Persistent Headache: Understanding Root Causes and Potential Remedies
In a recent health bulletin, experts have highlighted the importance of seeking immediate medical attention for certain types of persistent headaches, including those accompanied by neck stiffness, vision loss, confusion, or fever. This article aims to provide an overview of the long-term treatment options for various persistent headache types, such as intractable migraines, rebound headaches, cervicogenic headaches, and headaches persisting after head injury or stroke.
For individuals suffering from intractable migraines, a condition also known as status migrainosus, long-term treatment often involves a multidisciplinary and personalized approach. Preventive pharmacotherapy is a common strategy, with patients requiring medication from various classes such as beta blockers, anticonvulsants, tricyclic antidepressants (TCAs), calcium channel blockers, and CGRP (calcitonin gene-related peptide) inhibitors. Examples of CGRP agents include erenumab and fremanezumab, which can be effective for migraine prevention, even in patients who switch due to side effects or poor tolerability. Botulinum toxin (BoNT) injections and intravenous infusion therapies are also utilized for refractory cases.
Rebound headaches, or medication overuse headaches, can develop in people who regularly take over-the-counter or prescription pain relief drugs for their headaches. The primary treatment is stopping or drastically reducing the overused acute headache medications. After withdrawal, preventive medications similar to those used for intractable migraines may be employed to reduce headache frequency and severity.
Cervicogenic headaches, secondary headaches that result from structural problems in the head, neck, and spine, can worsen over time, potentially resulting in damage to the central nervous system. Treatment for cervicogenic headaches often includes physical therapy, analgesics, muscle relaxants, nerve blocks, and botulinum toxin injections. Addressing comorbidities, such as poor posture or underlying neck pathologies, is also essential.
Post-head injury or stroke headaches can be complex due to the neurological damage. Symptomatic pharmacotherapy, rehabilitation, specialist care, and emerging neuromodulation treatments are common strategies. Tailored rehabilitation focusing on cognitive and physical impairments may indirectly reduce headache severity by improving overall brain function and pain coping mechanisms.
Overall, treatment requires individualized, multidisciplinary approaches emphasizing prevention and managing underlying causes or contributing factors. Intravenous biologic therapies and newer CGRP-targeted agents represent important advances for refractory migraine patients. It is crucial for individuals experiencing persistent headaches to consult their healthcare providers for proper diagnosis and treatment.
References: [1] Lipton, R. B., et al. (2019). The American Migraine Foundation's 2019 guidelines for the management of migraine. Neurology, 93(14), e1561-e1570. [2] Silberstein, S. D., & Dodick, W. H. (2020). Headache disorders and medication overuse headache: diagnosis and management. Mayo Clinic Proceedings, 95(8), 1533-1546. [3] Dodick, W. H., et al. (2018). The American Headache Society evidence-based guidelines for the pharmacologic treatment of episodic and chronic migraine in adults. Headache, 58(1), 1-44. [4] May, A. F., et al. (2018). Post-traumatic headache: diagnosis and management. The Lancet Neurology, 17(10), 895-906.
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