Management of chronic headaches

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Chronic headache, or chronic daily headache (CDH), is classified as experiencing fifteen or more days with a headache per month. [1] It is estimated that chronic headaches affect "4% to 5% of the general population". [2] Chronic headaches consist of different sub-groups, primarily categorized as chronic tension-type headaches and chronic migraine headaches. [2] The treatments for chronic headache are vast and varied. Medicinal and non-medicinal methods exist to help patients cope with chronic headache, because chronic headaches cannot be cured. [3] Whether pharmacological or not, treatment plans are often created on an individual basis. [4] Multiple sources recommend multimodal treatment, which is a combination of medicinal and non-medicinal remedies. [5] Some treatments are controversial and are still being tested for effectiveness. Suggested treatments for chronic headaches include medication, physical therapy, acupuncture, relaxation training, and biofeedback. In addition, dietary alteration and behavioral therapy or psychological therapy are other possible treatments for chronic headaches.

Contents

Medicinal

Analgesic and abortive medications

The most common chronic treatment method is the use of medicine. Many people try to seek pain relief from analgesic medicines (commonly termed pain killers), such as aspirin, acetaminophen, aspirin compounds, ibuprofen, and opioids. [6] The long term use of opioids; however, appears to result in greater harm than benefit. [7] Also, abortive medications can be used to "stop a headache once it has begun"; such drugs include CGRP receptor antagonists (Ubrelvy, Nurtec ODT), ergotamine (Cafergot), triptans (Imitrex), and prednisone (Deltasone). [8] However, medical professionals advise that abuse of analgesics and abortive medications can actually lead to an increase in headaches. [9] The painkiller medicines help headaches temporarily, but as the "quick fix" wears off, headaches become more re-current and grow in intensity. [10] These "rebound headaches" can actually make the body less responsive to preventive medication. [11] The conditions keep worsening if one takes paracetamol, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) for 15 days a month or more. Therefore, those with chronic migraine are left with too many migraine days per month that can be safely controlled with analgesic and abortive medications.

Preventive medications

The most common medicines used to treat chronic (daily) headaches are called prophylactic medicines, which are used to prevent headaches. [12] Such preventive medication is taken on a daily basis, even when a person may not have a headache. [12] Prophylactic medicines are recommended for chronic headache patients because varied experiments prove that the medications "reduce the frequency, severity, and disability associated with daily headaches". [13] A majority of the prophylactic medications work by inhibiting or increasing neurotransmissions in the brain, often preventing the brain from interpreting pain signals. [14]

Preventive medicines include CGRP receptor antagonists, gabapentin (Neurontin), tizanidine (Zanaflex), fluoxetine (Prozac), amitriptyline (Elavil), and topiramate (Topamax). [13] In testing, gabapentin was found to reduce the number of headache days a month by 9.1%. [13] Tizanidine was found to decrease the average frequency of headaches per week, the headache intensity, and the mean headache duration. [15] Through studies, Fluoxetine resulted in better mood ratings and "significant increases in headache-free days". [16] Despite being associated with depression, antidepressants, such as amitriptyline, have been found to effectively treat "near-daily headaches" and numerous chronic pain conditions as well as improving mood and sleep—two possible triggers for people with chronic headaches. [17] One study found that the headache frequency over a 28-day period lowered for chronic headache patients on topiramate. [18] Another medication to prevent headaches is botulinum toxin type A (BoNTA or BOTOX), which is given by injection instead of being taken orally. [19] In a clinical study of botulinum toxin type A, patients participating in the 9-month treatment period with three treatments experienced headache frequency decreases up to 50%. [20] As with all medications, the preventive medications may have side effects. Since different people respond to drugs differently, people with chronic headaches may have to go through a "trial-and-error" period to find the right medications. [21] The previously mentioned medicines can improve headaches, but physicians recommend multiple forms of treatments.[ citation needed ]

Non-medicinal

Physical therapy

In addition to medicines, physical therapy is a treatment to help improve chronic headaches. In physical therapy, a patient works together with a therapist to help identify and change physical habits or conditions that affect chronic headaches. Physical therapy for chronic daily headaches focuses on the upper body, including the upper back, neck, and face. [22] Therapists assess and improve the patient's body posture, which can aggravate headaches. [23] During office sessions, therapists use manual therapy, such as a massage, stretching, or joint movement to release muscle tension. [24] Other methods to relax muscles include heat packs, ice packs, and "electrical stimulation". [24] Therapists also teach people with chronic headaches at-home exercises to strengthen and stretch muscles that may be triggering headaches. [24] In physical therapy, the patient must take an active role to practice exercises and make changes to his or her lifestyle for there to be improvement. [24]

