Treatment of Headache
Firstly, it must be known what type of headache the patient has. Secondly, if there are any triggers, such as a change in sleep pattern or the taking of any food or drug, they must be identified and controlled. Healthy life habits have to be promoted, like maintaining regular sleeping hours, exercising, avoiding tobacco and alcohol, a balanced diet and avoiding constipation. And thirdly, a prescription for the treatment of acute attacks of pain should be given.
For migraine it is very important to start the acute treatment as near as possible to the onset of the appearance of the headache. Non-steroidal anti-inflammatory drugs with a rapid gastric absorption or triptans are used.
For tension headaches the use of relaxation techniques is chosen, along with exercise, anxiolytics, or paracetamol. In hemicranial headache indomethacin is prescribed, and in cluster headaches, subcutaneous sumatriptan or intranasal zolmotriptan.
In any case, it must be taken into account if the patient, despite following the previous prescriptions, is a candidate to receive continuous or preventive prophylaxis treatment in order to reduce the number of episodes and their intensity and to prevent the headache from becoming chronic.
50% of patients with <a href="/en/assistance/be-healthy/headache">headache</a> self-medicate, which often leads to the pain becoming chronic.
Treatment of Migraine
On the other hand, it is necessary to avoid the abuse of drugs, since it is one of the factors that can lead to the migraine becoming chronic. By abuse, it is understood the consumption of more than 10 anti-inflammatory drugs or more than 15 triptan drugs a month.
In general, preventive treatment is indicated when:
- there are three or more migraine attacks a month,
- if a symptomatic treatment is being taken two or more days per week,
- if the attacks are severe with no adequate response to the treatment or with contra-indications or secondary effects to them,
- if the attacks are with a prolonged aura or with a severe neurological focus.
The choice of one or other drug does not only depend on its efficacy, since there are no large differences between them, but on the patient’s profile, individualising the treatment depending on the possible secondary effects that they may cause; avoid increasing weight in females, impotence in males, making any depressive symptoms worse, etc.
As regards preventive treatment, in order to be effective, it has to last a minimum of between 3 and 6 months, and the optimum dose should be reached before rejecting it. There is a delay time between when it is started until it is effective that can vary between 10 days and 4 weeks. The treatment is considered effective when the frequency or intensity of the headache days is reduced by 50%. Once it is decided to withdraw it, it must be done slowly and gradually (1 month) and, in cases of refractory migraine, the doctor may recommend combining drugs.
The treatment is considered effective when the frequency or intensity of the <a href="/en/assistance/be-healthy/headache">headache</a> days is reduced by 50%.
Botulin Toxin. Currently it is only indicated in cephalalgia for the treatment of chronic migraine (patients that have more than 15 days of headache a month for the last three months, of which at least 8 fulfil migraine criteria). Even so, it has been effective in some patients with cluster headaches, trigeminal neuralgia, or nummular (coin-shaped) headaches.
The demonstration of its efficacy against a placebo in chronic migraine was obtained from two studies, PREEMPT I and PREEMPT II, which, between them, included more than 1,300 patients.
The treatment consists of injecting onabotulinum toxin A into different points of the pericranium musculature, blocking the peripheral sensitivity of the nociceptive receptors.
It is a straightforward technique in the hands of a trained neurologist, which does not affect the daily life of the patients, since they can continue their daily activities and with few secondary effects: pain and weakness in the neck, drooping of the eyelids, elevation of the eyebrow, discomfort at the injection sites.
In the long-term, according to the data of patients treated during more than 5 years, no new secondary effects have appeared, except two cases reporting an insignificant atrophy in the frontal and temporal muscles.
Half of the patients responded to the first session, 11% to the second, and 10% to the third. This is why it is recommended not to reject the treatment until has been tried on two occasions. On the other hand, the effect expires at three months; therefore, the treatment is repeated at this interval. It is possible that the response to the usual dose of 155 units is insufficient and it is decided to increase the dose to 195 units.
Nerve block. Anaesthetic blocks are a therapeutic option for the management of different headaches, either in isolated form or combined with other treatments. The local anaesthetics act by reversibly inhibiting the production and the conduction of the stimulus of any type of excitable membrane, especially in nerve tissue. In clinical practice, the most widespread technique is the blocking of the nervous occipitalis major (NOM) or greater occipital nerve.
There is increasing scientific evidence supporting the modulating role of the occipital nerves on the afferent nociceptors transported by the trigeminal nerve. On blocking the arrival of nociceptive impulses by the first cervical nerves, the anaesthetic block can act on this trigeminal-cervical complex by also inhibiting the transmission of the trigeminal afferents.
They are used in migraine, in trigeminal-autonomic cephalalgia, cervicogenic headache, as well as in post-traumatic headache and in different neuralgias: occipital nerves (Arnold neuralgia), supra-orbital, supratrochlear, lagrimal, infratrochlear, infraorbital, external nasal, and auriculotemporal nerve.
There is wide variability in applying these techniques, and for this reason the Spanish Neurology Society published the “Consensus guidelines on anaesthetic injection techniques of the pericranium nerves”.
Neuromodulation. Non-invasive neuromodulation techniques may be an option for patients that are unable to tolerate the side effects of oral medication. But the current scientific evidence is insufficient and more studies that can ensure the efficacy of these devices are needed, which seem safe and relatively useful in the majority of trials currently available.
Invasive neuromodulation (occipital and sphenopalatine stimulator) should be reserved for patients in whom oral treatments, botulin toxin and non-invasive neuromodulation have not been effective. It is currently carried out in specialised centres in tertiary hospitals and on very selected patients. It has numerous secondary effects (infections, migration of the electrode, etc.) therefore, they are not routine procedures.
Monoclonal antibodies against calcitonin gene-related peptide (CGRP) or its receptor. They are not a vaccine and do not cure the condition. They are drugs that are administered subcutaneously or intravenously that act at a preventive level by reducing the frequency and intensity of the headache. They are generally well tolerated and with no serious side effects.
They are currently in the investigation phase.