Chronic Headaches

Everyone gets headaches. However, for some people they are more than just an inconvenience.

Headaches are a common referral issue for Neurologists. In this post, I am going to try and explain my very basic first approaches to headaches.

What I commonly tell referring physicians and patients is that the first thing to determine is whether a person's headaches are a primary or secondary phenomena.

In medicine, there are what are called primary headache disorders. These are all laid out in the "The International Classification of Headache Disorders" or ICHD-3. These are disorders where people get headaches for no apparent reason. The most common examples of these headache types are tension headaches and migraine headaches. Discussing all the characteristics, treatment options and the like go well outside the scope of this post, though I will say there are some very helpful guidelines out there including those produced by the American Academy of Neurology, Canadian Headache Society and American Headache Society.

What requires more discussion is the secondary headache disorders. Put simply, pretty much any medical condition can cause headaches. The headaches are thought of as a symptom of that other condition. Diabetes, hypertension, insomnia, depression, pregnancy, thyroid disorders, anemia, etc., etc., can all cause people to have headaches.

Complicating matters, if you are a person who is susceptible to migraines or tension headaches, the headache you may get if one of those other conditions are at play may very well be migraine or tension like in quality. However, the management is very different. When headaches are secondary to another condition, the focus of treatment is to manage that primary issue. There are multiple reasons for this.

Untreated medical or psychiatric conditions tend to get worse if not addressed. This can affect both quality of life as well as your safety. Second, if the primary issue resolves, it is likely the headaches will resolve with it. Third, headaches that are the result of another condition generally do not respond to treatments the same way as primary headaches. This is well established in patients with chronic migraine and co-morbid medication overuse headaches.

When people are younger with no other medical or psychiatric conditions, primary headache disorders are much more common. However, as people get older and start accumulating more issues, it becomes that much more important to rule out other medical or psychiatric conditions that could be manifesting as a headache. This is where a thorough history from a primary care physician becomes essential to good patient care. For all the reasons above, until this general assessment takes place, further referrals are generally premature.

Assuming chronic headaches are the result of another condition, unfortunately, treatment options are often limited to broad acting, generally well-tolerated medications like Tylenol or NSAID's over limited durations. However, even these medications can cause adverse effects depending on dose and duration of use; including paradoxically, medication overuse headaches.

The take home message from all of this is to make sure that if you are suffering from chronic headaches, that you have an appropriate primary care work up with your family physician. This is particularly the case if you:

• Are over the age of 50

• Do not normally get headaches

• Are getting "thunderclap/worst headache of my life" headaches

• Have a headache accelerating in intensity

• If you have a history of HIV or cancer

• If you have any neurologic signs or symptoms along with your headaches

• If your headaches are failing typical management

• If you have sinus symptoms

• If you have been in an accident/trauma

• If you headaches are associated with other signs of illness

• If you have abnormal eye exams

• If your headache worsens with valsalva maneuvers (bearing down) or standing

• If your headache wakes you up from sleep or is worst first thing in the morning