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Treatment of Headache
Treatment of Headache AI~NOLD I~llIEDMAN,
M.D. *
IN DISCUSSING the treatment of headache, it should be remembered that \ve are dealing with a symptom which represents a disturbed physiologic state. rrhis article will consider the basic mechanism of headache and the use of pharmacological agents in the treatment of certain specific headache entities. In addition, the role of psychodynamic mechanisms in the production of chronic headache will be considered. It must be admitted that there still remain extensive gaps in our knowledge of causes and mechanism of headache but this does not prevent active and successful therapy in a large number of headache patients.
PHYSIOLOGIC MECHANISMS OF HEADACHE
Vascular Mechanisllls
It is well known that a great majority of headaches have a large vascular component. Studies of patients with migraine have given certain basic information regarding the mechanism of headache.! An initial vasoconstriction of the cerebral arteries produces visual scotoma and possibly other phenomena prjor to the onset of the headache. This prodromal period is then followed by dilatation and distention of cranial arteries primarily in the distribution of the external carotid such as the temporal artery. Pulsations of the temporal artery are increased in amplitude at the beginning of the headache phase of the attack. 2 , 3 Vasodilatation with increased amplitude of pulsations is presumed to cause the headache. When a vasoconstrictor agent such as ergotamine tartrate or noradrenaline is administered, the amplitude of pulsations decreases rapidly and the headache terminates. If treatment is delayed, then dilated vessels become edematous and will not react to vasoconstrictor drugs. In addition, there is transudation of fluid into the tissues sur-
* Physician-in-Charge, Headache Unit, and Attending Physician, Division of Neuropsychiatry, Montefiore Hospital; Associate Professor of Clinical Neurology, College of Physicians and Surgeons, Columbia Univers1:ty; Associate Attending Physician at the Neurological Institute, Presbyterian Hospital; Consultant in Neurology for Veter., ans Administration, New York, N. Y. 65D
660
Arnold Friedman
rounding the vessel. Alterat ions in the size and pulsations of the cranial indearteries do not entirely explain the pain, since they may exist fluid the that ed present been has ce penden tly of any headache. J1~viden lar molecu low of ce substan a s presen t in the edemat ous tissue contain been has It ld. thresho pain the g weight, which is responsible for lowerin not theorized that during an attack of vascula r headache there exists arteranial extracr large the of ion only a loss of tone and marked distent es ies, but also a dilatati on and increase in permea bility of the arteriol a enables bility permea ed increas This and capillaries in the same region. the into diffuse to ld thresho pain the substan ce capable of lowering subperiart erial tissues. It has been assumed that the presence of this headthat so , painful arteries large stance renders the distent ion of the ache ultimat ely results from a combination of the two factors. e Persist ent dilatati on of the blood vessels results in a rigid, pipelik the ng replaci ache steady a is stage state of the vessels. The pain at this d by earlier, throbbing, pulsati ng type. Prolonged headache, initiate and neck the of tions contrac ed vascula r changes, usually leads to sustain pain The pain." tion contrac e "muscl scalp muscles and the additio n of associated with spasm of the muscles may outlast the initial pain. If during an attack of migraine headache the tempor al veins and indiarteries are promin ent, examination of venous blood from this 4area rFurthe ized. arterial i.e., red, and cates it is under increased pressure below be may side painful the on more, the arteriovenous oxygen ratio that normal even during the pain-free interva ls. This may indicat e venous the of ization arterial arteriovenous shuntin g has occurred with the blood. Such shunts could render tissues anoxemic with lowering of of de amplitu in on reducti a pain threshold. It is possible that both enous arteriov the of closing a pulsati on of the affected vessels plus shunts is necessary to abort an attack of migraine headache. Muscu lar Mecha nisms
a Sustained contrac tion of skeletal muscles of the head and neck is Headscalp. and neck the frequen t source of pain and dysesthesia in such aches from this source occur in association with vascula r headaches rative, degene atory, as migraine as described above, and with inflamm l trauma tic and neoplastic diseases about the face, head, neck, cervica r, howeve d, observe nly vertebr ae and nerve roots. They are most commo in relationship to emotional tension, so-called tension headache. There is an is some evidence that hypoxia associated with these muscle spasms 6 , 6 Anothe r factor which may import ant factor in the inducti on of pain. of be partiall y responsible for the pain is an excessive concen tration tissues. the in s eceptor potassium in the muscle stimula ting the chemor ea Also, noxious stimula tion of the soft tissues of the neck may produc pain. head in central spread of the excitat ory effects resulting
Treatment of Headache
661
The fact that painful spasms of the muscles of the neck and scalp may be referred to the head and face suggests the possibility that such pain may be referred via the upper cervical nerve roots. Furthermore, one can palpate trigger zones in the neck which give rise to head and facial pain. The mechanism of projection of the pain from cervical nerve roots to the head and face has been postulated as traveling via the descending root of the trigeminal nerve or by reflex stimulation of the sympathetics. 7 Psychological Mechanisllls
The importance of psychological factors in patients with chronic headache is well documented. In many patients it is difficult to prove that psychogenic elements are the primary etiological agent. It must be remembered that psychic qualities are related to constitutionally determined differences in the individual, as well as to impaired physiological functioning. Therefore, in discussing psychological mechanisms, they are to be considered as functioning in the total environment of the individual and not as a solitary entity. Attempts have been made to attach certain specific personality profiles to patients having migraine and other types of chronic headache. It has been noted that many people with migraine are compulsive, perfectionistic and methodical. However, far more people with these personality traits do not have headache than those who do. In our experience the personality manifestations in people with migraine and other types of chronic headaches are extremely variable and may include a variety of precipitating psychodynamic factors. The conflicts most frequently observed in these patients are those related to hostile impulses directed against members of their families or persons who represent family figures. Other precipitating psychodynamic factors include identification, a wish to remain in a position of dependency, a method of gaining attention, etc. The symptom headache is a defense against the conscious recognition of the conflict. It acts as a protective mechanism for the patient, preventing him from recognizing his feelings toward someone he loves or upon whom he is dependent. It is accepted by many psychiatrists that, except for the intensity of the conflict, there is little difference psychologically between the patient who has migraine and the one with psychogenic or tension headache. In a large group of patients with headache the pain is the presenting symptom of an anxiety state or a depression. Frequently in such patients a careful investigation reveals a host of behavior disturbances and neurotic reactions forming an integral part of the presenting complaint of headache. The psychological picture and reactions in these patients are varied and numerous. In patients with psychic distress, headaches occur because of two mechanisms. In one group the mental conflict stimulates the autonomic
. 4. rnold Friedman
662
nervous system, producing changes in the caliber of the blood vessels of the head, or stimulates the somatic motor system with contraction of skeletal muscles of the neck and scalp. Such mechanisms may act initially independently or concomitantly. In another group the mechanism of the headache is on the basis of a conversion reaction. The symptom represents a specific unconscious symbolic meaning to the patient. In this patient the head is used as the organ of expression of the conflict. No attempt will be made to discuss the procedures used in psychotherapy. Emphasis is needed on the importance of discussing vvith the patient the limitations of therapy and the fact that it will be lengthy. Ventilation of wholly or partly unconscious emotional conflicts by the patient, environmental manipulation, re-education and direction are important techniques in therapy. Through it all the patient-physician relationship dominates the treatment. Such therapy is vvithin the province and ability of the interested general practitioner. In some patients, where the aim is considerable alteration and reorganization of the personality, analytical psychotherapy is necessary. PHARMACOTHERAPY The selection of drugs to be used in treatment of patients with chronic headaches is complicated by the fact \ve are dealing ,,,ith a problem which has strong psychological connotations to the patient, for a symption which is related to the head carries \vith it a considerable emotional threat to the patient, such as fear of loss of mind, disorder of the brain or loss of intellectual capacity. I~esponse to a remedy \V"ill be \veighted by the physician-patient relationship, constitutional make-up and age of the patient, duration of symptoms, psychological status, and understanding of the pharmacologic actions of the drugs being used. 8 In the treatment of headache by chemical agents, two general aspects should be considered: (1) symptomatic, i.e., the treatment of an attack; (2) prophylactic, or the prevention of attacks. 1-'he goals in pharmacotherapy are to interrupt the mechanism producing pain, to raise the pain threshold, and to reduce emotional tension and anxiety responsible for or associated with this pain. In the present text we will discuss the drugs commonly used in the treatment of headache \vhich in our experience have been the most effective. 9 Emphasis will be placed on treatment of the types of headache which the clinician is most likely to meet in his practice. Specific Drugs Analgesics. The commonest analgesic used in the treatment of headache is the antipyretic coal-tar derivatives, particularly acetylsalicylic acid and acetophenetidin. Their action is more effective ,vhen they are
Treatment of Headache
663
