Treatment for Headache

Medication Treatment for Headache

Triptans

Triptans are prescribed for migraine and cluster headache. Triptan are prescribed as a nasal spray and intravenous therapy. Sumatriptan injection is very effective in treatment of cluster headache and works within 15 minutes. Nasal route of sumatriptan is effective in 30 minutes. In most of the cases, effect of nasal treatment last less than 45 minutes. Quality of pain relief is better with intravenous therapy than nasal spray treatment. Newer triptans with fewer side effects used are zolmitriptan (Zomig) in oral or nasal spray forms.

Treatment for Headache: Medications, NSAIDs, Opioids, Oxygen Therapy, Surgery

Side Effects of Sumatriptan are as follows:

  • Nausea.
  • Dizziness.
  • Muscle weakness.
  • Heaviness or pressure in the chest.
  • Tingling and numbness in the toes.
  • Rapid heart rate.

Complications of Sumatriptan:

  • Stroke secondary to vasoconstriction of cerebral arterial blood vessels.
  • Heart attack and angina secondary to vasoconstriction of coronary artery.
  • Hypertension cause by vasoconstriction of peripheral arterial system.
  • Serotonin syndrome is a life-threatening condition. Sumatriptan increases overall concentration of serotonin in brain. Symptoms observed are tachycardia, nausea, vomiting, diarrhea, hallucination, anxiety, tremors and restlessness.

Ergotamine

Dehydroergotamine (DHE) is prescribed for migraine and cluster headache. Most of the patient suffering with cluster headache responds within 5 minutes with no pain. Ergotamine can be prescribed as tablets, suppositories and nasal spray.

Side Effects of Ergotamine:

  • Tachycardia.
  • Nausea and vomiting.
  • Diarrhea.
  • Dizziness.
  • Muscle weakness.
  • Heaviness or pressure in the chest.
  • Tingling and numbness in the toes.

Complications of Ergotamine:

  • Stroke secondary to vasoconstriction of cerebral arterial blood vessels.
  • Heart attack and angina secondary to vasoconstriction of coronary artery.
  • Hypertension cause by vasoconstriction of peripheral arterial system.
  • Serotonin syndrome is a life-threatening condition but less severe than Triptans. Sumatriptan increases overall concentration of serotonin in brain. Symptoms observed are tachycardia, nausea, vomiting, diarrhea, hallucination, anxiety, tremors and restlessness.

Lidocaine (Local Anesthetics)

Lidocaine- is a local anesthetics and used in resistant cases to treat cluster headache. Lidocaine nasal drops or nasal spray is recommended for optimim effects. Group of patients with history of cluster headache may not respond to lidocaine treatment. Reports suggest that it is helpful for most patients within about 40 minutes.

Side Effects of Lidocaine:

  • Unpleasant taste.
  • Numbness of area treated.

Capsicum for Headache

Capsicum originated from hot pepper and it is used for tension and cluster headache. Capsicum is applied over occipital skin and also inside nose. It is a safe medication and available as over the counter product in pharmacy.

Side Effects of Capsicum:

  • Burning sensation over skin and nose.
  • Sneezing and watery eyes.
  • Stomach upset.
  • Sweating.
  • Flushing and running nose.
  • Dermatitis.

Serious Side Effects of Capsicum:

  • Liver and kidney damage.
  • Stop using 2 weeks before surgery may cause side effects bleeding.

Calcium Channel Blockers for Headache

Calcium channel blockers influences the calcium channel of smooth muscle of blood vessels. Calcium channel blocker is effective in treating hypertension and coronary vascular disease. Migraine or sinus headache and cluster headache is secondary to changes in diameter of cerebral blood vessels. Calcium channel blocker causes changes in diameter of cerebral blood vessel resulting in reduction of headache symptoms. Verapamil is a prefer calcium channel blocker used for preventive treatment of cluster and migraine headache. Medication should be taken for 2 to 3 weeks to build maximum effects.

Side Effects of Calcium Channel Blockers:

  • Constipation.
  • Severe Hypertension - If discontinued abruptly.
  • Bradycardia and Hypertension - If overdose.
  • Heart Failure - History of congestive heart failure.

Lithium for Headache

Lithium (Eskalith, Lithane, Lithobid, Lethonate, Lithotabs), commonly used for bipolar disorder, may also help prevent cluster headaches. The patient usually receives benefit within 2 weeks of starting to take the drug, and often within the first week. Lithium may be used alone or with other drugs. Lithium can have many side effects including trembling of hands, nausea, and increased thirst. Weight gain is a common side effect with long-term use.

