Headaches: Mechanisms and Management Bernard M. Abrams, M.D. |
||||||||||||||||||
Objective:
The goals of any headache evaluation are two-fold: 1) the recognition of common syndromes for which treatment is available, and 2) the recognition of syndromes which constitute a threat to life or function. The headache evaluation consists of a detailed history, pertinent information from the physical examination and pertinent diagnostic laboratory studies. Of these far and away, the most important element is the headache history. The late Dr. A.L. Sahs stated, "If you have thirty minutes to see a patient, spend twenty-nine on history, one on the examination".(1) Mechanisms of head pain The mechanisms of head pain include:
The major categories of headache disorders are given in Table 1 GENETIC MECHANISMMigraine is well known to be a familial disorder with the risk factor of migraine 50% more likely in relatives of migraineurs than in controls. But the patterns of inheritance are complicated and, as a result, the role of inheritance of migraine is unclear. Rapid molecular biological technological advances are being applied to analysis of migraine. Specific mutations leading to an increased risk of rare forms of migraine have been identified in both mitochondrial DNA and a calcium gene channel. Approximately one-half of the families known to have familial hemiplegic migraine, including all families with FHM and progressive cerebellar ataxia show genetic linkage to chromosome 19p 13. This type of migraine appears to be caused by a mutation in a subunit of neuronal P/Q-type Ca++ channels. BIOLOGICAL BASIS There are 2 fundamental theories concerning the genesis of migraine: (1) vascular and (2) neurogenic although it is now believed that both are involved in the migrainous process. It is also noted that testosterone levels are altered during an attack of cluster headaches. Acute cluster headaches triggered by nitroglycerine have been studied by PET scan. The activated areas fall into 3 categories: (1) areas generally associated with pain; (2) an area that seems specific to cluster headache; and (3) vascular structures. The anterior cingulate was significantly activated, as would be expected, because activation of the anterior cingulate by pain is observed in most human PET studies. Activation was also noted in the frontal cortex, insulae, and ventroposterior thalamus contralateral to the side of the pain. In addition, activation in the ipsilateral basal ganglia was observed. The only activated area that is unique to cluster headache is the ipsilateral hypothalamic grey matter in the region of the base of the third ventricle. Activation of the hypothalamic grey matter is not seen in migraine, nor in experimental first trigeminal division head pain. This region is not activated when the patient is not having a bout. During acute cluster headache attacks, activation is observed in the region of the cavernous sinus and has been shown using MRA to be caused by internal carotid artery vasodilatation. Similarly, during experimental head pain induced by injection of capsacin, the same region is activated. This finding implies that the activation of the carotid does not relate specifically to cluster headache, but it is a trigeminovascular autonomic reflex caused by first division pain. The flow changes are, therefore, an epiphenomenon of the trigeminal activation. This mimics Ekbom's classic observation made during angiography of a patient suffering from an acute cluster headache that there are changes in the internal carotid artery. Headache evaluation
Little guidance is offered for the headache history by standard textbooks of neurology (2) because major attention is usually directed toward entities producing headaches which leaves the questioner to evolve his own set of headache questions based upon diverse information from a wide variety of conditions. While headache history guidelines and lists are available, (3,4 ) the author has evolved a list of twenty questions in order to elucidate the headache history. Because the classification of headache has recently undergone revision (5) and there has been a rapid flux in the current conceptions of the pathogenesis of various types of headaches with what was formerly known as muscle contraction (presently called tension type), and migraine being conceived of as much more of a unified disease rather than two diseases. (6) The present author has chosen to classify headaches as:
In the headache evaluation, factors that cause concern are:
QUESTION 1: WHERE AM I? While on the surface this may seem like a frivolous question designed to test the examiner's own sense of orientation, it is on the contrary the beginning of a separation of headaches into one or two types. One finds oneself in the emergency room seeing a patient in two types of situations: 1) an acute life threatening situation, or 2) the first chronic benign headache which is severe. Life-threatening headaches present as either headaches of great severity associated with meningeal signs, and immediately suggest the need for contrast studies, usually an immediate CT scan followed by a lumbar puncture, or hemispheric type syndromes giving unilateral signs, symptoms, and perhaps signs of increased intracranial pressure. Confusion arises with the first chronic benign headache, such as a migraine headache in a l5-year old young lady. Therefore one may have to go through the entire differential diagnosis and also do everything required of an acute life threatening headache in order to rule out any life threatening problem. The first headache of a chronic benign sequence which is severe enough, migraine cluster muscle contraction headache, trigeminal