Two Women With Severe Headaches: Different Symptoms, Similar Approaches

CASE 1:
A 32-year-old woman complains of daily headaches.The headaches vary in severity, but she usually has severeheadaches (8 on a 10-point visual analog scale[VAS]) once or twice a week; she describes the latter assevere throbbing or pounding pain on the top of thehead but also involving the occipital and frontalareas--and occasionally one or the other temple. Theseepisodes, which are usually associated with some nauseaand sensitivity to bright light and loud noises, typicallylast up to 48 hours if untreated.

The patient also has headaches that are not nearlyas severe (3 or 4 on a 10-point VAS) but are almostconstant. She describes them as mild to moderate, dull,pressure-like pain located primarily on the top of herhead and occipital area bilaterally. She is able to functionwith these headaches more easily than with the severeones, although she sometimes needs to use overthe-counter (OTC) medications to lessen the intensityof the pain.

She started having severe episodic headaches inher early 20s; these became progressively more frequent.In addition to the increasingly frequent severeheadaches, about 5 years ago, she began having milderheadaches as well. These also became gradually morefrequent-and eventually occurred daily. She has haddaily headaches for about 2 years.

She has been using oral sumatriptan, 100 mg, forher severe headaches and notes that this reduces theseverity of the pain significantly within 1 to 2 hourswhen she is able to take the medication shortly afterpain onset. However, she seldom takes it early enough tohave this effect. She uses OTC acetaminophen oribuprofen for her milder headaches once or twice a day,about 2 days a week.

Results of physical and neurologic examinationsand MRI and CT scans of the head are all normal.

• What changes might increase theeffectiveness of abortive treatments inthis patient?
• Might there be a rationale forprophylactic therapy in this patient?

THE DIALOGUE:Primary care doctor: This patient has 2 different types ofheadache. What diagnosis would you make in this case?

Headache specialist: This patient has had daily headachesfor the past 2 years. In addition to mild, constantdaily pain, she also has a different, more severeheadache once or twice a week. Her severe headachesmost likely represent migraine without aura. It seemsthat she is able to control the severe headaches witha triptan, provided she takes the medication earlyenough.

This last point is very important. Often, we seepatients who state that the abortive migraine medications,including triptans and ergotamine-containingagents, are not effective or have only a very limited benefit.However, the reason for this apparent lack of efficacyis often that the patients do not take the medicationsearly enough. In fact, if a migraine is fully developed(which may not occur until 1 to 2 hours after headacheonset), even appropriately selected and dosed medicationsmay not be effective.

Primary care doctor: How early do abortive medicationsneed to be taken to be effective?

Headache specialist: These agents generally need to betaken as early as possible.¹ Patients who have migrainewith aura or cutaneous allodynia can use the aura orallodynic symptoms as a signal to begin treatment.²

Primary care doctor: Should a patient still take an abortivemedication once a headache has developed? For example,if a patient wakes up in the morning with a headachethat is already severe, what should he or she do?

Headache specialist: We still encourage our patientsto take medication in the late stages of migraine-eventhough the data regarding the effectiveness of such a strategy are conflicting. Some headache experts haveconcluded that abortive medications are usually significantlyless effective if they are taken after cutaneous allodyniahas developed.2,3 Others believe that these agentscan relieve symptoms even in late stages of migraine development.4 Last year we conducted a study in which weanalyzed the degree of symptom relief achieved withsubcutaneous sumatriptan in patients with migraine whotreated their headaches during the developed stages ofallodynia and of migraine itself. Our results were verypromising: the majority of study participants becamepain-free even when they initiated treatment after cutaneousallodynia had developed.

Primary care doctor: So what treatment strategy wouldyou recommend for this patient?

Headache specialist: We would recommend treatmentwith her current medications, taken early in the course ofa migraine whenever possible. In those instances whenshe is not able to take her medications at headache onset,we would suggest using a parenteral abortive medication,such as sumatriptan, 6 mg SQ; the newer 4-mg versionof sumatriptan SQ; ketorolac, 30 mg IM; or even diphenhydramine,50 mg IM.

Therapy with corticosteroids (eg, methylprednisoloneacetate, 80 mg IM) may be effective. This therapyis extremely effective in some patients; however, itshould not be used regularly. We recommend the use ofcorticosteroids for patients who have prolonged migraines(ie, those that last longer than 48 hours) butno more than once a month.

