Handbook of Psychology

Headache Treatment 251

recurrent headache sufferers do present to a health care prac-
titioner, their headaches are most commonly managed with
a combination of medication and advice from the treating
clinician. In fact, among primary care headache patients,
over 80% reported the use of over-the-counter medications
and over 75% reported the use of some form of prescription-
only medications for the management of their headaches
(Von Korff, Galer, & Stang, 1995). A number of effective
pharmacologic options are available to treat headaches and
these may be categorized into three broad classes: sympto-
matic, abortive, and prophylactic medications.

Symptomatic Medications

Symptomatic medications are pharmacologic agents with
analgesic or pain relieving effects. These include over-the-
counter analgesics (i.e., aspirin, acetaminophen), nonsteroidal
anti-in”ammatory agents (i.e., ibuprofen), opioid analgesics,
muscle relaxants, and sedative/hypnotic agents, which are con-
sumed during the occurrence of headache to provide relief
from pain. Von Korff et al. (1995) found that ibuprofen
accounted for 84% of all use of nonsteroidal anti-in”ammatory
consumption in a sample of over 600 primary care headache
patients. The most commonly consumed opioid analgesics
were acetaminophen with codeine (33%), meperdine (also
known as Demerol; 21%), and percocet (15%). Midrin (33%),
cyclobenzaprine (28%), and methocarbonal (10%) were the
most commonly consumed sedative/hypnotic medications.

Abortive Medications

Abortive medications are pharmacologic agents that are con-
sumed at the onset of a migraine headache, in an effort to ter-
minate or markedly lessen an attack. Ergotamine tartrate
preparations were the mainstays of abortive care until the
early 1990s when triptans, designed to act on speci“c sero-
tonin receptor subtypes, were introduced. Multiple triptan
formulations are now available, differing with respect to
potency, delivery mode (oral vs. other, for patients likely
to vomit during attacks), time of peak onset, duration of
sustained headache relief, rate of headache recurrence, im-
provement in associated symptoms, safety, and tolerability
(Rapoport & Tepper, 2001; Tepper, 2001). Evidence support-
ing ef“cacy is mounting but, as pointed out by Rapoport and
Tepper, nonindustry sponsored research is lacking. We are
unaware of research comparing triptans to behavioral ap-
proaches. Comparison of a combined behavioral treatment
(relaxation + thermal biofeedback) to ergotamine tartrate for
migraine and migraine combined with tension-type headache
revealed similar levels of treatment response. Improvements

for the medication group were evident quicker (within the

“rst month), whereas improvements for the behavioral group

did not occur until the second month of treatment. Only the

behavioral group showed reductions in analgesic usage, how-

ever (Holroyd et al., 1988).

Prophylactic Medications

Prophylactic medications are consumed daily in an effort to

prevent headaches or reduce the occurrence of attacks in the

chronic sufferer. Beta blockers, calcium channel blockers,

and antidepressants (e.g., tricyclics, serotonin-speci“c reup-

take inhibitors) are used most frequently as prophylactic

medications for migraine headache (Tfelt-Hansen & Welch,

2000a, 2000b). Recent metaanalyzes comparing various pro-

phylactic agents, conducted with child as well as adult

patients, have shown them to be superior to varied control

conditions (waiting list, medication placebo, etc.) (Hermann,

Kim, & Blanchard, 1995; Holroyd, Penzien, & Cordingley,

1991). One of these analyzes (Hermann et al., 1995), along

with an additional metaanalysis (Holroyd & Penzien, 1990),

found various behavioral treatments achieved outcomes sim-

ilar to those for varied prophylactic medications.

For tension-type headache, the most commonly adminis-

tered medications include tricyclic and other antidepressants,

muscle relaxants, nonsteroidal anti-in”ammatory agents, and

miscellaneous drugs (Mathew & Bendtsen, 2000). A recent,

large-scale randomized controlled trial found stress manage-

ment and drug prophylaxis to be equivalent in effectiveness

(although time of response was quicker for medication). The

combination of the two treatments was more effective than

either treatment by itself (Holroyd et al., 2001). Combined

care is probably the most common treatment in clinical

practice.

While a number of medications are effective in the treat-

ment of recurring headache, concern exists regarding the risks

of frequent, long-term use of certain medications. Major risks

associated with pharmacological management of recurrent

headache disorders include the potential for misuse and de-

pendency (Mathew, 1987), as discussed previously. Several

other risks may be associated with chronic/frequent use of

headache medications, including the potential for rebound

headache, the possibility of drug-induced chronic headache,

reduced ef“cacy of prophylactic headache medications,

potential side effects, and acute symptoms associated with

the cessation of headache medication (such as increased

headache, nausea, cramping, gastrointestinal distress, sleep

disturbance, and emotional distress).

Unfortunately, chronic/frequent use of prescription-only

medication has been reported by 10% of primary care