Man With Incapacitating Daily Headaches

A 39-year-old man complains of severe daily headaches that he describes as throbbing and "burning," with a sensationof pressure. He rates the severity of his pain as 8 to 10 on a 10-point visual analog scale (VAS) in which 10 isthe most severe. The mean duration of the headaches is 12 hours, and the mean frequency is 5 days per week. Betweenthe episodes of severe headache, he has constant "minor" headaches that are not as severe (mean severity, 3 to 5 on a10-point VAS). Within the past 5 months, he has never been totally free of headache.The patient's headaches started during his 20s. At that time, they were very severe but not as frequent. The frequencyof the headaches slowly increased over 2 to 3 years until they occurred on more than 15 days each month. For the past7 years, he has had daily headaches, which have worsened and become disabling in the past 4 months.His treatment history is extensive; he has tried a variety of appropriate medications, but none have enabled him tocontrol his headaches and to function normally. Preventative medications he has tried include verapamil, fluoxetine,paroxetine, amitriptyline, divalproex, topiramate, and celecoxib. The abortive medications include several potent antimigraineagents (sumatriptan, almotriptan, and zolmitriptan). In addition, for pain relief, he has tried over-the-counteranalgesics, oxycodone, and propoxyphene. For the past 7 months, he has used butalbital-containing medications every day.A recent MRI scan and MR angiogram and results of a neurologic examination are all normal.
Which clues in the history and clinical picture point to the diagnosis?How would you intervene to alleviate this patient's disabling headaches?How would you institute effective preventative therapy?Primary care doctor: This patient's headaches are of differenttypes and have some unusual features (such as "burning").This makes the clinical picture unclear. How wouldyou arrive at a diagnosis?
Headache specialist: I suspect your patient has reboundheadache, which is now termed "medication-overuseheadache," according to the classification proposed by theInternational Headache Society in 2003.^1,2 The new classificationprovides valuable criteria regarding the type ofmedications and frequency of use associated with thiskind of headache. According to the new classification,medication-overuse headache is diagnosed if:
The patient is taking an ergotamine, a triptan, an opioid,or a combination of various pain medications on more than10 days per month (or simple analgesics on more than 15days per month) for more than 3 consecutive months.The patient has chronic headaches that have worsenedduring the period of medication overuse.Discontinuation of the agent suspected to have causedmedication-overuse headache results in noticeableimprovement.¹Your patient's headaches have been getting worsewhile he has been taking butalbital-containing medicationsdaily; this strongly suggests that he is experiencing medication-overuse headache.Primary care doctor: This man tried various medicationsand even used a combination of several preventativemedications and abortive medications. Yet the agents hetried-especially the triptans-did not help him. So howdo you conclude that he has medication-overuse headacherather than some type of secondary headache?
Headache specialist: First, his normal MRI scan, MR angiogram,and neurologic examination results help rule outsecondary headache. In cases such as this, it is importantto perform all these studies, as well as a psychologicalevaluation, to avoid misdiagnosing secondary headache.
Also, a patient who is overusing pain medications-and in whom medication-overuse headache develops as a result-may simply not benefit from any kind of preventativetreatment until the habituating medication is stopped.I believe this applies in this man.
Primary care doctor: What approach would you recommendat this point?
Headache specialist: I would recommend inpatient treatment.This is a very effective method of managing intractableheadaches. First, a multidisciplinary approach can beemployed that combines pharmacologic, nonpharmacologic,and educational strategies. Also, inpatient treatmentallows the use of more "aggressive" therapies, which oftenrequire parenteral administration and dosing every 6 to 8hours. Round-the-clock treatment is essential to break theexisting headache cycle and is a very effective methodof acute (abortive) treatment. It is very difficult to employthis type of therapy in an outpatient setting.
Primary care doctor: Should all patients with medication-overuseheadache be hospitalized for treatment?
Headache specialist: Not necessarily. You need to considerwhat types of medications are being abused. It is alsoimportant to review the patient's treatment history anddetermine whether any previous treatment was successful.If it was, then you need to compare the previousheadache pattern with the current headache problem todetermine whether the headaches have worsened sincethat time.
