This site is intended for health professionals only

A holistic approach to managing headache

Manuela Fontebasso
MB ChB
GP and Clinical Assistant in Neurology
York District Hospital
E:manuela.fontebasso@york.nhs.uk

Any individual presenting with headache needs to be assessed in order to exclude a potentially serious or sinister secondary headache. A carefully taken history will enable you to identify any potential "red flags" and make a diagnosis. The correct diagnosis will then direct you to the treatment pathway. Involvement of the patient at an early stage of the decision-making process will empower them to make the necessary changes essential to a holistic approach to care.

What headaches are you likely to see?
The most common episodic headache is likely to be a tension-type headache (TTH), but the headache having the most impact is migraine. Identifying the headache is about asking the right questions (see Table 1).(1)

[[NIP14_table1_42]]

While 10% of migraine patients experience aura (a subjective sensation that precedes the attack), 20% can experience both types of attack.(1) The aura lasts up to 60 minutes and is completely reversible. Speech disturbance and sensory symptoms can extend into the headache phase but should settle before the headache does.
Another high-impact, short-lived episodic headache is cluster headache, which affects 1% of the population. While migraine affects 15-18% of women and only 6% of men, the sex ratio is reversed with cluster - male: female is 6:1.(1) Cluster may be confused with migraine or trigeminal neuralgia (see Table 2).(2)

[[NIP14_table2_43]]

What about chronic headache symptoms?
Patients may complain of daily or near-daily headache. There are two questions to ask these patients: "How many different headaches do you have?" and "How often do you take painkillers to treat your headache?" If the reply is " At least two" or "I can't do without my painkillers" then you probably have someone who has chronic daily headache (CDH) and may have someone who has medication overuse headache (MOH) (see Table 3).

[[NIP14_table3_44]]

CDH affects 5% of the population and 9% of women. Of those with MOH, 65% have migraine and 27% have TTH.(3) Preventing the steady slide from episodic headache to CDH is about getting the diagnosis right at the time of initial presentation and then initiating the most appropriate treatment for that headache.

The holistic approach to the headache sufferer
The diagnosis needs to be explained to the patient, and the options available need to be discussed. Involving the patient at this stage empowers them to take control of their symptoms and make changes that are often essential to moving the process forward. All patients benefit from some diet and lifestyle advice (see Table 4).(1)

[[NIP14_table4_45]]

Which drug, when and why?
Choosing the right drug for the right headache and adopting realistic goals and expectations is the next step to a successful and positive outcome. This will be patient- and diagnosis-specific and is often modified by any coexisting conditions or drug usage.

Managing migraine
When treating the acute attack a high dose of a simple analgesic and/or a gastric emptying antiemetic can be taken as soon as the aura or prodrome symptoms develop. The sooner the medication is taken the more effective it is likely to be and the less likely there is to be a recurrence of symptoms. Simple analgesics are most effective when taken early but can be used at any time in the attack (see Table 5).(4,5)

[[NIP14_table5_45]]

If this is not effective then a triptan can be used as soon as the headache starts. Triptans are most effective when taken early, but can only be used in the headache phase. Choosing a triptan is a trade-off between the delivery system, speed of onset, efficacy, side-effect profile, headache recurrence rate and cost (see Table 5).(4,5) Offering to review the patient allows an assessment of the response to drug therapy to be made and further advice given as to alternate drug options.
If there is no aura or prodrome then the patient may choose a stepped or stratified approach depending on what works best for them. A stepped approach means the patient will take the simple analgesic first and if this is not effective will then take the triptan as a "rescue" medication. A stratified approach means that the patient will decide which treatment to use depending on the circumstances and severity of the attack. This approach gives the patient the chance to choose the treatment that best meets their needs at that time. 
If there is a poor response to acute treatment, a high incidence of side-effects with acute treatment, or the frequency of attacks increases then prophylaxis needs to be considered. The drug should be started at the lowest possible dose and the dose increased slowly to minimise the risk of side-effects. It needs to be taken at the right dose for long enough to be effective.
 
