60-80%. This means that there are a range of effective drug treatments for headache and in turn a significant number of very rich drug companies.
The key I think is in tailoring every drug regime to the individual patient you are seeing. There is no one size fits all. Each drug has to be explained to each individual and the appropriate medication found.
The medication of migraine can be split into two groups. There are the acute treatments of migraine and there are the prophylactic or preventative drug treatments.
The treatment of migraine can either be acute, that is trying to reduce the impact of any individual headache or migraine attack. Alternatively, as discussed later, treatment can be on a daily basis in order to try and reduce the total headache load.
Most headache sufferers by the time they get to a specialist would have tried various over-the-counter preparations. These include Paracetamol, Aspirin and the non-steroidal anti-inflammatory drugs such as Ibuprofen. When these simple medications are effective in blocking the headache, then nothing much else needs to be done.
By the time a consultant opinion is obtained, such treatment has failed and hence the need for referral.
Although, as has been stated earlier, the overuse of analgesia is to be discouraged, that comment does not apply to the treatment of any acute headache. The commonest mistake is not to use three Paracetamol, soluble Aspirin or Ibuprofen usually combined with an anti-emetic (anti-sickness) pill such as Domperidone which assists the absorption of the painkilling tablets. The anti-sickness medications themselves may also have some migraine-relieving properties in their own right. Part of the migraine phenomenon is the inability to absorb medications because the sphincter or muscle at the lower end of the stomach closes off. This is the reason why migraine attacks are usually accompanied by nausea and/or vomiting and loss of appetite.
There are more powerful anti-inflammatory medications such as Diclofenac or Tolfanamic Acid. These can be administered by themselves or with Paracetamol together with an anti-emetic. This is a little cocktail of medications which can be very effective.
For people who vomit early in the attack, this may be ineffective and there are anti-sickness preparations that dissolve in the mouth or can be given by suppository. All of this needs to be discussed with your managing clinician.
There are a group of acute migraine drugs known as the triptans which have been designed to block the acute migraine attack. There are seven different triptans. Each of them has a slightly different chemical structure. They work in a different way on different people. They are also available in four different forms, namely tablets, nasal sprays, wafers that dissolve on the tongue, and one injectable form.
All the triptans tend to work about 60-80% of the time. They are probably the most effective single acute agents for migraine relief although they are much more expensive than simple painkilling tablets. The skill is in finding which of the agents suits each individual person the best.
Simple advice given by myself includes taking three soluble Aspirin with the anti-emetic at the very onset of the attack. If in one hour, there is no benefit, then I recommend one of the triptans in wafer form to be taken at that time. Each attack is in effect a model of treatment for the next so that the best regime of treatment is found for each individual patient.
Although the triptans are said not to be that effective in acute tension type headache, in my experience mainly because of difficulty in differentiating acute tension type headache from migraine, there is often benefit from this same regime whatever the diagnosis.
If any treatment regime does not work, then that is an indication for further interaction with the managing clinician who can once again tailor the treatment needs.
There is evidence showing that the combination of an anti-inflammatory drug for instance with a triptan is better than either alone. Other medications are available and should be discussed with your Neurologist.
We know that preventing migraine frequency and severity improves quality of living. Perhaps not surprisingly, there is now also evidence showing that if you take a prophylactic medication, there is more likely to be a better response to acute migraine therapy.
Prophylactic therapy also reduces the likelihood of headache transformation from acute migraine or tension type headache syndrome to chronic daily headache which encompasses chronic migraine and chronic tension type headache syndromes.
Amazingly only one drug has ever been specifically developed for migraine prophylaxis and that was an agent called Methysergide. This drug is still available but it does have long-term side-effects and hence is only used in certain specific situations.
All of the other migraine prophylactic drugs have emerged purely by chance. What this means is that a medicine has been given for some other condition. Whether or not the primary condition was actually treated, we do not know but patients ended up saying to their doctors that their headaches had got much better. This then led to doctors using these drugs specifically in headache sufferers in so-called pilot studies. Formal trials have taken place with many of these agents demonstrating that they do benefit.
The current indications for using prophylactic therapy would include the following:
It is a strange truth that the selection of migraine preventative therapy tends to depend on the side-effect profile for any patient rather than the benefit. An exceptional number of drugs have been tried in order to try and prevent headaches. They tend on the whole to fall into a number of groups. Those groups include anti-epilepsy drugs, anti-depressants, heart drugs and then a whole range of other drugs as well.
One of the problems with this group of treatments is that some of the possibly most effective agents are not going to be fully investigated at this stage because they are quite old, out of patent for their original use and hence there is little or no benefit from the perspective of the pharmaceutical company in order to undertake the very large trials that would be necessary to show benefit.
In order to know if there is any benefit, doctors rely on so-called clinical trials. Some trials are obviously better than others depending on how they are designed, the way in which headache is measured and then the number of people who are enrolled into the study. We recognise that there are Class 1, Class 2 and Class 3 trials.
