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Assessment:
Differential Diagnosis: Most headaches are benign and are probably migraine or tension-type headaches
Cluster headaches are more unusual. Secondary headaches can be referred pain from HEENT, etc. Finally
there are the serious, life-threatening conditions such as hemorrhage, infection, or increased intracranial
pressure from an acute hydrocephalus or a tumor. Most brain tumors do not initially cause headaches.
Plan:
Treatment
- Meningitis should be treated as soon as suspected. (See Neurology: Meningitis)
- First or worst headache needs emergent evacuation (CT, MRI and/or spinal tap may be needed).
- Treat source of secondary headache, such as sinusitis, if recognized.
- Treat primary headache symptomatically. Some patients need all three methods.
a. Behavioral/nonpharmacologic: Ensure patients sleep regularly, get aerobic exercise, manage
stress constructively and eat a healthy diet. Avoid caffeine or analgesic withdrawal.
b. Prophylactic medications (oral): Inderal 40 – 160 mg/d, Pamelor 25 – 75 mg q hs, Neurontin 300 mg
tid, or Depakote 500 mg bid. Start at a low dose and increase every 2 weeks to effect. Ask women
about pregnancy before prescribing.
c. Abortive or acute therapy:
(1) Pain relief: 2 – 3 adult aspirin tablets, or 1000 mg Tylenol, or 800 mg Motrin with food, or 500
mg Naprosyn with food works for most headaches. Caffeine in coffee or cola sometimes helps.
Midrin (2 initially, then 1 q 1 h to max of 5 in 12 h) is a combination medication with acetaminophen.
Fiorinal and Fioricet (1-2 po q 6 h prn) each have caffeine and a mild barbiturate as well as aspirin
or Tylenol respectively. IM Toradol 60 mg is an option for nausea. The “Triptans”, such as
sumatriptan (Imitrex) 50 – 100mg po, 20 mg in a nasal spray, or 6 mg in a sq auto-injector or
rizatriptan (Maxalt) 5 –10mg po are the most effective migraine medications, but nothing works
for everyone. Narcotics are rarely needed. Beware that overuse of analgesic medications can
produce rebound headaches.
(2) Nausea or vomiting: Reglan 10 mg po q 8 h prn or Compazine 5-10 mg IM q 3-4 hrs, max 40
mg/day.
Patient Education
General: Migraine is not curable and will recur. Medications and behavioral interventions can decrease
frequency, severity or duration. Most prophylactic medications take weeks to months to work, therefore
patience is necessary. Smoking can worsen migraine. For women, menses often worsen migraines. Most
migraine medications are FDA categories C (toxic in animals) and D (risk of human toxicity) for Pregnancy, and
Ergots (Cafergot and others) are X (contraindicated in Pregnancy.)
Activity: Regular aerobic exercise is helpful. Regular, adequate sleep is advised
Diet: Avoid red wine, cheeses, NutraSweet, preservatives in bologna and salami, and chocolate.
Medications: NSAIDs (FDA C) can cause GI problems. The Triptans (FDA C) can cause a chest tightening
sensation and should not be used in those with a risk of vascular disease. Ergots (FDA X) should also not
be used in those with vascular disease or risk factors. Ergot products and Triptans should not be given
within 24 hrs of each other. Prophylactic medications like Pamelor (FDA D) or Neurontin (FDA C) can
cause sedation, usually manageable if titrated up slowly. Inderal (FDA C) can cause fatigue, bradycardia,
and is contraindicated in asthma. Depakote (FDA D) can cause weight gain (a good reason to prescribe
exercise!)
No Improvement/Deterioration: Always reconsider your diagnosis if the patient does not do well. Unfortu-
nately, some patients have no response to treatment or nd the side effects intolerable. Refer those who do
not respond for imaging and neurology evaluation.