There are two approaches to preventive treatment, one by reducing the sensitivity of the migraine generator by means of drugs, and the other by reducing the number of impulses reaching the migraine generator.
All drugs have side effects and this approach is only recommended if all else fails. In addition, the drugs used to prevent primary headaches are often not effective.
It is preferable to make every effort to diagnose where abnormally high numbers of impulses are coming from and why, and to treat the cause or causes. In most primary headache sufferers, it is possible to achieve effective prevention without the use of drugs.
The best way to get to the root of the problem is by a “multidisciplinary” approach. There are so many different structures in the head and neck, all of which can be involved in the headache process, that no single specialist can have all the knowledge necessary to make a comprehensive assessment and diagnosis. For this reason, the expertise of different specialists who would normally treat headache patients in isolation, is combined and integrated into a single more comprehensive body of knowledge. This makes it possible to provide a co-ordinated treatment plan, so that all the contributing factors are addressed.
There are several common-sense courses of action that may well prevent headaches by removing the triggering factors: A change in lifestyle that reduces stress may be enough – although for the majority of people, changing one’s lifestyle is in practice impossible.
Some sufferers notice that certain situations or habitual patterns of behaviour are likely to trigger headache. Avoiding certain trigger foods and chemical compounds (perfumes, smoke) may be helpful in the management of migraine. Getting regular exercise, avoiding excessive caffeine and alcohol, stopping smoking and ensuring adequate hydration may also be helpful in some individuals, and they also have all sorts of other benefits.
Drugs for headache are either prophylactic or symptomatic.
Prophylactic medications are taken daily and are directed towards preventing the headache from developing in the first place. They are not pain medications.
There are a wide variety of prophylactic medications. Tricyclic antidepressants, like amitryptyline, are frequently used, and can ease headache even in those patients not clinically depressed. Other medications include several of the anti-epileptic drugs and the calcium channel blockers. Beta-blockers, used to lower blood pressure in other patients, are effective in migraine.
Although prophylactic or preventive medications may sometimes be effective in certain headache or migraine sufferers, the results have generally not been encouraging. There is also the very real problem of side effects, which can be more unpleasant than the headaches. A large percentage of people who have been prescribed preventive medications, stop taking them either because they are not effective, or because of the unpleasant side effects. For these reasons, prophylactic medication should be reserved for those patients who have not responded to other preventive treatment options.
Symptomatic, abortive or rescue medication
One of the main problems with taking painkillers for headaches, is that it often leads to Medication Overuse Headache (MOH). MOH is a problem that occurs in headache sufferers who have to take painkillers on a regular basis - the headaches become more frequent and more severe! Because of this, the patient increases the dosage and takes the drugs more often, and a vicious circle is set up, making the headaches worse and worse. This can happen with any of the painkillers, but is far more likely to occur when the medication contains more than one drug, and especially if it contains caffeine, ergotomine or codeine.
When the three are combined in one pill, there is an even greater likelihood of MOH developing. It is important that you examine the box or insert of the medications you use, and check what they contain. And remember - MOH can occur with prescription or Over-The-Counter headache medication.
If you suffer from headaches, the answer is not to rely on medication or painkillers. The correct way to deal with the problem is to have a proper diagnosis of the causes of the headache. If the causes can be successfully treated, the headaches no longer occur, and it is no longer necessary to rely on potentially harmful “rescue” medication.
If you have not been able to have the proper diagnosis and treatment yet, and are forced to use medication, then symptomatic or “abortive” medications are the pain medications that should be used. These are drugs are designed to stop the headache once it has started.
Once a headache has taken hold, any of a wide selection of abortive medications are used. These include simple analgesics like paracetamol and aspirin, anti-inflammatories and muscle relaxants. Narcotic analgesics may be necessary for the most severe headaches, but they are best limited to one-off usage, and should not be prescribed longer-term, as they are habit-forming. Often a trial-and-error approach is necessary to match an individual patient with the most suitable medication.
Migraine is often associated with intense nausea, and an anti-emetic (a drug that treats nausea and vomiting) may bring a measure of relief. Medications that act on the calibre of blood vessels have an important place in migraine therapy - the ergot drugs of old have largely been replaced by the newer “triptan” medications like sumatriptan, which has oral, subcutaneous and intranasal forms. Unusual primary headaches like cluster may respond to breathing oxygen.
It should be mentioned that all headache medications have side-effects, and so should be used judiciously.
Reviewed by Dr Elliot Shevel, director: Headache Centre.
Updated: August 2006