Headache and Its Treatment
by,
W. Steven Pray, Ph.D., R.Ph.
Professor of Pharmacy Practice, School of Pharmacy, Southwestern Oklahoma State University, Weatherford, OK
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The pharmacist fields questions about numerous types of minor aches and pains. One of the foremost types is headache, which is described by physicians as the most common symptom suffered by patients.1
Headache Etiologies That Mandate Referral
The majority of adult patients with headache have tension-induced headache or migraine. However, there are warning signs of more serious etiologies that mandate immediate referral to a physician. Some of these signs are described in this month’s patient information section and indicate one of three serious underlying conditions.
Subarachnoid hemorrhage is signaled by "thunderclap" headache. This type of headache has sudden, severe onset and reaches peak intensity within a few minutes.2
Giant cell arteritis is possible when the patient is over the age of 50 years and has a first headache which may be accompanied by scalp tenderness, malaise, low-grade fever, and anorexia.
Bacterial meningitis is a possibility when the patient has general illness and fever which may be indicative of infection.3
The great fear of the typical patient is that headache is caused by a brain tumor. However, a brain tumor is not a common cause of headache.2 Only one-fifth of brain tumors cause headache as the only symptom; either seizures or neurologic dysfunctions are the usual symptoms that cause the tumor patient to make the initial physician appointment.
Types of Headache
While this discussion does not fully describe all of the different types of headaches possible, a brief description of some of the most common ones are presented.
Migraine: Perhaps the most well-recognized headache, migraine can last from 4–72 hours.1,4 It is diagnosed when one of the following four criteria is present: the pain is unilateral, seems to pulse, inhibits or prevents the individual from carrying out his or her daily activities, and is worsened when the patient carries out routine activities. Also, the individual often experiences sensitivity to light or sounds, nausea, vomiting, or diarrhea.5
Migraine may begin with a prodrome or premonitory symptom such as visual disturbances, light sensitivity, hyperactivity, mild euphoria, lethargy or frequent yawning. The patient may then experience an aura followed by the headache, the headache termination, and a postdrome, or post-headache symptom such as fatigue, irritability or listlessness. The aura, only experienced by 20% of patients, consists of specific neurologic symptoms, such as unilateral paresthesias and/or numbness, aphasia, or language disturbances that slowly evolve over 5–20 minutes and last one hour or less.6 Not all patients experience the prodrome and postdrome. Prodrome should not be confused with the aura and can manifest as specific physical symptoms or simply as a general odd feeling that occurs anywhere from hours to days before the onset of the headache.
Tension Headache: Tension headache may last only 30 minutes, or may continue for up to one week.1,7 It is also known as muscle contraction headache because of the suspected etiology. Patients often experience accompanying neck tightness, tenderness in the shoulders, lower back pain, or other similar indicators of tension during work or recreational activities.
Patients describe the pain as a nonpulsing feeling of pressure, tightening or squeezing. They are usually able to carry out routine daily activities without worsening of the mild to moderate pain. Both sides of the head are affected, and physical activity does not worsen the pain. Tension headache usually does not produce the nausea, vomiting, photophobia and phonophobia that characterize migraine.
Cluster Headache: Cluster headache is more common in young or middle-aged males, who may experience one to three attacks daily, each peaking in 10–15 minutes and lasting 45–60 minutes.
Patients describe a penetrating and excruciating head pain. The patient may also experience nasal congestion and tearing of the eye on the affected side of the head.2 The pain often occurs at night, unlike most other types of headache.
This headache is called "cluster" because the symptoms return in clusters every one to two years, with remission periods averaging two years each between the clusters. Each cluster can last for two to three months. Cluster headache can coexist with migraine, further complicating the clinical picture.8
Coital Headache: Coital headache is more common in males.2 The patient complains of a severe headache of sudden onset either before, during, or just after orgasm. It may last for a few minutes or for hours.
Sinus Headache: Patients with sinus headache describe a dull, constant pressure. The pharmacist can help the patient recognize this etiology by discovering the presence of a previous or coexisting upper respiratory tract infection. Quite often, the patient has tried to clear the respiratory passages by blowing his or her nose, which forces infected fluids into the sinuses. The pain worsens when the patient bends over. The physician will treat the infection with an antibiotic or antibacterial appropriate to the organism causing the infection, and the headache can be treated with analgesics.
