Scott, Shelby R. M.D., FACSM, FAAFP
Shelby R. Scott, M.D., FACSM, FAAFP, is part-time faculty at Natividad Medical Center in Salinas, CA, and associate clinical faculty at University of California-San Francisco School of Medicine. She practices Family Practice and Sports Medicine in the Santa Cruz area of California.
Headache (HA) is a very common medical condition. In the United States alone, 150 million days of work and 329,000 days of school are lost every year because of migraine HAs. The annual cost is $10 million in doctor visits and $13 billion in lost work just in the United States (5,6). There are many different types of HAs, but more than 90% are attributed to migraine, tension, or cluster-type HAs (7). Tension HA is the most prevalent, but the exact representation in the population has not been studied (Table 1). Migraine is the most commonly diagnosed HA at medical visits, affecting between 12% and 16% of people in North America (Table 2). Migraines affect three times as many women as men. Cluster HAs are less common, affecting only 0.1% of the population (Table 3). Cluster HA is more common in men than women and has a familial tendency. First-degree relatives have a 14-fold increase in the incidence of cluster HA.
The triggers for HA are different for each person. The best way to determine specific triggers is by keeping a HA diary and listing any activities or foods that help with or worsen a HA. It is a common misperception that HA is a sign of needing eyeglasses or a new prescription. This is true for some people, but not everybody. Others think that HAs are caused by high blood pressure. A HA with marked elevation in blood pressure is a symptom of a hypertensive crisis but is not associated with mildly elevated blood pressures. Although exercise may make some HAs worse, regular physical activity can help prevent HAs for some people. Because each person has a specific pattern of things that trigger or ameliorate his or her HA, it is important for people with recurrent HAs to consistently journal their specific HA modifiers. Recognition of HA patterns and modifiers is very important in HA management.
It is a common misconception that an HA is a sign of a brain tumor or aneurysm. People often think that a HA warrants immediate cerebral imaging with a magnetic resonance imaging scan or a computerized tomographic scan. Headaches are very common, as mentioned above, but HAs that need imaging are rare. However, any HA associated with dangerous signs, or "red flags," does warrant further studies (Table 4). This includes HA associated with nausea and vomiting, HA that worsens despite treatment, a change in the pattern of HA, and symptoms suggesting another medical condition. Other reasons for imaging include the "worst headache of (someone's) life"; sudden onset of a severe persistent HA; HA associated with a fever or stiff neck; and HA with seizure, personality change, confusion, or loss of consciousness. Anyone with atypical symptoms also needs brain imaging.
Tension HA is the most commonly diagnosed form of HA. It has a distinct pattern of presentation. There are many different nonmedical therapies that are popular in the treatment of tension HA. Many people try massage, heat or water therapy, acupuncture, and botulinum toxin (Botox) injections. Some people with tension HA respond well to behavior modification techniques such as biofeedback and relaxation techniques (9). Because most people with tension HA self-diagnose and self-treat, it is difficult to perform controlled prospective studies on treatment for tension HAs. As a result, there are very few studies for treatment of tension-type HA. Treatment is anecdotal or whatever works for that individual.
In contrast, people who have migraine HA do seek medical care (2). They are often thwarted in their search for a diagnosis and treatment. Many become frustrated and begin self-treatment after a few failures with traditional medicines. Unfortunately, the treatment of migraine HA is complex, with many different options. Because people respond to medicines differently, it may take months to develop an appropriate treatment regimen for a specific person (8). The first step in the treatment of migraines is acute pain medicines. There are many different classes of medication available. As with any medication, it is important to treat until the pain is gone. Because migraines affect mobility of the gut, nausea and vomiting are common symptoms associated with migraine. Reglan (metoclopromide) can help with the gut symptoms. By helping with gut motility, Reglan can increase the efficacy of other migraine medications. Acute treatment medications are available by both injection and nasal administration. Oral medications are still the most frequently prescribed and work well for most migraine sufferers. Migraines also seem to have the most diverse triggers. Keeping a concise diary of activity before a migraine can help determine a pattern of attacks and prevent future HAs.
Medications can help prevent problems and lost days of work if migraines occur two or more times per month, are associated with severe symptoms, require medication more than twice per week, do not respond to regular migraine treatment, or are associated with neurological symptoms. Commonly used medications for the prevention of migraine include blood pressure medications such as β-blockers or calcium-channel blockers (10). The antidepressant amitriptyline has shown good evidence for migraine prevention. There is less evidence supporting the use of fluoxetine, a selective serotonin reuptake inhibitor, but it is also commonly prescribed. Some physicians prescribe antiseizure drugs such as divalproex sodium and sodium valproate. The seizure medications have more untoward side effects than the other classes of medications, including anti-inflammatory medications. There are some studies demonstrating that naproxen and dihydroergotamine can prevent migraines without serious side effects.
There is a certain subtype of migraines called menstrual-related migraines (MRMs). These are similar to regular migraines but are triggered by menses. The treatment and prevention of this type of migraine are slightly different. Some women are better and some worse with hormonal treatment for MRM. There are some well-designed controlled studies demonstrating the efficacy of transdermal estrogen, or female hormone, for MRM (4). Standard transdermal treatment or oral contraceptives are not indicated for prevention of MRM because the decline in estrogen in the inactive pill week is equivalent to the decline experienced in the natural cycle, which is responsible for the MRM. Other studies show efficacy with triptans, specifically, sumitriptan, frovatriptan, and naratriptan. There are no studies that can demonstrate benefits with naprosyn, although it is very frequently prescribed by primary care physicians for menstrual disturbances. Many women try natural remedies for their MRM HA, such as naturally occurring hormones. There was one prospective randomized controlled study that negated the efficacy of phytoestrogens, or plant-based estrogen products, for MRM. Phytoestrogens are products available at natural supplement markets without prescription. Initial treatment of MRM should be the same as for migraine occurring at any time: a rapid-onset triptan administered early in the mild pain stage. If MRM persists despite as-needed treatment, then treatment should address prevention. Prevention is best achieved with extended-cycle oral contraceptives, including transdermal estrogen, regular-cycle oral contraceptives with supplemental estrogen for the placebo days, or targeted supplemental estrogen. Treatment with hormonal supplements for MRM is no different from birth control and is not indicated for any woman older than 35 years who smokes. In addition, any use of estrogen is controversial in women with migraine associated with neurological symptoms. All women need to discuss the options available for treatment with their primary care provider.
In summary, keep in mind the warning symptoms for all forms of HA and immediately seek medical attention if indicated. Most HAs are diagnosed and treated at home. In people seeking medical attention, most will have migraine HAs. These are usually well treated with normal HA medication. If there is no response, there are some medications specific for migraine and some for the prevention of migraines (Table 5).
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