The Rewards of Teaching Chronic Headache

R2: I have to admit that I was not particularly excited to see another chronic pain patient this afternoon. This is a 42-year-old woman with a history of migraines for more than 20 years. The headaches have not been controlled well, and she is here for a refill of her medication.

Dr N: I hope you don’t feel too discouraged. Chronic pain is treatable. There is a lot you can do to help the patients. And chronic headaches are very treatable. You can often help the patient achieve a dramatic improvement. So, how do you know that the patient has migraines?

R2: The patient tells me that she has had migraines for years. She has been given that diagnosis by many doctors. She is just here for refills of her medications.

Dr N: What do you think is the diagnosis? What are the criteria for this diagnosis?

R2: Migraines tend to be unilateral, and the headaches are severe.

Dr N: That’s right. In addition, there is a set of criteria from the International Headache Society that was first published in 1988 and updated in 2004. Most clinicians use these criteria—the criteria are not only used in typical headache studies but also in review articles, as found in American Family Physician. We can take a quick look.If you remember the Web site for the International Headache Society (IHS), you can find the criteria there, at http://ihs.classification.org, or you can simply search in Google for International Headache Society or “criteria migraine.”

R2: So, looking at this table—a migraine is a severe, pulsating, often unilateral headache, worsened by routine activity. Right?

Dr N: If you apply the IHS criteria, they only need to have two of the four, plus one of the following: nausea, vomiting, photophobia, or phonophobia. Plus a history of five total attacks; the headaches last 4–72 hours. Why do you think it is important to apply the criteria to your diagnosis? What difference does it make?

R2: I suppose it might mean that the treatment is different.

Dr N: Correct. Even in a patient with a long history of migraines, I like to ask the diagnostic questions to convince myself that the original diagnosis was correct, since that will change your treatment.

R2: On the other hand, I figure that if the headaches are controlled with an NSAID (non-steroidal anti-inflammatory drug), it doesn’t make much difference whether it is migraines or tension headache.

Dr N: Good point. In her case, however, it sounds like she’s having trouble getting pain control. If she truly had migraines, then you could use a triptan for an acute attack, and one of the medications for prophylaxis.1 But, if she has tension-type headaches, then these medications are not likely to be helpful. I find it rewarding to work with patients who have migraines. I feel as though I can make a difference. You can improve the clinical course for a lot of patients with headaches, if you understand the diagnoses and the medications.

Getting back to this patient, what do you want to do for her acute headaches?

R2: She is currently taking an NSAID. Maybe I should use something stronger since the headaches frequently require her to miss work. Would we consider a narcotic?

Dr N: There is at least some evidence that the regular use of narcotics is associated with progression of migraines. I would not be opposed to occasionally using narcotics for a very severe migraine, but let’s try a triptan for this patient. How many headaches is she having per month?

R2: Three to four. I think that is probably frequent enough to consider a prophylactic agent.

Dr N: That sounds reasonable to me. Most articles recommend considering prophylaxis when patients have more than two headache episodes per month. Name a medication.

R2: I have seen patients on beta-blockers for prophylaxis; I think I might try that.

Dr N: Not all beta-blockers are equally effective for this use. Unless there is a contraindication to the use of a beta-blocker, I would recommend propranolol or timolol. Evidence to support the use of those two beta-blockers is better than it is for the other beta-blockers. There are several other medications we can consider later if that doesn’t work. What are some other choices for prophylaxis?

R2: I have seen folks on amitryptiline, low dose.

Dr N: That’s a standard one. You can also consider topiramate, valproate, and divalproex. So, if you start her on a beta-blocker, when should you see her back?

R2: I think I will see her back in about a month.

Dr N: Sounds reasonable. That would give you time to look for side effects and also decreased strength and/or frequency of recurrence. Make sure that the she is scheduled to see you and not another resident or an attending. This is a diagnosis that is much more effectively treated within a continuous relationship. Your relationship with her will help you to improve her headaches. Set some realistic treatment goals with the patient; you should be able to make her headaches less frequent and less severe. You should be able to improve this patient’s lifestyle. I have seen patients come back very grateful that I’ve helped to improve their lives. This doesn’t have to be a major burden for you; it can actually be fun.

Mark T. Nadeau, MD, MBA, University of Texas Health Science Center at San Antonio, Author
Alec Chessman, MD, Medical University of South Carolina, Editor

References

  1. Bigal ME, Ferrari M, Silberstein SD, et al. Migraine in the triptan era: lessons from epidemiology, pathophysiology, and clinical science. Headache 2009;49:S21-S33.
  2. Modi S, Lowder D. Medications for migraine prophylaxis. Am Fam Physician 2006;73:72-8.
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