Cervicogenic headache.

The relationship of the neck to headache has been recognized by physicians for over a century. However, whether the neck is the cause of a separate diagnostic entity, cervicogenic headache or simply a part of other headache complexes is the source of controversy. In recent years, there has been an increasing awareness of neck symptoms associated with headache. Various criteria for the diagnosis of cervicogenic headache have been put forward, but a clear consensus is lacking. Unfortunately, this has resulted in reports of varying prevalence, varying treatment recommendations and literature reports that require scrutiny for diagnostic criteria used in selecting patients to be treated. Review of the literature shows many older uncontrolled studies and later literature reports describe only small numbers of patients. Cervicogenic headache or headache related to the neck afflicts many persons and research with adequate patient inclusion is needed. This paper describes cervicogenic headache and treatment options.

Headache pain.

The headache problem with its debilitation and pain has been noted throughout medical history. It is one of the most common outpatient complaints and affects more than 45 million Americans. The lost days to work and family and the immeasurable suffering of patients can be lessened with the understanding and knowledge of a caring physician. Osteopathic physicians with expertise in holistic and musculoskeletal concepts are particularly well prepared to help. The establishment of an accurate diagnosis through a careful history and physical examination is essential before the physician can develop an effective treatment plan. Treatment can be abortive, prophylactic, or symptomatic, or a combination. Abortive treatment is geared to reverse the headache once begun; prophylactic treatment usually involves the use of daily medications to prevent, decrease frequency, or lessen severity of attacks; and symptomatic treatment is for relief of pain or accompanying symptoms. Most headaches experienced are of the tension type, whereas most debilitating headaches are of the migraine type. Cluster headache, though experienced by a small percentage of sufferers, is especially severe, and is useful in differential diagnosis.

Acetaminophen, aspirin, and caffeine versus sumatriptan succinate in the early treatment of migraine: results from the ASSET trial.

OBJECTIVE: To address the need for a rigorous, direct comparison of prescription and over-the-counter (OTC) migraine drugs and to expand the database on early treatment of migraine. BACKGROUND: Most people who experience migraine use OTC medications to treat their symptoms, but no head-to-head clinical trials comparing these agents with prescription migraine therapies have been published. In addition, even though most migraineurs treat early in the attack, few studies have been conducted to reflect this treatment pattern. METHODS: We compared a combination of nonprescription migraine medication (acetaminophen 500 mg, aspirin 500 mg, and caffeine 130 mg) with a prescription migraine product (50 mg sumatriptan) in a randomized, controlled clinical trial in which subjects treated at the first sign of a migraine attack. Subjects who reported vomiting during more than 20% of migraine episodes or who required bedrest during more than 50% of migraine episodes were excluded from the study. Of the 188 subjects randomized, 171 took study medication and were included in the analysis. CONCLUSION: The combination of acetaminophen, aspirin, and caffeine was significantly more effective (P > .05) than sumatriptan in the early treatment of migraine, as shown by superiority in summed pain intensity difference, pain relief, pain intensity difference, response, sustained response, relief of associated symptoms, use of rescue medication, disability relief, and global assessments of effectiveness. An additional, larger clinical trial is needed to confirm these results.

Headache in medical education: medical schools, neurology and family practice residencies.

OBJECTIVE: To explore the extent of headache education received by medical students and residents. BACKGROUND: Headache is a common, often severe, and sometimes disabling problem. However, 49% of sufferers do not seek professional treatment-of those who do, only 28% are very satisfied. One possible reason is limited education of physicians about headache. METHODS: Surveys were sent to all allopathic and osteopathic medical schools, 200 family medicine residencies, and all 126 neurology residencies. Information requested included the amount and perceived adequacy of headache education and any plans to increase headache education. RESULTS: Response rates were 35% to 40%. Medical school lecture hours ranged from 0 (4%) to >5 (24%) with 92% having no plans for an increase in headache education. Family Medicine residency lecture hours ranged from 1--3 (30%) to >5 (34%) and case presentations from 1--5 (23%) to >5 (41%), with 88% of program directors having no plans for increase. Neurology residency lecture hours ranged from 1--3 (11%) to >5 (64%) and case presentations from 1--5 (23%) to>0 (57%), with 80% having no plans for increase. CONCLUSION: Undergraduate medical education in headache is limited. Despite medical schools perceiving their training as adequate, both neurology and family practice residency program directors believe entering residents are inadequately prepared in headache upon entering the program.

Managing intractable migraine with naratriptan.