Side Effects of Lithium:

  • Thinning of the hair and hair loss.
  • Mild tremor.
  • Loss of appetite.
  • Tiredness.
  • Nausea.
  • Severe allergic reactions.
  • Skin - Rash, hives, itching.
  • Respiratory system - Bronchospasm, dyspnea andtightness in the chest.
  • Cardiovascular system - Slow or irregular heartbeat.
  • Central nervous system - Confusion, restlessness, tremor, dizziness, faintness, bladder and bowel incontinence, numbness of skin, ringing in the ear, restlessness, seizures and severe or persistent headache.
  • Musculoskeletal system - Tremors, involuntary muscle twitching, decrease muscle tone and coordination.
  • Gastrointestinal system - Edema of oral cavity and tongue, nausea and diarrhea.

Anti-Seizure Medication Treatment for Headache

Anti-seizure medications are thought to reduce the occurrence of migraines by calming inflamed blood vessels in the brain, which may lead to migraine pain or sinus headache. However, none of these medications is a cure for migraines. Antiepileptics are diverse group of medications used as antiseizures. Some of the medication within this large group is been used to treat headache. In research there were areas of hyper activities in brain were recognized in epilepsy and headache patients. Antiepileptic medications reduced area of irritability by its molecular action at voltage gated sodium channel. Most common used antiepileptic in headache treatment is Topamax, Depakote and Neurantin.

Topamax - Oral tablet is taken everyday as prescribed even if headache symptoms are absent.

Side Effects:

  • Tachycardia.
  • Dyspnea - breathlessness or shortness of breath.
  • Chest pain.
  • Urine - bloody or cloudy.
  • Cognitive symptoms - thoughts of suicide or aggressive behavior.
  • Depression.

Depakote - Depakote (valproic acid) is available as capsule, tablet and syrup.

Side Effects:

  • Liver damage.
  • Pancreatitis.

Neurontin (Gabapentin) used in post-herpetic neuralgia, diabetic neuropathy and fibromyalgia.

Side Effects:

  • Nausea.

Serious Allergic Reaction:

  • Skin - Rash, hives, itching.
  • Respiratory System - Bronchospasm, dyspnea and tightness in the chest.
  • Central Nervous System - Seizures and Tremors.
  • Musculoskeletal System - Tremors.

Corticosteroids for Headache

Corticosteroid drugs (also called steroids) are used in allergic reaction and autoimmunediseaseas anti-inflammatory medications. Corticosteroids are membrane stabilizing agents, prescribed for headache to prevent irritability of cortical and subcortical centers. It enhances the effect of verapamil in treatment of headache and often prescribed with verapamil. Prednisone is been tried as short term breakthrough pain meds for cluster headache. It is often prescribed as tablet form prednisone and injection form decadron.

Side Effects of Corticosteroids:

  • Symptoms like diabetes increase blood sugar level.
  • General Symptoms - Dry mouth, fatigue, weakness, blurred vision, facial swelling, infection, avascular necrosis and glaucoma.
  • Central Nervous System - Anxious, depression, confusion, insomnia, mania, psychosis.
  • Gastrointestinal System - Stomach bloating feeling, increase appetite, weight gain, abdominal pain, diarrhea and peptic ulcer.
  • Urination - Frequent urination.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) for Headache

NSAIDS are anti-inflammatory medication abbreviated as NSAIDs. NSAIDs are used for treatment of headache in combination with other medications. Mild headaches are often treated by NSAIDs alone.

Analgesics - NSAIDs are not effective in severe pain and also pain caused by non-inflammatory etiology.

Most Prescribed NSAIDs - aspirin, ibuprofen (motrin, advil) and naproxen (aleve).

Side Effects - Complications caused by NSAIDs can be devastating if continued for prolong period of time.

  • Dose dependent side effects - Dyspepsia, ulcer, perforation, upper gastrointestinal bleeding and severe blood loss. Combination of aspirin and COX 2 inhibitor (Celebrex) may block cardio-protective effects of aspirin.
  • Myocardial infarction and stroke - NSAIDs with COX2 inhibitor may increase risk. Combination of NSADs and COX 2are not recommended in-patient with history of myocardial infarction and heart attack.
  • Erectile dysfunction.

NSAIDs Combinations With Other Medications Used In Headache

Most acute attacks of tension-type headaches get better without any treatment. Over-the-counter pain relievers such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) can treat mild symptoms. Aspirin or ibuprofen (generic, Advil, other brands) are usually the first choices, followed by naproxen (generic, Aleve). Some patients may also find helpful medications that combine a pain reliever with caffeine.

