Overview: Headache

• Headache is one of the most common complaints that brings a patient to the attention of health care providers.

• Ninety percent of all headaches are either migraine, with or with- out aura, tension-type headache (TTH), or a mixture of the two.

• Sixteen percent of women and 6% of men suffer from migraine.

• The remaining 10% of headaches seen by caregivers are secondary to disorders of the tissues of the head and neck including the cervical spine, sinuses, temporo-mandibular joints, dental structures, soft tissue trauma and post-traumatic conditions, with primary tumors, infection, and metastatic cancers constituting a small fraction of possible causes.

Important Points to Consider

Patients with migraine often suffer from tension-type headache and other forms of headache. A carefully recorded history of headache symptom characteristics helps establish criteria that lead to diagnoses and helps to highlight distinctions that guide specific therapies.

Daily use of a compound containing 400 mg of riboflavin, 300 mg of magnesium, and 100 mg of feverfew has been shown to be effective in reducing the frequency of migraine in adults.

Magnesium aspartate, in contrast to magnesium oxide, is easily absorbed and rarely causes diarrhea when used for migraine prevention. Avoid giving either preparation at the same time as calcium, zinc, or iron. Dose: 500 to 1000 mg each night.

Prevention Prescription: Migraine

• Identify and avoid environmental factors that consistently lead to headache (e.g., allergens, fluorescent lights, loud noises, fumes, and dust).

• Implement a sleep hygiene program, using a prebedtime routine that signals a time leading to restorative sleep. Avoid excessive sleep as well as inadequate sleep.

• Eliminate foods that lower the threshold for migraine (e.g., chocolate, aged and yellow cheeses, caffeine, red wine, dark beer, shellfish, and meats processed with nitrates).

• Water and fluid intake should be a minimum of 40 to 60 oz per day for an adult.

• Maintain an exercise program: aerobic level activity, for a minimum of 30 minutes, three times a week.

• Regularize meals, sleep, exercise, and use of medications for prevention.

• Keep a diary documenting headache frequency and intensity, response to medications, association with major life changes, stress, and changes in physiologic states, such as menses, pregnancy and illness. Share diary information with caregivers.

Therapeutic Review: Migraine

Lifestyle

• Regular meals and sleep, sleep hygiene, aerobic exercise three times a week, headache calendar, stress management, avoidance of environmental triggers

• Consideration of discontinuation of hormonal birth control method if menstrual migraine is evident or the history suggests cause and effect

Nutrition

• Elimination of food triggers: wine, aged cheese, milk (dairy), cashews, chocolate, processed meats, caffeine

Biochemical Supplements

• Magnesium aspartate: 500 to 1000 mg nightly

• Riboflavin: 200 mg twice daily

• Coenzyme Q10: 150 mg daily

Botanicals

• Feverfew: 125 mg up to three times daily

• Butterbur (Petasites hybridus): 50 mg three times daily

• For sleep: valerian root extract: 100 to 300 mg nightly; melatonin: 6 to 10 mg nightly

Pharmaceuticals

• Aspirin: 325 mg daily

• Amitriptyline: 10 to 150 mg nightly

• Propranolol: 60 to 180 mg daily

• Gabapentin: 300 to 600 four times daily

• Topiramate: 100 to 200 mg nightly

• Verapamil: 180 to 480 mg daily

• Valproate: 500 mg three times daily

• Botulinum toxin: subcutaneous 100 units every 3 months

Mind-Body Therapy

• Biofeedback: 10 sessions

• Cognitive behavioral therapy

• Hypnosis

• Mindfulness meditation: 8-week course

Biomechanical Techniques

• Consider in cases where muscle tension in the jaw, neck, or shoulder is prominent

• Chiropractic

• Craniosacral therapy

• Massage

• Dr. Mosaraf Ali's Neck Massage (Integrated Medical Centre London and New Delhi)

• Bioenergetics

• Acupuncture: six to eight sessions over 8 weeks, repeated as needed

Acute Migraine Treatment

Use of specific abortive measures depending on efficacy, cost, side effects, and ease of administration; use of narcotics and antiemetics not covered

Lifestyle

• Darkened, quiet environment, maintenance of hydration, meals if possible, sleep

Biochemical Supplements and Herbals

• Magnesium sulfate: 2 g IV in 100 mL saline over 30 minutes

• Ginger tea for nausea: 8 oz every 3 hours

• Aromatherapy (peppermint)

Pharmaceuticals

• Naproxen sodium: 250 to 500 mg every 4 hours

• Ibuprofen liquid: 200 to 400 mg every 2 hours

• Lidocaine 4% liquid: 0.25 mL in each nostril every 1 hour

• Isometheptene (Midrin): two tablets at onset, then one tablet every 45 minutes x three

• Triptans: many available; dosing routines identical: initial dose at the onset of head pain, followed no sooner than 2 hr by a second dose if necessary; limit: three doses in 24 hr

• Valproate: 1 g IV over 1 hour

• DHE-45: 1.5 mg IV over 30 minutes preceded by promethazine (Phenergan) 20 mg IV

Mind-Body Therapy

• Self-hypnosis training

• Practiced biofeedback routine

• Relaxation

Biomechanical Techniques

• Craniosacral therapy

• Massage, slow stretch

Bioenergetics

• Acupuncture

• Reiki

Key Web Sources

• National Institutes of Health (NIH) National Center for Comple- mentary and Alternative Medicine (NCCAM) http://nccam.nih.gov/health/acupuncture/acupuncture-for-pain.htm.

• NIH National Institute of Neurologic Disorders and Stroke (NINDS). http://www.ninds.nih.gov/disorders/migraine/migraine.htm.

• American Headache Society. http://www.achenet.org/education/ patients/index.asp.

• National Headache Foundation. http://www.headaches.org/cms.

• National Headache Foundation Headache Diary. http://www.headaches.org/For_Professionals/Headache_Diary.

• Migraine Disability Assessment Test (MIDAS). http://www.headaches. org/pdf/MIDAS.pdf.