Legitimize the headache problem as a physical illness. Statements such as "Headaches are just like asthma, diabetes, or hypertension - a physical medical condition" - go a long way toward establishing trust between the patient and clinician. When we mention that it is a medical condition, often times inherited, and that there is too little serotonin in the brain in people with some headaches, patients are extremely receptive. Once we have established receptivity, the patients are much more amenable to addressing such comorbidities as anxiety and depression, with therapy or by other means. However, if we focus initially on the patient's stress, anxiety, depression, and psychological comorbidities, patients are often turned off to the clinician unless we do state that we are treating the headaches as a legitimate medical illness.
We must try to achieve a balance between medication and headache; I tell the patients that we are trying to improve the headaches 50-90%, while minimizing medications.
The initial history and physical is the best time to consider a list of medications; at that point we have a good grasp of the patient's comorbidities. If we list in the chart the therapeutic alternatives (in case our initial medications do not work), later we (or our partners) do not have to reconstruct the entire history with the patient.
In choosing preventives, assess other conditions, particularly anxiety, depression, insomnia, gastritis, GERD, IBS, constipation, hypertension, asthma, and sensitivities or allergies to drugs. These often determine which therapeutic option to pursue.
Keep track of sensitivities and allergies to medications in a prominent place in the chart. If the patient has had severe reactions to two SSRIs, a third is not a good choice. However, those reactions may not be readily apparent in the chart. If they are extremely fatigued on one B-blocker, a second will probably not prove helpful in the long term.
It helps to view chronic headache as a continuum or spectrum. The "in between" headaches may not fall neatly into the current tension-type or migraine categories. Whether these are severe tension-type or milder migraines, they often respond to the same medications.
Start with low doses of medication, particularly with antidepressants and other preventives. Headache patients tend to fairly somatic, and there is no need to push medicine very quickly. One exception to this is in patients with severe "new onset daily persistent headache"; these patients may be less patient.
Keep a drug medication flow chart. Headache patients are constantly having medications stopped and re-started, and, over 10 years, a patient may have been on 50 different medications. It is impossible to piece through 40 progress notes trying to determine what the next best course of action is. A drug medication flow chart from the beginning helps immensely.
When we place patients on antidepressants, we need to make it clear that we are trying to help their headache directly by increasing serotonin. We also state that we certainly hope this helps anxiety and depression. Patients are often confused as to the reason why they are given an antidepressant. It helps if we make it clear that we are NOT trying to treat their headache by treating depression.
Watch for soft bipolar signs in headache patients who have anxiety and depression. Bipolar disorder tends to be underdiagnosed, and the clinical stakes for missing it are enormous. Bipolar disorder, primarily mild and soft (Bipolar II or III), is seen in as many as 6% to 7% of migraineurs. While many of these patients will do well on an antidepressant, it is often necessary to add a mood stabilizer (e.g., Depakote, lithium, Tegretol, Neurontin).
Many patients are frustrated by the lack of efficacy and/or side effects of daily preventives. Tell them that only 50% (at most) of patients achieve long-term relief with preventives. This helps them to realize therapeutic failure is not their fault.
We need to stick with preventive medications for at least four weeks (or longer); if we abandon them too quickly, we may not see the beneficial effect. However, few patients are willing to wait months for positive benefits from a medication.
We cannot promise patients that their headaches will improve with psychotherapy (as it often does not), but coping with headaches and the stresses that headaches produce is often improved with therapy. Unfortunately, because of the stigma, time, and money, only a minority of patients will actually go to a therapist. However, those who do go will usually benefit.
Patients with chronic daily headache may view the headache situation in black-and-white terms; they will come back for a return visit and state, "Well, I still have a headache every day." They need to accept that if we have gone from moderate-to-severe headaches (7 on a scale of 1-10) to mild-to-moderate (4 on a scale of 1-10), that the situation is improved and we should not change all the medication. If the patients keep a headache chart or calendar, this may help. Patients need to be willing to accept 50-90% improvement in frequency and/or severity.
While most patients are honest about analgesic use, some are embarrassed to tell us how much they are utilizing. Between OTC analgesics and herbal preparations, many patients are consuming larger quantities of medications than we realize.
Weight gain is a major issue; even though a drug may be more effective, choosing one that avoids the potential for weight gain (in those prone to it) is more likely to lead to long-term success. Fatigue is another major reason for patients abandoning a preventive medication.
Do not confuse addiction with dependency. When treating chronic daily headache, dependency has to be accepted. Unfortunately, DSM-IV is inadequate in addressing prescription abuse.
What to do when nothing works: Before giving up on a patient with severe, refractive chronic daily headache, consider "end of the line" strategies such as: MAOIs, daily long-acting opioids (e.g., methadone, Kadian, Oxycontin, MS-Contin), stimulants (e.g., dextroamphetamine, methylphenidate, phentermine), IV DHE, daily triptans in limited amounts, daily IM DHE (or nasal), or combinations of approaches.
Using a medication to establish a diagnosis may NOT be accurate. For instance, DHE or triptans may mitigate the pain of subarachnoid hemorrhage or even
tumors.
Acceptance of the chronic illness (headache) is a helpful state of mind for the patient. Acceptance is different than resignation. Acceptance helps to ease anxiety ("Isn't there a cure; these must be curable".)
When patients feel that they can actively help their headaches (self-efficacy), by medication, biofeedback, or other means, it improves their sense of well-being.
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