Headache (migraine). Therapies
What types of treatment are available for headaches (migraines)?
Almost all primary, and many secondary headaches can be easily treated today. The patient should be informed, however, that not all primary cephalgias can be "cured", but rather that treatment aims primarily to reduce the number of headache attacks ("prophylaxis") or end a specific attack as quickly and effectively as possible ("attack therapy"). Most headache syndromes can be treated on an outpatient basis, but during the initial phase in particular should be closely monitored by a headache specialist. During this period it is advisable to keep a "headache diary", which the patient uses to record the headache attacks and their characteristics. These records help the treating physician to design and monitor the specific treatments.
Secondary cephalgias necessitate hospitalisation
Many secondary cephalgias necessitate admission to a neurological clinic, since it is important in such cases to rapidly establish the diagnosis and commence with therapy. Often the headaches improve by removing the cause and the patient is actually "cured". Chronic headaches, which have arisen as a result of the incorrect use of pain relievers, necessitate "withdrawal" from the causative medications. Depending on the substance used, this may likewise ensue with hospitalised monitoring for a few days. It is important that an individually designed treatment plan is created for each patient which, aside from the cephalgia itself also takes into account the patient's age, accompanying illnesses, lifestyle, personal expectations and potential contraindications. In most cases a combination of medicinal and non-medicinal therapies is advisable.
Headache (migraine). Diagnostics & Therapies
Diagnostics. How are headaches, e.g. migraines, identified?
More than two thirds of all cephalgias can be diagnosed by a neurologist experienced in headaches, simply by thorough questioning of the patient ("anamnesis") and full physical examination. If there are typical symptoms and clear findings on physical examination, further examinations are necessary only in exceptional cases. In principle, complementary diagnostic measures performed for primary cephalgias will deliver normal, i.e. unremarkable findings. Additional technical examinations are therefore always required if secondary cephalgias are suspected. Sometimes, however, the specialist may need to arrange further examinations for primary headache syndromes – especially if the nature or frequency of the headaches changes noticeably or if an apparently typical "migraine" occurs for the first time at an unusual stage (e.g. in old age). In the case of patients suffering headaches for the first time – even with a clear diagnosis – additional examinations may be wise at the beginning in order to rule out similar diseases with a different cause.
Complementary examinations for headaches (migraines)
A complementary examination may also be undertaken in order to reassure a patient regarding serious illnesses (brain tumour, stroke). Imaging methods in particular (CT, MRI) may become an additional psychological burden, e.g. during the initial diagnosis of migraine patients, despite the disease being harmless.
Complementary examination for headaches (migraines): Computed tomography
Computed tomography (CT) of the head uses X-rays to produce layered images of the brain, bones and blood vessels. Using this technique, a radiologist can identify whether there have been any circulatory disorders or a brain haemorrhage. In recent years computed tomography has lost importance in the precise diagnosis of headaches, since more accurate procedures have become available.
Complementary examination for headaches (migraines): Magnetic resonance imaging
Magnetic resonance imaging (MRI) also produces layered images of the brain and blood vessels, but they are achieved by using a strong magnetic field. The detail achieved with MRI is usually much greater. Hence, even the smallest of changes (e.g. inflammations, small growths, pathological aneurysms) to the order of just a few millimetres can be visualised. Such an examination is quite expensive and time-consuming, however.
Complementary examination for headaches (migraines): Lumbar puncture
In rare cases it is necessary to carry out a lumbar puncture (withdrawal of cerebrospinal fluid from the lumbar region). To this aim, the neurologist inserts a very thin needle into the subarachnoid space between two of the lumbar vertebrae while the patient is seated or lying down, and removes a few drops of the cerebrospinal fluid. In the laboratory, the fluid can be examined to discover, relatively rapidly, whether e.g. cerebral haemorrhage or meningitis has occurred. Contrary to popular opinion, this examination is hardly painful at all, takes just a few minutes and is virtually harmless. Above all, damage to the spinal cord is not possible (unlike epidural anaesthesia, for instance!).
Complementary examination for headaches (migraines): Laboratory tests
Often, a simple blood test can help to determine a number of values which reveal typical changes with certain types of headache. Any patient suffering from headaches should at least once be examined with a view to blood count (red and white blood cells, platelets), inflammatory values, thyroid levels and kidney function. In individual cases, special examinations may also be added for detecting rare forms of vasculitis, for example, which can trigger headaches.
Therapy. Treatment of headaches (migraines).
