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In PPM's new Case Chat series, a recent chronic headache case is used to discuss how treatment approaches have evolved, including primary care assessment tools and multitherapy use.  
A telemedicine evaluation of a headache patient is always interesting and important. In this article, I  briefly talk about two common types of headache – primary chronic daily headache and idiopathic intracranial hypertension headache – and review how to conduct a neurological examination as part of a real-time audio/video telehealth visit.
In this video Q&A, neurologist and headache expert Lawrence Robbins, MD, and patient advocate Jaime Sanders answer common patient questions on migraine treatments, self-care strategies, anxiety and depression as part of migraine disease, coping during COVID, and more.
Most experts agree that neuroimaging should be used sparingly and with caution when diagnosing and treating migraine. Yet, when to use and when not to use neuroimaging has long been a vexed issue. It’s not always clear when the risks of neuroimaging are justified.
On Saturday, June 13, the American Headache Society (AHS) launched its annual scientific meeting, focused on headache medicine in the era of COVID and frontiers in headache research.
The prevalence of migraine in children increases with age and may affect up to 23% of children by age 15, which highlights a need for adequate treatment in these populations.
The prevalence of chronic migraine (CM) is estimated to be about 1.4% to 2.2% worldwide.1 Several preventive treatments are available for patients afflicted with this condition, including sodium valproate, topiramate, and propranolol.
While chronic headache disorders such as cluster headache and migraine are common, they are also largely underestimated and difficult to treat. Many patients experience a poor response to pharmacologic treatment because of inadequate analgesia, intolerable side effects, or the development of drug tolerance.1
Clinicians have long noted the connection between migraine and obesity. “Most neurologists have seen enough studies that show the link between obesity and migraine,” shared Sylvia Lucas, MD, PhD, clinical professor of neurology, specializing in headaches, at the University of Washington School of Medicine in Seattle.
Early clinical experience with a number of CGRP inhibitors for the prevention of migraine, including Aimovig, Emgality, and Ajovy.
In terms of treating migraine, a recent animal study explored how males and females may respond differently to calcitonin gene-related peptide (CGRP).
Headache and trigger points are often interconnected, especially when treating tension-type headaches (TTH).
The need for a refractory chronic migraine scale for adults and adolescents.
Photobiomodulation and sphenopalatine ganglion blocks are reviewed as migraine alternative treatments. Learn more about light therapy's effectiveness for migraine.
The author offers anecdotal evidence of ketamine as an anesthetic agent for relieving and reducing episodic as well as chronic cluster headache attacks.
The authors share how an osteopathic approach to treating cervicogenic headache, which stems from the spine, may save time and cost
Understanding the overlap between chronic migraine or tension-type headache (TTH) and central pain conditions.
Older adults of both sexes may be at higher risk.
A retrospective review of the author's early clinical experience with the CGRP inhibitor erenumab (Aimovig) for the prevention of migraine.
A look at the differences in risk, presentation, and care of migraine between men and women.
gammaCore is the first non-invasive, hand-held medical therapy applied at the neck as a therapy to prevent cluster headache.
Clinicians can help to answer tough questions about homeschooling and school absences when a child is living with a chronic painful condition.
Biohaven has received FDA authorization to dose first subject with BHV-3500, a new third-generation CGRP.
Many biological factors, including sex hormones, have been reported as a major contributor to migraine.
Biohaven, Lilly, and Allergan's new research from the American Headache Society (AHS) meeting.
Headache expert Lawrence Robbins, MD, asks a series of questions clinicians need to address before prescribing the long-awaited CGRP antagonists for migraine prevention.
In this exclusive roundtable, developers recap the data on their CGRP inhibitors, including Aimovig, the first-ever monoclonal antibodies specifically designed to prevent chronic or episodic migraine.
In  this exclusive roundtable, Amgen/Novartis, Allergan, Lilly, and Teva recap the data that is moving their CGRP migraine preventives to the finish line. Introduction to CGRPs by Lawrence Robbins, MD
Men with chronic migraine have been shown to be at a high risk of sleep apnea and other disorders.
