Page 231 Guide to Pain Management in Low-Resource Settings

Headache 219

via a nonrebreathing facial mask for 15 to 20 minutes, • Although headache is one of the most common
can be eff ective in up to 60–70% of attacks, but pain reasons for patients to consult their doctor, and
frequently recurs. Th e aim of the preventive therapy despite its enormous impact, it is still under-rec-
is to produce a rapid remission of the disorder and to ognized and undertreated.
maintain that remission with minimal side eff ects un- • Inaccurate diagnosis is probably the most com-
til the cluster bout is over according to its natural his- mon reason for treatment failure. A systematic
tory, or for a longer period in patients with chronic CH. approach to classifi cation and diagnosis is there-
Steroids are very eff ective in interrupting a bout. Sub- fore essential both for clinical management and
occipital injections of long-acting steroids should be research.
preferred to oral treatment, to lessen the risk of “corti- • Improvements in treatment have been less dra-
co-dependence.” Verapamil is the next preventive drug matic than remarkable revelations from basic and
of choice, but lithium, topiramate, methysergide, or cor- clinical research on headaches.
ticosteroids can also be used. Functional imaging data • Finally, while the eff ective newer treatments are
suggest the hypothalamus to be the origin for CH. quite expensive, e.g., newer antiepileptics and
triptans, older drugs are still available everywhere
Can headache medication with a good benefi t-cost ratio: NSAIDs (for acute
cause headache? treatment) and beta-blockers and/or ribofl avin
(for prophylactic treatment) in migraine, and oxy-
Overuse of acute medication is the most frequent factor gen (for acute treatment) and verapamil (for pro-
associated with the transformation of episodic migraine phylactic treatment) in cluster headache.
into chronic daily headache. Th e latter is called “medica-
tion overuse headache” (MOH) in the 2nd edition of the References
International Classifi cation of Headache Disorders (ICHD-
II, 2004). It is classifi ed as a secondary headache disorder, [1] Cohen AS, Matharu MS, Goadsby PJ. Trigeminal autonomic cephalal-
which may evolve from any type of primary headache, but gias: current and future treatments. Headache 2008;47:969–80.
[2] Colas R, Munoz P, Temprano R, Gomez C, Pascual J. Chronic daily
mainly from episodic migraine, and in a lower proportion headache with analgesic overuse: epidemiology and impact on quality
of life. Neurology 2004;62:1338–42.
in tension-type headache. MOH is a disabling health prob- [3] Ferrari MD, Roon KI, Lipton RB, Goadsby PJ. Oral triptans (serotonin
lem, which may aff ect 1–2% of the general population. 5-HT 1B/1D agonists) in acute migraine treatment: a meta-analysis of 53
trials. Lancet 2001;358:1668–75.
Th e most effi cient treatment for MOH is abrupt [4] Fumal A, Schoenen J. Current migraine management—patient accept-
ability and future approaches. Neuropsychiatr Dis Treat 2008;4:1043–
drug withdrawal and immediate prescription of a pre- 57.
ventive drug (an antimigraine agent if the primary head- [5] Fumal A, Schoenen J. Tension-type headache. Where are we? Where do
we go? Lancet Neurol 2008;7:70–83.
ache is a migraine, or tricyclics in case of TTH), but [6] Goadsby P. Recent advances in the diagnosis and management of mi-
there are no studies comparing diff erent strategies. Th ere graine. BMJ 2006;332:25–9.
[7] International Headache Society. Th e International Classifi cation of
are thus no clear, worldwide accepted guidelines regard- Headache Disorders. 2nd edition (ICHD-II). Cephalalgia 2004;24(Suppl
1):1–160.
ing modality of withdrawal or treatment of withdrawal [8] Mateen FJ, Dua T, Steiner T, Saxena S. Headache disorders in de-
symptoms. Oral prednisone, acamprosate, tizanidine, veloping countries: research over the past decade. Cephalalgia
2008;28:1107–14.
clomipramine, and intravenous dihydroergotamine were
found useful for withdrawal headaches, but results are
confl icting, for example, prednisone shows both posi- Websites
tive and negative results. It seems clear that after the fi rst
International Headache Society (IHS): http://www.i-h-s.org/
2-week physical withdrawal period, comprehensive long-
Following the listing by the World Health Organization of the world’s 100
term management of the biopsychosocial problem of poorest countries (British Medical Journal 2002;324:380), IHS off ers Associ-
ate Membership free to individuals living in those countries who qualify for
these patients is necessary to minimize relapse. Ordinary Membership. Associate Membership carries the responsibilities to
the Society of Ordinary Membership (other than payment of the member-
ship fee), but off ers limited benefi ts. Th ese include on-line access to the
Pearls of wisdom Society’s journal Cephalalgia.
American Headache Society (AHS): www.americanheadachesociety.org/
• Recurrent headache disorders impose a substan- World Headache Alliance (WHA): http://www.w-h-a.org/
tial burden on individual headache suff erers, on
their families, and on society.