BACKGROUND: Intractable migraine presents a significant treatment challenge to both patient and physician. Most attacks are treatable or self-limiting, but occasionally they may continue for extended periods regardless of treatment. OBJECTIVE: To determine the efficacy of naratriptan 2.5 mg twice daily for the treatment of intractable migraine. METHODS: We reviewed 24 patients treated with naratriptan twice daily for an intractable migraine attack. Patients were permitted to take prophylactic medication if such treatment had been effective in the past. RESULTS: Nineteen patients (79%) improved. Twelve patients showed excellent response with cessation of pain and associated symptoms, 7 patients partially responded with lessening of pain and cessation of associated symptoms, and 5 patients were nonresponsive. CONCLUSION: Short-term daily administration of naratriptan may be effective in terminating status migrainosus.

Migraine medication attributes important for patient compliance: concerns about side effects may delay treatment.

OBJECTIVES: To determine the level of concern among migraineurs about migraine prescription medication tolerability and adverse effects and the impact of these concerns on their self-management of migraine. METHODS: Self-completion questionnaires were mailed from the National Family Opinion household panel to a prequalified sample of 4000 adults (aged 18 years or older) who reported severe headache and migraine. Those who met the International Headache Society symptom criteria for migraine and reported use of prescription medication to treat their migraines were included in the descriptive analysis. RESULTS: A total of 2444 (61%) sufferers of severe headache/migraine returned a completed survey, and 56% of these (n = 1160) met the target criteria for the study. Of those meeting the criteria, pain relief and speed of onset were important product attributes for 75% to 77% of sufferers, and the absence of adverse effects was important to over 40%. Two-thirds of sufferers specifically had delayed or avoided taking a current prescription medication because of concerns about adverse effects. These concerns led to a delay in taking medication in 37% of treated migraine episodes and to medication avoidance in 44% of untreated attacks during the previous 6 months, resulting in more intensive and longer duration of pain, the need to rest and cancel social activities, and suboptimal performance. Almost 8 of 10 (79%) sufferers showed an interest in trying a novel product with similar efficacy but fewer adverse effects than other prescription migraine medications. CONCLUSIONS: Adverse effects are an important factor in migraine management, and concern about adverse effects significantly affected patient compliance.

Divalproex sodium in the treatment of migraine and cluster headaches.

The discovery of a new class of effective migraine-abortive medications, the triptans, has sparked a new interest in the study of vascular headache. Over the past few years, the Food and Drug Administration (FDA) has approved six new abortive pharmacologic therapies, with several others in various stages of clinical trials. Unfortunately, concurrent pharmacologic changes in headache prophylaxis have not kept pace with their abortive counterparts. However, divalproex sodium (Depakote), which is approved by the FDA as a migraine prophylactic agent, is the first in the anticonvulsant class of medication for migraine headache and has expanded the options in headache treatment. The objective of this retrospective multicenter study of 284 patients with migraine or cluster headaches was to examine the clinical efficacy and safety of divalproex sodium as prophylaxis in monotherapy and in polytherapy. Sixty-one percent of migraineurs and 73% of cluster patients noted a decrease in pain with divalproex sodium and continued that therapy for more than 3 months. Reported negative side effects included weight gain, nausea, somnolence, tremor, alopecia, dysequilibrium, and rash. However, only 14% of subjects discontinued therapy due to these side effects. Overall, divalproex sodium was found to be an effective and generally well-tolerated prophylactic treatment option as monotherapy or in polytherapy for migraine and cluster headache.

Migraine: diagnosis, management, and new treatment options.

OBJECTIVE: The safety and tolerability of medications used to treat acute migraine attacks are summarized, the classification of headaches and the causes of and diagnostic criteria for migraine are reviewed, and the clinical tolerability profiles and therapeutic benefits of second-generation triptans are presented. BACKGROUND: Migraine is a paroxysmal disorder characterized by attacks of headache, nausea, vomiting, photophobia, and phonophobia. Drugs used to prevent migraine and those that effectively treat acute migraine attacks are readily available. METHODS: Mild or moderate migraines are often treated with aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs, antiemetic drugs, or isometheptene. Triptans (5-HT1 receptor agonists) are used to treat moderate or severe migraine and when nonspecific medications have been ineffective. Because sumatriptan, the first triptan used, is effective but can induce adverse events, second-generation triptans (zolmitriptan, naratriptan, rizatriptan, and almotriptan) were developed to increase the benefit-to-risk ratio in migraine management. RESULTS: Important pharmacologic, pharmacokinetic, and clinical differences exist among those drugs, but the tolerability profile of the newer triptans is very good, and they provide rapid relief from headache and sustained duration of effect. CONCLUSION: Primary care physicians must manage migraine patients with treatments that demonstrate a balance between efficacy and tolerability.