Why headache treatment fails
Authors:
Lipton, RB; Silberstein, SD; Saper, JR; Bigal, ME and Goadsby, PJ
Source: Neurology, 2003;60:1064-1070
Management of headache disorders – a leading reason for neurologic outpatient visits – is often difficult. The authors have summarised and categorised the common reasons for treatment failure, leading to referral to sub-speciality headache centres.
They have groups these treatment failures into five broad categories:
- The diagnosis is incomplete or incorrect;
- Important exacerbating factors have been missed;
- Pharmacotherapy has been inadequate;
- Non-pharmacologic treatment has been inadequate;
- Other factors, including unrealistic expectations and comorbidity, exist.
1. The diagnosis is incomplete or incorrect
Perhaps the most common reason for treatment failure is that the diagnosis is incomplete or inaccurate. This issue takes three major forms:
- a secondary headache disorder goes undiagnosed, e.g. medication misuse with rebound headache, giant cell arteritis, carotid dissection, high- and low-pressure headaches, chronic sphenoid sinusitis, etc.
- a primary headache disorder is misdiagnosed, e.g. hemicrania continua, with its chronic, unilateral pain, is commonly mistaken for chronic (transformed) migraine; paroxysmal hemicrania is occasionally mistaken for cluster headache.
- or two or more headache disorders are present and at least one goes unrecognised.
2. Important exacerbating factors have been missed
Medication overuse, caffeine overuse, dietary or lifestyle triggers, hormonal triggers, psychosocial factors, or the use of other medications that trigger headaches, such as nitroglycerine, may lead to intractability.
3. Pharmocotherapy may be inadequate
Inadequate pharmacotherapy may occur if inappropriate treatments are selected, if excessive initial doses are used, if final doses are inadequate, if the duration of the treatment is too short, if combination treatment is required, if the patient fails to absorb the drug, or if the patient is non-compliant.
4. Non-pharmacologic treatment has been inadequate
Patients who are tense sometimes need physical medicine or behavioural interventions. Physical therapy is often a useful adjunct. Cognitive training may help patients who are tense and anxious and have trouble getting their headaches under control.
5. Other factors
Treatment may fail if the patient has unrealistic expectations. As symptoms improve, patients’ expectations may escalate and they may forget how bad there headaches were previously.
Comorbid conditions occur in migraineurs with a greater frequency than would be expected by chance, and may complicate therapy. Migraine is comorbid with depression, anxiety, affective disorders, stroke, and epilepsy. Concomitant diseases occur together with chance frequency; common concomitant diseases that limit options in migraine treatment include asthma, ulcers and gastritis, and vascular disease and uncontrolled hypertension.
The third main reason treatment may fail is when inpatient treatment is required but not offered. When outpatient treatment fails and patients have continuing and severe pain and disability, more aggressive treatment interventions may be required.
