Diagnosis and Treatment of Chronic Headaches

In evaluating patients with chronic headache, the first consideration is distinguishing between tension and migraine types. The following three symptoms, all with the letter S, distinguish the typical tension-type and migraine headaches from each other.

  • Sidedness: on either but just one side in migraine, global in tension type.
  • Steadiness: not steady but throbbing in migraine, steady in tension type.
  • Sympathetic Symptoms: nausea/hypersensitivity in migraine, lack of these in tension type.

Tension headaches are also more likely to respond to over-the-counter (OTC) medications, as the patient may already have discovered. This too is a sympathetic nervous system effect seen in migraines, that of delayed stomach emptying. Now the seemingly easy treatability of the tension headache is actually a double-edged sword. If a person frequently and regularly takes an OTC medication in response to initial pain, they can also paradoxically invoke medication overuse headaches (MOH) in themselves. Thus, although medication overuse can occur with either tension or migraine headaches, the typically lower cost and therefore more widespread use of OTC meds for headaches makes MOH an important topic for caregivers to discuss with patients. It should be evaluated as a possible cause for daily or near-daily headaches.

People can be susceptible to either belief of ‘when in doubt, take something’ or the related canard that if a little is good then more is better. The caregiver can be in a positive position to non-judgmentally point out these common pharmacological fallacies, and counsel patients to be careful of over-medicating themselves. Though hard to induce in patients, such behavioral changes nonetheless need to be at the very least talked about by caregivers, with the possibility of more strict “doctor’s orders” being given depending on circumstances and severity of symptoms.

The potential severity of tension type headaches mean that those patients who present with this type of chronic headache may have pronounced or readily declared symptoms. Yet the treatability of tension type headaches with OTC medications probably leads to fewer proportional presentations of this for the primary caregiver. Many sufferers of chronic tension headaches will be found to have MOH. This leaves a relatively high proportion of chronic headache complaints seen in the clinic proving to be of the migraine type in their basic nature. True migraines – with or without auras, but certainly with some sympathetic nervous system symptoms – can indeed occur chronically in some sufferers. Having a migraine headache on the majority of days in a month can and does have severe impacts on the quality of life of those who suffer from them.

Migraine response to non-medical interventions, i.e. “complementary and alternative” medicine (CAM), is quite varied, depending on the individual and the regimen followed. This combined with migraines being less amenable to treatment with OTC medications, leads such patients to see a doctor to be prescribed medications that can relieve symptoms of migraines, or help prevent their occurrence in the first place. Acute relief of symptoms was traditionally accomplished with ergotamine compounds, now superseded by the triptan class of medications that likewise work on serotonin receptors. The degree of relief experienced with triptans is highly variable, however. Key in this is the timing of taking the drug relative to onset of symptoms, plus inter-individual variations between people that are pharmaco-genomic in nature. This means that taking of a triptan as soon as possible after symptoms begin must be attempted, and the nasal spray forms of triptans that exist are expressly designed for rapid delivery. Nonetheless, there will be a sizable minority of people who do not respond to triptans. Some of these will respond to a modest dose increase, such as a doubling or as is otherwise within the recommended dose limits. Yet some will remain basically refractory to medication.

If you are suffering from one or more of these conditions, and you would like us to help, please call our office today at 713.467.4082.