combined with or added to caffeine or as a mixture with barbiturate or codeine. Although the types of pain relieved by the coal-tar derivatives are usually those of low intensities, they represent the safest and most efficient analgesics for headache sufferers. rfhey act by raising the pain threshold possibly through depression of the pain centers in the thalamus. Salicylates reach a maximum blood level several hours after ingestion and their therapeutic effect is gone within three to four hours. The duration of action may be prolonged by the administration of frequent doses. For relief of severe pain it is necessary to use the opiate analgesics. Ho,vever, except in rare situations, we are limited to the use of codeine, i.e., methyl morphine, for treatment of severe headache. Codeine not only acts by raising the pain threshold but probably has other central effects on the cerebral cortex which reduce the emotional tension and produce a sedative effect. Codeine is administered as a phosphate or sulfate. Codeine combined with the salicylates and caffeine is the drug of choice to control headache caused by inflammation of cranial structures, space-occupying lesions, head trauma, and in severe headaches associated with some systemic disturbances. More recently there has been introduced a codeine substitute, Propoxyphene Hydrochloride, which has been reported as having the analgesic potential of codeine without the side effects or addicting properties. Ilypnotics and Sedatives. Hypnotics and sedatives seldom control severe or persistent headaches unless combined with an analgesic. When barbiturates are combined vvith salicylates the combination frequently is more effective than when the analgesic is used alone. This occurs in spite of the fact it is not possible to demonstrate a decrease in pain perception beyond that produced by the analgesic itself. Such a combination is particularly effective in the treatment of tension headache. Barbiturates of short and medium action are to be used in the treatment of headache. Tranquilizers. The tranquilizing drugs are effective in controlling tension headache and the associated autonomic nervous system symptoms in some patients. In others with similar symptomatology they are not effective. The value of these drugs in psychosomatic problems is far from being adequately assessed. lo Our experience has been mainly with four agents of this group: reserpine; chlorpromazine hydrochloride (Thorazine); 2 methyl-2-N-propyl-l, 3-propanediol dicarbamate (meprobamate; Miltown; Equanil); and 2-p-chlorophenyl-3-methyl-2, 3-butaneidiol (Ultran). The dosage with these drugs is highly individualized~ for instance, some patients respond to small doses of the drug, while others need much more. Therefore, securing adequate dosage range and proper dosage which can be adapted to the patient's condition becomes of paramount importance. We advocate that the drug be discontinued
664
Arnold Friedm;an
if the patient does not respond within two months. In general, our observations indicate that patients who do not respond to one tranquilizer do not respond to another drug of this type. The importance of proper physical and mental examinations in patients receiving these drugs is obvious, for they are capable of producing both physical and mental symptoms. Of course results with the tranquilizerB, BedativeB and other drugs in the treatment of headache must be compared \vith the high percentage of good results secured with the use of placebos in these patients. Unfortunately there are no entirely satisfactory methods of evaluating objectively the results of a predominantly subjective symptom such as headache. Anticonvulsants. The use of anticonvulsant drugs as a means of preventing migraine headaches has been unsuccessful except in a small number of patients who have a family history heavily weighted with migraine and/or epilepsy, give a history of aphasia, hemiplegia, paresthesias prior to or during the headache attack, and reveal an abnormal electroencephalogram with spiked patterns. In some patients the hydantoins may be combined with caffeine for more effective results. Stimulants of the Central Nervous System. Caffeine is a methylated xanthine \vhich is a powerful central nervous system stimulant whose main action is on the psychic and sensory functions. Present evidence indicates caffeine tends to constrict the cerebral arterioles and reduce cerebral blood flow. Caffeine is widely used in the treatment of headache and it is usually combined with salicylates in the treatment of the routine type of headache and with ergotamine in migraine. Whether its effectiveness is due to its vasoconstrictor action or the fact it potentiates the action of other drugs is still unknown. Caffeine can also be responsible for headache, as observed in the caffeine withdrawal headache. Caffeine is used alone in the treatment of postlumbar headache and some recommend it as symptomatic treatment for headaches associated with hypertension. ])extro-amphetamine (Dexedrine) is a potent central nervous system stimulant. 'rhe central nervous system activity of Dexedrine is about t\vice as pronounced as that of Benzedrine. It is used in the treatment of headache combined with a salicylate, particularly for those headaches associated with depression, fatigue, and following a hangover. In some patients with tension headaches, combined with amobarbital, it is of value in interim and symptomatic treatment, as it has a beneficial effect on most and also seems to relieve the underlying tensions. Drugs Acting Directly on Blood Vessels-Dilators. Nitrites, particularly nitroglycerin, are used as a provocative test in patients with migraine. We have obtained positive results in only about 50 per cent of our patients. Papaverine and similar vasodilators, in our experience, have
Treatment of Headache
665
not been used effectively in the treatment of arteriosclerotic and other types of arteriovascular headache. Histamine and Antihistamine. There is considerable difference of opinion regarding the value of histamine in the treatment of headache. Histamine is present in all complete proteins and affects almost all tissues, producing dilatation of the smaller blood vessels, stimulation of glands, etc. It is inactive when taken by mouth, probably because of destruction by the enzyme which is present in the intestinal mucosa. Because histamine can produce headache when injected into a person, and Horton has described a type of headache which is called "histamine cephalalgia," the treatment of vascular headaches by using repeated doses of histamine in order to develop tolerance to this chemical agent has been recommended. However, in our experience and that of others, the treatment of vascular headaches by histamine desensitization has not proved successful. Antihistaminic agents have been used in the treatment of headache on the theory that any compound which is capable of blocking the action of histamine should prevent allergic manifestations. Our clinical observations indicate that the use of antihistaminic agents in the treatment of headache are limited to those patients \vhose headaches arc associated with an allergic manifestation such as vasomotor rhinitis. Individuals differ greatly in their response to antihistamines; therefore therapy with this type of medication must be flexible, and preparations changed according to the clinical response. Water and Electrolyte Metabolism-Diuretics. Present clinical and experimental evidence indicates that fluid and electrolyte changes in patients with vascular headache are associated phenomena and not a causal factor. However, in patients who, particularly during or prior to their menstrual periods, show a rapid weight gain and evidence of edema, a trial of diuretics is indicated. Acetazolamine (Diamox) and acid diuretic salts such as ammonium chloride may be administered prior to their periods. Such patients should also be placed on a salt-poor diet. Patients who have increased intracranial pressure may receive temporary relief by use of hypertonic solutions of glucose and sucrose. These substances act by reducing the brain edema, hence lessening traction on the pain-sensitive structures intracranially. Vitamins. Our experience with the administration of vitamins in preventing or aborting headaches has indicated that they are of little value. Multiple vitamin supplements are worthy of a trial in the elderly and debilitated patients with headaches, as a general supportive measure. Hormones. The treatment of migraine by use of hormones has generally not benefited our patients. In a few patients androgens, i.e., methyltestosterone, have been used successfully in patients whose headaches occur during menstruation or immediately before it. Methyl-
666
~4rr~old
Friedman
testosterone, which is available for buccal use, should be kept below 75 mg. per week. In females who at the time of menopause show marked signs of vasomotor instability including hot flashes, sweats, palpitation and headache, the administration of estrogens with or without androgens may be used. In most of these patients the symptoms are related to emotional factors and can be better relieved by suitable supportive psychotherapy and the conservative use of analgesics and sedatives. When estrogens are used they should be given in small doses, in cyclic fashion, with decreasing doses. All patients who are given estrogens should be carefully screened by gynecological examination before and during therapy. If small doses of the drug do not control the problem, large doses will be of no avail. In patients with hypothyroidism who complain of headache, the use of thyroid preparations may be quite helpful in relieving the symptom. ])rugs I nfiuencing the A utonomic Nervous System. Our discussion of drugs in this group will be limited to ergotamine tartrate which is the most effective agent available for symptomatic treatment of migraine. u . 12 Ergotamine is derived from lysergic acid and contains a polypeptide side chain. Dosage levels used in treatment of migraine have no significant adrenergic blocking action. Its effectiveness in an attack of migraine is due to its constrictor effect on the smooth muscles of the blood vessels and a decrease in amplitude of their pulsations. The fate and excretion of ergot alkaloids is still in need of further investigation. In those patients who tolerate ergotamine poorly, the use of dihydroergotamine methene sulfonate (D.H.E. 45) is indicated. More recently many forms of ergot derivatives have been made available as proprietary preparations, first incorporating caffeine and following that, antispasmodics, antiemetics, sedatives and central nervous system stimulants. Rectal use of ergotamine has proved empirically to be more efficacious than oral medication. In other types of vascular headaches, including atypical facial neuralgia, cyclic or histamine headache, and other migraine variants, ergotamine tartrate preparations are effective for symptomatic treatment. I~hysiotherapy. Sustained contraction of the muscles of the head and neck are frequently a mechanism which produces headache. Treatment of these muscular disorders is based on a variety of physical methods including hydrotherapy, electricity, exercise, massage and mechanical devices such as collars and traction. In some patients ethyl chloride spray may be employed to secure relief of muscle spasm and pain. Injection of procaine hydrochloride, 1 to 2 per cent, into tender areas of the neck is helpful temporarily in some headaches associated with discogenic disease, myofibrositis and myalgia of the neck.
