In an effort to more accurately diagnose and treat headaches in patients ages 12 years and older, the International Headache Society revised diagnostic guidelines associated with primary headache, including migraine. The guidelines, released in August 2004, also aim to increase functional status in patients with migraine. In addition, headache classifications were revised to include four divisions of primary headache: migraine, tension, cluster, and other. Finally, the guideline strives to reduce the amount of narcotic and/or barbiturate interventional treatment for primary headache by increasing education for both headache sufferers and primary care providers (PCPs). The guideline writers also wanted to reduce the number of imaging studies ordered and increase awareness of hormonal-mediated migraines. The authors recognized that migraine is the most common headache seen by PCPs.
In late 2004, the National Guideline Clearinghouse published Diagnosis and Treatment of Headache, which incorporated all of these revisions. A complete set of these guidelines can be found at http://guidelines.gov. Unless otherwise specified, all information in this article is derived from this guideline.
Diagnosis
Diagnosis and evaluation of headache requires a detailed headache history, focused physical examination, and a neurological examination. Headache history should include the characteristics of the headache such as aura, precipitating factors, relieving factors, intensity, quality, duration, and frequency. Headache history should also include age when headaches began, any changes in headache history, and family history of headaches and migraine. History is of utmost importance because many patients may not know the difference between migraines and other headaches.
Patients with headache generally exhibit a normal physical and neurological examination. When a deviation from normal is elicited from the examination or history, diagnostic testing should be considered to rule out secondary headache. Diagnostic testing may include computed tomography (CT), magnetic resonance imaging (MRI), electroencephalogram (EEG), lumbar puncture, and/or laboratory studies.
After a detailed headache history, evaluation of signs and symptoms, and a focused physical and neurological examination, symptoms that warrant further investigation into headache, possibly suggesting a secondary headache rather than primary headache, include: 1
* Subacute and/or progressive headaches which worsen over time (months)
* New or different headache
* Any headache of maximum severity at onset
* Headache of new onset after age 40
* Persistent headache precipitated by a Valsalva maneuver
* Symptoms such as fever, hypertension, myalgias, weight loss, or scalp tenderness, which may suggest a system disorder
* Presence of neurological signs that may suggest a secondary cause
* Seizures
The guidelines suggest that all patients should be considered for prophylactic therapy and that disability from migraine is an important issue for patients. Patients with three or more severe migraine attacks per month that fail to respond adequately to treatment should be considered for prophylactic treatment. Patient's who have fewer migraines but feel that the migraine's impact on their life is not acceptable are also candidates for prophylactic therapy. In fact, any patient who wants to be on prophylactic therapy should be considered.
Treatment
When treating headaches, note that abortive treatment used more than 2 days a week on a regular basis may lead to chronic daily or rebound headache. Patients with headache symptoms more than a few days a week should be on headache prevention treatment.
Headaches may be misdiagnosed as "sinus" because of autonomic symptoms such as nasal congestion, rhinorrhea, tearing, and/or eyelid ptosis or edema. The American Migraine Study II (AMS-II) found that 42% of migraineurs were misdiagnosed with sinus headache, 2 which may lead to overuse of allergy, sinus, and antibiotic medications.
Women may have several issues to consider when looking for pro-phylaxis. If migraines are menstrual-related and have not responded to standard cyclic pro-phylaxis, the use of estradiol patches or estrogen-containing contraceptives may be appropriate. In women who experience migraines during the perimenopause or menopause period, the use of estrogen-containing contraceptives or hormonal therapy may also work well. However, in women with migraines preceded by aura, the use of estrogen should be avoided.
Once migraine has been determined, it is important to initiate patient education. Migraine management should be centered on lifestyle and avoiding triggers. The patient should keep a headache diary, logging frequency, severity, possible and known triggers, treatment, and response to treatment. The headache diary not only helps identify triggers to avoid migraines, but also identifies possible overuse of abortive headache medications. Headache triggers may be environmental, lifestyle-related, hormonal, emotional, medication-related, or dietary.
Treatment Goals
In general, migraine prophylactic medication should be started slowly and titrated slowly to maximize therapy while avoiding side effects. The desired dose may need to be maintained a minimum of 8 to 12 weeks before maximum effect is achieved.
The goals of prophylactic therapy are to decrease frequency of migraines by one-half, decrease the pain and disability of each attack, and quicken the relief offered by an-timigraine therapy. Medications are designed to achieve therapy goals, decrease the side effect profile, and minimize potential medication interactions, and not interfere with comorbid conditions. When initiating prophylactic therapy, the patient should understand that finding the right drug at the right dose with the least amount of side effects might be a slow process. There may be a latency period of 3 to 6 weeks before any appreciable change is noted and a minimum of 8 to 12 weeks before maximum desired effect is achieved. Patients should also be advised that many bothersome but harmless side effects of medications will likely subside after a few weeks of treatment and the medication should not be discontinued without consulting the PCP.
First-line treatment should be based on not only a minimal side effect profile but on any comorbid conditions that may be helped or exacerbated by the choice. For instance, a beta-blocker would be con-traindicated in a patient with migraine and asthma, but a tricyclic antidepressant might be a good choice for a patient with migraine, asthma, and depression, or for a patient with migraine, asthma, and neuropathic pain (see Table: "Prophylactic Treatment for the Prevention of Migraines").
