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Preventing Headaches and Reducing their Impact
Whether speaking of migraines, tension-type headaches or other
recurring head pains, it's safe to say that the best headache
attack is the one you don't have. Even if you have found an
effective treatment for resolving a headache that is already
underway, there is nothing about today's as-needed treatment
that will keep next week's attack from occurring.
Headache treatments come in two forms'abortive and preventive.
The abortive form is familiar to most people. It means something
you do to get rid of a headache that has already started.
Usually it consists of an over-the-counter or prescription
medication, but in some cases, a non-drug approach works. By
contrast, a preventive treatment is something you do every day
with the goal of keeping some future attacks from even starting.
These, too, can involve drug and non-drug strategies.
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Billions of dollars are spent each year on abortive remedies.
For the most part, they are dollars well spent. And for people
who have infrequent headaches that are rapidly and reliably
resolved by an abortive treatment, a preventive treatment might
be needless.
But if attacks are frequent, hard to resolve, interfere with
usual activities'or side-effects from the abortive treatment
interfere with usual activities'then a preventive treatment
should be considered. Employing a preventive remedy does not
preclude also using an abortive measure: each can be part of an
integrated plan.
Before discussing specific treatments for specific headache
types, let's consider the impacts of recurring headaches. The
more obvious impact is the sheer unpleasantness and suffering
involved in an attack. However, another impact'though less
obvious'is in its own way just as important. And that is the
associated disability or loss of function that comes with an
attack.
If a headache attack is severe, then whatever else was planned
for that day goes out the window'it's just not going to happen.
If an attack is moderate in intensity, then usual activities
might be possible, but occur more slowly, less efficiently, or
require more effort to produce. This, too, represents
headache-associated disability.
An increasing trend in the field of headache management is for
practitioners to address their patients' loss of function as
well as their pain and suffering. Drs. Richard Lipton and Walter
Stewart designed a questionnaire to estimate headache-associated
disability, called the MID
AS (Migraine Disability Assessment) scale which can also be
used for non-migraine headaches.
Measuring and then re-measuring MIDAS is one method for judging
if a preventive treatment is effective. But to accurately detect
the effectiveness (or lack of effectiveness) of a preventive
headache treatment there should also be some sort of day-by-day
recording system.
It might be as minimal as a check-mark on the calendar for each
day with any symptoms. Another system is to summarize at the end
of each day that one day's headache-impact by selecting one of
the following four descriptions'none, mild, moderate or severe.
Numerically inclined people can assign scores of 0-3 to these
choices and then run averages and other statistics for each
calendar month.
For people with recurring or continuous pain there is a tendency
to live moment-to-moment without a view of the longer-term
pattern. A recording system helps capture the big picture. It
would be a mistake to judge the effectiveness of any treatment
by what happened with symptoms in just the last few days.
Generally, a month or longer is required to judge fairly and
accurately.
So now that we have decided to consider a preventive treatment
for our headaches and have put in place a system for measuring
the treatment's outcome, what specific remedies are available?
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It depends, of course, on the kind of headaches being treated.
Let's discuss two of the most common types'migraine and
tension-type headaches.
For prevention of migraine, the best-studied and most effective
drug treatments are available by prescription only in the U.S.
These include propranolol (brand name Inderal), amitriptyline
(Elavil), divalproex (Depakote) and topirimate (Topamax).
Riboflavin (vitamin B2) at 400 milligrams per day was shown in
one controlled study to have migraine-preventing actions. (At
this dose'far higher than what is needed to treat vitamin
deficiency'riboflavin should be considered a drug rather than a
vitamin.) The herb feverfew has also shown benefit in controlled
trials, but it is important to remember that this, too, is a
drug and can have side-effects. As is the case with other drugs,
it should not be used during pregnancy.
Non-drug strategies of proven effectiveness in migraine
prevention include therapist-supervised programs of stress
management, relaxation, biofeedback and cognitive-behavioral
therapy. Studies of acupuncture have shown mixed results.
Avoiding individually determined triggers for
attacks carries no risk and can reduce the attack rate.
For tension-type headaches amitripyline is the best-studied drug
for prevention of attacks. Note that this drug is also a leading
treatment for migraine, so people unlucky enough to have both
kinds of headaches can obtain benefit from just one drug.
Unfortunately, even at the low doses used for headache
prevention, amitriptyline can cause daytime drowsiness (even
when administered at bedtime) or annoying oral dryness. Because
of this, substitution of a better-tolerated, though less-studied
drug in amitriptyline's family (tricyclic antidepressants) is
sometimes required. Tizanidine (Zanaflex) has also shown benefit
in controlled trials.
Non-drug strategies for tension-type headache have also been
proved effective. These include similar behavioral interventions
to those mentioned for migraine'stress management, relaxation,
biofeedback and cognitive-behavioral therapy.
It would be wonderful if preventive treatments stopped headaches
entirely. If they did, a measurement system would not be
necessary. But a more realistic goal for preventive treatment is
to reduce overall headache symptoms by at least half, or to an
extent that an individual patient finds meaningful. When this
occurs, a preventive approach can be a valuable addition to a
program of headache management.
(C) 2005 by Gary Cordingley
About the author:
Gary Cordingley, MD, PhD, is a clinical neurologist, teacher and
researcher. For more health-related articles, see his website
at: http://www.cordingleyne
urology.com
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