Treatment oj· Headache
667
Surgery
Treatment of head pain by surgical techniques is limited to a fe,v specific conditions. They may be effective in the presence of intracranial mass, such as tumor, abscess, hematoma or aneurysm. Head and neck pain developing from cervical disk and cervical rib may be relieved by surgical approach. In neuralgia (trigeminal, glossopharyngeal, etc.), surgery is frequently indicated. Glaucoma, which may produce headaches similar to migraine, will frequently necessitate surgical intervention. In this group treatment is for the underlying specific condition and headache is an incidental symptom. Surgical procedures for migraine are usually not recommended. They are of two types: reduction of arterial dilatation by ligation or neurectomy, or interrupting of the afferent nervous pathways transmitting pain from arteries. Novocain and alcoholic infiltration of arteries have been used but only with temporary success. Another group of vascular headaches belonging in the migraine class are frequently called atypical facial neuralgia. The attacks differ from migraine in that they are of short duration with marked manifestations of cranial autonomic activity on the side with pain, including ipsilateral stuffiness of the nose and injection of the eye. Section of the greater superficial petrosal nerve has been suggested as a means of relieving this syndrome. la No great therapeutic triumph has emerged from this procedure or from sympathectomy, removal of the sphenopalatine ganglia or trigeminal rhizotomy. Following sudden rotation of the head, injury of the upper cervical nerves may occur with onset of cephalic neuralgia. Cocainization of the cervical nerve root may effectively stop such pain. In patients with severe hypertension, headaches are frequently present. The use of the Smithwick operation in certain special selected cases has been sugge~ted as a means of lowering blood pressure and eliminating headaches. It should be noted that the correlation between height of blood pressure and severity of headache has never been clearly demonstrated. In the management of the patient with headache we must consider the fact that we are dealing with a symptom and not a disease. Many headaches are secondary to a specific acute illness and are treated through control of the primary pain and correction of the underlying disorder. However, the majority of treated cases of chronic headache fall into a group in which the symptoms are due to migraine or are primarily associated with emotional disturbance, tension headache. For purposes of diagnosis and therapy, we classify our headaches in the categories14 listed on page 675.
1 mg.
(CAFERGOT)
Ergotamine tartrate Caffeine Bellafoline Pentobarbital sodium (CAFERGOT PB) Ergotamine tartrate Caffeine Bellafoline Pentobarbital sodium (CAFERGOT PB)
2 mg. 100 mg. 0.5 mg. 60 mg.
1 n1g. 100 mg. 0.125 mg. 30 mg.
suppos.
tab.
suppos.
2 mg. 100 n1g.
Ergotalnine tartrate Caffeine
(CAFERGOT)
tab.
1 mg. 100 mg.
tab.
amp.
FORM
Ergotamine tartrate Caffeine
(GYNERGEN)
t 0.5
Ergotamine tartrate
(GYNERGEN)
50.25 mg. mg.
AMOUNT
Ergotamine tartrate
MEDICATION
1. Specific Therapy-Pharmacotherapy
A. Sym.ptom.atic Treatlllent
1-2 suppos.
2-6 tabs.
1-3 suppos.
2-6 tabs.
2-6 tabs.
0.25-0.5 mg.
DOSAGE
spasmodic and sedation
V.,. asoconstriction, anti-
Vasoconstriction
ACTION
As above plus dryness of mucous membranes and skin, drowsiness
"
Nausea, vomiting, numbness and tingling of hands and feet, muscle pains in thighs and neck, abdominal pain, prostration
EFFECTIVE DRGGS FOR ACUTE ATTACK
SIDE EFFECTS
OF SPECIFIC HEADACHE SYNDROMES
l\figraine and Vascular Headache
TREAT~IENT
As above plus glaucoma
Septic infectious states, vascular diseases, coronary sclerosis, history of angina, pregnancy, hypertension, imp3ired renal or hepatic function
CONTRAINDICATIONS
;:s
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Rest in dark room-ice bag to head.
(AMYTAL)
may also be used Amobarbital sodium
90 mg.
25 nlg.
Chlorpromazine
tab.
tab.
tab.
30 mg.
(THORAZINE) COMPAZINE and TRILAFON
tab.
tab.
tab.
210 mg. 150 mg. 30 mg.
50 mg. 25 mg.
nlg. mg. mg. mg.
1 mg.
1 100 0.1 130
Acetylsalicylic acid Acetophenetidin Caffeine plus Codeine phosphate
2. N onspecijic Therapy
(MIGRAL)
Ergotamine tartrate Caffeine Cyclizine H Cl
(WIGRAINE)
Ergotamine tartrate Caffeine Belladonna alkaloids Acetophenetidin
.A.ntiemetic, sedation
1-2 tabs.
Sedation
Raise pain threshold
1-2 tabs.
1-2 tabs.
Analgesic, sedation
Vasoconstrictor, antiemetic
Vasoconstriction, antispasmodic and analgesic
2 tabs.
1-4 tabs.
2-6 tabs.
Sensitivity to drug
Same as for Ergotamine Tartrate
Septic infectious states, vascular diseases, coronary sclerosis, history of angina, pregnancy, hypertension, impaired renal or hepatic function plus glaucoma
Sleepiness, skin erup- Sensitivity to drug, cardiotions, mental disturbvascular renal disease and ances impaired hepatic function
Severe nausea and vomit- Addiction ing, constipation Drowsiness, hypotension, Gallbladder-liver disease jaundice, agranulocytosis
Fatigue, lassitude
"
Nausea, vomiting, numbness and tingling of hands and feet, muscle pains in thighs and neck, abdominal pain, prostration plus dryness of mucous nlenlbranes and skin
OJ
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(ULTRAN)
2-p-chlorophenyl-3methyl-2, 3 butanediol
(MILTO'VN; EQUANIL)
Meprobamate
MEDICATION
300 mg.
400 mg.
AMOUNT
tab.
tab.
FORM
t.i.d.
1 tablet
2-4 tabs. a day
DOSAGE
Tranquilizer
Tranquilizer
ACTION
SIDE EFFECTS
Drowsiness, lassitude, skin eruption, nausea
EFFECTIVE DRUGS FOR PROPHYLAXIS
"
Sensitivity to drug
CONTRAINDICATIONS
Pharmacotherapy: As an adjunct to psychotherapy in severe cases of tension and anxiety, pharmacotherapy may be helpful. In son1e patients pharmacotherapy alone reduces the frequency of attacks.
Surgery: In general, these procedures should be avoided and have not been successful in preventing the recurrence of headache except in a fe"r isolated instances. These are discussed in the section on "Treatment of Headache by Surgery." In an occasional patient 'whose headaches are incapacitating and who is refractory to all types of medical and psychiatric therapy, or in the presence of vascular disease which may prevent specific treatment, surgery may be considered.
Psychotherapy: Attempt to give patients understanding and insight into their behavior and attitudes 'which produce stress, and to reduce anxiety and tension in their life situations. Re-education and reorientation with respect to the patient's personal, economic, and social life, etc.
General Measures: Avoidance of fatigue and stress. Adequate hygiene. Avoidance of specific activities, dietary indiscretions, alcohol, etc., 'which may precipitate an attack.
B. Prophylactic TreatlDent of Migraine (Preventing Recurrence of Attacks)
~
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R..
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~
R..
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C
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~
1-3 tabs. a day
1-3 caps.
cap.
100 mg.
. .~nticonvulsant
An ticonvulsan t
Sedative
1-2 tabs. a day
tab.
tab.
90 nlg.
