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Treatment of Headache in Norway and Sweden


Consultant: P.O. Lunberg, MD, PhD.
Professor and Head, Department of Neurology
University Hospital Uppsala, Sweden

This Article, Entitled Treatment of Headache in Norway and Sweden appeared in the Headache Quarterly 1995; Vol 6(2):pages 102-112.

Reproduced by Permission of P.O. Lundberg, MD, Ph.D., and Headache Quarterly

It is our opinion that this is one of the best reviews of headache management available anywhere. The comprehensive protocols used in Scandinavia have been established after more than 25 years of objective research. They recognize the often overlooked cervicogenic headache and incorporate occipital nerve blocks into the initial diagnostic evaluation. Most American physicians do not.


TOPICS INCLUDED IN THIS ARTICLE

INTRODUCTION
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Several different pathogenic mechanisms may cause headache. In migraine and cluster headache, it is assumed that the pain originates from pain receptors in relation to intracranial blood vessels in the distribution area of branch I of the trigeminal nerve. Pain receptors are stimulated mechanically or by inflammation of vessels, nerves, and membranes. Other kinds of headache may arise from pain receptors in the neck or the muscles of the head. Headache may originate in the central nervous system, and be secondary to intracranial processes. The clinical presentation and the emotional reaction to pain may, to some extent, depend on the personality and earlier experiences of the patient.

DIAGNOSIS
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Primary and Secondary Headache

In secondary headache, a defined organic cause of the pain can be found by means of supplementary diagnostic methods, such as computed tomography and examination of the blood and cerebrospinal fluid. Diagnosis of primary headache is based on recognition of a characteristic pattern. This is verified by a thorough history and to some extent, by clinical observations between and during attacks.

In more difficult cases, the diagnosis of primary headache can be established only after secondary headache is excluded. Typical cases of the most common kinds of headache can be diagnosed and treated by general practitioners.

HISTORY
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ANAMNESIS
A good history is fundamental in the diagnosis of headache. Specific elements should be included:

TABLE I


CLINICAL EXAMINATION
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A clinical examination in General Practice should be made even when the history is typical. Facets of the exam are described in Table 2.

TABLE 2


LABORATORY EVALUATION
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There is no specific need of blood examination for the typical case of primary headache. If specific underlying pathology is suspected, hemoglobin, SR (Sed rate), C-reactive protein, and possibly leukocytes and blood glucose should be measured. At clinical suspicion of pituitary pathology causing amenorrhea, galactorrhea, diabetes insipidus, or symptoms of acromegalia, the general practitioner may start investigation by endocrinological laboratory examinations while the patient is waiting for appointment with a specialist. When the diagnosis is dubious, referral to a specialist or examination by imaging techniques should be considered.

EEG
EEG is not suitable in routine examinations for headache. Unspecific deviations from the standard may often create unnecessary anxiety.

IMAGING
  • Computer tomography is the most usual method to exclude intracranial structural changes, both for the general practitioner and for the specialist. If necessary, the examination, the examination should be made with contrast.
  • Cerebral/cervical magnetic resonance tomography should, in view of the present low capacity of such equipment, be used only by specialists, and mainly when changes in the posterior fossa, tumor of the pituitary gland, or pathology of the neck are suspected.
  • Angiography is very rarely used; it is only performed for special indications and is not to be prescribed by the general practitioner.
    REFERRAL TO NEUROLOGIST OR SPECIALIZED HOSPITAL UNIT

    The following anamnestic symptoms should lead to prompt referral to a hospital or a specialist:

    Other difficult patients who should be referred to a hospital or specialist:

    Referral to a hospital may be necessary in the event of:

    THE DIFFERENT TYPES OF HEADACHE
    In the majority of headache patients, an approach where drugs are not used is to be preferred, and non-drug elements of the treatment are always important. Guidelines for medical treatment are efficacy, safety, convenience, and economic justification.


    TENSION HEADACHE
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    Tension headache is very common and is not likely to be hereditary. Pericranial tenderness is often, but not always, found at palpation. This sign is not necessarily related to the intensity of the pain. Apart from this, the clinical examination is usually normal.

    Tension headache is characterized by a pressing and constricting, but non-pulsating pain of mild to moderate intensity. It is bilateral and is not aggravated by normal physical activity. There is no special circadian variation of the pain. Changes in frequency or intensity may be related to psychological strain. Nausea and photo- phonophobia may be seen. Vomiting is rare. The patients often complain of dizziness.

