An initial and fundamentally important step in the management of headache is to differentiate those headaches that are the result of other, often serious, conditions ('secondary' headaches) from headaches that are not caused by an underlying disease process ('primary' headaches).
Although symptomatic treatment of pain is also necessary in secondary headaches, it is crucial to treat the underlying cause. In the case of a brain tumor, this may mean surgical excision or a shunt to reduce raised intracranial pressure; antibiotics for bacterial meningitis; and surgical drainage of an intracranial hemorrhage.
Primary headaches are the far larger group, and include tension headaches and migraine. These headaches are managed symptomatically - there is no underlying disease to also take care of.
There are several common-sense courses of action that may well prevent headaches in the first place: A change in lifestyle that reduces stress may be enough.
Some patients notice that certain situations or habitual patterns of behaviour are likely to cause headache. Avoiding certain trigger foods and chemical compounds (perfumes, smoke) may be central to the management of migraine. In most people, getting regular exercise, avoiding excessive caffeine and alcohol, stopping smoking and ensuring adequate hydration are cornerstones of treatment, and are just as important as drug management. They also have all sorts of other benefits.
Drugs for headache are either prophylactic or symptomatic. Prophylactic medications are taken daily and are directed towards preventing the headache from developing in the first place. They are not pain medications. Symptomatic or “abortive” medications are pain medications - analgesics - and are designed to stop the headache once it has started. Often a trial-and-error approach is necessary to match an individual patient with the most suitable medication.
There are a wide variety of prophylactic medications. Tricyclic antidepressants, like amitryptyline, are frequently used, and can ease headache even in those patients not clinically depressed. Other medications include several of the anti-epileptic drugs and the calcium channel blockers. Beta-blockers, used to lower blood pressure in other patients, are effective in migraine.
Once a headache has taken hold, abortive medications are used. These include simple analgesics like paracetamol and aspirin, anti-inflammatories and muscle relaxants. Narcotic analgesics may be necessary for the most severe headaches, but they are best limited to one-off usage, and should not be prescribed longer-term, as they are habit-forming.
Migraine is often associated with intense nausea, and an anti-emetic may be enough to halt a migraine. Medications that act on the caliber of blood vessels have an important place in migraine therapy - the ergot drugs of old have largely been replaced by the newer “triptan” medications like sumatriptan (Imitrex), which has oral, subcutaneous and intranasal forms. Unusual primary headaches like cluster may respond to breathing Oxygen.
It should be mentioned that although there are many efficacious medications for headache, all have side-effects, and so should be used judiciously. In fact, so-called “rebound headache” is a well-recognised result of medication overuse, and if severe, may necessitate hospitalisation for medication withdrawal.
Reviewed by Dr Andrew Rose-Innes, MD, Department of Neurology, Yale University School of Medicine, New Haven.
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