Access to the PPM Journal and newsletters is FREE for clinicians.
4 Articles in Volume 2, Issue #4
An Historical Perspective: A Global View of Evolving Pain Treatment Modalities
Percutaneous Disc Decompression/ Discectomy - A Case Report
Practical Headache Pearls
Temporomandibular Joint Disorder Mimic Ernest Syndrome Diagnosis and Treatment

Practical Headache Pearls

Extensive experience in evaluating and treating migraineurs yields observations that can help the practitioner grapple with the complexities of migraine patients.
The treatment of headache patients is a complicated art. It involves establishing a longterm relationship with a patient, legitimizing headaches as a medical illness, and utilizing both medication and non-medication tools. While medications remain the mainstay of therapy, the goal is to achieve a balance between all possible treatment modalities. Psychological co-morbidities, such as anxiety and depression, play a major role in the approach to the treatment of the headache patient. The following are some practical “pearls” gleaned from years of treating these complicated patients.


Migraine tends to be under-diagnosed. Chronic sinus headaches are often, in actuality, migraine. One recent study indicated that over 95% of patients with a history of chronic sinus headaches were actually experiencing migraine. While the sinus medications may be of benefit in migraine patients, migrainespecific medications would usually be more effective.

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 (Depakote, lithium, Tegretol, Neurontin).

Using a medication to establish a diagnosis may not be accurate. For instance, Dihydroergotamine (DHE) or triptans may also mitigate the pain of subarachnoid hemorrhage or even tumors.


The initial history and physical is the best time to consider a list of medications; at that point one would have a good grasp of the patient’s co-morbidities. If the practitioner lists in the chart the therapeutic alternatives (in case initial medications do not work, one does not have to reconstruct the entire history with the patient at a later date.

Keep track of sensitivities and allergies to medications in a prominent place in the chart. If the patient has had severe reactions to two Selective Serotonin Re-uptake Inhibitors (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 beta blocker, a second will probably not prove helpful in the long term.

Keep a drug medication flow chart. Headache patients are constantly having medications stopped and restarted, and over 10 years, a patient may have been on 50 different medications. It is impossible to sort through a multitude of progress notes trying to determine what the next best course of action is. A drug medication flow chart from the very beginning helps immensely.


In choosing preventives, assess other conditions, particularly anxiety, depression, insomnia, gastritis, Gastroesphageal Reflux Disease (GERD), Irritable Bowel Syndrome (IBS), constipation, hypertension, asthma, and sensitivities or allergies to other drugs. These often determine which therapeutic option to pursue.

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 be fairly somatic, and there is no need to increase medication very quickly. One exception to this is in patients with severe “new onset daily persistent headache”; these patients may be less patient.

Persist with preventive medications for at least four weeks (or longer); if abandoned too quickly, one may not see the anticipated beneficial effect. However, few patients are willing to wait months for positive benefits from a medication.

Do not confuse addiction with dependency. When treating chronic daily headache, dependency has to be accepted. Unfortunately, the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) is inadequate in addressing prescription abuse.

Before “giving up” on a patient with severe, refractive chronic daily headache and nothing seems to work, consider “end of the line” strategies such as: Monoamine Oxidase Inhibitors (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.

For those refractory patients, occasionally it will be necessary to use more than the recommended amount of triptans. Many patients have discovered that the only medication that helps is a triptan, but they end up utilizing these on a daily basis. While there is no evidence that long-term use is harmful, we have no evidence to prove that these are safe. There have been several small studies on frequent or long-term use of triptans, but the class of drugs is too new to guarantee long-term safety.


Outside of medication, patients often benefit from 20 minutes (or more) of exercise on a daily basis. Low-level exercise programs is recommended, such as treadmill, stationary bike, and walking. For those who are not motivated to exercise, we encourage the “chunks of time” method of exercising: 10-20 minutes at a time, once or twice daily. Many patients with headache have associated neck pain and tightness in neck muscles; yoga may help to relieve stress and improve neck or back pain.

While most natural treatments do not benefit the patients, a few have proven safe and effective in double-blind studies. Feverfew appears to be an effective herb, is relatively safe, and may help to prevent migraines in certain patients. In addition, magnesium as a supplement has also been utilized as a natural preventative. Many parents do not want their adolescents on daily medication, but are willing to start with feverfew as a milder alternative.

Coping with headaches and the stresses that headaches produce (rather than the headache itself) is often improved with therapy. Unfortunately, because of stigma, time and money, only a small minority of patients will actually go to a therapist. However those that do go will usually benefit.

Patient Communication

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 physician. When migraines are legitimized as a medical condition that is oftentimes inherited, and exhibits tangible low levels of serotonin in the brain, patients are extremely receptive. Once receptivity is established, the patient is much more amenable to addressing such co-morbidities as stress, anxiety, depression and other psychological co-morbidities, with therapy or other means.

Patients are often confused as to the reason they are given an antidepressant for migraine. It is important to clarify that the object of this modality is to directly increase serotonin in the brain, rather than trying to treat their headache by treating depression. Nevertheless, a helpful side benefit may be a reduction in anxiety and depression accompanying such debilitating attacks.

Practitioners must try to achieve a balance between medication and headache; the author communicates to patients that the goal is to improve headache relief 50%-90%, while minimizing medications.

Some patients with chronic daily headache may view their headaches in black and white terms. On a return visit they may say, “Well, I still have a headache everyday.” 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 the current medication need not be changed. It will be helpful in such situations that the patients keep a headache chart or calendar. 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 report how much they are utilizing. Between over-thecounter analgesics and herbal preparations, many patients are consuming larger quantities of medications than the practitioner may realize.

Weight gain is a major issue; even though a drug may be more effective, choosing one that avoids weight gain (in those prone to obesity) is more likely to lead to long- term success. Fatigue induced by a drug is another major reason patients may abandon a preventive medication.

Last updated on: December 27, 2011
close X