Successful Treatment of Headache Requires Thorough Assessment, Use of 'Essential Tools'

LAS VEGAS—Headache treatment depends on several factors: making an accurate diagnosis, ruling out alternative etiologies, ordering appropriate studies, and addressing the headache's impact, with the ultimate goal of headache relief.

That's the recommendation of Charles E. Argoff, MD, Professor of Neurology, Albany Medical College, and Director, Comprehensive Pain Program, Albany Medical Center, Albany, New York, who presented the course, “Essential Tools for Treating the Patient in Pain™: Headache Evaluation, Examination and Treatment” at PAINWeek 2014.

“Patients want to know what is wrong and that their complaints are taken seriously,” he said.

He reviewed the International Headache Society (IHS) classification of headaches. Primary headache disorders include migraine, tension-type, and cluster, while secondary headache disorders refer to an underlying organic cause that must be specifically treated. This includes, for example, brain tumor, head trauma, analgesic rebound, sinusitis, subarachnoid hemorrhage, meningitis and other infections.

The basic examination of the patient with headache should include vital signs and behavior, as well as dermatological and neurological (symmetry, ocular, and gait) signs. He outlined when it is appropriate to consider CT versus MRI scans, perform lumbar puncture, and order serologic testing, EEGs, carotid Doppler or other diagnostic examinations.

One diagnostic challenge, he pointed out, is that the vast majority of migraine headaches—81%—are incorrectly self-identified by patients as sinus, tension, or menstrual headaches. According to IHS criteria, a diagnosis of acute sinus headache is considered a secondary diagnosis resulting from acute sinusitis and requires the presence of purulent nasal discharge and pathologic sinus findings, including from tests such as X-rays, CTs, or MRIs. “Chronis sinusitis is not validated as a cause of headache or facial pain unless relapsing into an acute state,” he said.

Factors confounding diagnosis are that the sinus features of headache may hide the presence of migraine. Similarly, tension headaches may be marked by stress triggers, bilateral or nonthrobbing head pain, and the presence of neck pain, all of which are hallmarks of migraine. In fact, “stress is the most frequently reported trigger of migraine,” he said.

The multidisciplinary treatment of chronic headache requires pharmacotherapy and other medical/surgical care with appropriate medicine reorganization; restorative care, including active physical and occupational therapy; and psychological counseling utilizing cognitive-behavioral pain management strategies.
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