Amgen, Novartis, Alder, Allergan, BioHaven, Lilly, and Teva are all anticipating FDA approval of their novel anti-CGRP chronic migraine preventive medications in 2018
CGRP receptor antagonists have been well tolerated in studies.
Findings challenge a 2006 FDA advisory, questioning its validity
Lilly survey results point to need for new headache and migraine treatments as well as patient education.
Diagnosing medication overuse headache, versus medication overuse, can be a tough task for practitioners. Here's how to differentiate the two.
Two New Pain Relief Stimulators May Alleviate Chronic Pain from Cluster Headaches & Migraines
Device from Cefaly Technology promises to abort migraines more effectively than triptans.
A patient’s perception of stress appears to offer a good forecast factor to predict the onset of episodic migraines.
Three case studies and a review of current practice guidelines offer insight into treating patients with chronic pain and other symptoms after a sport-related concussion.
Two studies published in the New England Journal of Medicine report favorable results when targeting calcitonin gene-related peptide with mAb treatments for migraine pain.
A new study demonstrated that dermal application of zolmitriptan may provide significant relief from headache pain and most bothersome migraine symptoms.
John Claude Krusz, PhD, MD, provides 6 case reports where he as employed IV propofol in his out-patient clinic) to effectively management otherwise intractable migraine headaches.
For patients with migraines, defining the migraine will ensure proper selection of the medications and complementary therapies based on individual needs to address comorbidities and patient preferences.
Headache expert Duren Michael Ready, MD, provides tips on what to try when nothing else is working.
7 tables with commentary help readers deconstruct the diagnosis of migraine.
A lifetime of observations has been complied in Advanced Headache Therapy a new book by Lawrence Robbins, MD. Read Dr. Michael Ready's review.
Case presentation of a chronic migraine patient in her mid-20's. Learn step-by-step treatment plan.
Boys and girls experience headaches at a similar rate until they reach adolescents, when hormones kick-in. Learn more about how migraines affect boys and girls during childhood through adolescents.
Up to 4% of adults suffer from chronic headaches, mostly migraines. Dr. Lawrence Robbins reviews what we know about migraine types, comorbidities, as well as migraine triggers, and treatments.
Patients with refractory chronic migraine (RCM) experience a great deal of disability related to their chronic headaches.
Patients with refractory chronic migraine (RCM) experience a great deal of disability and loss of their quality of life. Chronic migraine occurs in approximately 2% of the population, but we do not know the epidemiology or rate of occurrence of RCM.
Migraine headaches are a common cause of disability in the United States, affecting approximately 60 million American adults, or 17.1% of women and 5.6% of men.1 To help define migraines better, the term classical migraine has been replaced with migraine with aura, and nonclassical migraine now is referred to as migraine without aura.
Children and teens are more likely to have a traumatic brain injury (TBI), including concussion, and take longer to recover than adults. TBI symptoms may appear mild, but the injury can lead to significant life-long impairment affecting an individual’s memory, behavior, learning, and/or emotions.
The stories are heartbreaking. The young athlete who sustains a concussion while competing and needs intensive rehabilitation for cognitive, balance, sleep, and emotional symptoms—occasionally with long-term disability and pain.
Chronic refractory migraine rating scale helps physicians better predict outcomes for patients with migraines.
As 2013 winds down, I want to recognize the year’s most significant research advance in practical pain management. This year’s award goes to the elucidation and understanding of the sequelae of head trauma.
Abortive and prophylactic therapies work well to stem severity and frequency of cluster headaches.
Headache may just be the tip of the iceberg in patients suffering a traumatic brain injury.
With traumatic brain injuries on the rise, pain practitioners need to understand the biomechanics, pathophysiology, and symptomatology of these injuries.
Each adolescent with refractory headaches is unique, and requires an individualized approach. This involves the parents, siblings, school, and health care villagers (physicians and therapists) working together with the goal to decrease pain and increase function.
Latest in a series of clinical pearls for practical headache treatment from Practical Pain Management and a headache specialist.
2 cases are presented on new daily persistent headache. How do you manage this pain patient?