After 6 to 12 months of prophy-lactic treatment, begin a gradual taper. Contraindication to gradual taper is if the migraines have become more frequent or more severe. In the case of worsening migraine, an alternative drug from the same class or another class should be tried. Note that the guideline states that failure on one drug from a specific class (for example, beta-blockers) does not equate to failure of the entire class. A single medication should be tried until maximum dose is reached or until side effects become unacceptable before another medication or a combination of medications is attempted. If a combination of medications is tried, each should be titrated slowly to achieve migraine goals with the least amount of side effects of either medication alone or in combination.
Biofeedback can be used as pro-phylaxis for migraine prevention and has been used as an adjunctive treatment. It may be a good stand-alone option for pregnant women or other patients in whom pharmacological therapies may be con-traindicated. However, biofeedback is time-consuming, requires a high degree of commitment from the patient, and may not be covered by insurance. Cognitive behavioral therapy may also be helpful for prevention of migraine by helping the patient learn to manage stress and anxiety, which are possible triggers of migraine. Relaxation training may also teach long-term relaxation techniques that will decrease the response of headache from emotional triggers.
Alternative Treatment
The herb butterbur root, Petasites hybridus, has shown documented efficacy in the prevention of migraine. The usual dosage in the studies was 100 to 150 mg daily. Another herb, feverfew, with the active ingredient parthenolide, has been shown to be effective when 250 mcg is used on a daily basis. However, quality control is an issue when using herbs, and the amount of active ingredient can vary between manufacturers. Information regarding quality from selected manufacturers can be found on an independent laboratory Web site at http://www.consumerlab.com.
In some patients, supplementation with 400 mg of riboflavin (vitamin B2) daily decreased frequency of migraines. In Europe, supplementation of 400 to 600 mg daily of magnesium also decreased frequency of migraines.
Botulinum toxin A, injected into the forehead to reduce wrinkles, was reported to have a positive effect on patients who also had migraines. In a placebo-controlled, randomized trial, botulinum toxin A injections were found to be beneficial. There was enough positive evidence for this intervention that the guidelines state that the use of botu-linum toxin A injection should be considered when first-line medications have either failed or are con-traindicated.
Hormonal Migraines
In general, menstrual-associated migraines occur on day 1 plus or minus 2 days of her menstrual cycle, and the woman is free of migraine the rest of her cycle. To determine menstrual-only associated migraine, have the patient keep a continuous record of her cycle for at least 2 months, recording menstrual cycle, headache day and timing, severity, and duration. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used first-line cyclically as prophylaxis of menstrual-associated migraine. Beginning 2 to 3 days before the anticipated onset of headache, the woman begins the NSAID and continues the NSAID treatment until the at-risk period is over- generally 5 to 6 days total. However, with the recent Food and Drug Administration's withdrawals and concerns regarding certain NSAIDs, including COX-2 selective agents and naproxen (Aleve), exercise caution when suggesting these agents. In women who cannot use NSAIDs or in whom NSAIDs did not work, hormonal prophylaxis can be tried. Estradiol 50 to 100 mcg patches applied 48 hours prior to expected migraine onset and continued for 1 week may prevent migraine occurrence related to decreasing levels of estrogen during the late luteal phase of the menstrual cycle. Estrogen-containing contraceptives have had mixed results on migraine prophy-laxis in patients, so they can be tried, but may not be effective. In patients with severe symptoms in whom other therapies have not worked, leuprolide acetate (Lupron Depot) 3.75 mg intramuscularly monthly along with 0.1 mg trans-dermal estradiol and oral medrox-yprogesterone acetate 2.5 mg daily, or micronized progesterone 100 mg daily, can also be tried.
In patients in perimenopause or menopause, treatment with hormones may cause migraines to improve, worsen, or remain unchanged. Each individual woman is different and each case will devise its own therapy. Treatment options may include transdermal or oral estrogen, progestin or micronized progesterone, or estrogen-containing contraceptives.
Contraindications for use of estrogen-containing compounds include risk factors for coronary artery disease and migraine with aura. Migraine with aura is a risk factor because there may be an increased risk of stroke associated with the use of estrogen in this population.
If patients who previously did not have migraine with aura develop the condition while on estrogen-containing compounds, the estrogen component should be discontinued. It has also been noted that women with migraines who take oral contraceptives may increase their risk of stroke. Women who smoke, take oral contraceptives, and have migraine further increase the risk of stroke.
Whether or not a patient is on prophylactic therapy, it is also necessary to have medications available that will help with abortive therapy or acute migraine (see Table: "Abortive Treatment for Migraines").
Again, note that patients who use abortive therapy more than 2 days/week should be considered for prophylactic therapy. The guideline does not recommend the use of opiates or barbiturates for abortive migraine management.
There is also insufficient evidence to support the following additional therapeutic interventions for abortive therapy. Acupuncture was found to be expensive and have mixed results. Cervical manipulation via chiropractic care, if performed improperly, demonstrated significant risk of cerebral infarction and death, therefore this type of therapy is not recommended. The use of a transcutaneous electrical nerve stimulator was not more effective than placebo. Massage, homeopathy, and naturopathy were found to lack sufficient evidence to be recommended.
Excellent, specific algorithms for diagnosis and management of headache including migraine treatment (abortive), migraine prophy-laxis, menstrual-associated migraine, headaches while on estrogen-containing contraceptives or while considering estrogen-containing contraceptives, peri-menopausal or menopausal migraine, tension-type headache, and cluster headache can be found within the brief summary document, "Diagnosis and Treatment of Headache" at http://guidelines.gov. A personal digital assistant (PDA) version of the guideline is also available at the same Web site. The PDA document is free, but you will need a document reader such as PalmReader, TealDoc, or iSilo.
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