Headaches and Other Facial Pain Syndromes

Shweta Teckchandani, DO

Marc Lenaerts, MD, FAHS

Charles De Mesa, DO, MPH

INTRODUCTION

Headaches are a worldwide problem affecting people of all ages, socioeconomic backgrounds, and races. According to the World Health Organization,¹ 50% of the general population have headaches during any given year. Headache disorders are a public health concern, given the socioeconomic burden directly due to health care costs and indirectly due to missed workdays or reduced competence.² Given that most patients with headache initially present in a primary care setting, it is highly important to obtain the correct diagnosis with an appropriate plan of care. Headaches fall under two categories namely, “primary” and “secondary.” By definition, a primary headache is due to the headache itself, whereas a secondary headache is due to a demonstrable organic disease or an underlying structural abnormality. Ninety percent of headaches seen in practice are primary headaches, and less than ten percent are secondary headaches.³ Because secondary headaches are rare and pose significant risks, they must be effectively ruled out.

PRIMARY HEADACHE DISORDERS

The 3 types of primary headaches are migraine, tension type, and trigeminal autonomic cephalgias (TACs).⁴^,⁵ Tension-type headache (TTH) is the most prevalent affecting 60% to 80% of the population.⁶ However, in the outpatient setting, migraine is far more common than tension type and cluster because it is disabling enough for an individual to seek medical attention.⁷

MIGRAINE

The estimated global prevalence of migraine is 14.7% (1 in 7 people).⁸ It is more prevalent than diabetes, epilepsy, and asthma combined.⁹ Clinical features of migraine include localized unilateral headaches but may present as bilateral, retro-orbital, occipital/suboccipital, parietal, or central facial. It is throbbing in quality, and the intensity is variable from mild to extremely severe and disabling. The patient may be irritable and complain of symptoms of photophobia, phonophobia, osmophobia, and kinesiophobia (fear of physical movement). There may be accompanying gastrointestinal symptoms of anorexia, nausea, vomiting, or diarrhea. Occasionally, patients will present with migraine with an aura which may include cortical symptoms such as visual spots and flashes of lights. Other less common aura symptoms include hemiparesis, hemisensory loss, aphasia, confusion, and amnesia, which are fully reversible.

DIAGNOSTIC CRITERIA⁴

A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4 to 72 hour (untreated or unsuccessfully treated)²^,³
C. Headaches have at least 2 of the following 4 characteristics:
- 1. unilateral location
- 2. pulsating quality
- 3. moderate or severe pain intensity
- 4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
D. During headache at least 1 of the following accompanies:
- 1. nausea and/or vomiting
- 2. photophobia and phonophobia
E. Not better accounted for by another International Classification of Headache Disorders-3 (ICHD-3) diagnosis.

TREATMENT

Treatment strategies should focus on improvement in functionality and reduction in the number of headache days. The best approach to manage migraine is to individualize the treatment based on the patient’s unique symptoms and should include medication management and other nonpharmaceutical treatment strategies.

Have a low threshold for treatment and be an advocate for prevention because it will help prevent transformation into chronic migraine. Prophylaxis is indicated for greater or equal to 3 attacks a month. Monitoring side effects and reassessing efficacy are important. Consider comorbid conditions in treatment such as hypertension, depression, and seizures because they may help guide medication selection. Attempt therapy long enough to determine effects. For example, provide greater and equal to a 6-week trial with greater than or equal to 6-month maintenance. Do not stop too quickly as these regress the benefit of treatment strategies.

If the individual experiences one headache a month but nothing else helps, then prevention or prophylaxis is still reasonable. The goal in prevention is fewer headaches (e.g., decrease frequency by 50%), decrease in intensity and duration of pain, reduced need for rescue medication, and improved efficacy of abortive therapy. Understand and explain to the patient that this may take 2 months for full benefit.

An important consideration before prophylaxis is initiated is to assess for medication-overuse headaches. If the patient is using abortive therapy more than 10 days a month, he or she may be experiencing rebound headaches. In such cases, the abortive medication should be withdrawn before starting prophylactic therapy.⁹

Migraine Abortive Treatment

Early abortive treatment is essential in migraine management for maximum benefit. A study using almotriptan (Axert) showed that abortive therapy when initiated within 1 hour of headache onset has greater relief and lower recurrence rates of pain than nonearly users.¹⁰ When deciding for treatment, aggressive and larger dose of the variety of choices may be selected, and this may vary over time. It may be necessary to change medication that is a therapeutic failure. The goal of aborting a headache is to stop it as early and aggressively as possible with the least side effects to improve quality of life and function.

