SCOTTSDALE, ARIZ. – Consider a range of explanations when a chronic daily headache patient does not improve with standard therapy, Dr. Joel R. Saper suggested at a symposium sponsored by the American Headache Society.
Some top reasons include medication-overuse headache (formerly known as rebound headache), a wrong diagnosis, and psychobiologic or behavioral barriers to treatment, when a person with chronic daily headache fails to improve. Improperly selected or improperly dosed medication are other possible culprits, said Dr. Saper, founder and director of the Michigan Head Pain & Neurological Institute at the University of Michigan, Ann Arbor.
“My best two pieces of advice are to consider that individual as the first patient you've ever seen with chronic daily headache,” Dr. Saper said, “and it's not daily chronic headache until you've ruled out everything else.” The differential diagnosis includes the other primary headache disorders and organic causes of intractable headache such as sphenoid sinusitis, an Arnold-Chiari malformation, and pseudotumor cerebri.
“The more you treat patients with chronic daily headache, the more you learn you did not get it right the first time,” Dr. Saper said.
Patients who take almost any headache medications 2 or 3 days a week for months are at higher risk for medication-overuse headache (Curr. Pain Headache Rep. 2005;9:430–5). This progressive disorder is characterized by predictable and escalating headache frequency and medication use in patients with pre-existing headache.
“If you start a drug and are not there to deal with its consequences, you put all of us at risk,” Dr. Saper said. “You better be willing to monitor them” and change therapy when warranted.
Headache is a symptom of more than 300 illnesses, making diagnosis of a primary disorder difficult. Causes of headache include cerebral venous occlusion, Lyme disease, infiltrative disease, exposure to toxins, AIDS, and opportunistic meningitis.
Psychiatric, behavioral, and drug misuse barriers are more pervasive than perhaps appreciated, Dr. Saper said. Remember the basics, such as a thorough physical examination, comprehensive history, and getting collateral information from relatives, he suggested.
“Are we dealing in some cases with challenging headaches or a challenging individual with headaches? It is important to ask when someone is not getting better,” Dr. Saper said.
Drug abuse and medication noncompliance are also possible when a patient is not improving, he said.
Interventional procedures are sometimes necessary to treat intractable headaches. A neural blockade such as an epidural or C2-C3 might help, or consider neural stimulation, Dr. Saper said.
Sometimes, hospitalization is required to reach a correct diagnosis. “An outpatient visit is a snapshot, a moment that you spend with that patient,” Dr. Saper said. “When trained staff is with a patient 24 hours a day, you begin to learn something about that case you would not learn in an outpatient setting.” For example, how does a patient interact with their family? Does the patient sneak down to the hospital cafeteria and eat something they are not supposed to?