Antispasmodic, sedative, vasoconstrictol
. ~. ntispasmodic, sedative
Tranquilizer, antihypertensive
1 Spacetab twice daily
1 Spacetab twice daily
1-2 tabs. a day
100 mg.
tab.
0.2 mg. O.6mg. 40 mg.
Methyl-phenyl-ethylhydantoin (MESANTOIN) Diphenylhydantoin (DILANTIN)
tab.
0.25 mg. 50mg.
Bellafoline Phenobarbital (BELLADENAL) Bellafoline Ergotamine tartrate Phenobarbital (BELLERGAL) Amobarbital sodium (AMYTAL)
tab.
0.25 mg.
Reserpine (SERPASIL)
Morbilliform rash, dizziness, nystagmus, ataxia
Sleepiness, skin eruptions, mental disturbances Sleepiness, paresthesias, ataxia, aplastic anemia
Dryness of nasa,] mucosa, sleepiness
Drowsiness, dryness of nasal mucosa, nausea, depression Dryness of nasal mucosa, sleepiness
~
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~
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Sensitivity to drug
Sensitivity to drug, cardiovascular renal disease and impaired hepatic function Sensit-ivy to drug
~ ~
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~ Glaucoma; vascular disease ~ ~
Glaucoma
Depressed patients
tab.
tabs.
tab.
5mg. 32 mg. 160 mg. 160 mg.
210 mg. 150 mg. 30mg.
FORM
200 mg. 150 mg. 40mg. 50mg.
AMOUNT
2 tabs.
1-2 tabs.
1-2 tabs.
DOSAGE
DRUGS
ACTION
Analgesia, sedation
A.nalgesia, stimulation
SIDE EFFECTS
Fatigue, lassitude
Anti-appetite, 'waking effects
Fatigue, lassitude
FOR ACUTE ATTACK
Analgesia, sedation
EFFECTIVE
Sensitivity to drug
Sensitivity to drugs, coronary or cardiovascular disease, severe hypertension
Sensitivity to drug
CONTRAINDICATIONS
B. Prophylactic Treat:ment (Preventing Recurrence of Attacks) General Measures: Same as for migraine. Psychotherapy: As in most cases of migraine, the patient with the complaint of tension headache is in need of psychotherapy because of the personality disturbance, the headache being only one of many manifestations of the problem. Therapy is directed towards changing the behavior and attitudes in the life situation, reducing tension and fatigue. Pharmacotherapy (See "Prophylactic Treatment of l\tligraine"): Amobarbital Sodiunl (A.nlytaJ) Belladenal; Bellergal MiltJwn; Equanil Ultran
Acetylsalicylic acid Phenacetin Caffeine Sandoptal (FIORINAL) D-amphetamine .A.mobarbital Acetylsalicylic acid Phenacetin (DAPRISAL) .> . \.cetylsalicylic acid Phenacetin Caffeine
MEDICATION
1. Specific Therapy
A. Sy:mpto:matic Treat:ment
Tension Headache
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Analgesic:*
Antibiotics Chemotherapy
TUMOR, ABSCESS
Subdural
MUSCULAR AND OSSEOUS
Subarachnoid
AURAL
Local analgesic infiltration
OCULAR
Elevation of head during resting hours
SCLEROSIS
ARTERIO-
GLAUCOMA
Caffeine Sodiunl benzoate 360 mg. (5Y2 grains) I.V. Recumbency with gradual elevation
LUMBAR PUNCTURE
See ·'Surgery" Correct erProstigmine rors of 1'e- Surgery fraction
NEURALGIAS
Lumbar puncture
Management of underlying disorder
ORAL
INFECTIONS
Antibiotics Chemotherapy
Headaches Due to Extracranial Disorders
NASAL AND PARANASAL
Chemotherapy See "Physiotherapy" Antispasmodics and Mild vasoconstrictors sedatives* Symptomatic: Analgesic: Aspirin conlpound Codeine; Fiorinal Sedation * See "Tension Headache-Prophylactic Treatment"
Specific:
Intracerebral
Management of the underlying disorder, which is usually surgical intervention
Extradural
Aspirin C0111pound plus codeine Demerol Antienletic:* Thorazine; Compazine; Trilafon * See Migraine-Nonspecific therapy
Symptomatic:
Specific:
HEMORRHAGE
Headaches Due to Intracranial Disorders
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.A.spirin Codeine compound .. ,
HISTAMINE HEADACHE
,
,
.
TENSION
See "Treatment of Tension Headaches" Psychotherapy
CONVERSION
Psychogenic Headaches
,
~!Iigraine"
.
ARTERITIS (TEMPORAL)
the underlying cause Avoiding the offending Desensitization 'with histamine Corticosteriods allergens Local infiltration Desensitization Surgery Corticosteroids See "Treatn1ent of Allergy Headache" (cortisone, prednisone) Antihistamine See "Symptomatic Treatment of
ALLERGY ~fanagement of
CHRONIC
See "Tension Headache-Symptomatic and Prophylactic Treatment"
Headaches Associated with Systen1ic Disturbances
INFECTION; ENDOCRINE; METABOLIC
Analgesic:
See "Tension HeadacheProphylactic Treatment"
Restriction of salt Antihypertensive drugs Sympathectomy
HYPERTENSION
ACUTE
l\lanagement of surgical problem Aspirin compound} Codeine p.r.n.
Shock
Specific: Management of the underlying cause Symptomatic: Analgesic: Aspirin compound Codeine
Symptomatic:
Specific:
Nonspecific:
Specific:
Headaches Associated with Cranial Trauma
~
~
~
~
~
~
~.
R: ~
c
~
~
~
675
Treatment of Headache CLASSIFICATION OF HEADACHES FOR PURPOS~~S 0(1' DIAGNOSIS AND TREATMENT
1. Migraine Migraine variants Vascular headaches Atypical facial neuralgias 2. Tension headache 3. Headache associated with intracranial disturbances Arteriosclerotic brain diseases Vascular anomalies Aneurysms Tumor Infections 4. Headache associated with extracranial disturbances Eye Ear Nose Bones of the skull and neck 5. Headache associated with cranial trauma 6. Headached associated with systemic disease Hypertension Allergy Arteritis (temporal) Fevers Infection 7. Psychogenic headache Conversion Tension headache
In the preceding tables an outline for treatment of specific headache syndromes has been presented. This is based on the above classification of headaches and should be used as an addendum to the material in the text. REFERENCES 1. Wolff, H. G.: Headache and Other Head Pain. New York, Oxford University Press, 1948, p. 348. 2. Tunis, M. M. and Wolff, H. G.: Analysis of Cranial Artery Pulse Waves in Patients with Vascular Headache of the Migraine Type. Am. J. M. Se. 224: 565, 1952. 3. Brazil, P. and Friedman, A. P.: Craniovascular Studies in Headache; A Report and Analysis of Pulse Volume Tracings. Neurology 6: 96, 1956. 4. Heyck, H., Zurich, Switzerland: Personal communication. 5. Dorpat, T. L. and Holmes, T. H.: Mechanisms of Skeletal Muscle Pain and Fatigue. Arch. Neurol. & Psychiat. 6: 628, 1955. 6. Tunis, M. M. and Wolff, H. G.: Studies on Headache; Cranial Artery Vasoconstriction and Muscle Contraction Headache. A.M.A. Arch. Neurol. & Psychiat. 71: 425, 1954. 7. Judovich, B. D.: Herniated Cervical Disc; New Fornl of Traction Therapy. Am. J. Surge 84: 646, 1952. 8. Friedman, A. P. and Merritt, 11. H.: Treatment of Headache. J.A.M.A. 163: 1111 (March) 1957.
676
Arnold Friedman
9. Friedrnan, A. P.: Modern Therapy in Neurology. St. Louis, C. V. Mosby Co., 1957, p. 272. 10. Friedman, A. P.: Use of Tranquilizers in the Treatment of Headache. Am. Pract. & Digest of Treatment 8: 94 (Jan.) 1957. 11. Friedman, A. P. and von Storch, J. C.: Recent Advances in the Treatment of . Migraine. J.A.M.A. 145: 1325, 1951. 12. Graham, J. R.: Treatment of Migraine. New England J. Med. 253: 770, 1955. 13. Gardner, W. J., Stowell, A. and Dutlinger, R.: Resection of Greater Superficial Petrosal Nerve in Treatment of Unilateral Headache. J. Neurosurg. 4: 105, 1947. 14. Friedman, A. P.: Headache: Diagnosis and Treatnlent. J. Am. Geriat. Soc. 3: 399, 1955. 71 F~ast 77th Street New York 21, N. Y.