Categories can be nonspecific or specific. Nonspecific medications include acetylsalicylic acid (ASA), N-acetyl-p-amino-phenol (APAP), and nonsteroidal anti-inflammatory drugs (NSAIDs) (although some specificity is present because these act on inflammation not just pain). Triptans are first-line therapies for moderate to severe migraine, or mild to moderate migraine, that has not responded to adequate doses of simple analgesics.¹¹ They can be effective by activating serotonin receptor type 1 subtypes b, d, and f. They are more targeted because they do not act on the dopamine receptor and therefore do not cause nausea, whereas dihydroergotamine (DHE) and older ergotamines can cause nausea. Other potential options with good evidence of efficacy for migraine abortive therapy include antiemetic agents such as promethazine, prochlorperazine, and metoclopramide.¹²

Adverse effects should be explained including chest, neck, and head pressure; tingling; paresthesia; and flushing, as well as central effects of dizziness and sedation. These are transient though and are not indicative of absence of relief. Such counseling can be effective for the patient. Contraindications are coronary artery and cardiovascular diseases. Relative contraindications are in hemiplegia, brainstem, and aura migraines.

MIGRAINE PROPHYLAXIS

Pharmacologic treatment typically involves daily preventive medication. It should be noted that only 2 agents (onabotulinumtoxinA and topiramate) have strong evidence in chronic migraine,¹³ although there are other medications for episodic migraine. First-line agents typically used with evidence of efficacy belong to 3 broad classes namely antihypertensives, antiepileptics, and antidepressants (see Table 14-1).¹⁴ The doses vary highly, the medication must be titrated slowly, and the patient must be informed that titration may take weeks for the individual to tolerate it.

Calcium channel blockers are not as effective as beta-blockers but well tolerated in some patients. Several studies have also shown efficacy of nutraceuticals such as riboflavin, magnesium, and coenzyme Q10 for prophylaxis.¹⁵ If the individual has high blood pressure, medications used such as lisinopril and candesartan demonstrate randomized control trials with data to support their use, but these are generally of shorter duration. Nevertheless, they are good choices for those unable to use the other medications. Smaller study on tizanidine appears supportive as well.

OnabotulinumtoxinA injection therapy is FDA approved only for chronic migraine, and emerging
data suggest this treatment modulates central sensitization rather than a muscle effect. Injections are repeated every 12 weeks and are based on the PREEMPT protocol (Figure 14-1). This treatment does not work in episodic migraine or TTH contrary to one would presume.

TABLE 14-1 Migraine Prophylaxis

MEDICATION	DAILY DOSE RANGE	POSSIBLE ADVERSE EFFECTS	CONTRAINDICATIONS
Antiepileptic Drugs
Valproate	250-500 mg bid	Alopecia, weight gain, tremors	Pregnancy Liver disease
Topiramate	50 mg bid	Paresthesias, word-finding difficulty, cognitive slowing	Pregnancy history of nephrolithiasis Glaucoma
Beta-Blockers
Propranolol	80-240 mg divided bid or tid	Hypotension, fatigue	Asthma Diabetes
Tricyclic Antidepressants
Nortriptyline	10-150 mg daily	Weight gain, dry mouth, drowsiness	Cardiac conduction abnormalities
Amitriptyline	30-150 mg daily	Weight gain, dry mouth, drowsiness	Cardiac conduction abnormalities
Venlafaxine	75-150 mg daily	Nausea vomiting	Do not use with MAOIs—increases risk of serotonin syndrome
Calcium Channel Blockers
Verapamil	80-480 mg divided tid	Constipation, atrioventricular conduction disturbances	Cardiac conduction abnormalities
Angiotensin-Converting Enzyme Indicator
Lisinopril, generic	5-40 mg daily	Hypotension	History of angioedema
Angiotensin-Receptor Blocker
Candesartan	8-21 mg daily	Hypotension	Allergic to sulfonamide drugs
Republished with permission of Dove Medical Press Ltd from Garza I, Swanson JW. Prophylaxis of migraine. Neuropsychiatr Dis Treat. 2006;2(3):281-291; permission conveyed through Copyright Clearance Center, Inc.