    Tension headaches may be episodic or chronic. In the chronic form the headache is present for more than 15 days per month, during at least 6 months. The chronic form frequently coexists with typical migraine attacks ("mixed headache").

    TREATMENT
    Treatment of episodic tension headache should be administered by the patient or the general practitioner. Referral to a specialist may become necessary n the more serious chronic tension headache, especially when combined with migraine. Those patients should be followed up by appointments every 6 to 12 months with a general practitioner.

    NON-DRUG TREATMENT OF CHRONIC TENSION HEADACHE

    Information about this condition, especially that it is perhaps benign, may be of importance. Physical training, relaxation, and biofeedback may be of help with regard to awareness of the muscles and control of muscle tension. Physiotherapists can given valuable instructions to the patient.

    Simple technique for biofeedback on unconscious tension of the facial muscles is to stick surgical tape on the forehead. A more advanced technique is to let the patient listen to his or her own tense muscles by means of an EMG apparatus.

    Psychosocial evaluation and talks about lifestyle may help to identify modifiable causal connections. Ergonomic adjustment of the body positioning at work will help in some cases.

    Transcutaneous nerve stimulation and acupuncture may help some patients during difficult periods, but tends to lose effect over time.

    DRUG TREATMENT OF CHRONIC TENSION HEADACHE
    Drug treatment is rarely indicated in chronic tension headache; in particular, there is no indication for muscle relaxants. The patient is commonly using a number of analgesics when referred to the specialist. It is important to decrease the use of analgesics; if possible, they should be completely withdrawn.

    Tricyclic antidepressants may have some effect on a small number of patients. There is no scientific support for trying this treatment as a routine. Evening doses of 10 to 50mg may be tried, and should be withdrawn if no effect is seen after 2 months. Depression should be treated with the medication most suitable to the needs of the patient.


    MIGRAINE
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    Migraine is quite common. Approximately 75 percent of the patients are women. In most cases, family members have a similar kind of headache.

    Frequently occurring provocative facts are stress, relaxation after stress ("weekend headache"), menstruation, alcohol, irregular meals, and insufficient sleep. The duration of migraine attacks ranges from 4 to 72 hours. The frequency of attacks varies, but most patients have between one and four attacks per month.

    In migraine, the headache is often unilateral, starting frontally. The pain is pulsating with moderate intensity, and is worsened by moderate physical activity. The pain is accompanied by anuses, possibly vomiting, and possibly phono- and photophobia. The pain may be bilateral; if it is unilateral, the typical pain may change side from one attack to the next.

    Migraine is without (approximately 80 percent of the cases) or with aura. Some patients may have both forms. In the aura phase, symptoms appear which are believed to come from the brain cortex or medulla. These usually consist of flickering scotomas or somewhat more infrequent unilateral paresthesia. In rare cases, there may be transient speech problems, unilateral muscular paresis, dizziness, confusion, and reduced consciousness. This may necessitate referral to a specialist to exclude TIA. The aura phase will normally develop during 5 to 20 minutes and does not exceed 60 minutes. Headache, nausea, phono- and photophobia will follow the neurological symptoms immediately or after a pain-free interval of less than one hour. The aura phase may continue into, or start during, the painful period. The headache itself may be completely absent, especially in males.

    TREATMENT
    Non-Drug Treatment during Attacks

    Non-drug treatment should be first choice. This consists of identification and avoidance of proving factors. Bed rest in a dark, quite, cool room will ease the discomfort. Biofeedback, physiotherapy, and acupuncture may be used both supplementary during treatment and prophylactically, especially in treatment-resistant migraine and mixed headache. The effect is usually moderate and transient.

    Drug Treatment during Attacks

    The main principle for drug treatment during an attack is sequential testing of active ingredient, dose, and formulation (such as oral tablets, soluble tablets, suppositories, nasal spray (only in Norway), parenteral). The list below has the safest, best-know, and cheapest drugs at the top of the list. Hence, there is little reason to try treatments further down the list if a drug has given a satisfactory response. Lowest effective dose should be aimed at, especially for ergotamine.