Options include:(1,2)
1.    b-blockers:
        a.    Propranolol, single daily dose, up to 320mg.
2.    Tricyclic antidepressants (TCADs):
        a.    Amitriptyline, single or split dosing, up to
            150mg.
        b.    Imipramine or dothiepin can be used.
        c.    Low doses often effective.
3.    Antiepileptic drugs (AEDs):
        a.    Sodium valproate (eg, Epilim Chrono; Sanofi-
        Synthelabo), split doses, 500-1000mg daily.
        b.    Gabapentin, split doses, 600-1,800mg daily.
        c.    Topiramate, split doses, 75-100mg daily.

Managing TTH
Simple analgesics are best avoided in TTH as it is easy for MOH to develop. Taking a simple analgesic on 5 or more days in each week, a combination analgesic on
3 days in each week, and opiates more than 2 days in each week can lead to MOH.(6) Taking three doses on
1 day in a week is less of a problem than taking a dose on three separate days.
Diet and lifestyle changes are an important first step (see Table 4). If symptoms persist then prophylaxis helps reduce the risk of MOH. TCAD or AED drugs are useful (see dosing above).

Managing cluster headache
A fast-acting triptan is effective in tackling the acute cluster attack. An alternative is 100% oxygen at 9 litres per minute through a nonrebreathing mask for 15 minutes. 
Aborting the episodic cluster is best achieved using high-dose oral steroids, usually 60mg daily for 2 weeks. If the episodes become chronic, verapamil can be used firstline at a dose of 80mg three times daily initially (up to 720mg daily). Lithium or AEDs are alternatives.(2)

Managing MOH
The only way to break the escalating cycle of analgesic use and daily headache symptoms is to stop all the painkillers completely for a minimum of 6-8 weeks. Making diet and lifestyle changes help in reducing some of the headache symptoms. The patient will need a lot of support from friends, family and work colleagues during this process as well as you as a member of the primary healthcare team.
Using appropriate prophylaxis can help manage the chronic pain component of their symptoms and reduce the overall frequency of headache symptoms. TCADs or AEDs are useful.

Managing CDH or chronic TTH
Diet and lifestyle advice needs to be stressed and often has significant impact. A low threshold for prophylaxis assists in reducing the overall number of headache days. TCADs or AEDs are useful.

Conclusion
Headache symptoms are common in primary care. Taking time to listen to the patient story is vital to enable you to get the diagnosis right and hence assist the patient in finding the right treatment approach that best meets their needs. A holistic approach is essential in identifying all possible triggers and empowering the patient to take back control. It is about finding what works for the individual and being responsive to the needs of that individual.

References

  1. MacGregor A. Managing migraine in primary care. Oxford: Blackwell Science; 1999.
  2. Peatfield R, Dodick D. Headaches. 2nd ed. Oxford: Oxford Health Press; 2003.
  3. Deiner H-C. A personal view of the classification and definition of drug dependence headache. Cephalalgia 1993;13 Suppl 12:68-71.
  4. Dowson AJ, Gruffydd-Jones K, Hackett G, et al. Migraine management guidelines. London: Synergy Medical Education; 2000.
  5. Steiner TJ, MacGregor EA, Davies PTG. BASH guidelines for all doctors in the diagnosis and management of migraine. London: BASH; 1998.
  6. Silberstein SD. Drug induced headache. Neurol Clin North Am 1998;16:107-23.

Resources
British Association for the Study of the Headache
W:www.bash.org.uk
Headache UK
W:www.headacheuk.org
Migraine Action Association
W:www.migraine.org.uk
Migraine in Primary Care Advisors
W:www.mipca.org.uk
The Migraine Trust
A UK medical research and patient support charity for the condition
W:www.migrainetrust.org
Ouch (UK)
Organisation for the understanding of cluster headaches in
the UK
W:www.clusterheadaches.org.uk
The International Headache Society
W:www.i-h-s.org

Forthcoming conference
15th Migraine Trust International Symposium
20-23 Sept 2004
Kensington
Town Hall
London
For further ­information contact:
Conference Secretariat
T:020 8977 0011
F:020 8977 0055
E:mtis@hamptonmedical.com
W:www.migrainetrust.org/research

Courses for nurses
The Migraine Trust has
developed a "Distance Learning University Diploma" Course on Headache.
For more ­information contact:
The Course Administrator
Centre for Community Neurological Studies
Leeds Metropolitan University
Leeds LS1 3HE
T:0113 283 5918 E:j.buckingham@lmu.ac.uk