Highlights of the 5th Annual Association of Family Practice Physician Assistants (AFPPA) Conference: Headache Management -- Evaluation and Treatment

San Antonio, Texas; November 19-23, 2003

Jim Meeks, PA-C


February 12, 2004

In This Article

Treatment of Headache

Tension headache. Most patients self-treat this type of headache with OTC medications. Reductions in stress and changes in daily living activities designed to reduce the frequency and intensity of episodes are recommended. Aspirin, acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAIDs) are generally effective. Caffeine-containing compounds can increase the effectiveness of acetaminophen or aspirin. Patients need to be cautioned about overuse of these medications, as this can lead to caffeine withdrawal and rebound headaches. Persistent tension-type headache may respond to prescription analgesics, but these should be used only on a limited basis. If control is difficult or unsatisfactory, a reassessment of the condition is warranted.[8]

Cluster headache. Schuman[1] outlined treatment recommendations for cluster headache. The primary treatment is administration of high-flow oxygen, 10 L/minute for 10 minutes. If there is no improvement, treatment with sumatriptan 6 mg subcutaneously (SQ) is recommended. Oral medications are not particularly effective due to the nature of this headache, which presents with sudden severe pain and typically has rapid resolution. Another treatment option is administering dihydroergotamine 1 mg intramuscularly (IM), SQ, or intravenously (IV). Recommended nonacute preventive treatments include indomethacin 25-50 mg 3 times daily; verapamil, total dose of up to 480 mg daily; high-dose corticosteroids for up to 2 weeks; and lithium.[1]

Migraine headache. Pharmacologic treatment of migraine falls into 2 basic categories: preventive and abortive. Preventive drugs are used with the goal of reducing the overall number of attacks and are used for patients who experience more than 2 headaches per week. The classes of drugs for treatment, as mentioned by both presenters, included tricyclic antidepressants, selective serotonin reuptake inhibitors, NSAIDs, beta-blockers, calcium channel antagonists, and antiepileptics.[1,2]

Abortive therapy is employed when headache is already present. With the advent of sumatriptan in 1993, the treatment of migraine headache changed dramatically. The triptan class of drugs has now become the cornerstone of therapy. Treatment objectives include: the patient should be pain-free within 2 hours of using the medication; the patient should not experience headache recurrence within 24 hours once he or she is pain-free; and the patient should be able to return to full preheadache activity within 2-4 hours of treatment. In addition, the patient should experience few to no side effects from the treatment.

Nett[2] strongly emphasized the importance of these treatment objectives and the elimination of the "sick role." Educating the patient in the use of these medications and the expected outcome is extremely important for reversing the perception of disability associated with migraine headaches and previous treatments that involved sedating narcotics.

There are several key points to consider when prescribing a triptan.[2] Use of a triptan medication allows for overall improvement in patient disability by treating the condition without sedation. Failure of 1 triptan does not mean a failure of the entire class of drug. Instead, the patient should be tried on 1 drug for a minimum of 3 headaches before switching to another in the triptan class.

Finally, early and aggressive treatment of the migraine headache is the key to success.[2] Patients must be educated on this point. Treatment should begin within 15 minutes of onset. If patients wait longer, in an attempt to see if this is going to be a "bad one," they will have less success in obtaining relief. Nett[2] also suggested that any repeat dose of a triptan be given at 60 minutes, not at 2 hours as is common practice. He suggests that patients who wait 2 hours to repeat the dose will often end up in need of rescue intervention.


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