  • Ibuprofen. (Advil, motrin)
  • Naproxene. (aleve, napralan, naprosyn,anaprox)
  • Acetaminophen/butalbital. (bupap, cephaldine, phrenllin)
  • Acetaminophen/butalbital/caffeine. (esgic, fioricet)
  • Aspirin/butalbital/caffeine. (Fiorinal)
  • Acetaminophen/butalbital/caffeine/codeine. (fioricet with codeine)
  • Acetaminophen/dichoraphenazone/sometheptene mucate. (midrin)
  • Acetaminophen/phenyltolaxamine. (percogesic)
  • Acetaminophen/isometheptene mucate. (prodrin)

Anti Anxiety Medications for Headache

Sedatives are used in treatment of headache. Most common indication to use sedatives or anti anxiety medications are Tension headache and prevent recurrent episode. Buspirone (Buspar) and alprazolam are prescribed as anti anxiety medications.

Side Effects of Anti Anxiety Medications:

  • Drowsiness.
  • Irritability.
  • Fatigue.
  • Low blood pressure.
  • Amnesia.

Opioid Medications for Headache

Opioids are used for treating tension headaches, which are not responding to NSAIDs and other medications. Acute and brief attack of headache most of the time gets better without any treatment. Patients may develop resistance and tolerance to opioid medication. Patients are advised relaxation treatment, cognitive behavioral therapy and lifestyle changes if failed to get pain relief with opioids. Daily attacks of headaches are treated with preventive medication such as NSADs, NSAIDs combine with opioids or opioids. All other options of medications should be tried before introducing opioid medications. Patient dependent on opioids for pain relief at time may behave like drug addict. Opioid dependence some time needs higher dosage and frequent need of pain medications. These symptoms are because of opioid dependence to achieve pain relief and classified as Pseudoaddiction. Opioids do cause addiction in few patients and treatment of headache with opioids become difficult.

Side Effects of Opioids:

Common Side Effects of Opioids:

  • Nausea.
  • Vomiting.
  • Constipation.
  • Dry mouth.
  • Itching.
  • Miosis.

Less Common Side Effects of Opioids:

  • Skin - Itching, urticarial, hypothermia and histamine induced flushing.
  • Eyes - Miosis.
  • Gastrointestinal - Nausea, vomiting, dry mouth, constipation and biliary spasm (colicky pain).
  • CNS - Depression, confusion, hallucination, delirium and dizziness.
  • Respiratory system - Depression.
  • CVS - Bradycardia and occasional may be tachycardia.
  • Orthostatic hypotension.
  • Kidney, Ureter and Bladder (KUB) - Urinary retention and ureteric spasm.
  • Musculoskeletal - Muscle spasm.

Botox for Headache

Botulinum toxin A (Botox) injections are typically used to smooth wrinkles in practice of plastic surgery. Botox is also being studied for treatment of headaches, including the prevention of cluster headaches. Research is still preliminary and there is not sufficient evidence to support its efficacy. Botox is treatment of choice for headache localized over frontal, occipital and cervical (neck) region. Headache over parietal (top of head), temporal area (side of head above ear), between eyes and behind ear does not respond to botox injection.

Frequent Common Side Effects:

  • General Symptoms - Irritated eyes, facial pain, flu-like symptoms, inability to focus the eyes, neck pain, redness, swelling, tenderness at the injection site; sensitivity to light, sweating and tiredness.
  • CNS - Anxiety, arm or leg pain, back pain, dizziness, drowsiness and headache.
  • Gastrointestinal System - Nausea, constipation, dry mouth, dry and indigestion.
  • Respiratory System - Increased cough, mild sore throat and runny nose.
  • Musculoskeletal - Stiff or weak muscles at or near the injection site.

Severe Allergic Reactions Need Immediate Medical Attention:

  • Skin - Swelling of the mouth, face, lips, or tongue; fever and chills.
  • Respiratory system - Unusual hoarseness, wheezing, chest pain, difficulty swallowing or breathing, persistent sore throat and shortness of breath.
  • Kidney Ureter Bladder - Blood in the urine; burning, numbness, or tingling; burning with urination; difficult, frequent, or painful urination,loss of bladder control, eyes-double or blurred vision, or other vision changes; drooping of the upper eyelid and eyelid swelling.
  • Central Nervous System - Fainting; seizures, headache, dizziness speech changes or problems and worsening migraine.
  • Cardiovascular System - Irregular heartbeat.
  • Musculoskeletal System - Loss of strength, paralysis and severe or persistent muscle weakness.

Melatonins-(N-acetyl-5-methoxytryptamine) for Headache

Melatonin is found in animals, plants, and microbes. Melatonin sold over the counter in USA. In animal research melatonin was investigated against carcinogens. Melatonin prevents initiation of impairment of DNA by carcinogens. Impaired DNA otherwise would have initiated cancer growth.

Melatonin is been prescribed for headache and several other diseases. Melatonin is widely used as an antioxidant in diseases such as immunodeficiency syndrome, autism, aging, Alzheimer disease, delirium mood disorder, alternative medicine, tinnitus, cancer and gallstone.

