Diagnosis & Methods

Diagnosis
At the outset, in our setting it is crucial to establish that the headache being presented is Not due to any ominous condition.  (This is the definition of a “Primary” Headache).  Prior studies (MRI’s, CAT Scans of the head, etc.) would have been shown to be normal.  “Blood analysis” (such as comprehensive metabolic profiles, thyroid profiles, etc.) would have been shown to be normal.  Medical records are reviewed.  Then and only then, are we certain that our patient does not have an ominous condition causing their headache.
 
Subsequently, we proceed to study the behavior of the headache.  This is crucial to identify what type of headache we are dealing with.  For example, if it is a “migraine” headache, we must attempt to uncover what type of migraine it is, as “migraines” present in several different subtypes.  Such subtypes should be treated differently for the best possible outcome.  For example, the “Common Migraine” should be treated differently from the “Classic Migraine”.  In other words, the physician should precisely know what type of headache they are dealing with.  This is the key to successful headache management.  This is the reason that often our initial evaluation can take as long as two hours.  In our setting, this is done in a one on one fashion.  This physician listens and attempts to answer as many questions as she can.  The process is painstaking, but it pays off in successful management; having a headache free life.  Both the patient and physician welcome the opportunity for exchange of information.  For many, it is the first time they have been listened to by a physician for this long.

Our Methods
The clinic uses a  multi-disciplinary  approach for the

treatment of headache patients.  This is essential, as most of

our  patients  have  multiple  dimensions to  their   headaches. 

For  example, if a certain  patient has neck  pain, possibly the

use of physical therapy may be appropriate.
 
In  terms  of  medication,  a  variety  of  preventive   headache

medications  are   utilized,   depending   upon   the   type   of

headache  being  presented.   Medications  we  use  are safe,

well  tolerated  and  have no  adverse  effects  from  long-term

use.  As a rule, they are non-habituating.  Preventive medications are preferred, especially since they do not produce the so called: “Rebound-Headache Phenomenon”.  Furthermore, the preventive medication of choice is unique to the type of headache at issue.  Therefore, the medication of choice in our setting is not based on random trial and error, as is often the case.
 
In general, after the initial evaluation, options for the patient are presented, and the pros and cons of each are discussed.  Other concomitant problems are also discussed, whether they may include neck problems or tempomandibular issues.  We often encounter anxiety, depression and poor sleep.  Those problems are addressed.  Nutritional counseling is stressed and is an important component of the program.  Issues of sleep are discussed, as good sleep hygiene is crucial for headache management.
 
Patient education is a crucial aspect of our program, and is one of the reasons we have a successful outcome among our patients.  Our goal is self-empowerment for the patient.  Self-empowerment allows the patient to master their headache, as opposed to the converse.  The patient learns that headache intensity and frequency is under their control, to a large extent.  They learn how to minimize most of their triggers; once they identify them.  Engagement in overall wellness is key.  Good eating and sleeping habits, exercise, rest, avoidance of overexertion, relaxation, stress management are all important; our patient soon discovers.  The patient soon realizes that working with this physician is much like a journey of self discovery.  The element of mystery is soon removed from headache.  The patient is, again, in control.

What Is a Headache Preventive Medication?
This is a medication which has to be taken daily, whether the patient has a headache or not.  The goal of its use is the prevention of headache occurrence altogether.

How Are Headache Prevention Medications Prescribed?
Most preventive medications must be initiated at small doses; then increased by small increments, gradually and slowly, as the patient tolerates them.  Medications are usually increased over weekly visits until the maximum therapeutic dose is reached.  (This is defined as the dose expected to produce maximum medical improvement.)  In my setting, this goal is defined as having a patient who is headache free.  Furthermore, each preventive medication is unique.  This means that there is a specific rate of increase which varies from one medication to another.  Specific protocols are defined and published for each medication.  The most important guiding principle for a headache specialist is whether the patient is physiologically ready for such an increase or not.

How Is One Headache Preventive Medication Chosen over All Others?
I choose the preventive medication which is both safe for the patient (i.e. there are no specific contra-indications for the patient to take the specific medication safely); and it is the best preventive medication appropriate for my patient’s specific type of headache, based upon my best clinical judgment.  I never prescribe a medication which was tried before, and failed.

How Do We Know the Chosen Preventive Medication Was the “Right” Choice?
In general, I follow three parameters of head pain:  1) frequency of headaches; 2) duration of each episode; and 3) intensity level of head pain.  These three parameters all decrease with time until the patient is headache free. The patient should remember that success takes patience.  In other words, there is no “quick fix.”  Good compliance on the part of the patient helps a great deal.  Overall, prevention can take anywhere from three to six months.