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  • image Acute migraine therapies should provide consistent, rapid relief and enable the patient to resume normal activities at home, school, or work.
  • image A stratified care approach, in which the selection of initial treatment is based on headache-related disability and symptom severity, is the preferred treatment strategy for the migraineur.
  • image Strict adherence to maximum daily and weekly doses of antimigraine medications is essential.
  • image Preventive therapy should be considered in the setting of recurring migraines that produce significant disability; frequent attacks requiring symptomatic medication more than twice per week; symptomatic therapies that are ineffective or contraindicated, or produce serious side effects; and uncommon migraine variants that cause profound disruption and/or risk of neurologic injury.
  • image The selection of an agent for headache prophylaxis should be based on individual patient response, tolerability, convenience of the drug formulation, and coexisting conditions.
  • image Each prophylactic medication should be given an adequate therapeutic trial (usually 6 months) to judge its maximal efficacy.
  • image A general wellness program and avoidance of headache triggers should be included in the management plan.
  • image After an effective abortive agent and dose have been identified, subsequent treatments should begin with that same regimen.

On completion of this chapter, the reader will be able to:

  1. Describe signs and symptoms that characterize the clinical presentation of the primary headache disorders.

  2. List the diagnostic criteria for migraine with aura and migraine without aura as defined by the International Headache Society (IHS).

  3. Explain the pathophysiologic mechanisms identified with migraine headache.

  4. Describe the role of genetics in migraine and cluster headache susceptibility.

  5. Identify and describe different phases of a migraine attack.

  6. Discuss common secondary symptoms that accompany migraine headache.

  7. Discuss factors that precipitate migraine headache and strategies to address these factors.

  8. Describe the potential danger of medication overuse in headache disorders.

  9. Identify clinical controversies in headache management.

  10. Discuss the goals of long-term and acute treatment of migraine.

  11. Differentiate between the needs for symptomatic (abortive) and preventive (prophylactic) treatment for headache disorders and appropriate initiation.

  12. Differentiate among the various agents used for the acute and preventive treatment of the primary headache disorders.

  13. Describe the general approach to treatment for tension-type headaches.

  14. Describe the general approach to treatment for cluster headaches.

  15. Discuss the evaluation of therapeutic outcomes in the management of the primary headache disorders.

Headache is one of the most common complaints encountered by healthcare practitioners and among the top three principal reasons given by adults 18 years of age and over for visiting U.S. emergency departments.1 It can be symptomatic of a distinct pathologic process or can occur without an underlying cause. In 2004, the International Headache Society (IHS) updated its classification system and diagnostic criteria for headache disorders, cranial neuralgias, and facial pain2 (Table 45-1). Designed to facilitate headache diagnosis in clinical practice and research, the IHS classification provides more precise definitions and standardized nomenclature for both the primary (tension-type, migraine, and cluster headache) and secondary (symptomatic of organic disease) headache disorders. This chapter ...

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