neuralgia, sinusitis and many other types of headaches may lead the first time sufferer to the emergency room, whereas with repeated familiarity the patient would simply seek the appropriate treatment. If the physician is in the hospital called as a consultant, then one may be dealing with an acute or chronic life threatening situation which has gone beyond the emergency room stage. Presumably in the emergency room, all immediately demonstrable life threatening headaches will have been resolved so that the CT scan will have shown a subarachnoid hemorrhage, tumor, or cerebral edema, and the lumbar puncture will have ruled in or out any type of meningeal syndrome, most likely infection or subarachnoid hemorrhage. (7) Chronic headaches, either life threatening or benign will often warrant hospitalization, especially if associated with a systemic illness such as fever, leukocytosis, weight loss, claudication and joint manifestations, or if the patient is particularly emotionally labile. The entities of chronic meningitis, developmental abnormalities such as platybasia or Arnold-Chiari malformation, subdural hematoma or emotional disorders suggest themselves. In the office, most headaches are chronic benign headaches. Rarely they are chronic and life threatening. At a social event one approached by a headache sufferer will almost always be dealing with a chronic benign headache. QUESTION 2: WHAT'S THE MATTER? This is an open-ended question, and tends to eliminate most of the complaints while not leading the patient. It compromises between an economy of time and a freedom for the patient in allowing the patient to tell his/her own headache history. If the patient begins to delineate a headache history, he/she should be allowed to do so freely. However, at the conclusion of this period of the questioning, the patient should be asked if there is a second type of headache, or perhaps even a greater number that has been experienced by the patient previously. QUESTIONS 3 & 4: HAS THIS EVER HAPPENED BEFORE AND IF SO, IS IT If the patient has never had a headache of the type suffered at present before, it is a definite warning sign that one may be dealing with an acute life threatening headache. The "sentinel" headache of subarachnoid hemorrhage is well known and may be a minor feature. It is far more reassuring to hear that a patient has suffered the same headache before than to find out that the headache is occurring for the first time. Part of the interpretation depends upon how old the patient is. Obviously a 50-year old male who has never suffered a headache before and suddenly experiences a severe headache is much more at risk for an acute life threatening headache than is a 15-year old girl who has never experienced a headache before of similar type and who has a strong family history of migraine. Both of them demand a workup, but the index of suspicion is much higher with the older patient. By the same token, a headache which is relatively nondescript, but progressively increases in severity and decreases in the interval between headaches, also suggests the possibility of life threatening type situation. One must beware of chronic life threatening headaches such as that associated with slow-growing tumors, subdural hematoma or chronic meningitis. Oftentimes these headaches are relatively diffuse in their location and relatively nondescript in their character. Further, they may go away for periods of time which are variable, but may be up to several days or even weeks allaying one's suspicions that they are life threatening. Obviously the situation in which one finds oneself makes a great deal of difference. For example, if a patient had a severe head injury with unconsciousness three or four weeks before, then a headache which comes and goes may be of greater significance than a headache in a non-head injured patient under severe and episodic stress at work or at home. QUESTION 5: IF THIS HAS HAPPENED BEFORE, FOR HOW LONG, This question again points to the differential between acute or chronic life threatening and chronic benign. If a headache is a single episode in a sequence of recurrent headaches, then one can be more confident that it is a chronic benign, recurrent syndrome. The headache which has been present for many years off and on, or even many years continuously suggests a more benign process. However, again if that headache changes in character, for example, lasts longer, is of greater intensity, or is associated with neurological sequelae, then attention must be drawn to the possibility of it as a life threatening situation. QUESTION 6: IF THE HEADACHE IS THE SAME, WHAT IS THE By this time one can be fairly confident that he has differentiated between acute or chronic life threatening situations and chronic benign headaches. This question tends to differentiate between recurring vascular headaches versus chronic tension type headaches. Recurring vascular headaches tend to be episodic and associated with headache free periods, while chronic tension type headaches tend to be headaches which occur every day or at least frequently. There is of course a mixed type headache, in which chronic tension type headaches are interspersed or punctuated by vascular type headaches. QUESTION 7: WHAT IS THE CHARACTER AND LOCATION? A vascular headache is generally pounding in type, sometimes synchronous with the pulse. It can be diffuse or holocranial or unilateral. The classical migraine headache is unilateral, giving rise to its name of hemicrania. The tension type headache is a steady headache, usually generalized over the head, sometimes beginning in the neck muscles or suboccipital region, and then becoming holocephalic and sometimes beginning