This patient's chronic daily headache should betreated with preventive medications. (Preventive treatmentis indicated in any type of chronic headache disorder.)Because she has never tried prophylactic therapy,we would recommend starting with a ß-blocker.Depending on her sleeping pattern and presence of comorbidpsychological conditions (eg, depression or ananxiety disorder), we might also recommend the additionof a tricyclic antidepressant, an anticonvulsant, ora monoamine oxidase inhibitor.

CASE 2:
A 35-year-old woman complains of episodic severeheadaches that occur 3 or 4 times a month. She describesthem as severe throbbing or stabbing pain locatedin the frontal and temporal areas--usually on only oneside but occasionally involving the entire head; she ratesthe intensity of the pain as 10 on a 10-point VAS. Theheadaches usually last 2 to 3 days and are always associatedwith severe nausea, frequent vomiting, phonophobia,and photophobia so extreme that she needs to wearsunglasses even when indoors with the curtains closed.The pain is so incapacitating that she has to leave workearly or miss an entire day of work 2 or 3 times amonth, and she has to go to the emergency departmentabout once a month. She has been hospitalized twice forincapacitating headache and severe dehydration secondaryto frequent vomiting.

She has used a variety of pain medications, includingOTC drugs and such prescription medications assumatriptan, frovatriptan, zolmitriptan, ketorolac, butalbital-containing agents, hydrocodone, and methadone.She says that none of these medications were able to providesignificant or long-lasting relief from her headaches;at best, they reduced the severity of the pain slightly (to 7on a 10-point VAS) for 2 to 3 hours.

The headaches began during her teenage yearsand became more severe and prolonged after her firstpregnancy 3 years ago.

Results of physical and neurologic examinationsand MRI and CT scans of the head are all normal.

• What changes might increase theeffectiveness of abortive treatments inthis patient?
• Might there be a rationale forprophylactic therapy in this patient?

THE DIALOGUE:Primary care doctor: What would be your diagnosis inthis patient?

Headache specialist: This woman has episodic migrainewithout aura. What makes this case noteworthy is theseverity of her condition. Her headaches are incapacitating.She misses several days of work each month, andshe has severe nausea and frequent vomiting that haveresulted in severe dehydration with subsequent hospitaladmission. In our practice, we see patients who becomedecompensated by the severity of their headaches-and especially by the associated nausea and vomiting,which, when severe, can lead to dangerous complications,such as acute renal failure, that require immediatehospitalization.

Another important aspect of this patient'shistory is her inability to obtain significant relief fromher abortive medications, including highly potent antimigraineagents.

Primary care doctor: How do you explain the ineffectivenessof these abortive medications?

Headache specialist: There could be several reasons.The timing of the treatment is key, as we mentioned.She probably was not treating her headaches duringtheir early stages. Also, her frequent vomiting may accountfor the lack of effect. Finally, the medications thatshe has tried might simply not be effective for her.

Primary care doctor: What do you recommend for thispatient?

Headache specialist: We recommend early initiation oftreatment here with parenteral medications. She mightbenefit from either nasal sprays or intramuscularinjections (similar to those we recommended for thefirst patient).

We would also suggest experimenting with a differentclass of medications-for example, ergotaminecontainingagents. This woman could try dihydroergotaminenasal spray, 0.5 mg, or even dihydroergotamine,1 mg IM. Finally, she would probably benefit from theuse of preventive medications.

Primary care doctor: Why try prophylactic therapy in apatient with episodic headaches?

Headache specialist: In patients whose headaches are incapacitating,disabling, and intractable-even thoughepisodic-prophylactic therapy is appropriate. Preventivemedications might not only decrease the number ofheadache days but might also increase the effectivenessof abortive medications.

References:

REFERENCES:

1.

Winner P, Mannix LK, Putnam DG, et al. Pain-free results with sumatriptan taken at the first sign of migraine pain: 2 randomized, double-blind, placebo- controlled studies.

Mayo Clin Proc.

2003;78:1214-1222.

2.

Burstein R, Collins B, Jakubowski M. Defeating migraine pain with triptans: a race against the development of cutaneous allodynia.

Ann Neurol.

2004;55:19-26.

3.

Burstein R, Jakubowski M. Analgesic triptan action in an animal model of intracranial pain: a race against the development of central sensitization.

Ann Neurol.

2004;55:27-36.

4.

Linde M, Mellberg A, Dahlof C. Subcutaneous sumatriptan provides symptomatic relief at any pain intensity or time during the migraine attack.

Cephalalgia.

2006;26:113-121.