HEALTHHeadaches: A spectrum of pain presents a dilemma for doctorsThis widespread problem continues to present physicians with challenges in diagnosis and treatment.By Kathleen F. Phalen, amednews correspondent. Oct. 15, 2001. Emergency physician Stephen Epstein, MD, remembers his early days at Beth Israel Deaconess Medical Center's emergency department in 1996. There was a steady stream of headache pain regulars, and primary care doctors sometimes would provide residents with instructions to treat the most severe and chronic sufferers with Demerol. "The [primary care physicians] didn't know what else to do. They just threw up their hands," says Dr. Epstein, a spokesman for the American College of Emergency Physicians. "They were at their wits' end." But that course of treatment only exacerbated the vicious spiral of inadequately treated pain and debilitation common in headache management. As many as 45 million Americans complain of this baffling malady, accounting for 42 million primary care visits a year. Nearly 28 million of these headaches are actually migraine. Still, headache is vastly undertreated and misdiagnosed. The financial cost in lost work and productivity is staggering -- about $10 million annually. And worse, patients face disability in their professional and personal lives, not to mention the constant threat of unbearable pain.
Headaches cost about $10 million a year in lost productivity.
Dr. Epstein says some patients were coming into the emergency department for narcotics several times a month, some weekly. "Demerol [meperidine hydrochloride, Sanofi Pharmaceuticals Inc.] is a lousy drug. I might say to the patient, 'The best thing for your headache is Compazine [prochlorperazine, SmithKline Beecham Pharmaceuticals],' " he recalls. "And they'd say, 'My doctor sent me here for Demerol.' " Ultimately, Dr. Epstein and other emergency doctors began working with primary care physicians to address the problem. By setting up care meetings between the patient, the emergency physician, the primary care doctor and the pain clinic, the patient became a participant in treatment options. "We would start with, 'How are we going to treat your migraine?' " Things are getting better, Dr. Epstein says. But change is slow, and the headache hasn't gone away. "Some patients are still using narcotics regularly. We still have a legacy of that." Treatment challengesDr. Epstein's experience is only one example of challenges and frustrations headache pain presents for both doctors and patients. There are many reasons why, says Richard Lipton, MD, president of the American Headache Society. He points to a lack of training as one. "When I was in medical school I had one hour of headache education," says Dr. Lipton, who is also a professor of neurology at the Albert Einstein College of Medicine in New York. Generally, there are zero to two hours of education in medical school, he says. "And the specialist community has delivered confusing information to primary care. They have done a poor job of educating about diagnosis and treatment."
Taking pain relievers more than twice a week is enough to trigger a "rebound" headache.
Most headache patients are first seen by their primary care doctor, who has the daunting task of deciphering the cause from a host of more than 200 possibilities. Dr. Lipton describes headache -- migraines in particular -- as a sandwich disorder. On one end of the list of possibilities are very serious conditions such as a brain tumor. On the other, there are the minor headaches that about 90% of the population periodically suffer. The ones in the middle often get missed. "It's far more common to underdiagnose migraine," he says. "But we do more harm by missing [them]." So how is a primary care doctor going to wade through all of the possibilities in 10 minutes? It's a big challenge, Dr. Lipton says. The lab tests serve only to rule out what the problem is not, he says. So for primary care doctors, getting to the problem can be like finding a needle in the haystack. "They live in fear of missing that needle," he says. According to Dalal Chenouda, MD, assistant professor of internal medicine at the University of Connecticut Health Center in Farmington, headaches are one of the most common maladies she sees. But for her, nailing down the specifics about the pain begins with the basics. "I ask the patient, 'Is this the worst headache in your life?' If it is, I'll send them to the ER to rule out a bleed," Dr. Chenouda says. "If it's been going on for years and is in the back of the head and feels like a rubber band, it's probably tension." Diagnosing and treating headache is all about going back to the basic history, finding out about time of onset, age, frequency, family history, social history and medications, she says. "Sometimes if they stop their medications abruptly they get rebound," she says. "Our job is to determine what needs to be referred to a specialist." The reasons doctors get frustrated is that sometimes the treatment needs to be multidisciplinary, Dr. Chenouda says. "When patients aren't getting better, they need to be referred. But about 80% of our patients' headaches will fall into the migraine or tension-type." It's important to dispel myths about headache, says Andrew K. Oh, MD, assistant clinical professor of neurology and the director of the Headache Treatment Program at University of California at Irvine College of Medicine. "A lot of people think they have sinus headache or allergies," he says. "But generally not, especially if they are able to document a family history. I see people who have had sinus surgery and still have headaches. It wasn't their sinuses. There is a lot of misunderstanding about migraine." The worst case, he says, is the patient who is put on medications and then develops a tolerance, which leads to rebound headaches, caused by medication overuse. "Then they are put on narcotics like Vicodin [hydrocordone bitartrate and acetaminophen, Knoll Laboratories]," says Dr. Oh, who has been involved in several migraine genetic