in the frontal regions. A cluster headache is a stabbing type headache often described as a "hot poker" and is almost always unilateral and focal through the eye. Trigeminal neuralgia is focal, usually in the 2nd or 3rd division, and a flashing type pain of extremely high intensity. The headache associated with tumor, while focal, is generally nondescript. The patient with psychogenic headache will describe a generalized headache, usually with some bizarre features either as to the character of the headache or other features to be described below. In the patient with subarachnoid hemorrhage, if the patient retains consciousness it is not unusual to hear the headache described as tearing, bursting, exploding and certainly the worst headache the patient has ever experienced if they have experienced other types of headaches. QUESTION 8: WHAT IS THE ONSET TO PEAK TIME? Migraine headaches of the classic variety take thirty minutes to an hour to peak. The more common type takes one to two hours to peak. Muscle contraction or tension type headaches take two to four hours to peak. Cluster headaches may awaken the patient with the first REM, and then of course the patient has an "instant headache". If the patient is awake at the time of onset it takes five to ten minutes. There has been a tendency to regard the rapid onset to peak time as carrying a bad prognosis and import, and more often than not this is not true. Orgasmic headache, benign exertional headache, trigeminal neuralgia and the perceived onset of ice cream headache are almost instantaneous. Nonetheless, any patient who has a very rapid onset to peak time must be viewed with some concern. QUESTION 9: WHAT IS THE USUAL TIME OF DAY IT OCCURS AND Migraine occurs at any time, although probably more characteristically in the morning than any other time. The duration is between six and seventy-two hours and especially until sleep can be induced. Cluster headache occurs with the first REM, usually ninety minutes after the patient retires for bed. There is a tendency when medication is started for cluster headache to be "chased around the clock", and to occur then early in the morning and then with increasing medication, later in the day. Usually the common cluster headache occurs with a duration of twenty to forty minutes. Muscle contraction headache occurs usually from 4 pm on, and lasts somewhere in the neighborhood of six hours, although this is not inviolable. QUESTION 10: ARE THERE ASSOCIATED AND/OR RESIDUAL Sonophobia or noise intolerance is nonspecific. Photophobia occurs in vascular headaches. A stiff neck or meningeal signs requires workup for subarachnoid hemorrhage, and if a CT scan is normal, demands a lumbar puncture. Scotomata hemisensory defects, cranial nerve palsies preceding the headache suggest the possibility of a vascular type headache. Myosis and pseudoptosis or ipsilateral Horner's syndrome suggest cluster headaches. Any residual neurological deficit raises the possibility of complicated migraine headache on the basis of subarachnoid or intracerebral hemorrhage, cerebrovascular disease, meningitis or space occupying lesion. Fever associated with the headache suggests the possibility of infection. QUESTION 11: IS THERE AN AURA? Repeated headache preceded by scotoma, hemianopsia, cranial nerve palsies, hemisensory phenomena are almost always vascular, and represent classical migraine. QUESTION 12: WHAT MAKES THE HEADACHES WORSE? Vascular headaches are worsened by alcohol, tyramine containing foods, MSG (a common food additive), Nutrasweet, birth control pills, drugs containing vasoactive properties such as vasodilators. Stress or neck position usually implies muscle contraction headaches; bizarre things, psychogenic headache. Exertion generally implies benign exertional headache and the headache associated with intercourse if repeated more than once is almost undoubtedly an orgasmic headache. QUESTION 13: WHAT MAKES THE HEADACHES BETTER? Migraine headaches are made better by sleep, by ergot and by any pain medications. They are often improved by pressure over the side that is throbbing. Cold compresses are relatively nonspecific, and may improve migraine or muscle contraction headache. Heat usually improves muscle contraction headaches as does alcohol. A history of oxygen inhalation improving the headache suggests cluster headache. A history of nasal drainage followed by relief of headache suggests the possibility of sinus headaches. QUESTION 14: IS THERE A FAMILY HISTORY? A family history is present in migraine headaches in 75-85 percent, and in muscle contraction headaches, 50 percent. QUESTION 15: WERE THERE HEADACHES IN CHILDHOOD? While tension type headaches do occur in childhood, most childhood headaches have a vascular basis. QUESTION 16: WAS THERE MOTION SICKNESS, CYCLICAL These are childhood antecedents of migraine and oftentimes produce puzzling type syndromes for the pediatrician and only in retrospect is it noted that the patient has become a migraineur in adulthood. (8) QUESTION 17: WERE THERE ANY PRIOR DIAGNOSTIC TESTS? The implications of this almost seem too obvious to be discussed, but it is fairly clear that if a patient has had a workup including CT scan or MRI within the past year or two, that the possibility of a structural lesion is considerably diminished. The question of when to repeat studies comes up and it is the author's personal conviction that any change in the headache should militate in favor of a contrast study of the head, most usually CT scan or MRI regardless of the time of the last CT scan or MRI, but it is the author's practice that if a patient is not responding to treatment to repeat these studies if they have not been done within a one year period of time. QUESTION 18: WHAT WERE THE RESULTS OF PRIOR The results of prior medication should then be ascertained for two reasons. 