Medications that are so-called first-line drugs would have proven high levels of benefit (efficacy) based on at least two Class 1 trials.
These drugs include the following: Sodium Valproate and Topiramate, anti-epileptic drugs, Amitriptyline, an antidepressant drug, beta-blocking drugs such as Propanolol and Metoprolol and then the more old-fashioned serotonin antagonist, Methysergide
Strangely one of the triptans, a so-called serotonin antagonist, Frovotriptan, has also been shown effective. There is a herbal preparation called Butterbur, a petasite, which has also been shown effective.
Added to this group, there are medications that sit within a slightly lower class of benefit including blood pressure treatments called Candesartan and Lisinopril, the anti-epileptic drugs Gabapentin and Pregabalin, antidepressant drugs Fluoxetine and Venlafaxine, as well as a range of other medications including Cyproheptadine, Atenolol, a range of anti-inflammatory drugs, other triptans and vitamin B2 and Co-enzyme Q10.
There are then a range of other drugs that sit within a lower category of trial proof.
As can be seen, such a wide range of medications need a lot of consideration.
In my practice, I would say that the slow-release preparation of Sodium Valproate, Topiramate in low dose and Dosulepin, a tricyclic antidepressant drug, would be my own first choices.
In young men, Sodium Valproate chrono starting at the very low dose of 200 mg. at night would be a frequent first choice. In young women however where no drug is known to be safe in early pregnancy, Topiramate 25 mg. at night is often the most preferred agent because of all the migraine prophylactic agents, it seems to be the only one that reduces appetite. There is nothing more satisfying I find in the management of a lady migraine sufferer when she returns having excellent headache control with a low dose of Topiramate at night and having lost 7 kg. in weight when she has been overweight. Do remember that if headache load is reduced, then the increased socialising and return to normal life will usually lead to increased weight due to return of appetite unless exercise is increased.
Many neurologists and pain specialists use the drug, Amitriptyline, which is a tricyclic antidepressant drug, in low dose. There is no doubt that the tricyclic antidepressant drugs are an excellent pain-relieving treatment for many types of pain. This is recognised by the English government NICE who recommend the tricyclic anti-depressant drugs as a first-line choice for pain management after analgesia has not been effective.
In my experience, Amitriptyline, which is almost certainly a better antidepressant drug than Dosulepin, has too many side-effects in many neurological patients and so I tend not to use it.
Dosulepin or Nortriptyline tend to have a better side-effect profile. The skill however is to find the lowest dose that works. If the patient finds a low unit dose ineffective from a side-effect perspective, then they should reduce the dose even further in order to make sure that this potentially effective treatment is not denied to them. Often if they can tolerate the treatment in very low dose, then the treatment dose can be increased slowly without side-effects intervening.
One of the great advantages of the tricyclic antidepressant drugs is the effect that they have on a disturbed sleep pattern. Disturbed sleep in migraine sufferers is very common and often there is an associated low mood with the headache frequency and disturbed sleep pattern.
As I point out to many of my patients with a sleep disturbance and low mood, the tricyclic antidepressant drugs have a positive side-effect. That side-effect reflects that they are actually antidepressant drugs as well. They elevate a low serotonin level and this is known to increase or benefit mood.
It is however an interesting reflection that the doses of the antidepressant drugs used in headache control are much lower than the doses that would be recommended for the psychiatric treatment of depression.
All of the headache prophylactic drugs need to be carefully titrated for each patient to find the dose that works without significant side-effects. This is an art not a science. Often it takes time and the patient has to trust the judgement of the doctor in the same way as the doctor has to listen to the patient.
These medicines need to be used for a minimum amount of time. Do not expect benefit overnight and the build-up may take several weeks.
Once the treatment is found to be effective, it will not be needed lifelong. Usually it is necessary to treat for a minimum of three months though often six to twelve months may be necessary.
A lot will depend on all of the surrounding circumstances by which the headaches have emerged. If there is a lot of stress, as discussed above, in life, then breaking the headache pattern will enable more control of the living process and that may take time.
Once an individual has their living process under better control, then they will be able to consider reducing the headache prophylactic agent slowly with scientific evidence now showing that after a prolonged period of headache remission with the drugs, the drugs can be stopped and headache remission continue.
If these first-line drugs do not work, then as indicated there are a whole range of other first-line and second-line treatments that can be tried in order to block the headache frequency.
It is truly only very rarely that no treatment can be found for patients with tiresome headache.
This small group of patients may need other treatments that are beyond the scope of this article such as occipital nerve injections or even trials of botulinum toxin injections though the evidence for the latter is still rather limited, the treatment invasive and very expensive.
Each of these situations needs input from a specialist Neurologist in order to determine the level of investigation and how to treat.