Two Women With Severe Headaches: Different Symptoms, Similar Approaches

CASE 1: A 32-year-old woman complains of daily headaches. The headaches vary in severity, but she usually has severe headaches (8 on a 10-point visual analog scale [VAS]) once or twice a week; she describes the latter as severe throbbing or pounding pain on the top of the head but also involving the occipital and frontal areas—and occasionally one or the other temple. These episodes, which are usually associated with some nausea and sensitivity to bright light and loud noises, typically last up to 48 hours if untreated.

The patient also has headaches that are not nearly as severe (3 or 4 on a 10-point VAS) but are almost constant. She describes them as mild to moderate, dull, pressure-like pain located primarily on the top of her head and occipital area bilaterally. She is able to function with these headaches more easily than with the severe ones, although she sometimes needs to use overthe- counter (OTC) medications to lessen the intensity of the pain.

She started having severe episodic headaches in her early 20s; these became progressively more frequent. In addition to the increasingly frequent severe headaches, about 5 years ago, she began having milder headaches as well. These also became gradually more frequent—and eventually occurred daily. She has had daily headaches for about 2 years.

She has been using oral sumatriptan, 100 mg, for her severe headaches and notes that this reduces the severity of the pain significantly within 1 to 2 hours when she is able to take the medication shortly after pain onset. However, she seldom takes it early enough to have this effect. She uses OTC acetaminophen or ibuprofen for her milder headaches once or twice a day, about 2 days a week.

Results of physical and neurologic examinations and MRI and CT scans of the head are all normal.

• What changes might increase the effectiveness of abortive treatments in this patient?
• Might there be a rationale for prophylactic therapy in this patient?

THE DIALOGUE:
Primary care doctor: This patient has 2 different types of headache. What diagnosis would you make in this case?

Headache specialist: This patient has had daily headaches for the past 2 years. In addition to mild, constant daily pain, she also has a different, more severe headache once or twice a week. Her severe headaches most likely represent migraine without aura. It seems that she is able to control the severe headaches with a triptan, provided she takes the medication early enough.

This last point is very important. Often, we see patients who state that the abortive migraine medications, including triptans and ergotamine-containing agents, are not effective or have only a very limited benefit. However, the reason for this apparent lack of efficacy is often that the patients do not take the medications early enough. In fact, if a migraine is fully developed (which may not occur until 1 to 2 hours after headache onset), even appropriately selected and dosed medications may not be effective.

Primary care doctor: How early do abortive medications need to be taken to be effective?

Headache specialist: These agents generally need to be taken as early as possible.¹ Patients who have migraine with aura or cutaneous allodynia can use the aura or allodynic symptoms as a signal to begin treatment.²

Primary care doctor: Should a patient still take an abortive medication once a headache has developed? For example, if a patient wakes up in the morning with a headache that is already severe, what should he or she do?

Headache specialist: We still encourage our patients to take medication in the late stages of migraine—even though the data regarding the effectiveness of such a strategy are conflicting. Some headache experts have concluded that abortive medications are usually significantly less effective if they are taken after cutaneous allodynia has developed.^2,3 Others believe that these agents can relieve symptoms even in late stages of migraine development. ⁴ Last year we conducted a study in which we analyzed the degree of symptom relief achieved with subcutaneous sumatriptan in patients with migraine who treated their headaches during the developed stages of allodynia and of migraine itself. Our results were very promising: the majority of study participants became pain-free even when they initiated treatment after cutaneous allodynia had developed.

Primary care doctor: So what treatment strategy would you recommend for this patient?

Headache specialist: We would recommend treatment with her current medications, taken early in the course of a migraine whenever possible. In those instances when she is not able to take her medications at headache onset, we would suggest using a parenteral abortive medication, such as sumatriptan, 6 mg SQ; the newer 4-mg version of sumatriptan SQ; ketorolac, 30 mg IM; or even diphenhydramine, 50 mg IM.