1) as a "therapeutic test", and 2) as a guideline to future treatment. The results of analgesics are nonspecific and avoidance of narcotic medication in a patient with chronic headache is mandatory . At this point it may become evident that the patient if not previously known to the physician is drug-seeking. One of the surest signs of this is the specification of a powerful narcotic as the only drug which will stop the patient's headaches. Drugs which have no pain reducing qualities in and of themselves such as ergot, midrin, oxygen, steroids and non-steroidal anti-inflammatory drugs generally indicate that the patient has vascular headaches if they are efficacious. Drugs with mild sedatives such as butabarbital in Fiorinal or Esgic plus are useful in patients who have tension type headaches. Prophylactic medications include lithium, Sansert, steroids for cluster headaches; an older drug that has been used for cluster is Periactin. Inderal or beta blockers, amitriptyline, Prozac, calcium channel blockers and more recently Depakote have been used in prophylaxis for migraine. There is a definite overlap between amitriptyline as a drug for muscle contraction headaches and vascular headaches. Oftentimes a patient will dismiss a drug as, "I'm allergic to it", and closer inquiry will reveal that the patient received too much of the medication over a short period of time and developed dose-related side effects, or that the medication was "not efficacious" which generally means that the medication has not been slowly and judiciously pushed to its limits. QUESTION 19: ARE THERE ANY OTHER MEDICAL ILLNESSES? This is especially important for ascertaining if the patient may have been given medications which may trigger headaches. For example, if the patient has heart disease, vasodilators may give headaches and the institution of estrogen therapy in a menopausal woman may also start up a new skein of headache. However other medical conditions such as polymyalgia rheumatica (usually given not as a diagnosis, but as a group of symptoms), rheumatoid arthritis which may give cervical spine disease, cancer which may give metastatic manifestations or immunosuppressive diseases should be clues as to the possible substratum on which serious and life threatening headaches may arise. QUESTION 20: IS THERE ANY PHYCHIATRIC ILLNESS, HISTORY OF A history of psychiatric illness does not necessarily mean the patient's headaches are psychiatric, but it is well to suggest the possibility that headaches may be stress related before having the patient undergo extensive testing. If extensive testing fails to yield an etiology for the patient's headache and then psychiatric consultation or psychiatric diagnosis is suggested, the patient may view the physician's suggestion as punitive. A history of substance abuse or drug addiction or alcoholism should militate very strongly against using narcotic drugs, benzodiazepines or other drugs with a potential for cross addiction. Sometimes the etiology of a headache will appear to be most obscure. It is the author's practice then to ask the patient to describe in full detail the circumstances of life under which the patient's headache started. If the patient states, "Nothing was going on", at the time the headaches began then it is the author's practice to inquire specifically about the patient's job, any deaths in the family, the state of health of other family members, any life transitions, and this will often reveal what was going on. Finally, it is the author's habit to ask the patient to describe a typical headache if they have many, and a headache in great detail if they have few, beginning with the circumstances the day before, if these can be identified, and proceeding through the entire headache plus the next day. THE TARGETED HEADACHE PHYSICAL EXAMINATIONThe headache patient will commonly show no abnormalities on examination if he has a chronic benign type of headache. Incidental abnormalities may be encountered which are not germane to the patient's situation. However in all patients, a careful general physical and neurological examination should be carried out. In addition to the general examination, the skull and spine should be examined. The patient should have a complete examination of the head, eyes, ears, nose and throat for sinus disease, temporomandibular joint disease and even dental disease. Oftentimes pain referred to the head will come from the teeth and while sensitivity to cold is nonspecific, sensitivity to warmth such as using a warm test tube on a tooth, tapping a tooth or having a patient hold a warm liquid in their mouth may be specific for an abscessed or diseased tooth. In the general examination attention should be pain to the possible existence of cafe au lait spots or other stigmata of the phakomatoses. Examination of the range of motion of the neck should be carried out as well as a complete neurovascular examination. In the elderly with any suspicion of temporal arteritis, examination of the joints of the body plus the temporal arteries is mandatory. The general configuration of the body especially a short neck or a low hair line may suggest congenital anomalies which may lead to headaches. The presence of obesity should be considered as a risk factor for the development of pseudotumor cerebri. While there are numerous texts on the neurological examination ranging from those which are short and easily mastered (9) to those that are exhaustive (10) the author prefers the following scheme because of its thoroughness, but efficiency.