Medication for headaches (migraines)
A variety of pain relievers are available today for the treatment of headaches. Not all of them are equally suitable, however, for treating all types of headache. Combination products (comprising several active substances) which are available over the counter in pharmacies or are readily prescribed by GPs have to a large extent proven to be of little use or even harmful. An open discussion with the treating neurologist is advisable in such a case.
Acute therapy for headaches (migraines)
Several products are available for the acute treatment of almost all types of headaches. They differ noticeably in their strength, side effects and price. There are even very specific pain relievers (known as triptans) which are very effective and intended exclusively for treating migraine headaches. In the majority of cases, however, even severe headaches can be adequately treated by simple and popular pain relievers such as Aspirin® or Paracetamol®, provided they are used correctly ("as early as possible and as much as necessary"). Only in the event of intolerance or a lack of efficacy is it necessary to switch to a different type of substance.
Prophylaxis for headaches (migraines)
If headache attacks occur frequently, it may under certain circumstances be useful to commence with medicinal prophylaxis. The regular, i.e. daily intake of a medication should enable the number of headache attacks to be clearly reduced over a period of several months. The medications used to such an aim are not usually pain relievers, but e.g. beta blockers, antiepileptics, antidepressants, etc. As a rule they are taken at a low dose and are tolerated well. A neurologist should be consulted to determine when and which product is useful for prophylaxis.
Botulinum toxin for headaches (migraines)
The use of botulinum toxin, a naturally occurring nerve toxin which is injected in the smallest of doses into the muscles of the neck and head, and is helpful in many neurological diseases, has recently been investigated in several studies, also of headache patients. As yet, no prolonged benefit could be ascertained in any form of cephalgia.
Herbal products for headaches (migraines)
There is little proof that herbal products are effective. Only in the prophylactic treatment of migraine attacks are butterbur and ergot used as a second-choice therapy.
Non-medicinal treatments for headaches (migraines)
Non-medicinal therapies assume an important role when dealing with the most common forms of cephalgia, especially since this is an area in which the affected person can make an active contribution. In chronic pain patients in particular, they should be monitored with as much attention as the intake of pain-relieving tablets.
- Exercises for managing stress and relaxation training, such as muscle relaxation according to Jacobson or autogenic training, are of primary importance.
- Regular (i.e. 2-3 times per week) endurance training (e.g. jogging, swimming or cycling) is just as beneficial.
- A change in habits (adjustment of sleep duration and sleep rhythm) is useful to some patients, e.g. if migraine attacks become more frequent at the weekends.
- If certain foods (e.g. cheese, alcohol) are clearly identified as the triggers for headaches, they should be avoided.
Acupuncture for headaches (migraines)
Results with regard to acupuncture have so far been ambiguous. Though experience shows that certain patients repeatedly report positive effects, scientific studies have as yet been unable to produce convincing results with any form of cephalgia. In light of the present trend, however, a therapeutic attempt is justified in particular for chronic headache syndromes.
Physiotherapeutic and physical treatments for headaches (migraines)
Heat treatments, massages and stretching exercises are worthwhile, particularly for chronic tension headaches. They may also be useful in individual cases of headaches caused by changes in the cervical spine.
Surgery for headaches (migraines)
In several secondary cephalgia syndromes surgery is helpful, any maybe even necessary, for remedying the headaches (e.g. for brain tumours, liquor retention, vascular changes). Due to the numerous triggers and the applied surgical procedures, we are unable to go into more detail here.
Surgery may, in rare cases, also prove to be a useful therapeutic approach for primary cephalgias or neuralgias. Surgery for trigeminal neuralgia is the most commonly performed procedure so far. If an oppressive blood vessel has been identified as the trigger for the pain, various techniques are used to either destroy the nucleus of the pain-inducing trigeminal nerve in the brain or relieve the trigeminal nerve. Just recently it has also been possible to "cut out" the pain-sensitive structures in trigeminal neuralgia using special radiation techniques (radiosurgery, "gamma knife").
Surgical techniques have also been developed for neuralgias of other nerves in the head or neck, whereby sometimes electrical stimulation electrodes are connected to the affected nerves and inserted under the skin. Such methods have so far been used only in a few patients. The results have been contradictory to some extent and thus attempts must first be made to fully exhaust the possibilities of medicinal therapy.
Cluster headaches which no longer responded to any other therapies were recently subjected - successfully - to deep brain stimulation ("brain pacemaker"). This method is still in the experimental stage, however, and on account of the low case numbers may only be performed in a highly specialised clinic.
These centres of excellence of our clinics and hospitals have doctors and therapists qualified to treat headaches.