Article explores medication-overuse headaches, a condition that is commonly overlooked and difficult to treat.
Pain case challenge: In headache patients, anxiety may increase pain while pain may fuel anxiety. How to treat? Hear from a headache expert.
Review will highlight the current definitions of migraines as well as treatment options. Written by a migraine expert; includes review of current migraine medications.
A wide variety of complementary and alternative medicine (CAM) therapies exist for the treatment of migraine, including pharmacologic supplements, physical therapies, medicinal herbs and teas, and relaxation techniques. Should you be using these CAM therapies for migraine patients?
A 66-year-old man with long-standing history of chronic neuralgia of the right occipital nerve presents with constant, daily pain of variable intensity associated with photophobia, phonophobia, and frequent nausea. Case Challenge from Practical Pain Management.
The use of topical treatment modalities for migraine and/or tension-type headaches holds the promise of providing a safe alternative or adjunct to systemic medications. Such treatment also may reduce narcotic dependence and the incidence of rebound headaches.
Non-migrainous, persistent head pain can be challenging to diagnose, as both intra- and extracranial etiologies must be considered. Article covers use of EMG for patients with persistent head pain.
What do you do when your patient does not do well on their current migraine medications? An Ask the Expert question answered by Dr. John Claude Krusz.
Many cases of post-traumatic headache (PTH) go undetected and are inadequately treated. Article describes evaluation, diagnosis, and treatment of PTH.
Read about this case: Heather is a 30-year-old hairdresser in a salon. Her work can be very physical, and her life has not been easy. Heather is currently on 50 mg of topiramate and 25 mg of quetiapine to prevent headaches but cannot tolerate higher doses of either medication.
This article presents a novel approach to evaluating the potential contribution of dysfunctional muscles of the head to headache. The analysis is based on dynamic and quantitative surface electromyography (SEMG) of a number of muscles through a range of motions and facial expressions.
Headache patients often have complex medical and psychological issues so that managing the headaches requires a combination of science, art, and compassion. The following are 35 pearls that the author has accumulated in his practice with this patient population.
The number one drug used by neurologists for migraine and daily headache, topirimate, is still reluctantly used by primary care physicians. This article is an attempt to demystify a very effective medication in the physician's migraine armentarium.
Article discusses how initial treatment of pediatric headaches may benefit by using conservative, reversible modalities for tension headache before resorting to medications for migraine.
Article provides an overview of treatment-resistant Migraines. Alternate strategies may be required for overcoming the treatment resistance of certain types of migraines.
Cervicogenic headaches—often misdiagnosed as a sinus headache or ocular disturbances—may be effectively managed by the use of anesthesia to block the occipital nerve branches.
Discussion of triptan options in the treatment of migraines. Reviews available migraine medications.
A case report on the use of a combination sumatriptan and Fioricet protocol in successful first-line treatment of post-dural puncture headache.
Puncturing the dura membrane in a way that leaves a self-sealing flap may entirely eliminate post-procedure spinal fluid leakage that triggers puncture headaches.
The combination of headache and chronic pain in a patient presents challenges to both headache and pain management clinicians due to the lack of overlap between the two specialties.
Modern management modalities are vital to treating headaches effectively.
An overview of the efficacy of several triptan agents in menstrually-related migraine (MM), as well as of other treatment modalities that are commonly used in the treatment of MM.
Extensive experience in evaluating and treating patients with migraines yields observations that can help the pain practitioner grapple with the complexities of migraine patients.
Long-acting opioids can help alleviate the pain associated with severe, refractory chronic daily headaches.
The use of sEMG biofeedback is effective for the treatment of chronic tension headaches. Get tips on how to use this on your patients from a pain management expert.
Sumatriptan 6mg subcutaneous is approved in a variety of countries for the acute treatment of migraine headache. Additionally, it is approved for the acute treatment of cluster headache attacks in the United States as the result of clinical trials. Two studies using subcutaneous sumatriptan 6mg, both reported by Ekbom,1,2 examined the 6mg subcutaneous dose.
