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Evaluation and Management of Headache Symptoms



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Am Fam Physician. 1998 Aug 1;58(2):523-527.

Headache evaluation is complicated by patients with overlapping symptoms and more than one type of headache. The major types of headache include migraine (with or without aura), tension-type headaches and drug-rebound (or chronic daily) headaches. Maizels reviewed the steps involved in evaluating and managing the patient with headache.

Migraine headaches are usually accompanied by nausea, photophobia or phonophobia. Auras, most commonly described as visual flashing lights, zig-zag lines or blind spots, may also be present. Migraine headaches are likely to have reliable triggers and patterns, and are usually relieved after sleep. Tension-type headaches may exist in a continuum with migraine headaches and are not directly related to muscle tenderness; rather, muscle tenderness is a secondary phenomenon. It is believed that migraines result from a disturbance of the serotonergic system of the midbrain and that all migraine abortive and prophylactic medications influence the serotonin pathway. Vascular changes are most likely secondary rather than causative. The etiology of the tension-type headache is less clear but is thought to be an integration of vascular, myofascial and supraspinal factors.

Drug-rebound headaches presenting as chronic daily headaches are common. The use of analgesic medications, even as little as 1,000 mg per day of aspirin or acetaminophen, can cause this type of headache. Any symptomatic headache remedy may cause drug rebound headache, but it is most likely with the use of ergotamines, narcotics and products that combine caffeine or butalbital with aspirin or acetaminophen. Many clinicians limit the use of all symptomatic medication to two days a week. Patients need much encouragement when attempting withdrawal from the causative medication and should be told they will feel worse for about two weeks. The addition of amitriptyline (10 to 25 mg) or a nonsteroidal anti-inflammatory drug (NSAID) such as naproxen may provide relief.

Treatment of acute headache should be based on the past experience of the patient, the headache severity, associated symptoms and the medication side-effect profile. Some choices are described in the accompanying table. Headaches accompanied by severe nausea may be treated by adding a dopamine antagonist anti-emetic such as metoclopramide. More severe headaches may require parenteral therapy with dihydroergotamine or a specific serotonin1 (5-HT1) receptor agonist such as sumatriptan or one of the newer triptans.

Medications for Symptomatic/Abortive Treatment of Headache

Drug Dosage Remarks Side effects/contraindications

Mild headaches

Use maximal tolerated doses at onset; e.g., naproxen at 775 mg, ibuprofen at 1,200 mg

Side effects: gastrointestinal intolerance, bleeding, fluid retention

Aspirin

NSAIDs (naproxen, ibuprofen, etc.)

Contraindications: peptic ulcer disease, warfarin use; use with caution in patients with congestive heart failure, renal insufficiency

Aspirin or acetaminophen with butalbital, caffeine

One to two tablets at onset, repeated every four hours; maximum: four tablets per day

Highly prone to drug rebound; limit use to two days per week

Side effects: sedation, same as for aspirin (above)

More severe headaches

Isometheptene, dichlorphenazone, acetaminophen

Two tablets at onset, then one every hour; maximum: five tablets per day

Vasoconstrictor-sedative combination

Side effects: dizziness;

Contraindications: glaucoma, severe renal or liver disease, coronary artery disease, hypertension, concomitant use of MAO inhibitors

Ergotamine tartrate, caffeine

One to two tablets orally at onset; may repeat within 30 minutes and every four hours; maximum: five tablets per day

Highly prone to drug rebound: limit use to two days per week

Side effects: nausea, abdominal pain, paresthesias, chest tightness; ergotism (ischemia of extremities)

Contraindications: coronary artery disease, peripheral vascular disease, hypertension, renal or liver diseases, sepsis, pregnancy

Metoclopramide

10 mg orally, intramuscularly or intravenously

Combine with any other agent to increase efficacy

Side effects: dystonic reactions; avoid use in children

Most severe headaches

Dihydroergotamine

1 mg intramuscularly orsubcutaneously, up to every eight hours; 2 mg intranasally; see also intravenous protocol

Low rate of relapse; ideal for persistent headache

Side effects and contraindications: same as for ergotamine, but does not cause drug rebound headache

Sumatriptan succinate

6 mg subcutaneously; 25 to 100 mg orally; 5 to 20 mg intranasally; for relapse, may repeat one dose within 24 hours

High rate of relapse; sumatriptan given subcutaneously is the drug of choice for severe migraine or rapid onset of symptoms

Side effects: atypical sensations (tingling, numbness, warmth, cold, heaviness), flushing, chest pain, neck pain

Contraindications: coronary artery disease or Prinzmetal angina; hemiplegic or basilar migraine. Do not use within 24 hours of using ergots or MAO inhibitors


NSAIDs = nonsteroidal anti-inflammatory drugs; MAO inhibitors = monoamine oxidase inhibitors.

note: All agents may be combined with anti-emetics for greater effect. Drugs are listed in groups of approximate order for increasing severity of headache.

