NEW YORK CITY—Are the traditional views of migraine management still valid in today's health care environment or have medical science and patient expectations outpaced traditional migraine treatment? At the Advances and Innovations in Headache Management symposium held at Columbia Presbyterian Medical Center in New York City, headache and pain specialists discussed progressive perspectives on such topics as treatment concerns specific to women, the relevance of facial pain, and the roles of alternative and behavioral therapy.

A WOMEN'S DISEASE?

"Headache is by and large a women's issue and a women's disease," said Elizabeth Loder, MD. Of the 24 million Americans estimated to have significant headaches, Dr. Loder explained, 18 million (75%) are women. According to Dr. Loder, who is Director of the Pain Management Program at the Spaulding Rehabilitation Hospital, Boston, headaches tend to be more frequent and severe in female patients. "For example, women require, on average, several more hours of bed rest following a migraine than men do," she added.

In childhood, migraine is equally common in boys and girls. After puberty, however, the incidence of migraine increases in girls, presumably because of hormonal cycling. By the fourth and fifth decades of life, the preponderance of headache in women peaks, and women continue to be predisposed to headache even after menopause. "The early hormonal events that render women prone to migraine appear to induce a lasting change in the central nervous system," said Dr. Loder, who is also an instructor at Harvard Medical School.

Menstruation-related migraine is real, Dr. Loder said, but it is less common than supposed. "Any event that occurs around menstruation is likely to be attributed to menstruation," she noted, but for migraines to be plausibly related to menstruation, "the woman should develop the headache within two days of the onset of menses." Among female migraineurs, approximately 40% report there is no menstruation– headache link, 46% report headaches during periods but at other times as well, and 14% report headaches only during their periods. When patient self-reporting is combined with headache diaries, however, the percentage of headaches temporally associated with menstruation is smaller. Before concluding that a woman has menstruation-associated migraine, Dr. Loder cautioned, a combined headache and menstruation diary should be kept for at least three months.

"A migraine triggered by hormones is still a migraine," Dr. Loder continued, noting that appropriate treatment for such women comprises standard migraine therapy and should not initially be based on hormonal manipulation. All of the available pharmacologic therapies are as effective for menstruationrelated migraine as they are for headaches unrelated to menstruation, she said. There is no need, she added, to immediately consider estrogen supplements or continuous use of oral contraceptives (OCs). In any case, she continued, data on the impact of OCs in migraine are mixed: "Approximately one third of patients experience a worsening of migraine when taking OCs, one third note no change, and one third feel better—but this cannot be predicted for an individual patient."

According to Dr. Loder, migraine often improves with age and rarely commences after age 60. In the perimenopausal period of time, however, a woman's previously controlled migraines can become difficult to treat. "Women who were getting by with episodic treatment for acute episodes may require prophylactic therapy during this period of time," she said, adding that there is no established benefit to hysterectomy or oophorectomy in the treatment of severe migraine.

Recurrent severe headache in a woman can also be a red flag that she is the victim of domestic violence or has a history of physical or sexual abuse or other trauma in childhood. "Keep a high index of suspicion for abuse," Dr. Loder advised, "when a woman has headaches that are highly refractory to treatment or she exhibits unusual responses to treatment, such as anxiety during biofeedback or dislike of hands-on therapy."

FACIAL PAIN OR HEADACHE?

There is a large overlap between headache and facial pain, noted David A. Keith, BDS, DMD, Associate Professor of Oral and Maxillofacial Surgery at Massachusetts General Hospital, in Boston. In Dr. Keith's clinic population of patients with chronic facial pain, 50% have headaches; and in headache clinics, at least 20% of patients have myofascial facial pain. "Orofacial pain conditions associated with headache include temporomandibular joint (TMJ) disorders, cluster headache, trigeminal neuralgia, atypical facial pain, and pathology of the teeth and jaws," said Dr. Keith, who is also Director of the Harvard/Massachusetts General Hospital Orofacial Pain Center. Facial pain also can mask occult cancer, he added.

According to Dr. Keith, the diagnosis in a patient with orofacial pain depends to some extent on the specialty of the examining physician. "Dentists tend to adjust teeth and use dental appliances, oral surgeons may prescribe medications, and clinician educators tend to direct patients to behavior modification programs," he said. Even so, the various groups claim high degrees of success, and the fact is that from a clinical point of view they may be justified. "With just a simple dental device," he noted, "many patients with documented migraine, tension-type, or cluster headaches find at least some degree of relief."

Dr. Keith described a patient at the Orofacial Pain Center who received a diagnosis of cluster headache after suffering from left-sided facial pain for three years. The pain began in the left eye, spread to the jaw, and then involved the skull. The patient had seen a primary care physician, an ophthalmologist, an otorhinolaryngologist, and a dentist before coming to the center. The diagnostic tip-off to cluster headache, according to Dr. Keith, is the pain diagram. "They are almost always the same—pain around the eye, in the upper jaw, in the forehead, and, finally, the back of the head," he noted. "I have seen patients who have undergone needless dental extraction because no one recognized cluster headache," he added.

Cluster headaches are usually responsive to pharmacologic intervention, and a successful therapeutic trial confirms diagnosis. In the acute setting, Dr. Keith said, an attack can be aborted by administering 100% oxygen via a tight mask at a rate of 8 to 10 L/min for two to three minutes. Prophylactic measures include cyproheptadine, ergot alkaloids, lithium carbonate, and methysergide.