M.D. *
IN DISCUSSING the treatment of headache, it should be remembered that \ve are dealing with a symptom which represents a disturbed physiologic state. rrhis article will consider the basic mechanism of headache and the use of pharmacological agents in the treatment of certain specific headache entities. In addition, the role of psychodynamic mechanisms in the production of chronic headache will be considered. It must be admitted that there still remain extensive gaps in our knowledge of causes and mechanism of headache but this does not prevent active and successful therapy in a large number of headache patients.
PHYSIOLOGIC MECHANISMS OF HEADACHE
Vascular Mechanisllls
It is well known that a great majority of headaches have a large vascular component. Studies of patients with migraine have given certain basic information regarding the mechanism of headache.! An initial vasoconstriction of the cerebral arteries produces visual scotoma and possibly other phenomena prjor to the onset of the headache. This prodromal period is then followed by dilatation and distention of cranial arteries primarily in the distribution of the external carotid such as the temporal artery. Pulsations of the temporal artery are increased in amplitude at the beginning of the headache phase of the attack. 2 , 3 Vasodilatation with increased amplitude of pulsations is presumed to cause the headache. When a vasoconstrictor agent such as ergotamine tartrate or noradrenaline is administered, the amplitude of pulsations decreases rapidly and the headache terminates. If treatment is delayed, then dilated vessels become edematous and will not react to vasoconstrictor drugs. In addition, there is transudation of fluid into the tissues sur-
* Physician-in-Charge, Headache Unit, and Attending Physician, Division of Neuropsychiatry, Montefiore Hospital; Associate Professor of Clinical Neurology, College of Physicians and Surgeons, Columbia Univers1:ty; Associate Attending Physician at the Neurological Institute, Presbyterian Hospital; Consultant in Neurology for Veter., ans Administration, New York, N. Y. 65D
660
Arnold Friedman
rounding the vessel. Alterat ions in the size and pulsations of the cranial indearteries do not entirely explain the pain, since they may exist fluid the that ed present been has ce penden tly of any headache. J1~viden lar molecu low of ce substan a s presen t in the edemat ous tissue contain been has It ld. thresho pain the g weight, which is responsible for lowerin not theorized that during an attack of vascula r headache there exists arteranial extracr large the of ion only a loss of tone and marked distent es ies, but also a dilatati on and increase in permea bility of the arteriol a enables bility permea ed increas This and capillaries in the same region. the into diffuse to ld thresho pain the substan ce capable of lowering subperiart erial tissues. It has been assumed that the presence of this headthat so , painful arteries large stance renders the distent ion of the ache ultimat ely results from a combination of the two factors. e Persist ent dilatati on of the blood vessels results in a rigid, pipelik the ng replaci ache steady a is stage state of the vessels. The pain at this d by earlier, throbbing, pulsati ng type. Prolonged headache, initiate and neck the of tions contrac ed vascula r changes, usually leads to sustain pain The pain." tion contrac e "muscl scalp muscles and the additio n of associated with spasm of the muscles may outlast the initial pain. If during an attack of migraine headache the tempor al veins and indiarteries are promin ent, examination of venous blood from this 4area rFurthe ized. arterial i.e., red, and cates it is under increased pressure below be may side painful the on more, the arteriovenous oxygen ratio that normal even during the pain-free interva ls. This may indicat e venous the of ization arterial arteriovenous shuntin g has occurred with the blood. Such shunts could render tissues anoxemic with lowering of of de amplitu in on reducti a pain threshold. It is possible that both enous arteriov the of closing a pulsati on of the affected vessels plus shunts is necessary to abort an attack of migraine headache. Muscu lar Mecha nisms
a Sustained contrac tion of skeletal muscles of the head and neck is Headscalp. and neck the frequen t source of pain and dysesthesia in such aches from this source occur in association with vascula r headaches rative, degene atory, as migraine as described above, and with inflamm l trauma tic and neoplastic diseases about the face, head, neck, cervica r, howeve d, observe nly vertebr ae and nerve roots. They are most commo in relationship to emotional tension, so-called tension headache. There is an is some evidence that hypoxia associated with these muscle spasms 6 , 6 Anothe r factor which may import ant factor in the inducti on of pain. of be partiall y responsible for the pain is an excessive concen tration tissues. the in s eceptor potassium in the muscle stimula ting the chemor ea Also, noxious stimula tion of the soft tissues of the neck may produc pain. head in central spread of the excitat ory effects resulting
Treatment of Headache
661
The fact that painful spasms of the muscles of the neck and scalp may be referred to the head and face suggests the possibility that such pain may be referred via the upper cervical nerve roots. Furthermore, one can palpate trigger zones in the neck which give rise to head and facial pain. The mechanism of projection of the pain from cervical nerve roots to the head and face has been postulated as traveling via the descending root of the trigeminal nerve or by reflex stimulation of the sympathetics. 7 Psychological Mechanisllls
The importance of psychological factors in patients with chronic headache is well documented. In many patients it is difficult to prove that psychogenic elements are the primary etiological agent. It must be remembered that psychic qualities are related to constitutionally determined differences in the individual, as well as to impaired physiological functioning. Therefore, in discussing psychological mechanisms, they are to be considered as functioning in the total environment of the individual and not as a solitary entity. Attempts have been made to attach certain specific personality profiles to patients having migraine and other types of chronic headache. It has been noted that many people with migraine are compulsive, perfectionistic and methodical. However, far more people with these personality traits do not have headache than those who do. In our experience the personality manifestations in people with migraine and other types of chronic headaches are extremely variable and may include a variety of precipitating psychodynamic factors. The conflicts most frequently observed in these patients are those related to hostile impulses directed against members of their families or persons who represent family figures. Other precipitating psychodynamic factors include identification, a wish to remain in a position of dependency, a method of gaining attention, etc. The symptom headache is a defense against the conscious recognition of the conflict. It acts as a protective mechanism for the patient, preventing him from recognizing his feelings toward someone he loves or upon whom he is dependent. It is accepted by many psychiatrists that, except for the intensity of the conflict, there is little difference psychologically between the patient who has migraine and the one with psychogenic or tension headache. In a large group of patients with headache the pain is the presenting symptom of an anxiety state or a depression. Frequently in such patients a careful investigation reveals a host of behavior disturbances and neurotic reactions forming an integral part of the presenting complaint of headache. The psychological picture and reactions in these patients are varied and numerous. In patients with psychic distress, headaches occur because of two mechanisms. In one group the mental conflict stimulates the autonomic
. 4. rnold Friedman
662
nervous system, producing changes in the caliber of the blood vessels of the head, or stimulates the somatic motor system with contraction of skeletal muscles of the neck and scalp. Such mechanisms may act initially independently or concomitantly. In another group the mechanism of the headache is on the basis of a conversion reaction. The symptom represents a specific unconscious symbolic meaning to the patient. In this patient the head is used as the organ of expression of the conflict. No attempt will be made to discuss the procedures used in psychotherapy. Emphasis is needed on the importance of discussing vvith the patient the limitations of therapy and the fact that it will be lengthy. Ventilation of wholly or partly unconscious emotional conflicts by the patient, environmental manipulation, re-education and direction are important techniques in therapy. Through it all the patient-physician relationship dominates the treatment. Such therapy is vvithin the province and ability of the interested general practitioner. In some patients, where the aim is considerable alteration and reorganization of the personality, analytical psychotherapy is necessary. PHARMACOTHERAPY The selection of drugs to be used in treatment of patients with chronic headaches is complicated by the fact \ve are dealing ,,,ith a problem which has strong psychological connotations to the patient, for a symption which is related to the head carries \vith it a considerable emotional threat to the patient, such as fear of loss of mind, disorder of the brain or loss of intellectual capacity. I~esponse to a remedy \V"ill be \veighted by the physician-patient relationship, constitutional make-up and age of the patient, duration of symptoms, psychological status, and understanding of the pharmacologic actions of the drugs being used. 8 In the treatment of headache by chemical agents, two general aspects should be considered: (1) symptomatic, i.e., the treatment of an attack; (2) prophylactic, or the prevention of attacks. 1-'he goals in pharmacotherapy are to interrupt the mechanism producing pain, to raise the pain threshold, and to reduce emotional tension and anxiety responsible for or associated with this pain. In the present text we will discuss the drugs commonly used in the treatment of headache \vhich in our experience have been the most effective. 9 Emphasis will be placed on treatment of the types of headache which the clinician is most likely to meet in his practice. Specific Drugs Analgesics. The commonest analgesic used in the treatment of headache is the antipyretic coal-tar derivatives, particularly acetylsalicylic acid and acetophenetidin. Their action is more effective ,vhen they are
Treatment of Headache
663