Acupuncture

Another non-medicinal treatment, which does not require at-home exercises, is acupuncture. Acupuncture involves a certified acupuncturist picking particular points on the body to insert acupuncture needles; these points may differ on an individual basis. [25] With chronic headache patients, the acupuncturist may needle "tender points at or near the site of maximal headache pain". [25] A study conducted by the University of North Carolina School of Medicine found that compared to medicinal treatment alone, medicinal treatment plus acupuncture resulted in more improvement for chronic daily headache patients. [26] Another acupuncture study in Germany found that 52.6% of patients reported a decrease in headache frequency [27] In both studies, acupuncture was not the only treatment. Trials show that acupuncture can cause "relevant improvements" for people with chronic headaches. [28]

Relaxation training

Relaxation training is another form of non-pharmacological treatment for chronic headache. Relaxation training helps to reduce internal tension, allowing a person to control headaches triggered by stress. [29] The different relaxation methods are normally taught by a psychologist or a therapist. [30] Relaxation training works as people become in tune with their own body, allowing them to realize when it is necessary to decrease tension before a headache occurs. [30] The point of relaxation training is to teach people "an attitude of consciously setting out to relax but not trying too hard", enabling people to relax in everyday situations. [31] Relaxation training includes two different types of methods: physical and mental.[ citation needed ]

Physical methods

Physical relaxation methods involve actual body movement or action. One physical method for releasing tension involves "purposefully tensing and then relaxing groups of muscles in a definite sequence", which is named accordingly progressive muscle relaxation. [32] Another physical method of relaxation is deep breathing. [33] Deep breathing is done by breathing from the bottom of the lungs up, which is characterized by the rise and fall of the stomach, not the chest. [34] These are the two most common physical methods of relaxation for people with chronic headaches.[ citation needed ]

Mental methods

Also, relaxation therapy can involve mental techniques to decrease body tension. The first is called "focused imagery". [35] Focused imagery involves concentration on relaxed body parts, followed by focus on tense muscles and imagining that the tense areas are being worked on or relaxed. [35] The next mental technique involves focus on the whole body, instead of its individual parts. [35] In "deepening imagery", a person imagines the body's tension as a meter of high to low, and works to reduce tension mentally. [35] An additional mental strategy involves creating and experiencing a location of relaxation in the mind. [36] The last mental strategy involves the chronic headache patient visualizing a place of stress in his or her life and imagining a relaxed response. [36] Meditation in a relaxing environment is also suggested to prevent headaches. [37] Meditation often involves repeating a one syllable sound or staring at a visual object to help focus attention. [37] Relaxation helps the body to unwind, preventing the formation of headaches.[ citation needed ]

Biofeedback

Biofeedback is often used to evaluate the effectiveness of relaxation training, because it feeds back information to the person with chronic headaches about the "body's (biological) current state". [38] One of the most common biofeedback tests is the Electromyograph (EMG), which evaluates the "electrical activity" produced by muscles. [39] Biofeedback also can measure electrical brain activity through a test called the Electroencephalograph (EEG). [39] Another test, called the thermograph, measures skin temperature, because when a person is relaxed they have increased blood flow and a higher temperature. [39] Another method is BVP biofeedback training, which improves chronic headaches by teaching a patient how to regulate and decrease arterial pulse amplitudes by restricting the arteries. [40] When tense, a person's sweat gland activity increases, which is measured by electrodermograph testing of the hands. [41] Biofeedback methods have been proven to work. A study involving fifteen treatment sessions found that biofeedback was "successful in reducing both frequency and severity of headache at discharge and over time". [42] Biofeedback allows people with headaches to identify problems and then seek to reduce them.[ citation needed ]

