Chronic headaches

Chronic/recurring headaches are common. Truly sinister causes are possible, but obviously not typical. In my experience, assessment and management of these is often suboptimal.

Some patients may attribute some episodes to “tension headaches“. That is certainly plausible, but people with migraines can experience headaches of multiple forms; in that case episodes of different description should be treated in a similar way.

Migraine treatments can be considered in abortive(“rescue”), salvage and prophylaxis phases. Abortive treatments must be taken as soon as possible at the start of an episode, or ideally before it (“aura”); the window may be only 20 minutes. The choice of medication is in fact much less important. For example, dispersible aspirin works very well for many, even though most have moved on to prescribed “triptans”.

Once the migraine attack is in full swing abortive treatments will no longer work. In the ED patients are sometimes given intravenous chlorpromazine, typically inducing sleep (“salvage”). For home use the equivalent would be prochlorperazine (“Stemetil”). Prophylaxis(preventatives) might be an unpopular concept, but have the most potential to help. Adverse effects may be possible so work with your GP from a wide range of choices. Some patients are eventually referred on to neurologists, for botulinum toxin (“Botox”) or the new CGRP inhibitor class of drugs.

Trigeminal autonomic cephalalgia (TAC) is a relatively new grouping which includes cluster headache. Some presentations can easily be mistaken for migraines; and as a result, undertreated. There is some overlap with migraines in the medications used, but there are also notable distinctions, especially the use of the specific anti-inflammatory, indomethacin.

Analgesic-rebound headaches are the complication from treatment overuse, especially migraines. These are insidious, and may not be apparent to the patient until pointed out. There may be an overuse of triptans, codeine or even paracetamol. Prophylaxis should be started as soon as possible. Some patients might have developed codeine dependence, and would then require opioid agonist therapy (OAT), in either sublingual or subcutaneous forms.

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