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Management of Headache and Headache Medications

Sternberg, Timothy L. DMD, MD

Book Review
Free

Anesthesia Pain Clinic, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425.

Management of Headache and Headache Medications, Lawrence D. Robbins. New York: Springer-Verlag, 1994, ISBN 0-387-94040-5, 3-540-94949-5, 217 pp, $65.00.

Despite a promising introduction by Dr. Prithvi Raj, A Pain Specialist's Approach to the Headache Patient is a superficial monograph on commonly encountered headaches that takes the reader little beyond the level of knowledge found in basic medical texts. According to the introduction, the intent of this publication is to update physicians in the management and pathology of headache syndromes. The monograph is written by Seymour Diamond, MD, with one chapter each contributed by Drs. Steven Waldman and Michael Maliszewski.

The first six chapters, written by Dr. Diamond, deal with basic headache evaluation, pathophysiology, and medical treatment. "The Approach to Headache" explains the Diamond Headache Clinic's classification system and work up of headache patients. Although this classification system is simple and useful, this reviewer take exception with the author's contention that episodic muscle tension headaches are seldom seen by physicians and with the lack of mention of analgesic rebound headaches. The remainder of the chapter succinctly explains an organized and directed history and physical.

Chapters 2 through 5 deal with the diagnosis and treatment of migraine, cluster, and tension headaches and contain the bulk of the useful information found in this book. The chapters on migraine and cluster headaches each contain a helpful therapeutic Table thatlists accepted first-line therapy. The chapter on tension headaches reflect the author's bias that depression causes chronic tensions headaches (versus chronic headaches causing depression), and the only pharmacotherapy offered is antidepressants. These chapters contain cumbersome treatment algorithms that all eventuate in referral of the patient to a headache specialist.

The chapter "Organic Causes of Headache" contains too little of what must be known of this important subject by a pain management physician, and it also contains some misconceptions. For example, an acute epidural hematoma is usually associated with a brief lucid interval between head injury and coma, not an acute subdural hematoma, as the author states. Furthermore, accepted and effective therapy that every physician should know is omitted. The only treatment offered for postlumbar puncture headaches is horizontal bed rest; no mention is made of epidural blood patches, oral analgesics, or intravenous caffeine.

"The Role of Neural Blockade in the Management of Common Headache and Facial Pain Syndromes" by Dr. Waldman describes cervical epidural, occipital, and trigeminal nerve as well as spheno-palatine and stellate ganglion blocks in a brief chapter. These descriptions are too simplistic for the anesthesiologist pain specialist and certainly too superficial for pain practitioners not already practicing neural blockade on a regular basis. "Management of the Headache Patient: A Behavioral Medicine Approach" by Dr. Michael Maliszewski presents a coherent introduction to behavioral medicine as it relates to the headache patient.

In summary, A Pain Specialist's Approach to the Headache Patient could be useful to anesthesiologist pain practitioners who only treat headaches in a limited fashion but is insufficient for specialists who deal with anything other than uncomplicated vascular and tension headaches.

Management of Headache and Headache Medications by Lawrence Robbins, MD, is a concise and easy to read text that fills a void in headache pain literature. The author describes how to manage these difficult patients and their medications rather than simply listing treatment regimens for various headaches categories. In doing so, he has produced a practical text full of useful, readily applicable information.

The first five chapters deal with migraine headaches. The introductory chapter is brief but contains several useful tables on migraine characteristics, somatic symptoms, and common food precipitants. One chapter each is dedicated to abortive and preventive medications. Contained in these chapters are quick references guides that tabulate first-, second-, and third-line therapies. These handy references are followed by straightforward text, which lists generic drug names as well as trade names, doses, side effects, and management. A quick reference guide also lists therapy for antiemetic therapy as it relates to migraineurs. A chapter titled "Hormones and Headaches" concisely explains how to treat menstrual migraines as well as headaches during pregnancy. The final chapter on migraines is dedicated to case studies and, although the information is somewhat superfluous, is clinically oriented and fun to read. The sections dedicated to tension and cluster headaches follow a similar format, explaining abortive and preventive first-, second-, and third-line therapy using reference guides followed by a chapter on sample case studies. This text is objective in the treatment of psychological factors contributing to tension headaches and provides a good description of traditional antidepressants as well as serotonin-specific uptake inhibitors that are useful in the treatment of headaches.

The final two chapters deal with special subtypes ranging from headaches in children to headaches after age 50. There are even several pages on exertional and sexual headaches. The section on lumbar puncture headaches practically explains when intravenous caffeine and epidural blood patches are indicated.

Although Management of Headache and Headache Medications is not comprehensive, it is complete in its coverage of primary headaches and contains minimal repetition and no inconsistencies. In summary, this is an extremely useful book that would be a valuable and efficient resource for any pain clinic in which headaches are a component of the referred patient population.

Timothy L. Sternberg, DMD, MD

Anesthesia Pain Clinic; Department of Anesthesia and Perioperative Medicine; Medical University of South Carolina; Charleston, SC 29425

© 1997 International Anesthesia Research Society