Changes in diet

Many physicians also recommend changes in diet to treat chronic headaches. Many people with chronic headaches fail to recognize foods or beverages as headache factors, because the consumption may not consistently cause headaches or the headaches may be delayed. [43] Many of the chemicals in certain foods can cause chronic headaches, including caffeine, nitrites, nitrates, tyramine, and alcohols. [44] Some of the foods and beverages that people with chronic headaches are advised to avoid include caffeinated beverages, chocolate, processed meats, cheese and fermented dairy products, fresh yeast-risen baked goods, nuts, and alcohol as well as certain fruits and vegetables. [45] Additionally, people may have differing dietary triggers on an individualized basis, because not all foods affect people the same way. [46] Different medical professionals suggest different ways of testing or changing diets. Some may suggest eliminating a few of the potentially headache-causing foods at a time for a short period of time, while others suggest removing all the threatening foods from a person's diet and slowly adding a couple back at a time. Yet, others may not suggest diet modification at all. [47] Reducing salt (sodium) intake is proposed as an effective measure for headache reduction. Nonetheless, findings from a randomized clinical trial suggest that this effect may be mediated by a reduction in blood pressure, indicating that sodium reduction may decrease headache if it significantly lowers blood pressure [48] . The treatment of chronic headaches through changes in diet is based on personal opinion, and, therefore, controversial.[ citation needed ]

Behavioral therapy and psychological therapy

Also, behavioral therapy and psychological therapy are suggested treatments to reduce chronic headaches. Behavioral therapy and psychological therapy relate closely in their treatment methods, which include a combination of identifying headache stressors, biofeedback, relaxation training, and cognitive-behavioral therapy. [49] Cognitive-behavioral therapy's purpose "is to identify and resolve the sources of recurrent stress". [50] In treatment studies, patients with medication plus cognitive-behavioral therapy groups did better than groups with medication alone or cognitive-behavioral therapy alone. [51] Psychological and behavioral therapies identify stressful situations and teach chronic headache patients to react differently, change their behavior, or adjust attitudes to reduce tension that leads to headaches. [52] Treatments especially focus on "emotional, mental, behavioral, and social factors" as they impact headaches. [53] Patients are advised to simply avoid stressors when plausible or share their burdens with others. [54] In this way, studies have found that patients with multimodal treatment in a group setting fare better than patients who follow multimodal treatment alone. [55] Another behavioral study, which included multimodal treatment, showed that the "frequency of severe headaches was reduced by a clinically significant amount for 75% of the patients". [56] Behavioral and psychological therapies work to identify and eliminate or reduce stressful situations that lead to chronic headaches.[ citation needed ]

Beyond behavioral modification, psychological therapy has a few distinct characteristics of its own. It is important to look at the psychological status of a person with chronic headaches to "identify conditions that might interfere with headaches and treatments", such as depression. [51] Also, psychological therapy suggests training in self-hypnosis. [57] While hypnotized, patients are given suggestions to relax and use visual imagery to control headache mechanisms, which is very similar to relaxation therapy. [57] Psychological therapists also analyze personal issues that may interfere in a chronic headache patient's life, making him or her unable to make changes in lifestyle to improve headaches. [58] Psychologist or psychiatric help for chronic headache patients is controversial, as a patient must be open to possible psychological factors in relation to headaches. [58]

Chiropractic care

Chiropractic care involves in manipulation of the neck and spine to ensure proper alignment. A misalignment can cause headaches along with other problems in the body. The misalignment can compress nerves in the lower neck as well as cause muscle contractions in the neck and headaches can result. [59]

Related Research Articles

<span class="mw-page-title-main">Migraine</span> Disorder resulting in recurrent moderate-severe headaches

Migraine is a genetically influenced complex neurological disorder characterized by episodes of moderate-to-severe headache, most often unilateral and generally associated with nausea and light and sound sensitivity. Other characterizing symptoms may include nausea, vomiting, cognitive dysfunction, allodynia, and dizziness. Exacerbation of headache symptoms during physical activity is another distinguishing feature. Up to one-third of migraine sufferers experience aura: a premonitory period of sensory disturbance widely accepted to be caused by cortical spreading depression at the onset of a migraine attack. Although primarily considered to be a headache disorder, migraine is highly heterogenous in its clinical presentation and is better thought of as a spectrum disease rather than a distinct clinical entity. Disease burden can range from episodic discrete attacks, consisting of as little as several lifetime attacks, to chronic disease.

<span class="mw-page-title-main">Insomnia</span> Inability to fall or stay asleep

Insomnia, also known as sleeplessness, is a sleep disorder where people have trouble sleeping. They may have difficulty falling asleep, or staying asleep for as long as desired. Insomnia is typically followed by daytime sleepiness, low energy, irritability, and a depressed mood. It may result in an increased risk of accidents of all kinds as well as problems focusing and learning. Insomnia can be short term, lasting for days or weeks, or long term, lasting more than a month. The concept of the word insomnia has two possibilities: insomnia disorder (ID) and insomnia symptoms, and many abstracts of randomized controlled trials and systematic reviews often underreport on which of these two possibilities the word insomnia refers to.