In this man's case, the medications being overusedcontain a narcotic (butalbital). Thus, detoxification may requiresubstitution therapy (eg, phenobarbital). In addition,outpatient treatment has repeatedly failed. Both thesefacts support inpatient treatment.
Primary care doctor: What other criteria should be consideredbefore making the decision to admit a patient withheadache?
Headache specialist: There are several others (Table). It isalways important to assess the current clinical presentationof the headache, as well as the patient's status. Whattype of headache is he or she experiencing? Consider inpatienttreatment for different kinds of chronic headache,and for certain other types of headache, such as statusmigraine, which requires aggressive abortive treatment toresolve the pain.
The level of the patient's disability, which is usually afunction of the frequency and severity of the headaches, isalso a determining factor. Patients with severe associatednausea and/or vomiting may require admission becauseof dehydration and decreased functioning.
Another important consideration in the decision tohospitalize is the method of treatment that will be used.In addition to aggressive abortive treatment and detoxificationtherapy, initiation of certain types of preventativetreatment (eg, monoamine oxidase inhibitors [MAOIs]or combination therapy with various agents) may requirecareful inpatient observation because of the possibility ofdrug interactions or reactions.
Primary care doctor: What does inpatient treatment entail?
Headache specialist:Treatment at an inpatient centertypically involves:
Detoxification therapy.Acute (reversal) therapy.Prophylactic therapy.Nonpharmacologic therapy.
Detoxification therapy is required for patients withmedication-overuse headache to help them discontinuethe habituating medications. To avoid possible withdrawal,especially for those who have been overusing narcoticcontainingmedications (such as butalbital), substitutiontherapy may be needed.
Various agents are used in acute (reversal) pharmacotherapy.I frequently use the dihydroergotamine(DHE) protocol (DHE mesylate, 0.5 mg, administeredintravenously over 2 to 3 minutes in combination withondansetron, every 8 hours for 3 days).³ I also use theNSAID ketorolac, 30 mg (if the patient was not abusingit previously). The ketorolac is alternated with muscle relaxants(eg, IV orphenadrine, 30 mg) and antiemetics.In some cases, I may use IV valproate, 1000 mg as needed(not daily), as an abortive agent. If the patient complainsof very severe headache and other abortive drugs are noteffective, corticosteroids might be used (IM methylprednisolone,80 mg as needed [not daily]). For pain relief,IV methadone, 10 mg, in combination with IV promethazine,50 mg as needed (not daily), may be given. Anypain medications previously abused by the patient areavoided. This type of intensive reversal treatment oftenallows patients to experience their first headache-free(or almost headache-free) interval-which increases theirwillingness to cooperate with further treatment.
Primary care doctor: The reversal treatment you describediffers from traditional outpatient treatment. What aboutpreventative treatment? Is the prophylactic therapy institutedduring inpatient treatment different from that usedon an outpatient basis?
Headache specialist: Yes and no. Sometimes I use traditionalpreventative medications, such as ß-blockers, calciumchannel blockers, divalproex, and topiramate. Antidepressantsare prescribed for many patients-with the tricyclicantidepressants (TCAs) as first choice. However,TCAs are prescribed only if the patient has never beentreated with these agents or has had a previous positiveexperience with a TCA. For those patients who have hadnegative experiences with these antidepressants, anotheroption must be explored. In such patients, the MAOI antidepressants,such as phenelzine and isocarboxazid, arethe "last resort."⁴
I prefer to initiate treatment with MAOIsin an inpatient setting because of the extensive list of associatedcontraindications, dietary limitations, and interactionswith other medications. Inpatient initiation facilitatesthorough patient education regarding medications andfoods to avoid in order to prevent undesirable interactionsand side effects.
Primary care doctor: You have mentioned nonpharmacologicinterventions. Could you elaborate?
Headache specialist: Nonpharmacologic interventions arean important part of headache management. These includebiofeedback training, stress management therapy,relaxation training, physical therapy, and psychologicaland/or psychiatric consultations. It is also important to reviewand challenge patients' diet and sleep habits. In general,I try to teach patients how to deal with pain, managestress without pain medications, and use more appropriatecoping strategies.^5,6.