How Do You Treat a Patient With Refractory Headache?

RIVIERA BEACH, FL—Neurologists sometimes encounter patients with headaches that have not responded to prior treatment. These patients may be demoralized, and neurologists may be at a loss for a way to relieve their pain. Effective treatment is possible for many of these patients, according to Thomas N. Ward, MD, Emeritus Professor of Neurology at Dartmouth College in Hanover, New Hampshire. He described the process of differential diagnosis, as well as outpatient and inpatient therapeutic options for refractory headache, at the 44th Annual Meeting of the Southern Clinical Neurological Society.

Confirm the Diagnosis

When faced with a patient with refractory headache, a neurologist should first verify the diagnosis and rule out the possibility of secondary headache. These steps will improve the likelihood of a positive outcome. “If you follow the fundamentals and treat the type of headache it is, you usually get a pretty good result,” said Dr. Ward.

A patient with headache on 15 days per month or more has chronic daily headache. The duration of the headaches can provide the basis for a more specific diagnosis. Headaches of short duration (ie, less than four hours) may be symptoms of cluster headache, chronic paroxysmal hemicrania, hypnic headache, or trigeminal neuralgia. Headaches of long duration (ie, more than four hours) may indicate chronic migraine, chronic tension-type headache, hemicrania continua, or new daily persistent headache.

A patient with headache on 15 or more days per month, and for whom headaches on at least eight days per month meet the criteria of migraine, has chronic migraine. The two best-supported treatments for chronic migraine are topiramate and onabotulinumtoxinA. In patients with chronic migraine, what appears to be a tension-type headache may eventually declare its true nature and become a migraine headache with accompanying pounding and photophobia. What looks like a tension-type headache in a migraineur may respond to a triptan, said Dr. Ward.

Stop Medication Overuse

Medication overuse can confound the diagnosis and alter the headache itself. Many patients with refractory headache overuse medication but may fail to mention this to a neurologist. The overused medication may be a prescription or an over-the-counter drug such as ibuprofen, acetaminophen, or a combination that includes caffeine. Drugs with short half-lives appear to be particularly likely to cause medication overuse headache.

Some patients may be overusing opioids for their headache. “Opioids for headache are not a good idea,” said Dr. Ward. “Nothing good will come of it.” These drugs may cause central sensitization and reduce the efficacy of other headache remedies.

The risk of medication overuse headache increases if the patient uses combination analgesics, ergotamine, or triptans on 10 or more days per month, or simple analgesics on more than 15 days per month. “The clinical question I always ask patients is, ‘Are you taking more pills and having more headaches?’ If the answer is ‘yes,’ then they have medication overuse headache,” said Dr. Ward.

If patients stop taking the overused medication, they may have a withdrawal headache that is worse than their normal headache. Medication overuse headache usually resolves itself after the overuse is stopped, and bridge therapies such as steroids, nonsteroidal anti-inflammatory drugs, or dihydroergotamine may alleviate pain during withdrawal. “If you can get the patient over that hump, which can be several days of bad headache, they often do remarkably better,” said Dr. Ward.

Get Back to Basics

Taking a careful history is essential to successful treatment. “If you do not get the original history, you could miss the diagnosis,” said Dr. Ward. The neurologist must know about the mode of onset of the patient’s headache, and also know all about his or her prior headaches.

A patient with refractory headache should undergo a thorough head and neck examination, but physicians sometimes neglect to perform it. An MRI of the brain with gadolinium generally is warranted. About 90% of patients with low CSF pressure have pachymeningeal enhancement, which is visible on MRI performed with gadolinium, said Dr. Ward. Blood work, however, usually reveals little and appears normal. Sometimes thyroid tests, a Lyme test, a blood count, and a serum creatinine test are helpful, and a serum erythrocyte sedimentation rate test in those over age 50 is important to obtain.

Lumbar punctures may be underused, said Dr. Ward. Although it is uncommon, some patients present with high intracranial pressure, but without papilledema. The correct diagnosis can lead to effective treatment for these patients.

Effective treatment also is more likely when the neurologist gets to know the patient. He or she can use preventive medications to reduce the number of headache days. The literature suggests that successful preventive therapy should achieve a target of four headache days or fewer per month.

Neurologists also should treat the patient’s comorbid conditions, which often are psychiatric in people with refractory headache. It is unusual to see a patient with chronic migraine who does not have anxiety and depression, said Dr. Ward. Patients with refractory headache also may have phobias, bipolar disorder, or posttraumatic stress disorder, which is a significant confounder.