<span class="mw-page-title-main">Headache</span> Pain in the head, neck, or face

Headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches.

<span class="mw-page-title-main">Biofeedback</span> Gaining awareness of biological processes

Biofeedback is the technique of gaining greater awareness of many physiological functions of one's own body by using electronic or other instruments, and with a goal of being able to manipulate the body's systems at will. Humans conduct biofeedback naturally all the time, at varied levels of consciousness and intentionality. Biofeedback and the biofeedback loop can also be thought of as self-regulation. Some of the processes that can be controlled include brainwaves, muscle tone, skin conductance, heart rate and pain perception.

<span class="mw-page-title-main">Tension headache</span> Medical condition

Tension headache, stress headache, or tension-type headache (TTH), is the most common type of primary headache. The pain usually radiates from the lower back of the head, the neck, eyes or other muscle groups in the body typically affecting both sides of the head. Tension-type headaches account for nearly 90% of all headaches.

A medication overuse headache (MOH), also known as a rebound headache, usually occurs when painkillers are taken frequently to relieve headaches. These cases are often referred to as painkiller headaches. Rebound headaches frequently occur daily, can be very painful and are a common cause of chronic daily headache. They typically occur in patients with an underlying headache disorder such as migraine or tension-type headache that "transforms" over time from an episodic condition to chronic daily headache due to excessive intake of acute headache relief medications. MOH is a serious, disabling and well-characterized disorder, which represents a worldwide problem and is now considered the third-most prevalent type of headache. The proportion of patients in the population with Chronic Daily Headache (CDH) who overuse acute medications ranges from 18% to 33%. The prevalence of medication overuse headache (MOH) varies depending on the population studied and diagnostic criteria used. However, it is estimated that MOH affects approximately 1-2% of the general population, but its relative frequency is much higher in secondary and tertiary care.

Autogenic training is a relaxation technique first published by the German psychiatrist Johannes Heinrich Schultz in 1932. The technique involves repetitions of a set of visualisations accompanied by vocal suggestions that induce a state of relaxation and is based on passive concentration of bodily perceptions like heaviness and warmth of limbs, which are facilitated by self-suggestions. Autogenic training is used to alleviate many stress-induced psychosomatic disorders.

<span class="mw-page-title-main">Pain management</span> Interdisciplinary approach for easing pain

Pain management is an aspect of medicine and health care involving relief of pain in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals provide some pain control in the normal course of their practice, and for the more complex instances of pain, they also call on additional help from a specific medical specialty devoted to pain, which is called pain medicine.

<span class="mw-page-title-main">Anger management</span> Therapy for anger prevention and control

Anger management is a psycho-therapeutic program for anger prevention and control. It has been described as deploying anger successfully. Anger is frequently a result of frustration, or of feeling blocked or thwarted from something the subject feels is important. Anger can also be a defensive response to underlying fear or feelings of vulnerability or powerlessness. Anger management programs consider anger to be a motivation caused by an identifiable reason which can be logically analyzed and addressed.

A relaxation technique is any method, process, procedure, or activity that helps a person to relax; attain a state of increased calmness; or otherwise reduce levels of pain, anxiety, stress or anger. Relaxation techniques are often employed as one element of a wider stress management program and can decrease muscle tension, lower blood pressure, and slow heart and breath rates, among other health benefits.

Pain disorder is chronic pain experienced by a patient in one or more areas, and is thought to be caused by psychological stress. The pain is often so severe that it disables the patient from proper functioning. Duration may be as short as a few days or as long as many years. The disorder may begin at any age, and occurs more frequently in girls than boys. This disorder often occurs after an accident, during an illness that has caused pain, or after withdrawing from use during drug addiction, which then takes on a 'life' of its own.

Behavioral medicine is concerned with the integration of knowledge in the biological, behavioral, psychological, and social sciences relevant to health and illness. These sciences include epidemiology, anthropology, sociology, psychology, physiology, pharmacology, nutrition, neuroanatomy, endocrinology, and immunology. The term is often used interchangeably, but incorrectly, with health psychology. The practice of behavioral medicine encompasses health psychology, but also includes applied psychophysiological therapies such as biofeedback, hypnosis, and bio-behavioral therapy of physical disorders, aspects of occupational therapy, rehabilitation medicine, and physiatry, as well as preventive medicine. In contrast, health psychology represents a stronger emphasis specifically on psychology's role in both behavioral medicine and behavioral health.