studies. "The pain gets so severe they go to the emergency department for Demerol. ... I believe no patient with chronic headache should be put on a narcotic." By the time a patient gets to a specialist, they've often been taking eight to 10 analgesics a day for years, had multiple MRIs, CTs, maybe even a lumbar puncture, and they've taken a myriad of prescription drugs. But they still have chronic, often daily headache. The irony of the whole scenario is, by the time they get to a specialist, they are often easier to diagnose, Dr. Lipton says. "This is my take on it as a specialist -- I have 45 minutes to take a history," he says. "And the patients are often easier to diagnose because they have had their headaches for a long time. They're just harder to treat." Beyond criteriaHeadaches come in two categories: primary, which have no trigger event; and secondary, which are the result of another illness, disorder or a hangover. Of the primary kind, migraine and tension-type are most common. According to the International Headache Society diagnostic criteria, migraine and tension-type headaches are very different. Migraine is characterized by episodic attacks, pain tends to be one-sided and throbbing, moderate to severe, and the headaches are always accompanied by another feature, such as sensitivity to light, nausea, aura and dizziness. Often triggered by tension, emotional problems, diet, caffeine, hormonal changes, lack of sleep, alcohol, and certain scents such as perfume or smoke, migraines are most common among women, but can strike anyone -- even young children. Tension-type headaches are generally bilateral with steady pain or pressure and no associated symptoms, but similar triggers. On the surface, the distinction seems clear. But it is not. "It turns out that some migraine sufferers have mild migraine that looks like tension-type," Dr. Lipton says. And it's these mixed features -- migraine with rebound; migraine with tension-type; migraine with daily, chronic pain -- that make things difficult. "There is a misconception that migraine fits into a box because of the IHS criteria," says Robert E. Shapiro, MD, PhD, assistant professor of neurology and director of the Headache Clinic at University of Vermont College of Medicine in Burlington. "But that often underestimates those who have migraine and don't fit the criteria ... daily chronic, tension, migraine. ... There is a migrainous spectrum of disorders." That's why, as Dr. Chenouda says, a patient history including family members' headaches is the foundation for diagnosis and treatment. Having patients keep a monthly headache diary can establish a record of when, where, how long, how severe and triggering events. Getting rid of rebound is critical, says Ivan S. Login, MD, professor of neurology at the University of Virginia Health Sciences Center in Charlottesville. "There are a couple of classes of people who come to see me. Those with bona fide migraines that are difficult to control and those with rebound." If the patient is taking a pain reliever more than twice a week, it's probably rebound. "One or two tablets every day is enough to do it," Dr. Login says. But treating rebound means getting patients to stop the drugs. "It's difficult to know what's going on until you get rid of the rebound state. Then you can analyze what kind." There are a host of treatment options, including antidepressants, calcium channel antagonists, NSAIDs, beta-blockers, anticonvulsants, triptans, biofeedback, acupuncture, cognitive behavioral therapy, hormone therapy, magnesium supplements, lifestyle changes such as eliminating caffeine and smoking, eating and sleeping at regular times, exercise and relaxation techniques. "Many times after they make lifestyle changes, they don't need any meds," Dr. Oh says. "And even if they have to be on a preventive, it is not a life sentence. Once they get through the vicious cycle ... we can taper off." HopeRecent research points to a familial connection to migraine. "For many years scientists believed that migraines were linked to the dilation and constriction of blood vessels in the head. Investigators now believe that migraine is caused by inherited abnormalities in certain cell populations in the brain," according to the National Institute of Neurological Disorders and Stroke. And for some forms of migraine, abnormal genes have been identified. Last year the U.S. Headache Consortium -- AHS, American Academy of Family Physicians, American Academy of Neurology, ACEP, American College of Physicians--American Society of Internal Medicine, American Osteopathic Assn. and the National Headache Foundation -- developed evidence-based diagnostic and treatment guidelines for primary care doctors. "For a very long time it has been our objective to improve migraine management," Dr. Lipton says. "We strongly believe that from a public health perspective we need to work with the primary care doctors." Because the guidelines are so comprehensive, Dr. Lipton says there is also a committee working on a user-friendly version. In addition, the AHS has developed teaching materials for residency programs and is completing a model curriculum for medical schools that will be ready next year. Perhaps as more doctors learn about headache, the tide will change. As Dr. Lipton says, working with headache patients is clinically satisfying. "You can make such a difference." ADDITIONAL INFORMATION:Age-old treatmentsHighlights of the long history of headaches:
How to dig for cluesHeadache experts recommend the following types of questions to better understand patients' headaches and more accurately diagnose migraine:
WeblinkAmerican Headache Society (http://www.ahsnet.org/) U.S. Headache Consortium's guidelines for migraine headache in the primary care setting, pharmaceutical management of acute attacks (http://www.ahsnet.org/guidelines.php) American Council for Headache Education (http://www.achenet.org/) Copyright 2001 American Medical Association. All rights reserved.
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