HENDERSON, NEV. – The concomitant and comorbid conditions associated with migraine and chronic daily headache offer both therapeutic challenges and opportunities, Dr. Elizabeth W. Loder said at a symposium sponsored by the American Headache Society.
These problems may not be severe enough to warrant inpatient therapy on their own, but when combined with headache, they result in such a burden of symptoms that hospitalization might make sense, said Dr. Loder, director of the headache management program at Spaulding Rehabilitation Hospital in Boston.
“Sometimes it's expeditious to do other things in the hospital, even though you're not necessarily admitting them for that reason,” she said. “For example, I think it's very useful to have polysomnography for oxygen levels done on all your headache patients admitted to the hospital. You'll find a lot of sleep apnea that way. Treating that in itself is important, but it may improve the headache situation as well.”
Some of the most frequent findings are other pain disorders. “It's very uncommon to have a headache patient in the hospital who doesn't also have some other pain disorder,” Dr. Loder said.
Among the most common pain disorders in this population are fibromyalgia, back and neck pain, musculoskeletal pain, irritable bowel syndrome, and noncardiac chest pain. Physicians should be wary of prescribing opioids or narcotics to headache patients who have these symptoms, because “there is a risk that the patient will start to use them for the other pain problems, and then will have difficulty controlling the use. There's also new evidence that long-term use of opioids actually may aggravate pain and make the patient less responsive to other treatment,” she said.
Raynaud's disease is also more common in migraine patients, as is a combination of Raynaud's and noncardiac chest pain. The cluster of symptoms may stem from underlying microvascular disease.
“The presence of Raynaud's has some treatment implications for migraineurs,” Dr. Loder said. Avoid the use of β-blockers and ergots, as they exacerbate Raynaud's. Calcium channel blockers, however, may improve the Raynaud's symptoms while acting as a migraine preventive.
Microvascular disease may also be implicated in the connection of migraine with coronary heart disease, Dr. Loder said. Numerous studies have documented the association, including the National Health and Nutrition Examination Survey, which found a doubling of the risk of heart attack in migraineurs. Subsequent studies have not upheld that conclusion.
“The evidence is conflicting,” Dr. Loder said. “None of the studies were designed specifically to look at the association of migraine with heart disease, so you're relying on previously diagnosed migraine” as the variable. Since most diagnosed migraine usually is severe, often with aura, the study populations are probably skewed. “What we are probably seeing is the incidence of cardiovascular disease in this particular population. But the definite statement on this awaits a prospective study.”
She said, however, that primary heart disease, including uncontrolled hypertension, severely limits migraine treatment options because triptans and dihydroergotamine are contraindicated in these patients. “Controlled hypertension is not a contraindication for triptan use, but patients might have other risk factors, so you might feel more comfortable assessing them in the hospital,” Dr. Loder said.