Disease Process

Headaches represent a very common complaint in primary care. They have many causes, ranging in seriousness from stress to brain tumor; therefore, the cause must be determined whenever possible for effective therapy to be determined.

Tension headache (THA), the most common type of headache, usually is described as vise-like pressure associated with stress and/or fatigue. The pain of THA usually is generalized but may be worse in the area of the neck and the back of head. These patients are generally treated with analgesics for mild to moderate pain. (See Chapter 43 for more information on pain management.)

Approximately 23 million Americans are afflicted with migraine headaches. Migraine headaches usually begin in the teenage years, peaking between the ages of 25 and 34; they are three times more prevalent among women than men. These headaches represent a debilitating and costly medical problem. For a variety of reasons, a large group of persons do not seek medical care for their migraines.

Migraine symptoms vary. All migraines are paroxysmal in nature—clearly defined attacks separated by symptom-free intervals. Daily or continuous headaches usually are not migraines but are tension or vascular headaches. Migraines are classified as with aura or without aura and are graded as mild, moderate, or severe in intensity. The duration of migraine is an important variable because the clinician must choose medications whose duration of action is adequate. Classic migraines go through specific phases (Table 44-2).

Complicated migraines, which are less common, are characterized by attacks in which neurologic symptoms last for the entire headache or for several days or weeks or, in some cases, leave a permanent neurologic deficit. Complicated migraines are divided into three subtypes. An ophthalmoplegic migraine affects the third, fourth, or sixth cranial nerve; permanent damage to the third nerve has been reported. Hemiplegic migraine is characterized by both motor and sensory symptoms that are unilateral and may last longer than the headache itself; this type is very rare. Complete recovery from these symptoms may take weeks, and permanent weakness can occur following multiple attacks. Basilar-type migraine is characterized by any combination of vertigo, diplopia, dysarthria, tinnitus, decreased hearing, ataxia, simultaneous bilateral paresthesias, and altered consciousness. It may be difficult sometimes to distinguish between visual symptoms of a classic migraine and basilar artery migraine, although the latter is more likely to affect both visual fields.

A transformed migraine is a long-lasting headache that results from overuse of pain and/or migraine medications. Following a migraine episode, the patient has rebound headache daily or nearly daily. Medications that can cause this include caffeine, acetaminophen, NSAIDs, barbiturates, sedatives, narcotics, ergots, and triptans.

Treating headaches with narcotics and barbiturates increases the risk for development of chronic migraine headaches and should not be considered first choice to relieve pain.

Assessment

Diagnosed migraine must meet specific criteria established by the National Headache Foundation (Box 44-1). A diagnostic workup headache history includes age of onset of headaches; duration of complaint; frequency and duration of each headache; site, quality, and time of onset; associated phenomena; and aggravating and relieving factors. Physical examination, including neurologic examination, is typically normal. Some patients experience substantial burden from their migraines. The Migraine Disability Assessment Scale (MIDAS) is a five-item questionnaire that is used in practice (see Goadsby et al, 2002, for questionnaire uhs.berkeley.edu/home/healthtopics/pdf/assessment.pdf) to help the clinician measure how much intervention is required to improve the patient’s quality of life.

Migraine headache often is stimulated by visual, olfactory, or other environmental triggers that may be identified. (See Box 44-3.) The patient must be screened for concurrent illnesses, especially cardiovascular problems such as increased blood pressure and CAD. These concurrent illnesses may affect treatment options.

Recent research suggests that patients who suffer from migraine could be more prone to clinical depression. Participants who experienced migraines had an 80% higher relative risk of developing depression than those without headaches, while participants who were depressed were 40% more likely to suffer migraines, researchers said. Clinicians might be aware of this relationship in their assessment and patient monitoring.

Combination Drugs

Isometheptenemucate is a sympathomimetic agent that acts as a vasoconstrictor of dilated cranial and cerebral arterioles. Midrin is a combination capsule that contains 65 mg of isometheptenemucate; 325 mg of acetaminophen, which exerts an analgesic effect; and 100 mg of dichloralphenazone, a mild sedative that acts centrally to allay anxiety. Caffeine, which is added to many migraine combinations, helps to promote constrictive properties and enhances absorption. ASA, acetaminophen, ibuprofen, and caffeine, all of which are commonly found in combination analgesic products used for the treatment of patients with mild to moderate migraine, have been shown through evidence-based studies to be effective in the prophylaxis and treatment of migraine.

Prophylactic Agents

See Table 44-1 for a list of prophylactic medications.

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