Therapy with corticosteroids (eg, methylprednisolone acetate, 80 mg IM) may be effective. This therapy is extremely effective in some patients; however, it should not be used regularly. We recommend the use of corticosteroids for patients who have prolonged migraines (ie, those that last longer than 48 hours) but no more than once a month.

This patient's chronic daily headache should be treated with preventive medications. (Preventive treatment is indicated in any type of chronic headache disorder.) Because she has never tried prophylactic therapy, we would recommend starting with a ß-blocker. Depending on her sleeping pattern and presence of comorbid psychological conditions (eg, depression or an anxiety disorder), we might also recommend the addition of a tricyclic antidepressant, an anticonvulsant, or a monoamine oxidase inhibitor.

CASE 2: A 35-year-old woman complains of episodic severe headaches that occur 3 or 4 times a month. She describes them as severe throbbing or stabbing pain located in the frontal and temporal areas—usually on only one side but occasionally involving the entire head; she rates the intensity of the pain as 10 on a 10-point VAS. The headaches usually last 2 to 3 days and are always associated with severe nausea, frequent vomiting, phonophobia, and photophobia so extreme that she needs to wear sunglasses even when indoors with the curtains closed. The pain is so incapacitating that she has to leave work early or miss an entire day of work 2 or 3 times a month, and she has to go to the emergency department about once a month. She has been hospitalized twice for incapacitating headache and severe dehydration secondary to frequent vomiting.

She has used a variety of pain medications, including OTC drugs and such prescription medications as sumatriptan, frovatriptan, zolmitriptan, ketorolac, butalbital- containing agents, hydrocodone, and methadone. She says that none of these medications were able to provide significant or long-lasting relief from her headaches; at best, they reduced the severity of the pain slightly (to 7 on a 10-point VAS) for 2 to 3 hours.

The headaches began during her teenage years and became more severe and prolonged after her first pregnancy 3 years ago.

Results of physical and neurologic examinations and MRI and CT scans of the head are all normal.

• What changes might increase the effectiveness of abortive treatments in this patient?
• Might there be a rationale for prophylactic therapy in this patient?

THE DIALOGUE:
Primary care doctor: What would be your diagnosis in this patient?

Headache specialist: This woman has episodic migraine without aura. What makes this case noteworthy is the severity of her condition. Her headaches are incapacitating. She misses several days of work each month, and she has severe nausea and frequent vomiting that have resulted in severe dehydration with subsequent hospital admission. In our practice, we see patients who become decompensated by the severity of their headaches— and especially by the associated nausea and vomiting, which, when severe, can lead to dangerous complications, such as acute renal failure, that require immediate hospitalization.

Another important aspect of this patient's history is her inability to obtain significant relief from her abortive medications, including highly potent antimigraine agents.

Primary care doctor: How do you explain the ineffectiveness of these abortive medications?

Headache specialist: There could be several reasons. The timing of the treatment is key, as we mentioned. She probably was not treating her headaches during their early stages. Also, her frequent vomiting may account for the lack of effect. Finally, the medications that she has tried might simply not be effective for her.

Primary care doctor: What do you recommend for this patient?

Headache specialist: We recommend early initiation of treatment here with parenteral medications. She might benefit from either nasal sprays or intramuscular injections (similar to those we recommended for the first patient).

We would also suggest experimenting with a different class of medications—for example, ergotaminecontaining agents. This woman could try dihydroergotamine nasal spray, 0.5 mg, or even dihydroergotamine, 1 mg IM. Finally, she would probably benefit from the use of preventive medications.

Primary care doctor: Why try prophylactic therapy in a patient with episodic headaches?

Headache specialist: In patients whose headaches are incapacitating, disabling, and intractable—even though episodic—prophylactic therapy is appropriate. Preventive medications might not only decrease the number of headache days but might also increase the effectiveness of abortive medications.