Treatment of Headache in Norway and Sweden -Part II

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


The diagnosis is based upon a history of sudden headache precipitated by physical exertion or sexual activity. The intensity of the pain is moderate or strong, and usually the pain is bilateral and pressing The first episode may resemble subarachnoid bleeding, which must be excluded.


Indomethacin may be used 2 hours before an activity which is expected to trigger a headache. Only limited therapeutic effect can be expected. Heavy use of prophylactic indomethacin on this indication may be undesirable due to the side effects, in which case beta blockers may be tried. They may, however, be unsuitable if they are found to adversely influence the male potency.


Trigeminal neuralgia is a characteristic pain syndrome, with pains which are short (usually a few seconds, maximum 2 minutes),intense and frequent, one-sided and stabbing. The pains are localized in the area of the trigeminal nerve, especially in the II and II branch. Attacks may be provoked from trigger points within the painful area. There is no loss of neurological function in typical trigeminal neuralgia. The patients should be referred to a specialist for diagnosis and treatment.

Atypical trigeminal neuralgia may be a symptom of a tumor or of multiple sclerosis. Such an etiology should especially be suspected when trigeminal neuralgia occurs in young individuals.

Preventive Drug Treatment
The side effects for all the following drugs may be difficult to handle:

  1. Carbamazepine is the least problematic of these drugs. The dose is increased gradually. The effective serum level will occasionally be as high as, or higher, than recommended level for treatment of epilepsy. in high-dose treatment, slow release formulations may be needed to minimize fluctuations in concentration of serum.
  2. Baclofen
  3. Phenytoin
  4. Combinations of the above mentioned drugs

The drugs may be withdrawn gradually over a period of months, if the pain has disappeared.

Surgical Treatment
If drug therapy is effective or poorly tolerated, invasive procedures may be tried.

  1. Surgical treatment with injections of glycerol or--rarely--alcohol destroy the nonciceptive pathways
  2. Microvascular decompression of the trigeminal root (primarily for patients under 65 years of age)


This is a one-sided pain, often resembling trigeminal neuralgia. It is always preceded by herpes zoster eruption.

Drug Treatment
Treatment in the local area with capsaicin (from chili pepper) e.g. using Allcocks Plaster, will eventually increase the local threshold of pain and thereby reduce the discomfort. The patient will have to accept the initial intense, burning sensation, which is caused by capsaicin-induced depletion of local inflammatory neropeptides. Tricyclic antidepressants and carbamezepine have some effect, but the results of clinical studies are ambiguous.

Non-Drug Treatment
Transcutaneous nerve stimulation may have some effect. Cutting the pathways of the nerves gives unpredictable results and is of doubtful value.


A patient may have a headache syndrome fitting into more than one diagnostic category. This can make diagnosis and treatment especially difficult. Tension headache coexists with migraine and rug-provoked headache. Patients with poor response to treatment, or patients who appear to have more than one type of primary headache, may need to be referred to a specialist.


This is not a formal diagnostic entity but refers to a chronic, almost daily, diffuse headache with unsatisfactory response to routine interventions. Elements of abuse of drugs are commonly present. the typical patient is a regular user of special drugs, e.g. ergotamine or analgesics.

Such patients represent a diagnostic and therapeutic problem If sufficient time has passed since the patient was thoroughly evaluated, a complete examination should be made. Atypical migraine, tension headache, cervicogenic headache, hemicrania continua, more unusual neuralgias, and drug-related headache are among the diagnostic options. More than one type of headache may be present.

Non drug treatment is desirable, but usually not feasible.

Management Issues
The general practitioner should manage these patients. Depending upon the particularities in the history and clinical picture of the patient, and the availability of these resources, it may be important to seek assistance from a neurologist (possibly by hospitalization in a neurological department) or a trained social worker. Anesthesiologists psychologists, or psychiatrists may provide additional valuable services. However, as a general rule the number of therapists should be kept to a minimum.

The patient and physician should make a formal agreement upon the treatment, including scheduled consultations so that the patient does not need to present new or more serious symptoms to obtain a new appointment. The patient must agree to make a personal contribution reducing or stopping the daily use of symptomatic drugs. The patient must not be told that he or she will become totally free from pain.

These patients tend to become heavily dependent on their physician. The general practitioner is advised to consult psychiatrists or psychologists upon how to handle troublesome behavior from the patient if a difficult situation should arise.

History regarding psychosocial circumstances (work, marriage, time and circumstances for worsening of the illness, influence of the disease on daily life, etc.) will often provide important information about secondary pains, personality disorders, and possible strategy for therapeutic intervention.

With some patients, the reason for the headache is to be found in primary psychological problems, such as generalized anxiety or depression. In these cases, use of simple diagnostic questionnaires suited for general practice (for example, Speilberg state and trait anxiety and Symptom check list SCL-90) may be indicated. With others, important social factors may appear (e.g. alcohol problems, sleep disturbances, life crisis). Destructive behavioral chains of action and defense mechanisms should be identified, and positive therapeutic alliances should be sought.

Withdrawal of Drugs
Revision of diagnosis with patients who are regular users of symptomatic drugs may only be feasible when all drugs are withdrawn and their effects and side-effects are gone. this may in itself be therapeutic in reducing the frequency of attacks and chronic pain. withdrawal of regularly used symptomatic drugs is likely to increase the effect of prophylactic agents.

Withdrawal of symptomatic drugs often requires hospitalization and management with of the types of drugs. Low doses of phenothiazines or thioxantenes with low specificity, such as levomepromazine or clorportixene, may be useful during withdrawal. Oxazepam can be useful in the acute phase, to be withdrawn as soon as possible (after 2 weeks at a maximum).

Supportive and Non-Medical Treatment
In general, alternative treatment modules lack documentation:
  1. Removal of the stigmata of possible psychosocial or psychiatric conditions.
  2. Training in mastering pain-associated problems. This can be done by seminars or work in groups focused on defining and mastering the problems.
  3. General physical training may have a positive effect on chronic conditions. Passive treatment such as heat and massage is counterproductive and should probably be avoided. Training program for the neck and muscles of the back (possibly instructed by a physiotherapist).
  4. Biofeedback and relaxation techniques. instruction may be given by psychologists, physiotherapists, etc.
  5. Acupuncture has been reported to have beneficial but transient effect on some patients, especially those with an element of tension headache.
  6. Transcutaneous nerve stimulation may have effect on some patients with moderate pain. if taken into consideration, it should be made an early choice among modalities of treatment.
  7. Focus should be put on the patientís resources for achievement and realization of his or her own goals and ambitions, apart form the role as a patient with chronic pain.

Drug Treatment

If evidence is found of depressive illness, antidepressants are indicated. effect will be seen within 4 to 6 weeks. Successful treatment should tentatively be withdrawn after a maximum of 6 months. The effect may continue after withdrawal.

Analgesics should be avoided as a regular therapy. When analgesics have to be used, OTC drugs are first choice. combinations of paracetamol and codeine should be avoided if possible and should never be given daily or in higher doses than standard recommendations. Pure opioid drugs should be totally avoided. do not use ergotamine or sumatriptan in chronic treatment resistant headache.

General rule in all treatment of headache:
Withdraw all drugs which do not give a convincing effect!



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


The information in this newsletter does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice.

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