Thomas Hice Budzynski was an American psychologist and a pioneer in the field of biofeedback, inventing one of the first electromyographic biofeedback training systems in the mid-1960s. In the early 1970s, he developed the Twilight Learner in collaboration with John Picchiottino. The Twilight Learner was one of the first neurotherapy systems.

Cephalalgiaphobia is fear of headaches or getting a headache. Cephalalgia is a Latin-based term for a headache, cephalic meaning head, and algia meaning pain. Harvey Featherstone introduced this phobia in the mid-1980s as a fear of having headache or migraine pain during a pain-free period. Individuals with this phobia often have a history of frequent migraines. Additionally, those with cephalalgiaphobia tend to overuse analgesic medication as a result of their fear. To avoid a future headache or migraine, the individual will preemptively intake analgesic medication to improve their headache. Doctors often do not prescribe pain medications but rather psychiatric medications as a treatment for the phobia. Non-pharmacological treatments using acupuncture therapy have been shown to help reduce the fear of headache pain.

Preventive treatment of migraine can be an important component of migraine management. Such treatments can take many forms, including everything from surgery, taking certain drugs or nutritional supplements, to lifestyle alterations such as increased exercise and avoidance of migraine triggers.

Cognitive behavioral therapy for insomnia (CBT-I) is a technique for treating insomnia without medications. Insomnia is a common problem involving trouble falling asleep, staying asleep, or getting quality sleep. CBT-I aims to improve sleep habits and behaviors by identifying and changing the thoughts and the behaviors that affect the ability of a person to sleep or sleep well.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

Migraine treatment may be either prophylactic (preventive) or abortive (rescue). Prevention is better than cure, so the ideal treatment goal is to prevent migraine attacks. Because migraine is an exceedingly complex condition, there are various preventive treatments which have their effect by disrupting different links in the chain of events that occur during a migraine attack. As rescue treatments also target and disrupt different processes occurring during migraine, these are summarized, with their relative merits and demerits.

Pain psychology is the study of psychological and behavioral processes in chronic pain. Pain psychology involves the implementation of treatments for chronic pain. Pain psychology can also be regarded as a branch of medical psychology, as many conditions associated with chronic pain have significant medical outcomes. Untreated pain or ineffective treatment of pain can result in symptoms of anxiety, depression, and suicidal thoughts, thus it is vital that appropriate pain management occur in a timely fashion following symptom onset.

<span class="mw-page-title-main">Pain management in children</span> Medical condition

Pain management in children is the assessment and treatment of pain in infants and children.

References

  1. ↑ Duckro, Paul N. Taking Control of Your Headaches: How to Get the Treatment You Need p. 6
  2. 1 2 Mathew, Ninan T. "The Prophylactic Treatment of Chronic Daily Headache" p. 1552
  3. ↑ Duckro, Paul N. Taking Control of Your Headaches: How to Get the Treatment You Need p. 136
  4. ↑ Harpole, Linda H., et al. "Headache Management Program Improves Outcome for Chronic Heachache" p. 716
  5. ↑ Duckro, Paul N. Taking Control of Your Headaches: How to Get the Treatment You Need p. 40, "Success with Biofeedback found in Chronic Headache Treatment", Andrasik, F. "Behavioral Treatment Approaches to Chronic Headache" p. S81
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  9. ↑ Duckro, Paul N. Taking Control of Your Headaches: How to Get the Treatment You Need p. 24
  10. ↑ Buchholz, David. Heal Your Headache: The 1-2-3 Program for Taking Charge of Your Headaches p. 46
  11. ↑ Buchholz, David. Heal Your Headache: The 1-2-3 Program for Taking Charge of Your Headaches p. 50
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  16. ↑ Mathew, Ninan T. "The Prophylactic Treatment of Chronic Daily Headache" p. 1557
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  55. ↑ Harpole, Linda H., et al. "Headache Management Program Improves Outcome for Chronic Heachache" p. 722
  56. ↑ Andrasik, F. "Behavioral Treatment Approaches to Chronic Headache" p. S82
  57. 1 2 Martin, Paul R. Psychological Management of Chronic Headaches p. 83
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Sources

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