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Never Give Up On Intractable Headaches.

BAL HARBOUR, FLA. -- When nothing you do seems to help a patient with intractable headache, don't blame the patient--and never give up hope, Dr. Joel R. Saper said at the annual meeting of the American Headache Society.

If the patient has complied with therapy, you must assume that he or she has an intrinsic disorder that defies medical understanding. Give patients a reasonable hope that progress in medical knowledge will someday help them to manage their chronic headache, said Dr. Saper, director of the Michigan Head Pain and Neurological Institute in Ann Arbor.

When all else fails, take more medical history that could provide clues to the headache's etiology. Check again to see whether patients have been avoiding their migraine "triggers."

Repeat tests or get additional tests, especially a lumbar puncture, to assess the presence of inflammatory or infectious changes or alterations in cerebral spinal fluid pressure. Dr. Saper routinely orders urine toxicology tests on newly referred patients.

In patients with unresponsive headaches, think particularly of these factors:

* Rebound headache. Excessive use of nearly any short-acting drug used to abort headaches can cause rebound headaches. The rebound headaches will continue until the patient stops taking the offending medication and remains off of it for days, weeks, or even months. In most cases, once the detoxification is complete, standard headache medications will work.

* Wrong diagnosis. A patient diagnosed with cluster headache, for example, may in fact have a variant called chronic paroxysmal hemicrania, which responds principally to indomethacin and not to cluster headache treatments.

Hypnic headache, a nocturnal headache with features similar to migraine, won't respond to migraine therapies but can be treated with lithium. Another headache disorder that shares some features with migraine is hemicrania continua, a persistent unilateral headache that responds to indomethacin. Organic causes of headache--sphenoid sinusitis, glaucoma, occult dental disorder, acoustic neuroma, and others--may cause a secondary headache or a primary one.

* Inadequate medication. Choosing the correct drug at adequate doses involves some trial and error. One strategy for both acute and preventative therapy is to give the patient a trial with each therapeutic mechanism available.

* Untreated comorbid disorders. One study showed that 60% of patients diagnosed with borderline personality disorder had severe headaches. Other studies suggest a link between the biology of borderline personality disorder and pain mechanisms.

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Comment:Never Give Up On Intractable Headaches.
Publication:Family Practice News
Article Type:Brief Article
Geographic Code:1USA
Date:Mar 15, 2001
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