Influenza-related Headache: Headache is a common symptom associated with influenza.9 The pharmacist can recognize this etiology by asking about concomitant symptoms such as abrupt onset of fever, malaise, myalgia, and a dry, hoarse cough.
Cold-induced Headache: Cold-induced headaches are brought on by exposure to cold temperatures or ingestion of cold liquids or solids; for example, a headache may be precipitated by walking in cold weather or eating ice cream.
Treatment of Headache
Ergot Derivatives: Ergotamine has been regarded as a drug of choice for migraine headache for decades, and is also used for cluster headache.10 Oral administration yields only a 2% bioavailability, although coadministration of caffeine may increase absorption. This low bioavailability also causes some physicians to prescribe sublingual tablets or suppositories. However, sublingual tablets are not much better than oral tablets. Suppositories allow more rapid absorption, but they only boost bioavailability to 5%.6,11
MIGRAINE PROPHYLAXIS
In an effort to prevent migraine recurrences, patients might be counseled by the physician to discontinue oral contraceptives (which increase the risk of migraine) and discontinue causal medications such as vasodilators. Patients may also be advised to avoid other possible headache triggers, such as caffeine (which can also help relieve headache), stress, anger, fluorescent lighting, and certain foods such as chocolate and red wine.6
Prophylactic agents for migraine are meant to prevent recurrence and reduce severity.4 These agents should be ingested for 1–3 months in order to obtain the maximal therapeutic response. Migraine prophylactic agents include beta-blockers (e.g., propranolol, timolol, nadolol, metoprolol, and atenolol), serotonin-influencing agents (methysergide, amitriptyline), calcium channel blockers, NSAIDs, phenelzine, and valproic acid.
There are numerous problems with using ergotamine. It may only be effective in half of patients using it. The well-known vasoconstriction produced by ergot lasts for 24 hours. Directions should be carefully explained to the patient to prevent overdosage.
Ergotamine produces adverse reactions (e.g., nausea and vomiting, vertigo, confusion, drowsiness, tiredness, fatigue, limb paresthesia, asthenia and abdominal pain) in 17%–41% of patients.11 Because migraine often causes nausea and vomiting, the use of ergot can worsen these symptoms. This may reduce compliance among patients.12
Ergotamine can also cause limb ischemia, arterial stenosis, myocardial infarction, cardiac valve lesions, anorectal ulcers, rectal stenosis and fibrosis.11 It should not be administered to patients with cerebral, coronary, and peripheral vascular disease.10 Adverse reactions are six times more common in females than in males. Ergotamine has been found to prolong or aggravate the aura and should only be used with caution in those patients who experience prolonged aura with their migraine headaches.12
Ergotamine can also induce headache.11 This headache is differentiated from the underlying migraine through a difference in symptoms. Ergotamine-induced headache is accompanied by malaise and nausea, and is described as a dull aching. In some cases the headache is due to withdrawal of ergotamine, a syndrome which often produces what the patient describes as "the worst headache I’ve ever had." Because oral tablets (in many cases) and suppositories are formulated with caffeine, headache experienced after the patients stops taking the drug may be the result of caffeine withdrawal rather than ergot withdrawal. This hypothesis is supported by the fact that rebound headache is not seen with sublingual tablets or with dihydroergotamine injection, both of which are free of caffeine.12 Use of the ergot derivative dihydroergotamine is limited by the fact that it is only available in parenteral form.
Ergotamine may produce physiological and/or psychological dependence, especially when the patient takes the product regularly two to three times weekly.12 Experts do not recommend gradual tapering, but instead advise abrupt discontinuation of ergotamine. In addition to the withdrawal headache discussed previously, the withdrawal syndrome includes malaise, prostration, nausea, and vomiting.
Sumatriptan and Related Products: Sumatriptan was found to be more effective against migraine than ergot; it also helps relieve the nausea and vomiting of migraine.10 Sumatriptan injection, self-administered by the patient, acts more rapidly than oral tablets.