The pain of the cluster attack is extreme and starts very quickly, usually without an aura or a warning. Read a discussion of cluster headache prevention in this article.
The involvement of the immune system in chronic headache has been speculated upon since the 1970s. 2,3 Various components of the immune system have been examined in relation to headache. 4,5 While great strides have been made in advancing our understanding of neuroimmunology, the complexities of the system make its specific role in headache pathology unclear.
Memantine has only recently been introduced in the U.S. for dementing disorders, although it has been used in Europe for some time. It blocks N-methyl-D-aspartate (NMDA) glutamate receptors that are thought to be intrinsic to pain transmission, windup, long-term potentiation and central sensitization.
Our patient Heather (not her real name) initially came in at age 24 and we chronicled her history and early treatment.1 In summary, Heather has moderate daily headache (CDH), with migraine 6 times per month. She also suffers from anxiety and depression (the mild end of the bipolar spectrum). Heather has irritable bowel syndrome (IBS; primarily diarrhea) plus neck pain.
A preventive is chosen with regard to the type of headache and presenting comorbidities—e.g., anxiety, depression, GI upset, medication sensitivities, etc.—and is individualized toward the patient’s needs. In using such medication, a realistic goal is to decrease the tension headache severity by 70%, not to completely eliminate the headaches.
Summary of cluster headache characteristics and update on abortive treatments utilizing first-line and second-line medications.
Ongoing studies implicate low vitamin D levels with many disease states, including pain and headaches.
By affecting chaotic (nonlinear) controls, new therapies may be employed that use less drug in the migraine cascade than is currently required.
Article discusses how neuromuscular dentistry looks at the system as a whole—including teeth and bones—together with a comprehensive evaluation of the musculature involved.
For many patients, refractory chronic migraines can be disabling and debilitating. Treating these patients may require a combination of therapeutic approaches.
Headaches, especially migraines, have a significant impact on the lives of young people. Article explores treatment options for adolescents with severe headaches.
With a higher than normal prevalence of moderate or severe personality disorder in patients who have migraines, recognizing the disorder allows alteration of both goals and approach.
While tension headaches are more prevalent in patients, there is often a presumptive migraine diagnosis due to the severity of pain, a migraine-centric focus, or the cross-over dental/medical nature of tension headaches themselves.
A review of long-term continuation rates of daily preventive medications for chronic daily headache (CDH).
This retrospective case series study revealed that Hackett-Hemwall dextrose prolotherapy appears to provide an effective, long-lasting treatment for recurring tension and migraine headache pain and their associated symptoms.
Study results for a group of difficult-to-treat migraineurs provide a basis for determining efficacy and guidelines for the use of long-term opioids in this population.
Stimulants may be beneficial for chronic migraine patients presenting with various comorbidities such as attention deficit hyperactivity disorder (ADHD), depression and fatigue.
An outpatient clinic can provide an effective variety of IV treatments—individually or in combination— for definitive control of pain for a variety of pain disorders, including migraines and fibromyalgia.
Report of successful treatment for migraine and/or tension headaches utilizing an anticephalgic photoprotective mask with a topical medication containing bryonia and rhus toxicodendron.
An under-diagnosed disorder, new daily persistent headache is characterized by an abrupt onset of a new headache disorder in someone not generally troubled by headache.
Chronic daily headache (CDH) is a disorder that is distressing for patients and frustrating for clinicians. The reasons why some patients may be predisposed to having chronic daily headache are not entirely clear. We now know of certain predicting factors that may indicate the likelihood of chronicity for migraine patients.
Outpatient intravenous ketamine treatment of CRPS-Type 1 simultaneously eradicated post-concussional migraine in patient.
A review of assessment and treatment of outpatient chronic headache patients along with a commentary on aggravating and mitigating factors.
A step by step guide through the diagnosis of a complex headache patient. How to diagnosis a chronic migraine patient.
Migraine-like Headache of Temporal Tendonitis
Electromedical Treatment of Headaches
With reasonable planning and preparation—by both the physician and the patient—an adequate headache evaluation is possible in a short visit.
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