The seventh cranial nerve is conveniently checked by having the patient close his eyes tightly and bare his teeth. He can also elevate his eyebrows and flare his nostrils. At this point, tongue movements can be checked including whether or not the tongue is protruded in the mid line. The tongue then should push the examiner's finger away in each cheek. The eighth cranial nerve should be checked already when the vibration is checked during the sensory exam. The ninth and tenth cranial nerves should be checked by observing the palate, the palatal movements and touching the back of the throat on either side with a cotton swab. The eleventh cranial nerve is checked by resistance of the patient to attempts to turn his deviated head from right to left, and left to right. At this point, the strength of anterior flexion and extension of the neck should be checked. Finally shoulder shrugging should be checked. This entire scheme of the neurological exam should not take more than five to seven minutes in a healthy, normal adult. Obviously any portion of the neurological exam which is abnormal should be followed up. CONCLUSION If one goes about the headache history and physical examination in a systematic way, one can rapidly exclude acute or chronic life threatening headaches and decide on which patients require immediate or at least further diagnostic testing. One can then separate out into the most likely type of common headache syndrome. Further, with these type questions in mind, when one is confronted with a new type of headache, one can then try to fit that headache into the framework or these questions so as to develop as "data bank" of questions for future delineation of any new syndrome. HEADACHE: FACTORS THAT CAUSE CONCERNClues to headaches which are life threatening and which cause concern come from the history, the physical examination and the diagnostic tests which are ordered. Saper (11) lists four key factors distinguishing physiological (primary) from secondary (organic) headache. These are:
Diamond and Dalessio (12) make no specific allusions to danger signs. A list of "danger signs" in headache pain patients that suggest the need for immediate attention are: (13)
An extensive list of headaches of acute type is included in Wiener. (14) Certain types of headaches may be difficult to diagnose even with a high index of suspicion and some situations which on the surface would appear ominous are more benign than commonly thought. The evaluation of factors which cause concern begins with the initial site of contact with the patient (Question 1). In the emergency room generally the patient has a severe headache although the first chronic benign headache which is severe, should be excluded. Questions 3 and 4: Has this ever happened before, and if so, is it progressive? If a patient has never had a similar headache before or the headache is progressively increasing in severity it raises the concern that the patient may have an ongoing process such as brain tumor or infection. A special case of headache which has never happened before is the so-called sentinel headache in subarachnoid hemorrhage. This has been extensively written about, and remains a subject of controversy. (15-26) It has been claimed (27) that sentinel headaches occur in the 40% of patients prior to aneurysmal rupture and that these warnings are very intense and abrupt in onset, "Like an unexpected clap of thunder", giving rise to the term thunderclap headaches. This conclusion however has been challenged by others. (28) Question 5: Similarly any headache which has happened before but has now changed is cause for concern. Patients who develop migraine headaches generally develop them before the age of 25 if not earlier. If the headache has occurred before but is changing in pattern, that is a concern. Question 7: The character and location of the headache may be quite nondescript even in a space occupying lesion. Question 8: The onset to peak time is a cause of concern if the headache peaks rapidly especially with exertion or coughing or sneezing. However the entity of benign exertional headache or onset of a neuralgia is an exception. Question 10: Associated and/or residual neurological phenomena or sequelae unless associated with well established migraine headache are a cause for concern. Exacerbating factors such as coughing, sneezing, straining or emotional excitement imply the possibility of space occupying lesions and/or aneurysm. Question 19: Any medical condition suggesting spread to the central nervous system such as prior history of cancer, especially lung, breast or kidney, history of HIV infection or chronic diabetes mellitus or other immunosuppressing conditions such as lymphoma must be viewed with alarm. Any headache which is associated with systemic symptomatology especially in the elderly should be considered for either spread of malignancy or systemic disease, or collagen vascular disease.Question 20: Any history of substance abuse