Algorithms(decision trees) do not work for headache patients(some illnesses, such as diabetes or high blood pressure, are more amenable to algorithms). So, official “guidelines” as to headache treatment do not work very well. This is becuase everybody is unique; if we have 100 different headache folks, we will go 100 different ways with medicines, non-medication therapies, etc. What drives where we go with meds is the headaches and comorbidities. The headache part includes: what type of headache(migraine vs. tension/chronic daily), severity, frequency, how well the “as needed” abortives work, etc.. The comorbidities include other conditions going on in the person, including anxiety, depression, IBS(irritable bowel syndrome), as well as other medical conditions(HTN, arthritis, diabetes, etc.). For instance, many people with chronic frequent headaches also have anxiety or depression or IBS; these color and influence our medical decision-making. In addition, of course input from the patient is paramount; they may not want to take a daily preventive, or may not want certain types of meds. Costs of meds, and insurance, also play a significant role. The care and treatment of a headache patient takes time and patience and significant thought; for some return visits, it would be helpful to have 2 hours! In addition, it “takes a village” to help a severe headache or pain patient; we “get other villagers” involved(whether it is psychotherapy, physical therapy, yoga, etc. etc.).

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