The authors outline an approach to treatment failure and identify five categories of reasons for treatment failure that leads to referral to the subspecialty headache centers where they practice.
The most common reason for poor response to treatment is that the diagnosis is incomplete or incorrect, the authors state. This can occur when a primary headache disorder is misdiagnosed (for example, migraine is mistaken for sinus or stress headache), a secondary headache disorder is missed (for example, a brain tumor), or two or more headache disorders are present and at least one goes unrecognized.
"Though severe headache sufferers often live in fear that a brain tumor might have been missed, fortunately this is a very rare event," said neurologist Richard B. Lipton, MD, of Albert Einstein College of Medicine in Bronx, N.Y.
The next most common reason for treatment failure is that factors which exacerbate the headache go unaddressed.
"Physicians need to know that both prescription and over-the-counter medications which relieve headaches can become a cause of headache if overused," Lipton said. "Many patients don't consider over-the-counter medications 'real drugs' and won't mention them to their doctor unless they are specifically asked."
Other exacerbating factors can include hormonal changes, dietary or lifestyle factors, and occupational and environmental exposures.
The third category of reasons for treatment failure is that the medication regimen may be inadequate. For example, an inappropriate medication may be selected, the duration of the treatment may be too short, or the patient may not be taking the medication as directed. Lipton notes that recent evidence shows that acute migraine treatment works best if given early in the course of the headache.
For selecting patients' initial therapy, the authors recommend following the guidelines developed by the U.S. Headache Consortium. The guidelines are available at http://www.aan.com/professionals/practice/.
The fourth category for treatment failure is that non-drug treatment may be inadequate.
"Some patients need physical medicine, such as nerve blocks, or physical therapy or behavioral interventions such as biofeedback and cognitive behavioral therapy, to get relief from their headaches," Lipton said.
The experts list "other factors" as the last category for treatment failure. One such factor is when patients have additional conditions, such as depression, stroke or epilepsy, which make the headaches more difficult to treat.
Lipton noted that this approach to treatment still needs to be verified by scientific studies. "We believe that the vast majority of refractory headache patients have a biologically determined problem that has been either misdiagnosed, mistreated or simply is very difficult to treat," he said. "But we have found that persistence in treating these patients can result in success."
The American Academy of Neurology, an association of more than 18,000 neurologists and neuroscience professionals, is dedicated to improving patient care through education and research. A neurologist is a doctor with specialized training in diagnosing, treating and managing disorders of the brain and nervous system such as stroke, Alzheimer's disease, epilepsy, Parkinson's disease, autism and multiple sclerosis. For more information about the American Academy of Neurology, visit its web site at http://www.aan.com.
For more information contact: Kathy Stone, 651-695-2763, kstone@aan.com.
For a copy of the study contact: Marilee Reu, 651-695-2789, mreu@aan.com.
Journal
Neurology