Evaluation of Headache

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Nonpharmacologic modalities, such as regular exercise,

relaxation, stress management, biofeedback, ice massage, physical therapy techniques, and other modalities may play a critically important role in both the prophylactic and abortive treatment of headache. A headache diary helps to identify precipitating factors so they can be avoided.

Most migraine sufferers require some sort of pharmacologic treatment. Patients who have infrequent headaches lasting less than 12 hours and fewer than four headaches per month should be tried on an abortive treatment alone.

Prophylactic treatment is indicated if the headaches are more frequent, last longer, or account for a significant amount of total disability per month. Many patients require concomitant prophylactic and abortive treatment.

Abortive treatments

Abortive treatments are usually more effective if they are given early in the course of the headache; a large single dose tends to work better than repetitive small doses.

Many oral agents are ineffective because of poor absorption secondary to migraine-induced gastric stasis.

Mild analgesics

Nonsteroidal antiinflammatory drugs (NSAIDs) are often effective for migraine with and without aura. NSAIDs may also be combined with metoclopramide to decrease nausea and vomiting. There are no studies comparing the relative efficacy of different NSAIDs.

If one NSAID is ineffective, a different drug may be tried Acetaminophen also can be used as an abortive agent in some patients, although most will not respond.

Acetaminophen and many other analgesics are not advisable in the patient who requires frequent medication since they have been associated with rebound headaches. Acetaminophen can be used in combination with NSAIDs; the combination of acetaminophen, aspirin, and caffeine may alleviate headaches in patients with uncomplicated migraine in one report.


A variety of ergotamine preparations, alone and in combination with caffeine and other analgesics, have been used for the abortive treatment of migraine. It is unclear if it is the ergotamine itself or the other ingredients in the combination drugs that provide the most effect.

Ergotamine tartrate may be associated with significant side effects; vascular occlusion and rebound headaches have been reported with oral doses exceeding 6 tablets per 24 hours or 10 tablets per week. Years of use also may be associated with valvular heart disease. Ergots should be avoided in patients with coronary artery disease because they cause sustained coronary artery constriction, peripheral vascular disease, hypertension, and hepatic or renal disease. They also should not be used in patients with complicated migraine because they may reduce cerebral blood flow.

Dihydroergotamine (DHE) is an alpha-adrenergic blocker that is a weaker arterial vasoconstrictor and more potent venoconstrictor than ergotamine tartrate. DHE 45 has fewer side effects than the latter; it does not cause the development of physical dependence or rebound headaches. It is available for intravenous, intramuscular, and subcutaneous use, and has recently received approval for intranasal use in the United States. It is usually administered in combination with an antiemetic drug.

Serotonin agonists

Sumatriptan, zolmitriptan, naratriptan and rizatriptan are selective serotonin 1b/1d agonists. Sumatriptan can be given as a subcutaneous injection, as a nasal spray, or orally. The advantages of the serotonin agonists over DHE 45 include not requiring premedication with potentially sedating antiemetics, and their beneficial effects upon other phenomena of migraine, particularly nausea and photophobia.

Common side effects of subcutaneous sumatriptan include an injection site reaction, chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, malaise, a feeling of warmth, and paresthesias. Most of these reactions occur soon after the injection and resolve spontaneously within 30 minutes. There have been rare reports of myocardial infarction and sudden death , possibly because these agents, like ergotamine, cause coronary artery constriction. Oral preparations are safe and effective.

Sumatriptan is contraindicated in patients with hypertension, ischemic heart disease, variant angina, and in the elderly. It also should not be used within 24 hours of the use of ergotamine preparations. It may be prudent to give the first dose of the drug under medical supervision for patients with risk factors but no known coronary artery disease (including men over the age of 40 and postmenopausal women).

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