combined with or added to caffeine or as a mixture with barbiturate or codeine. Although the types of pain relieved by the coal-tar derivatives are usually those of low intensities, they represent the safest and most efficient analgesics for headache sufferers. rfhey act by raising the pain threshold possibly through depression of the pain centers in the thalamus. Salicylates reach a maximum blood level several hours after ingestion and their therapeutic effect is gone within three to four hours. The duration of action may be prolonged by the administration of frequent doses. For relief of severe pain it is necessary to use the opiate analgesics. Ho,vever, except in rare situations, we are limited to the use of codeine, i.e., methyl morphine, for treatment of severe headache. Codeine not only acts by raising the pain threshold but probably has other central effects on the cerebral cortex which reduce the emotional tension and produce a sedative effect. Codeine is administered as a phosphate or sulfate. Codeine combined with the salicylates and caffeine is the drug of choice to control headache caused by inflammation of cranial structures, space-occupying lesions, head trauma, and in severe headaches associated with some systemic disturbances. More recently there has been introduced a codeine substitute, Propoxyphene Hydrochloride, which has been reported as having the analgesic potential of codeine without the side effects or addicting properties. Ilypnotics and Sedatives. Hypnotics and sedatives seldom control severe or persistent headaches unless combined with an analgesic. When barbiturates are combined vvith salicylates the combination frequently is more effective than when the analgesic is used alone. This occurs in spite of the fact it is not possible to demonstrate a decrease in pain perception beyond that produced by the analgesic itself. Such a combination is particularly effective in the treatment of tension headache. Barbiturates of short and medium action are to be used in the treatment of headache. Tranquilizers. The tranquilizing drugs are effective in controlling tension headache and the associated autonomic nervous system symptoms in some patients. In others with similar symptomatology they are not effective. The value of these drugs in psychosomatic problems is far from being adequately assessed. lo Our experience has been mainly with four agents of this group: reserpine; chlorpromazine hydrochloride (Thorazine); 2 methyl-2-N-propyl-l, 3-propanediol dicarbamate (meprobamate; Miltown; Equanil); and 2-p-chlorophenyl-3-methyl-2, 3-butaneidiol (Ultran). The dosage with these drugs is highly individualized~ for instance, some patients respond to small doses of the drug, while others need much more. Therefore, securing adequate dosage range and proper dosage which can be adapted to the patient's condition becomes of paramount importance. We advocate that the drug be discontinued
664
Arnold Friedm;an
if the patient does not respond within two months. In general, our observations indicate that patients who do not respond to one tranquilizer do not respond to another drug of this type. The importance of proper physical and mental examinations in patients receiving these drugs is obvious, for they are capable of producing both physical and mental symptoms. Of course results with the tranquilizerB, BedativeB and other drugs in the treatment of headache must be compared \vith the high percentage of good results secured with the use of placebos in these patients. Unfortunately there are no entirely satisfactory methods of evaluating objectively the results of a predominantly subjective symptom such as headache. Anticonvulsants. The use of anticonvulsant drugs as a means of preventing migraine headaches has been unsuccessful except in a small number of patients who have a family history heavily weighted with migraine and/or epilepsy, give a history of aphasia, hemiplegia, paresthesias prior to or during the headache attack, and reveal an abnormal electroencephalogram with spiked patterns. In some patients the hydantoins may be combined with caffeine for more effective results. Stimulants of the Central Nervous System. Caffeine is a methylated xanthine \vhich is a powerful central nervous system stimulant whose main action is on the psychic and sensory functions. Present evidence indicates caffeine tends to constrict the cerebral arterioles and reduce cerebral blood flow. Caffeine is widely used in the treatment of headache and it is usually combined with salicylates in the treatment of the routine type of headache and with ergotamine in migraine. Whether its effectiveness is due to its vasoconstrictor action or the fact it potentiates the action of other drugs is still unknown. Caffeine can also be responsible for headache, as observed in the caffeine withdrawal headache. Caffeine is used alone in the treatment of postlumbar headache and some recommend it as symptomatic treatment for headaches associated with hypertension. ])extro-amphetamine (Dexedrine) is a potent central nervous system stimulant. 'rhe central nervous system activity of Dexedrine is about t\vice as pronounced as that of Benzedrine. It is used in the treatment of headache combined with a salicylate, particularly for those headaches associated with depression, fatigue, and following a hangover. In some patients with tension headaches, combined with amobarbital, it is of value in interim and symptomatic treatment, as it has a beneficial effect on most and also seems to relieve the underlying tensions. Drugs Acting Directly on Blood Vessels-Dilators. Nitrites, particularly nitroglycerin, are used as a provocative test in patients with migraine. We have obtained positive results in only about 50 per cent of our patients. Papaverine and similar vasodilators, in our experience, have
Treatment of Headache
665
not been used effectively in the treatment of arteriosclerotic and other types of arteriovascular headache. Histamine and Antihistamine. There is considerable difference of opinion regarding the value of histamine in the treatment of headache. Histamine is present in all complete proteins and affects almost all tissues, producing dilatation of the smaller blood vessels, stimulation of glands, etc. It is inactive when taken by mouth, probably because of destruction by the enzyme which is present in the intestinal mucosa. Because histamine can produce headache when injected into a person, and Horton has described a type of headache which is called "histamine cephalalgia," the treatment of vascular headaches by using repeated doses of histamine in order to develop tolerance to this chemical agent has been recommended. However, in our experience and that of others, the treatment of vascular headaches by histamine desensitization has not proved successful. Antihistaminic agents have been used in the treatment of headache on the theory that any compound which is capable of blocking the action of histamine should prevent allergic manifestations. Our clinical observations indicate that the use of antihistaminic agents in the treatment of headache are limited to those patients \vhose headaches arc associated with an allergic manifestation such as vasomotor rhinitis. Individuals differ greatly in their response to antihistamines; therefore therapy with this type of medication must be flexible, and preparations changed according to the clinical response. Water and Electrolyte Metabolism-Diuretics. Present clinical and experimental evidence indicates that fluid and electrolyte changes in patients with vascular headache are associated phenomena and not a causal factor. However, in patients who, particularly during or prior to their menstrual periods, show a rapid weight gain and evidence of edema, a trial of diuretics is indicated. Acetazolamine (Diamox) and acid diuretic salts such as ammonium chloride may be administered prior to their periods. Such patients should also be placed on a salt-poor diet. Patients who have increased intracranial pressure may receive temporary relief by use of hypertonic solutions of glucose and sucrose. These substances act by reducing the brain edema, hence lessening traction on the pain-sensitive structures intracranially. Vitamins. Our experience with the administration of vitamins in preventing or aborting headaches has indicated that they are of little value. Multiple vitamin supplements are worthy of a trial in the elderly and debilitated patients with headaches, as a general supportive measure. Hormones. The treatment of migraine by use of hormones has generally not benefited our patients. In a few patients androgens, i.e., methyltestosterone, have been used successfully in patients whose headaches occur during menstruation or immediately before it. Methyl-
666
~4rr~old
Friedman
testosterone, which is available for buccal use, should be kept below 75 mg. per week. In females who at the time of menopause show marked signs of vasomotor instability including hot flashes, sweats, palpitation and headache, the administration of estrogens with or without androgens may be used. In most of these patients the symptoms are related to emotional factors and can be better relieved by suitable supportive psychotherapy and the conservative use of analgesics and sedatives. When estrogens are used they should be given in small doses, in cyclic fashion, with decreasing doses. All patients who are given estrogens should be carefully screened by gynecological examination before and during therapy. If small doses of the drug do not control the problem, large doses will be of no avail. In patients with hypothyroidism who complain of headache, the use of thyroid preparations may be quite helpful in relieving the symptom. ])rugs I nfiuencing the A utonomic Nervous System. Our discussion of drugs in this group will be limited to ergotamine tartrate which is the most effective agent available for symptomatic treatment of migraine. u . 12 Ergotamine is derived from lysergic acid and contains a polypeptide side chain. Dosage levels used in treatment of migraine have no significant adrenergic blocking action. Its effectiveness in an attack of migraine is due to its constrictor effect on the smooth muscles of the blood vessels and a decrease in amplitude of their pulsations. The fate and excretion of ergot alkaloids is still in need of further investigation. In those patients who tolerate ergotamine poorly, the use of dihydroergotamine methene sulfonate (D.H.E. 45) is indicated. More recently many forms of ergot derivatives have been made available as proprietary preparations, first incorporating caffeine and following that, antispasmodics, antiemetics, sedatives and central nervous system stimulants. Rectal use of ergotamine has proved empirically to be more efficacious than oral medication. In other types of vascular headaches, including atypical facial neuralgia, cyclic or histamine headache, and other migraine variants, ergotamine tartrate preparations are effective for symptomatic treatment. I~hysiotherapy. Sustained contraction of the muscles of the head and neck are frequently a mechanism which produces headache. Treatment of these muscular disorders is based on a variety of physical methods including hydrotherapy, electricity, exercise, massage and mechanical devices such as collars and traction. In some patients ethyl chloride spray may be employed to secure relief of muscle spasm and pain. Injection of procaine hydrochloride, 1 to 2 per cent, into tender areas of the neck is helpful temporarily in some headaches associated with discogenic disease, myofibrositis and myalgia of the neck.