Limitations of the agent include the high cost and frequency of headache recurrence. Sumatriptan has a half-life of only approximately two hours, and headaches tend to return within 24–48 hours after the dosage wears off. However, adverse reactions to sumatriptan are generally mild.
A sumatriptan nasal spray and related compounds (e.g., naratriptan, rizatriptan, zolmitriptan, and eletriptan) are awaiting FDA approval, which is considered imminent.
Nonspecific Prescription Products: A wide range of prescription analgesics are available for the symptomatic relief of various headache categories, such as tension, cluster and sinus. These treatments range from simple analgesics to nonsteroidal anti-inflammatory agents (NSAIDs) to opiates.
For less severe attacks of migraine, NSAIDs work well as abortive agents and may be considered the agents of choice.4 Naproxen sodium is frequently used and is effective in treating menstrually associated migraine, but does not alleviate vomiting in all cases.10
Aspirin, acetaminophen, and propoxyphene are also useful. Migraine attacks that are not severe usually do not require opiate derivatives for resolution.6 However, if an attack is not relieved by other agents, butalbital (a combination of caffeine, barbituate, and aspirin) or opiates such as codeine, meperidine and even morphine can be helpful in relieving pain.
Nonprescription Products Recommended for Migraine: Nonprescription oral analgesics such as aspirin, acetaminophen, ibuprofen, naproxen and ketoprofen have always been FDA-approved for headache treatment. However, recently an FDA advisory committee unanimously voted that there is sufficient evidence that Excedrin Extra Strength is effective for relief of migraine pain.
Should the FDA approve this labeling, it will mark the first time that a nonprescription product has specifically been approved for migraine headache. The product, which contains aspirin, acetaminophen and caffeine, was shown to be more effective than placebo in three clinical trials.13
PATIENT INFORMATION
What to Do When Headache Strikes
While most headaches are benign, some are warning signs to visit a physician without delay. For instance, a persistent headache that lasts day after day—especially if it becomes progressively worse—must be checked. If you experience the first headache of your life (especially if you are 50 years of age or older), or feel that your headache is the worst one you have ever had, you should see your physician immediately.
The "thunderclap" headache begins suddenly and produces severe pain from the onset which worsens over a very short time. While this may be a type of migraine, it should be checked. It may be caused by a serious problem such as an aneurysm, which may rupture. You should also see a physician if your headache is accompanied by fever or a feeling of illness.
Headache in Children: Headache in children is potentially serious. Children under the age of 2 years cannot be safely given any nonprescription pain product without a physician recommendation. Even in children over age 2, a physician visit is the best course of action. Some analgesics should not be given to children under age 12 or 16 years. The most common causes of headache in children are viral illness, sinusitis, migraine, and trauma. A patient who has hit his or her head and is suffering from a headache should be taken immediately to an emergency room to assess possible injury to the brain.
Prevention of Migraine: Migraine is a common, more severe type of headache which can be debilitating without adequate treatment. It occurs on one side of the head, tends to produce a pulsing pain, and can be accompanied by nausea, vomiting and/or painful reaction to light or sound. If you suspect you have migraine headaches, see your physician for evaluation and to discuss treatment. Fortunately, migraine headache may be prevented, at least some of the time, if you can identify the factors that cause an attack. For example, some are induced by oral contraceptives. The physician can help the patient choose an alternate product.
If migraine is triggered by too little or too much sleep, try to maintain regular times for going to sleep and arising. If stress, anger, excitement or emotional upset cause migraine, try to modify these emotions as much as possible. Avoid fluorescent lights if they seem to trigger an attack, and be especially wary of flashing or strobe lights. Avoid smoking and second-hand smoke. Strong odors such as perfume and cleaning solutions should be avoided. Alcohol, caffeine, chocolate, strongly sugared foods, aged cheeses, nitrates in meats, fruits, dairy products, pickled foods, and artificial sweeteners can trigger migraine and should be avoided.
Nonprescription Treatment: Headache can be helped by many nonprescription ingredients. If the headache is not serious, the patient may try aspirin, acetaminophen, ibuprofen, naproxen or ketoprofen. However, the dosing and directions on the labels must be followed exactly. If the directions are unclear or if you need further information, speak with the pharmacist.