    1. OTC analgesics (acetylsalicylic acid, paracetamol, phenazine, ibuprofen).
    2. OTC analgesics with additional metoclopramide. Metoclopramide is active against nausea and vomiting (preferably given rectally or parenterally) and increases absorption of drugs given orally.
    3. Nonsteroidal anti-inflammatory drugs, especially naproxen, possibly with addition of metoclopramide.
    4. Ergotamine (combinations are the only products on the market) and its derivatives (dihydroergotamine). The maximal recommended dose per attack per week and per year should not be exceeded. The drug has its best effect given rectally or parenterally because of unreliable absorption (when given by mouth), due to vomiting and gastric retention. The lowest effective dose should be given early in an attack and all of it given at once. Repeated dosing due to lack of effect should be avoided. Five days should pass between two doses of ergotamine and the dose per year should not, in any case, exceed 150 mg; preferably it should be below 100mg.
    5. Sumatriptan (Norway: The treatment must be instituted by a hospital or specialist in neurology). Sumatriptan is not a first-choice treatment, but may stop attacks in patients showing little response to other kinds of treatment. Sumatriptan and ergotamine must not be given in combination. Sumatriptan must not be given less than 48 hours after intake of ergotamine. When sumatriptan is first choice, 24 hours must pass before ergotamine can be given.

    Treatment with sumatriptan may be repeated after 4 hours if symptoms return. Recommended maximal daily dose must not be exceeded. Efficacy of sumatriptan is somewhat higher when given parenterally than when taken orally and 50mg taken orally is a suitable dose. Daily use of sumatriptan must be avoided. In addition to the drugs mentioned above, sedation may be valuable adjuvant in serious attacks.

    Prophylaxis

    A diary may contribute to the identification of the provoking facts (food, sleep, stress, etc.), to documenting the need for prophylactic treatment, and to evaluating treatment in progress.

    Prophylactic treatment is to be considered when a frequency of attacks is at least three per month, depending on the intensity and duration of the attacks. The patient must decide whether the therapeutic benefit offsets the burden of daily drug uptake. The aim for prophylactic treatment is a noticeable reduction in frequency (usually >50%) and severity of attacks, but total relief form attacks cannot usually be expected.

    The effect and side effects should be evaluated after 4 to 6 weeks. If ineffective, the drug should be withdrawn. Gradual withdrawal of apparently effective prophlyaxis should be attempted after at least a 6-month interval.

    Choice of drug includes:

    1. Beta blocker without intrinsic stimulating activity. (Atenolol, metoprolol, timolol, propranolol). Sixty to 70 percent of the patients respond to the treatment to some degree.
    2. Pizotifen. Approximately 50 percent of the patients respond to treatment. Agreement should be made in advance on how much weight gain the patient will tolerate. Information should be given about dietetic actions which may help control weight gain.

    Second line prophylactic drugs, to be initiated by a specialist include:

    1. NSAIDs: Naproxen may be effective but is little used, due to the adverse gastrointestinal effects.
    2. Methysergide. About 70 percent of the patients respond. Doses should not be higher than 6mg daily (preferably 3mg). Treatment periods of 3 to 6 moths should be followed by drug-free intervals of 1 to 2 months because the retroperitoneal and pleuro-peritoneal fibrosis seems to be linked to duration of continuous use as well as to dose level.
    3. Calcium channel blockers (not approved indication)

    Drugs with incomplete documentation or unsatisfactory effect include clonidine, valproate, amitriptyline. Prophylactic treatment will not influence choice of treatment during attacks. Ergotamine and sumatriptan must not be used prophlactically.


    CERVICOGENIC HEADACHE
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    Cervicogenic headache is a unilateral headache without change of side; however, the disease is often reproduced on the other side. Frequently, there is a non-radiating pain in the ipsilateral shoulder or arm. Usually, mobility of the neck is decreased. The precise classification of such patients has been discussed, and the term cervicogenic headache has only recently been widely accepted. The pain can be provoked by mechanical pressure against the upper part of the neck or back of the head or by particular movements of the neck.

    Peripheral nerve block (e.g. the major occipital nerve) may also alleviate the pain temporarily in regions (frontal, anterior temporal) outside the area of local anesthesia. Such result of a nerve block is diagnostic. Nerve blocks in this area may be made by general practitioners who are familiar with the technique.

    Treatment
    Physiotherapy and physical exercise may be of value to some patients.

    Medical Treatment

    NSAIDs have a justified but limited use in this type of headache. Repeated local corticosteroid injections in the occipital region have been tried with variable results.

    Surgical Treatment

    Thermocoagulation of planum occipitale ad modum Blume is the treatment of choice, but the result is variable. Such treatment is only carried out at special centers.


    CLUSTER
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    Cluster headache (Hortonís headache) is a rare condition which is seen mainly in males (80-85%). The pain in the individual attack is very intense and strictly unilateral with localization orbitally, supra- or retroorbitally, and/or temporal region. The attacks have a duration of 15 to 180 minutes. They usually occur 1 to 3 times per day (from once every 48 hours to 6 to 8 times per 24 hours), and are connected to one or more of the following unilateral signs: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, photophobia, perspiration of face and forehead (often subclinical), miosis, and low grade ptosis. A typical feature is that attacks in the cluster phase are commonly precipitated by alcohol.