Treatment oj· Headache
667
Surgery
Treatment of head pain by surgical techniques is limited to a fe,v specific conditions. They may be effective in the presence of intracranial mass, such as tumor, abscess, hematoma or aneurysm. Head and neck pain developing from cervical disk and cervical rib may be relieved by surgical approach. In neuralgia (trigeminal, glossopharyngeal, etc.), surgery is frequently indicated. Glaucoma, which may produce headaches similar to migraine, will frequently necessitate surgical intervention. In this group treatment is for the underlying specific condition and headache is an incidental symptom. Surgical procedures for migraine are usually not recommended. They are of two types: reduction of arterial dilatation by ligation or neurectomy, or interrupting of the afferent nervous pathways transmitting pain from arteries. Novocain and alcoholic infiltration of arteries have been used but only with temporary success. Another group of vascular headaches belonging in the migraine class are frequently called atypical facial neuralgia. The attacks differ from migraine in that they are of short duration with marked manifestations of cranial autonomic activity on the side with pain, including ipsilateral stuffiness of the nose and injection of the eye. Section of the greater superficial petrosal nerve has been suggested as a means of relieving this syndrome. la No great therapeutic triumph has emerged from this procedure or from sympathectomy, removal of the sphenopalatine ganglia or trigeminal rhizotomy. Following sudden rotation of the head, injury of the upper cervical nerves may occur with onset of cephalic neuralgia. Cocainization of the cervical nerve root may effectively stop such pain. In patients with severe hypertension, headaches are frequently present. The use of the Smithwick operation in certain special selected cases has been sugge~ted as a means of lowering blood pressure and eliminating headaches. It should be noted that the correlation between height of blood pressure and severity of headache has never been clearly demonstrated. In the management of the patient with headache we must consider the fact that we are dealing with a symptom and not a disease. Many headaches are secondary to a specific acute illness and are treated through control of the primary pain and correction of the underlying disorder. However, the majority of treated cases of chronic headache fall into a group in which the symptoms are due to migraine or are primarily associated with emotional disturbance, tension headache. For purposes of diagnosis and therapy, we classify our headaches in the categories14 listed on page 675.
1 mg.
(CAFERGOT)
Ergotamine tartrate Caffeine Bellafoline Pentobarbital sodium (CAFERGOT PB) Ergotamine tartrate Caffeine Bellafoline Pentobarbital sodium (CAFERGOT PB)
2 mg. 100 mg. 0.5 mg. 60 mg.
1 n1g. 100 mg. 0.125 mg. 30 mg.
suppos.
tab.
suppos.
2 mg. 100 n1g.
Ergotalnine tartrate Caffeine
(CAFERGOT)
tab.
1 mg. 100 mg.
tab.
amp.
FORM
Ergotamine tartrate Caffeine
(GYNERGEN)
t 0.5
Ergotamine tartrate
(GYNERGEN)
50.25 mg. mg.
AMOUNT
Ergotamine tartrate
MEDICATION
1. Specific Therapy-Pharmacotherapy
A. Sym.ptom.atic Treatlllent
1-2 suppos.
2-6 tabs.
1-3 suppos.
2-6 tabs.
2-6 tabs.
0.25-0.5 mg.
DOSAGE
spasmodic and sedation
V.,. asoconstriction, anti-
Vasoconstriction
ACTION
As above plus dryness of mucous membranes and skin, drowsiness
"
Nausea, vomiting, numbness and tingling of hands and feet, muscle pains in thighs and neck, abdominal pain, prostration
EFFECTIVE DRGGS FOR ACUTE ATTACK
SIDE EFFECTS
OF SPECIFIC HEADACHE SYNDROMES
l\figraine and Vascular Headache
TREAT~IENT
As above plus glaucoma
Septic infectious states, vascular diseases, coronary sclerosis, history of angina, pregnancy, hypertension, imp3ired renal or hepatic function
CONTRAINDICATIONS
;:s
~
~
~
~
~.
~~
~
s:
~ ~
;:s c
~
~
Rest in dark room-ice bag to head.
(AMYTAL)
may also be used Amobarbital sodium
90 mg.
25 nlg.
Chlorpromazine
tab.
tab.
tab.
30 mg.
(THORAZINE) COMPAZINE and TRILAFON
tab.
tab.
tab.
210 mg. 150 mg. 30 mg.
50 mg. 25 mg.
nlg. mg. mg. mg.
1 mg.
1 100 0.1 130
Acetylsalicylic acid Acetophenetidin Caffeine plus Codeine phosphate
2. N onspecijic Therapy
(MIGRAL)
Ergotamine tartrate Caffeine Cyclizine H Cl
(WIGRAINE)
Ergotamine tartrate Caffeine Belladonna alkaloids Acetophenetidin
.A.ntiemetic, sedation
1-2 tabs.
Sedation
Raise pain threshold
1-2 tabs.
1-2 tabs.
Analgesic, sedation
Vasoconstrictor, antiemetic
Vasoconstriction, antispasmodic and analgesic
2 tabs.
1-4 tabs.
2-6 tabs.
Sensitivity to drug
Same as for Ergotamine Tartrate
Septic infectious states, vascular diseases, coronary sclerosis, history of angina, pregnancy, hypertension, impaired renal or hepatic function plus glaucoma
Sleepiness, skin erup- Sensitivity to drug, cardiotions, mental disturbvascular renal disease and ances impaired hepatic function
Severe nausea and vomit- Addiction ing, constipation Drowsiness, hypotension, Gallbladder-liver disease jaundice, agranulocytosis
Fatigue, lassitude
"
Nausea, vomiting, numbness and tingling of hands and feet, muscle pains in thighs and neck, abdominal pain, prostration plus dryness of mucous nlenlbranes and skin
OJ
~
~
~
~
~ ~ ~
~ ~ ~
~
~
~
~
~
~
~
(ULTRAN)
2-p-chlorophenyl-3methyl-2, 3 butanediol
(MILTO'VN; EQUANIL)
Meprobamate
MEDICATION
300 mg.
400 mg.
AMOUNT
tab.
tab.
FORM
t.i.d.
1 tablet
2-4 tabs. a day
DOSAGE
Tranquilizer
Tranquilizer
ACTION
SIDE EFFECTS
Drowsiness, lassitude, skin eruption, nausea
EFFECTIVE DRUGS FOR PROPHYLAXIS
"
Sensitivity to drug
CONTRAINDICATIONS
Pharmacotherapy: As an adjunct to psychotherapy in severe cases of tension and anxiety, pharmacotherapy may be helpful. In son1e patients pharmacotherapy alone reduces the frequency of attacks.
Surgery: In general, these procedures should be avoided and have not been successful in preventing the recurrence of headache except in a fe"r isolated instances. These are discussed in the section on "Treatment of Headache by Surgery." In an occasional patient 'whose headaches are incapacitating and who is refractory to all types of medical and psychiatric therapy, or in the presence of vascular disease which may prevent specific treatment, surgery may be considered.
Psychotherapy: Attempt to give patients understanding and insight into their behavior and attitudes 'which produce stress, and to reduce anxiety and tension in their life situations. Re-education and reorientation with respect to the patient's personal, economic, and social life, etc.
General Measures: Avoidance of fatigue and stress. Adequate hygiene. Avoidance of specific activities, dietary indiscretions, alcohol, etc., 'which may precipitate an attack.
B. Prophylactic TreatlDent of Migraine (Preventing Recurrence of Attacks)
~
~
~
~
R..
~
~.
~
R..
~
C
~ '"i ~
~
1-3 tabs. a day
1-3 caps.
cap.
100 mg.
. .~nticonvulsant
An ticonvulsan t
Sedative
1-2 tabs. a day
tab.
tab.