Reprinted with permission from Maizels M. The clinician's approach to the management of headache. West J Med 1998;168:203–12.

Medications for Symptomatic/Abortive Treatment of Headache

View Table

Medications for Symptomatic/Abortive Treatment of Headache

Drug Dosage Remarks Side effects/contraindications

Mild headaches

Use maximal tolerated doses at onset; e.g., naproxen at 775 mg, ibuprofen at 1,200 mg

Side effects: gastrointestinal intolerance, bleeding, fluid retention

Aspirin

NSAIDs (naproxen, ibuprofen, etc.)

Contraindications: peptic ulcer disease, warfarin use; use with caution in patients with congestive heart failure, renal insufficiency

Aspirin or acetaminophen with butalbital, caffeine

One to two tablets at onset, repeated every four hours; maximum: four tablets per day

Highly prone to drug rebound; limit use to two days per week

Side effects: sedation, same as for aspirin (above)

More severe headaches

Isometheptene, dichlorphenazone, acetaminophen

Two tablets at onset, then one every hour; maximum: five tablets per day

Vasoconstrictor-sedative combination

Side effects: dizziness;

Contraindications: glaucoma, severe renal or liver disease, coronary artery disease, hypertension, concomitant use of MAO inhibitors

Ergotamine tartrate, caffeine

One to two tablets orally at onset; may repeat within 30 minutes and every four hours; maximum: five tablets per day

Highly prone to drug rebound: limit use to two days per week

Side effects: nausea, abdominal pain, paresthesias, chest tightness; ergotism (ischemia of extremities)

Contraindications: coronary artery disease, peripheral vascular disease, hypertension, renal or liver diseases, sepsis, pregnancy

Metoclopramide

10 mg orally, intramuscularly or intravenously

Combine with any other agent to increase efficacy

Side effects: dystonic reactions; avoid use in children

Most severe headaches

Dihydroergotamine

1 mg intramuscularly orsubcutaneously, up to every eight hours; 2 mg intranasally; see also intravenous protocol

Low rate of relapse; ideal for persistent headache

Side effects and contraindications: same as for ergotamine, but does not cause drug rebound headache

Sumatriptan succinate

6 mg subcutaneously; 25 to 100 mg orally; 5 to 20 mg intranasally; for relapse, may repeat one dose within 24 hours

High rate of relapse; sumatriptan given subcutaneously is the drug of choice for severe migraine or rapid onset of symptoms

Side effects: atypical sensations (tingling, numbness, warmth, cold, heaviness), flushing, chest pain, neck pain

Contraindications: coronary artery disease or Prinzmetal angina; hemiplegic or basilar migraine. Do not use within 24 hours of using ergots or MAO inhibitors


NSAIDs = nonsteroidal anti-inflammatory drugs; MAO inhibitors = monoamine oxidase inhibitors.

note: All agents may be combined with anti-emetics for greater effect. Drugs are listed in groups of approximate order for increasing severity of headache.

Reprinted with permission from Maizels M. The clinician's approach to the management of headache. West J Med 1998;168:203–12.

Headache prophylaxis includes resolution of trigger factors. Medication withdrawal should be considered. Prophylactic medication can be offered if severe attacks occur more than two or three times monthly or if attacks cannot be easily controlled with abortive medications. Prophylaxis may reduce migraine frequency by 50 to 60 percent. First-line agents are tricyclic antidepressants and beta blockers. Calcium-channel blockers and NSAIDS are less effective but may be tried before giving drugs that have greater side effects. Third-line agents include methysergide and monoamine oxidase inhibitors. Selective serotonin reuptake inhibitors should be considered for use in patients in whom depression is a significant factor of the headache symptoms. Divalproex sodium may be useful in reducing the frequency of migraine attacks.

In a discussion of worrisome headaches, the author concludes by discrediting the symptoms of the “classic” brain tumor headache. Neuroimaging is appropriate when the headache (1) is accompanied by unexpected neurologic signs or symptoms, (2) has new onset after age 50 or occurs in a patient with a history of cancer, (3) is triggered by cough, coitus or exertion, (4) is severe and sudden (“thunderclap headache”), (5) is different from a previously stable headache pattern or (6) is not diagnosable as a “primary” benign headache. Imaging is not necessary in the patient with a stable migraine pattern. There are no specific guidelines for the neuroimaging of tension-type headaches.

Maizels M. The clinician's approach to the management of headache. West J Med. March 1998;168:203–12.


Copyright © 1998 by the American Academy of Family Physicians.
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