Oxygen Therapy for Headache

Oxygen therapy - Oxygen percentage in atmosphere is 21%. Oxygen therapy can provide from 30% to 100% oxygen. Nasal oxygen therapy using nasal cannula provides 30 to 40% oxygen. Tight fitting face mask or endotracheal tube can deliver up to 100% oxygen. Oxygen therapy is been used in congestive heart failure, chronic obstructive lung disease (COPD), and allergic reaction causing shortness of breath, convulsion and hemorrhagic shock. Oxygen therapy up to 100% is used in cluster and tension headache on and often. Patient is advised to inhale oxygen for 15 minutes several times a day.

Surgery for Headache

Brain and Nerve Stimulator: Chronic cluster and migraine headaches in few patients are resistant to all treatments. These patients are imprisoned in house suffering with intense headache and unable to perform any kind of regular activities. Intense pain may bring multiple thoughts of suicide. These patients are given a trial of stimulator as a last option of treatment. Stimulator is placed over brain, vagus nerve or occipital nerve. Pain when predominantly located over occipital dermatome then occipital nerve stimulation will be treatment of choice. Cluster headache is treated with placement of stimulator over cerebral cortex, hypothalamus and vagus nerve. These treatments are considered experimental in United States.

Facial Nerve Ablation: Headache associated with facial nerve involvement is treated with gasserian ganglion neurotomy using either radiofrequency heat or chemical neurotomy using glycerol. Percutaneous radiofrequency gasserian ganglion rhizotomy is the treatment involves destruction of pain fibers in gasserian ganglion by heat from radiofrequency. Pain carrying fibers are also often destroyed in few cases using glycerol as a chemical rhizotomy.

Microvascular Decompression of Trigeminal Nerve: Trigeminal nerve pain is seen after postherpetic neuralgia and traumatic injury of trigeminal nerve. Chronic headache pain secondary to trigeminal neuralgia is treated with microvascular decompression of trigeminal nerve. Blood vessels surrounding trigeminal nerve are selectively ligated or cauterized to eliminate the pressure.

Craniotomy for Headache

Craniotomy is a surgical procedure performed to exposed brain and subcortical part of the brain. It is highly skilled procedure, which involves removal of part of the skull bone and reattached at the end of surgery. Surgery is coordinated with CAT scan and MRI studies.

Indication for procedure:

  • Tumor and Metastasis - Excision.
  • Aneurysm - Clipping and re-anastomosis.
  • Blood Clot - Evacuation and stoppage of bleeding.
  • Brain Abscess - Excision and drainage.
  • Skull Fracture - Repair.
  • Ischemic Brain Tissue - Excision.

Risk involved:

  • Infection.
  • Bleeding.
  • Seizures.
  • Dural tear - CSF leak.
  • Neurological deficit - sensory and motor nerve deficiency, paralysis.
  • Blood clot, thrombosis and embolism.
  • Cognitive deficiency - memory, emotional expression.

Cognitive Behavioral Treatments for Headache

Cognitive Behavior Therapy (CBT) is useful to assist change or modify behavior problems in patients suffering with chronic headache or sinus headache.

Undesired behavior - Try eliminate and reinforced the changed behavior.

Mode of Various therapies - Individuals and groups suffering with cluster headache and migraine.

Therapy as a Treatment - CBT is also been used in organic disorder such as headache primary and secondary causing severe pain not responding to any treatment. Also very effective inpatient suffering with headache and insomnia.

Integration of behavioral therapy with cognitive therapy.

Maladaptive thinking leads to change in affect and thus behavior.

Computer based supervised therapy with goal to change maladaptive thinking.

Principle of Treatment:

i) Points out over generalizing of symptoms.

ii) Magnifying negative feelings.

iii) Minimizing positive thoughts.

iv) Guiding to more realistic effective concepts.

v) Assess, reconceptualized and acquisition of positive skills.

Treatment Orientation:

i) Cognitively oriented.

ii) Behaviorally oriented.

iii) Imaginary exposure therapy combines both approaches.

Systemic Desensitization - Systematic desensitization involves gradually exposing a patient to anxiety-provoking stimuli until the anxiety response was extinguished, or eliminated.

Positive Reinforcement or reward improves behavior when compare with conditioning such as repetition of harmful behavior was punished and improvement in behavior was rewarded.

Behavioral Treatments for Headache

Behavioral therapies can be a helpful accompaniment to drug treatment. These approaches can help with pain management and enable patients to feel more in control of their condition. Behavioral approaches include:

  • Relaxation treatment combined with biofeedback.
  • Cognitive-behavioral therapy.

Also Read:

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: August 19, 2016

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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