    The attacks most frequently occur in cluster with a duration of a few weeks to 6 months, interrupted by periods of remission normally lasting 6 to 18 months. Approximately 10 percent of the patients have ongoing daily attacks for more than one year.

    Treatment

    Drug Treatment of Attacks

    1. Oxygen inhalation (100% 7liters/min in 15 minutes, open mask)
    2. Sumatriptan, 6 mg subcutaneously (not approved indication)
    3. Ergotamine suppositories (at prolonged attacks}
    4. Intramuscular use of ergotamine has shown encouraging results but such drugs are expensive, have very short shelf-life, and are no longer approved in Norway or Sweden. They are accessible in Norway (not in Sweden) on special license for compassionate use, and should only be used by specialists experienced in handling such drugs.
    5. Dihydroergotamine by nasal spray or injection

    Prophylaxis

    1. . Erogtamine, 3 to 4mg per day. May safely be given daily in the cluster period at this indication: where the cluster period is followed by a long-lasting remission in which prophylaxis is not necessary. A disadvantage is that during attacks the drug must not be combined with sumatriptan.
    2. Methysergide, 3 to 6 mg per day.
    3. Lithium, especially in chronic conditions but also in the periodic king (indication not approved in Norway). Individual dosing based on control of the concentration in serum (0.3 to 0.8 millimol per liter) will often be an effective level).
    4. Prednisolone. There is sparse documentation, but clinical practice indicates that it is an effective treatment. Prednisolone may be given initially in high doses (80 to 100mg per day). Reduction should take place within 2 to 4 weeks. in a short cycle, this may be a sufficient treatment. Since most cycles last for more than 3 weeks, another prophylactic drug must be introduced when prednisolone is being decreased. Breakthrough attacks may turn up, even at a dose of 30 to 40mg per day.
    5. Verapamil, 240 to 320mg per day (indication not approved in Norway)

    6. Pizotifen, 2 to 3mg per day.

    Combination of two different prophylactic preparations may be of benefit, e.g. prednisolone plus lithium or lithium plus verapamil. Often the patient will benefit from a combination of a prophylactic and symptomatic treatment.

    More information available on these topics in
    Treatment of Headache in Norway and Sweden- part 2
    article
  • DRUG RELATED HEADACHE/ ABSTINENCE HEADACHE

    The diagnosis is established with basis in carefully recorded drug history highlighting the relation in time between the intake of the drug and the headache. Some drugs can cause headache as a part of the pharmacological effect, such as the vasodilating drugs (nitrates, ACE inhibitors, calcium entry blockers of the dihydropuridine group, etc.). Indomethacin may sometimes cause headache. Other drugs cause withdrawal headache after cessation of chronic use.

    Persons with high intake of caffeine (coffee, cola, caffeine-containing analgesics) may experience headache 12 to 16 hours after the last intake. A high consumption of ergotamine often results in this kind of headache. It is seen quite often among patients using ergotamine, and can represent a considerable therapeutic problem. characteristically, the patient is involved in a self-propagating cycle of headache and drug use. In these cases, the frequency of the migraine attacks, if no drug has been used, would have been clearly reduced. Over consumption of ergotamine can lead to an increased frequency of attacks, up to daily headaches. Recently, reports have appeared on chronic use of sumatriptan, results in major headache upon withdrawal.

    Treatment

    In drug withdrawal headache, one of two strategies may be followed, either complete withdrawal from the drug or chronic supply. Caffeine is often difficult to stop using, because drinking coffee or tea is part of daily social events. Patients with caffeine-dependence should primarily use everyday commodities like coffee or tea, and not prescribed drugs, to keep away the symptoms of abstinence. A slow, gradual reduction of intake may proceed relatively well.

    As regarding ergotamine, the dangers of over-consumption may be considerable. Detoxification will often require hospitalization. The patient may be exhausted from intense and protracted abstinence headache accompanied by nausea, vomiting, restlessness, and insomnia. Compete withdrawal of ergotamine must be sought and will, in many cases, be the only justifiable solution. After detoxification, it is important to find a useful alternative to ergotamine or to make a plan for a limited and controlled use of the drug.


    Dr. Lichten's Ten Breakthrough Lectures including one on Migraine and Headache are available on CD-ROM in Audio-Visual Format. $59.99 plust $10 shipping and handling.

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