90 nlg.
Antispasmodic, sedative, vasoconstrictol
. ~. ntispasmodic, sedative
Tranquilizer, antihypertensive
1 Spacetab twice daily
1 Spacetab twice daily
1-2 tabs. a day
100 mg.
tab.
0.2 mg. O.6mg. 40 mg.
Methyl-phenyl-ethylhydantoin (MESANTOIN) Diphenylhydantoin (DILANTIN)
tab.
0.25 mg. 50mg.
Bellafoline Phenobarbital (BELLADENAL) Bellafoline Ergotamine tartrate Phenobarbital (BELLERGAL) Amobarbital sodium (AMYTAL)
tab.
0.25 mg.
Reserpine (SERPASIL)
Morbilliform rash, dizziness, nystagmus, ataxia
Sleepiness, skin eruptions, mental disturbances Sleepiness, paresthesias, ataxia, aplastic anemia
Dryness of nasa,] mucosa, sleepiness
Drowsiness, dryness of nasal mucosa, nausea, depression Dryness of nasal mucosa, sleepiness
~
~
~
~
~ .....,
~
~
Sensitivity to drug
Sensitivity to drug, cardiovascular renal disease and impaired hepatic function Sensit-ivy to drug
~ ~
~
~
~
~
~ ~ ~
~ Glaucoma; vascular disease ~ ~
Glaucoma
Depressed patients
tab.
tabs.
tab.
5mg. 32 mg. 160 mg. 160 mg.
210 mg. 150 mg. 30mg.
FORM
200 mg. 150 mg. 40mg. 50mg.
AMOUNT
2 tabs.
1-2 tabs.
1-2 tabs.
DOSAGE
DRUGS
ACTION
Analgesia, sedation
A.nalgesia, stimulation
SIDE EFFECTS
Fatigue, lassitude
Anti-appetite, 'waking effects
Fatigue, lassitude
FOR ACUTE ATTACK
Analgesia, sedation
EFFECTIVE
Sensitivity to drug
Sensitivity to drugs, coronary or cardiovascular disease, severe hypertension
Sensitivity to drug
CONTRAINDICATIONS
B. Prophylactic Treat:ment (Preventing Recurrence of Attacks) General Measures: Same as for migraine. Psychotherapy: As in most cases of migraine, the patient with the complaint of tension headache is in need of psychotherapy because of the personality disturbance, the headache being only one of many manifestations of the problem. Therapy is directed towards changing the behavior and attitudes in the life situation, reducing tension and fatigue. Pharmacotherapy (See "Prophylactic Treatment of l\tligraine"): Amobarbital Sodiunl (A.nlytaJ) Belladenal; Bellergal MiltJwn; Equanil Ultran
Acetylsalicylic acid Phenacetin Caffeine Sandoptal (FIORINAL) D-amphetamine .A.mobarbital Acetylsalicylic acid Phenacetin (DAPRISAL) .> . \.cetylsalicylic acid Phenacetin Caffeine
MEDICATION
1. Specific Therapy
A. Sy:mpto:matic Treat:ment
Tension Headache
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Analgesic:*
Antibiotics Chemotherapy
TUMOR, ABSCESS
Subdural
MUSCULAR AND OSSEOUS
Subarachnoid
AURAL
Local analgesic infiltration
OCULAR
Elevation of head during resting hours
SCLEROSIS
ARTERIO-
GLAUCOMA
Caffeine Sodiunl benzoate 360 mg. (5Y2 grains) I.V. Recumbency with gradual elevation
LUMBAR PUNCTURE
See ·'Surgery" Correct erProstigmine rors of 1'e- Surgery fraction
NEURALGIAS
Lumbar puncture
Management of underlying disorder
ORAL
INFECTIONS
Antibiotics Chemotherapy
Headaches Due to Extracranial Disorders
NASAL AND PARANASAL
Chemotherapy See "Physiotherapy" Antispasmodics and Mild vasoconstrictors sedatives* Symptomatic: Analgesic: Aspirin conlpound Codeine; Fiorinal Sedation * See "Tension Headache-Prophylactic Treatment"
Specific:
Intracerebral
Management of the underlying disorder, which is usually surgical intervention
Extradural
Aspirin C0111pound plus codeine Demerol Antienletic:* Thorazine; Compazine; Trilafon * See Migraine-Nonspecific therapy
Symptomatic:
Specific:
HEMORRHAGE
Headaches Due to Intracranial Disorders
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HISTAMINE HEADACHE
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TENSION
See "Treatment of Tension Headaches" Psychotherapy
CONVERSION
Psychogenic Headaches
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ARTERITIS (TEMPORAL)
the underlying cause Avoiding the offending Desensitization 'with histamine Corticosteriods allergens Local infiltration Desensitization Surgery Corticosteroids See "Treatn1ent of Allergy Headache" (cortisone, prednisone) Antihistamine See "Symptomatic Treatment of
ALLERGY ~fanagement of
CHRONIC
See "Tension Headache-Symptomatic and Prophylactic Treatment"
Headaches Associated with Systen1ic Disturbances
INFECTION; ENDOCRINE; METABOLIC
Analgesic:
See "Tension HeadacheProphylactic Treatment"
Restriction of salt Antihypertensive drugs Sympathectomy
HYPERTENSION
ACUTE
l\lanagement of surgical problem Aspirin compound} Codeine p.r.n.
Shock
Specific: Management of the underlying cause Symptomatic: Analgesic: Aspirin compound Codeine
Symptomatic:
Specific:
Nonspecific:
Specific:
Headaches Associated with Cranial Trauma
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Treatment of Headache CLASSIFICATION OF HEADACHES FOR PURPOS~~S 0(1' DIAGNOSIS AND TREATMENT
1. Migraine Migraine variants Vascular headaches Atypical facial neuralgias 2. Tension headache 3. Headache associated with intracranial disturbances Arteriosclerotic brain diseases Vascular anomalies Aneurysms Tumor Infections 4. Headache associated with extracranial disturbances Eye Ear Nose Bones of the skull and neck 5. Headache associated with cranial trauma 6. Headached associated with systemic disease Hypertension Allergy Arteritis (temporal) Fevers Infection 7. Psychogenic headache Conversion Tension headache
In the preceding tables an outline for treatment of specific headache syndromes has been presented. This is based on the above classification of headaches and should be used as an addendum to the material in the text. REFERENCES 1. Wolff, H. G.: Headache and Other Head Pain. New York, Oxford University Press, 1948, p. 348. 2. Tunis, M. M. and Wolff, H. G.: Analysis of Cranial Artery Pulse Waves in Patients with Vascular Headache of the Migraine Type. Am. J. M. Se. 224: 565, 1952. 3. Brazil, P. and Friedman, A. P.: Craniovascular Studies in Headache; A Report and Analysis of Pulse Volume Tracings. Neurology 6: 96, 1956. 4. Heyck, H., Zurich, Switzerland: Personal communication. 5. Dorpat, T. L. and Holmes, T. H.: Mechanisms of Skeletal Muscle Pain and Fatigue. Arch. Neurol. & Psychiat. 6: 628, 1955. 6. Tunis, M. M. and Wolff, H. G.: Studies on Headache; Cranial Artery Vasoconstriction and Muscle Contraction Headache. A.M.A. Arch. Neurol. & Psychiat. 71: 425, 1954. 7. Judovich, B. D.: Herniated Cervical Disc; New Fornl of Traction Therapy. Am. J. Surge 84: 646, 1952. 8. Friedman, A. P. and Merritt, 11. H.: Treatment of Headache. J.A.M.A. 163: 1111 (March) 1957.
676
Arnold Friedman
9. Friedrnan, A. P.: Modern Therapy in Neurology. St. Louis, C. V. Mosby Co., 1957, p. 272. 10. Friedman, A. P.: Use of Tranquilizers in the Treatment of Headache. Am. Pract. & Digest of Treatment 8: 94 (Jan.) 1957. 11. Friedman, A. P. and von Storch, J. C.: Recent Advances in the Treatment of . Migraine. J.A.M.A. 145: 1325, 1951. 12. Graham, J. R.: Treatment of Migraine. New England J. Med. 253: 770, 1955. 13. Gardner, W. J., Stowell, A. and Dutlinger, R.: Resection of Greater Superficial Petrosal Nerve in Treatment of Unilateral Headache. J. Neurosurg. 4: 105, 1947. 14. Friedman, A. P.: Headache: Diagnosis and Treatnlent. J. Am. Geriat. Soc. 3: 399, 1955. 71 F~ast 77th Street New York 21, N. Y.