Headaches that are unresponsive to treatment may be caused by a combination of conditions, Dr. Keith noted. "It is important to consider—and reconsider—problems that may be occult, including dental abscess, TMJ dysfunction, and sinusitis," he said.

HOW "ALTERNATIVE" IS ALTERNATIVE THERAPY?

Does alternative medicine have anything to offer patients with migraine or tension-type headaches? Probably, answered Alexander Mauskop, MD, Director of the New York Headache Center in Manhattan. Some alternative medicine approaches have become so popular that they may be almost mainstream, he added. He offered another compelling reason to be familiar with complementary modes of therapy, however. "Physicians who reject complementary medicine out of hand will be perceived as arrogant by patients," he explained. "On the other hand, if a physician displays knowledge of a therapy a patient is interested in, it will be easier to gain that patient's trust and guide him or her toward a wise therapeutic choice."

Dr. Mauskop, who is also Associate Professor of Clinical Neurology at the State University of New York Health Science Center in Brooklyn, suggested that clinicians not use every complementary approach to headache. Instead, a clinician should pick those that seem reasonable or appealing. His warning to physicians and patients alike: "No method will work unless it is performed correctly and used regularly for a sufficient duration."

Dr. Mauskop recommends aerobic exercise for headache patients. "Exercise relieves stress, causes release of endorphins in the brain, and improves cerebral circulation," Dr. Mauskop said. He also recommends acupuncture, which has a sound scientific foundation and a track record of success in headache management. "Acupuncture appears to be safe and effective," he said, "but the placebo effect cannot be ruled out because it is difficult to design randomized clinical trials involving needle insertion."

Chiropractic manipulation is often used by patients with migraine. However, Dr. Mauskop noted that there is a potential risk of stroke following cervical manipulation. He also offered advice about selecting a chiropractor: "A good chiropractor will give the patient exercises, because the only way to eliminate musculoskeletal pain and spasm is to strengthen and condition the muscles."

In small preliminary studies, topical application of capsaicin has been shown to abort cluster headaches, according to Dr. Mauskop. For best results, capsaicin is applied on the side of the face ipsilateral to the pain. Tiger Balm® and feverfew have also shown efficacy, he said. However, he noted that herbal products such as these are not regulated.

Because levels of ionized magnesium tend to be lower in patients with migraine and cluster headaches than in control subjects and patients with tension-type headaches, Dr. Mauskop has used intravenous magnesium therapy. "We found that only about 50% of patients with migraines or cluster headaches responded, but almost all of those who did had low pretreatment magnesium levels, whereas those who did not had normal pretreatment levels," he said. Oral magnesium supplementation, he noted, has also been shown to reduce the frequency of headaches in migraine patients. He also mentioned that patients with migraine might want to try Migra-Lieve™, a new product that contains magnesium, riboflavin, and feverfew.

Regarding another treatment, Dr. Mauskop quipped that the headache specialist may be borrowing from the plastic surgeon's toolkit. Patients treated with purified botulinum toxin for blepharospasm and wrinkles reported that their migraines stopped. "Purified botulinum toxin does not work for everybody, but it can provide up to three months of relief, with essentially no adverse effects, for some patients in whom all other treatments have failed," he said. Botulinum toxin for headache will eventually become mainstream medicine, he predicted.

HELPING PATIENTS HELP THEMSELVES

Cognitive behavior therapy and biofeedback are among the most widely used behavioral treatment approaches for headache. Behavioral medicine empowers headache patients, according to Nomita Sonty, PhD, Assistant Clinical Professor of Anesthesiology and Psychiatry at Columbia University in New York City. Cognitive behavior therapy helps patients monitor their thoughts, emotions, and behavior and it enables them to identify patterns associated with pain and disease, she said. As a result, patients develop the expectation that they can become effective problem solvers and active participants in their headache management. "Patients learn to perform specific behaviors to cope with distress, decrease pain, and develop and maintain generalized effective headache management strategies," she reported.

In the biopsychosocial model of headache, Dr. Sonty explained, "headache causation is multifactorial, and a patient's headache may depend on specific pathophysiologic mechanisms that may be triggered by numerous interactions, some of which the patient can learn to control or anticipate." These include the patient's physiologic status, environmental factors, the patient's ability to cope with environmental factors, and the consequences of the headaches.

Cognitive behavior therapy, she explained, comprises five stages: education, skills acquisition, cognitive and behavioral rehearsal, generalization, and maintenance. Education clarifies the relationship between triggers and headache and underscores the importance of treatment compliance. Acquired skills include headache monitoring, relaxation, biofeedback, and other stress management methods. Behavioral goal setting and the matching of strategies to situations appropriately constitute cognitive and behavioral rehearsal.

Biofeedback is another means of providing information about their internal physiologic events to patients who have severe headaches. "Biofeedback, which employs visual and auditory signals, allows headache patients to manipulate their physiologic events by manipulating the displayed signal," Dr. Sonty explained. Electromyography, skin conductance, thermal feedback, and stress profiling are a few of the types of psychophysiologic assessment and intervention that help patients manage headache and facial pain and promote relaxation and stress reduction.

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