For tension-type headaches,
treatment includes over-the-counter analgesic.
Those are generally going to be effective.
Acetaminophen, NSAIDs, not really
a difference in terms of efficacy.
Prefer acetaminophen for safety.
And really, you want to think about limiting the use
of rescue medications for all of these types of headaches
because we think about those main
categories of tension and migraine,
but actually right behind them is medication
rebound headache or analgesic rebound headache.
Anything that’s used for acute analgesia,
in this case acetaminophen or NSAIDs,
in migraine’s case can be
ergot medications or triptans,
overuse of those products can promote a rebound headache,
which is a difficult thing to
get out of because it cycles.
You take your take your analgesic,
you get some relief, but then
the headache comes back,
so you take more analgesics
and it's a self-propagating cycle
that can really be debilitating for patients.
Therefore, if patients have
frequent tension-type headaches,
consider prophylaxis with a
drug like amitriptyline, low dose,
can be effective for prevention of tension-type
headaches and break that analgesic overuse cycle.
But SSRIs don't really work.
Other types of treatment that
work for tension headaches,
biofeedback and relaxation therapy can be effective.
Psychotherapy can be effective
and even acupuncture has been
shown to be effective as well.
So, there’s some non-medical options
for patients with tension headache
because everybody's had at least one
tension headache in their lifetime.
For acute migraine headache, over-the-counter NSAIDs are
frequently effective, so that's a good place to start,
particularly if the pain is not that severe.
But 24 hours later, many times
the pain might be returning.
You’re going to use behavioral treatment and
recommending rest and lowlight for everybody.
Triptans are, I think, the most commonly used
acute analgesic for migraines specifically.
In terms of Triptans, they’re all similarly effective.
There is not one that really stands out
from the others in terms of efficacy.
So, therefore, the route of
administration is really important.
Oral drugs may not be tolerated among
a patient who is really nauseous and vomiting,
so there are other options.
Obviously, subcutaneous injections,
but also nasal spray formulations of drugs that can be
– not only avoid that GI pathway,
but also can work a little bit faster
for patients with severe symptoms.
So, it’s really the route of administration
I think trumps the actual drug
in terms of its efficacy because
they all work about the same,
but they also have similar warnings in terms of avoiding
among patients with active cardiovascular disease
and really being careful of using triptans among
patients taking SSRIs as both those agents
can increase serum serotonin levels
and promote serotonin syndrome.
So, migraine prophylaxis,
here’s something that’s very
nderused, yet highly effective.
When the headache frequency is at least twice a week,
it's time to think about prophylaxis because,
again, patients get in the cycle of these
analgesic overuse type headaches
and these rebound headaches.
And the number needed to treat among patients
with migraine frequent headaches is really low.
If you treat 10 patients,
2 to 4 are going to have a significant
reduction in their headache
frequency of 50%.
So, it doesn't take much to make a big
difference in terms of headache frequency.
And prophylaxis can also reduce
severity of the headaches as well.
How do you initiate prophylaxis?
What do you use?
Beta blockers tend to be
one of the most popular choices.
Generally, they’re pretty well tolerated
and you don’t need high doses
in order to have efficacy against migraine.
Similar for tricyclic antidepressants which
can be associated with more side effects.
Topiramate can be used as well.
It may be a little bit more expensive and
it’s also associated with some side effects.
And divalproex, very similar.
Other agents to consider, there's a lot of different options.
Some studies have shown that gabapentin is effective.
Other studies have shown that
calcium-channel blockers are effective.
The four that I listed here,
beta blockers, TCAs, topiramate, divalproex
are the ones that have probably the
strongest trials demonstrating efficacy.
But if one doesn't work,
you can switch to the other.
I would recommend that instead of just giving up
altogether because these patients really do suffer.
And these drugs can really be quite effective for
reducing headache severity and frequency as well.
And with that,
I hope that – again, we all have headaches,
so you’ve learned how to manage your
own headaches a little bit better,
but certainly with your patients as well.