should be viewed with suspicion. History of chronic daily intake of medications whether they be opiates or ergots should be considered for chronic daily headache. In the physical examination obviously papilledema, signs of surgical scars which could indicate prior cancer or other neurological abnormalities suggest the possibility of severe disease. Finally there is a subset of patients with uncommon syndromes (29) which should be considered. Ref. 29 also contains a table distinguishing subarachnoid hemorrhage from benign exertional headache. (Table 2) All patients with headache should be considered as having potentially serious intracranial or systemic disease. With attention to the targeted headache history, factors which cause concern can be delineated and confirmed by an appropriate physical and neurological examination as well as appropriate ancillary studies. An algorhithm has been included for summary purposes. (Figure 1) MANAGEMENT Headache mechanisms provide a clue both as to when to be alarmed with headaches and what might possibly help headaches. All of the danger signals in headaches point to mechanisms of head pain which are fairly obvious. Assuming that there are indications that this is a primary headache, then there are five papers which are evidenced based treatment guidelines. These are: Campbell JK, Penzien D, Wall EM, Evidenced-based guidelines for migraine headache: behavioral and physical treatments. Neurology, January 2000. Frishberg B, Rosenberg JH, et al. Evidenced-based guidelines in the primary care setting: neuroimaging in patients with nonacute headaches. American Academy of Neurology. Matchar DB, Young WB, Rosenberg, JA et al. Evidence-based guidelines for migraine headache in the primary care setting: pharmacological management of acute attacks. American Academy of Neurology, January 2000. McCrory DC, Matchar DB, Rosenberg JH, Silberstein SD, Efidenced-based guidelines for migraine headache: overview ofprogram description and methodology, Neurology, January 2000. Silberstein SD, Rosenberg J, Multispecialty consensus on diagnosis and treatment of headache. Neurology 2000; 54(8): 1553. Acute Treatment for migraine headaches in patients to moderate or severe migraine, DHE, or Triptans (Serotonin 1B/1D receptor agonists) should be used. Naratriptan, Risatriptan, Sumatript, and Zolmatriptan are effective and relatively safe. Ferrari MD, et at. Oral triptans (serotonin 5-HT 1B/1D agonists) in acute migraine treatment: a meta analysis of 53 trials. The Lancet, 358:1668-1675,2001. Anti-emetics such as Reglan may be useful as well as Compazine. Non-steroidals are not recommended. All the oral triptans appear to be equally effective. Sumatriptan by nasal spray or in subcutaneous injection may be faster acting. DHE appears to be less effective. Toradol while frequently used is not particular effective. Combinations such as acetaminophe, aspirin, and caffeine may be useful in mild cases. Opiate analgesics including nasal Stadol, appear to be more effective than oral opiates. Corticosteroids IV, plus anti-emetics are reasonably effective. Nasal lidocaine does not appear to be effective. As far as preventative treatment is concerned, the only FDA approved treatments are sodium valproate, amitriptyline, and Sansert. Nortriptyline appears to be useful. Other drugs used, but not proven include Doxepin, and Imipramine, mono amino oxidase inhibitors, and SSRI's. lnderal is the most useful of the beta blockers and while others like Timolol are useful they are not proven. Calcium channel blockers are often used but are not proven. Sansert is an effective drug with frequent side effects. Other drugs include Feverfew, magnesium, and B2 are unproven. For cluster headache, for the acute attack 100% oxygen at 10 to 12 liters per minute by mask for 20 minutes is useful. Injectable Imitrex has been useful also. DHE is sometimes effective. Locally applied Lidocaine nasal drops have been reported to be effective. Preventative treatments of limited courses of oral corticosteroids or Sansert can be very effective. Verapamil has been suggested and compares favorably with Lithium. Lithium may be used in the prophylactic treatment of chronic cluster headache. Valproic acid has been suggested but not proven. Topamax has been used in a number of cases and Neurontin in a single case. A surgical procedure in intractable cases is radiofrequency thermocoagulation of the trigeminal ganglion. Chronic daily headache (Spierings, Egilius L.H., Review Article, Chronic daily headache, Headache Quarterly, 2000; 11 : 181-196.) Many of these patients are rebound type patients. When treated with Amitriptyline there is a 30% improvement, but the with the withdrawal of analgestics, 72% improvement. When not treated with Amitriptyline and analgesics were continued there was an 18% improvement with analgesics withdrawn at 43% improvement. Hospitalization may be necessary for headache control in chronic daily or rebound headaches. References:
|