Table of Contents

1 Migraine and Headache: General ............................................................ 1
Migraine Treatment: 2015–2016 .................................................................. 1
Migraine Characteristics ....................................................................... 2
Visual Disturbances .............................................................................. 5
Miscellaneous Neurologic Symptoms .................................................. 5
Workup for Migraine ............................................................................ 6
Headache Triggers ................................................................................ 6
Medications: Abortives ......................................................................... 8
Miscellaneous Approaches ................................................................... 10
Medication Overuse Headache ............................................................. 17
Preventive Medications ........................................................................ 17
First-Line Preventive Medications for Migraine .................................. 18
Second-Line Migraine: Preventive Therapy ......................................... 23
Polypharmacy ....................................................................................... 25
Conclusion ............................................................................................ 26
Chronic Headache Management: Outpatient Strategies .............................. 26
A Guide to Treating Chronic Headache Patients .................................. 26
Clinical Pearls for Treating Headache Patients ............................................ 41
Medication ............................................................................................ 42
Patient Perceptions ............................................................................... 43
Broader Health ...................................................................................... 45
Strategies and Procedures ..................................................................... 46
Suggested Reading ....................................................................................... 47
2 Refractory (Difficult-to-Treat) Headache ................................................ 49
Difficult-to-Treat Chronic Migraine: Outpatient Medication Approaches .. 49
Challenges of Refractory Migraine ...................................................... 49
Pathophysiology ................................................................................... 51
Medication Overuse Headache ............................................................. 51
Treatments for RCM ............................................................................. 52
Opioids ................................................................................................. 52
Botulinum Toxin Injections .................................................................. 58

Daily or Frequent Triptans .................................................................... 59
Stimulants ............................................................................................. 60
Monoamine Oxidase Inhibitors ............................................................ 63
Injections and Nerve Blocks ................................................................. 64
Polypharmacy ....................................................................................... 65
Miscellaneous ....................................................................................... 65
New Developments .............................................................................. 66
Conclusion ............................................................................................ 66
RCM: The Use of LAOs .............................................................................. 67
Study Design ........................................................................................ 67
Patient Characteristics .......................................................................... 67
Inclusion Criteria .................................................................................. 68
Primary Outcome Measure: Efficacy ................................................... 68
Secondary Outcome Measures: Definitions and Criteria ..................... 68
Results .................................................................................................. 71
Discussion ............................................................................................. 72
Definitions of Substance Use and Misuse ............................................ 75
A Proposed Classification Scheme for Prescription Opioid Abuse ...... 77
Screening for Abuse ............................................................................. 78
Specific Psychiatric Problems and Risk of Abuse ................................ 78
Guidelines for the Successful Management of LAOs in
Headache Patients ................................................................................. 78
Conclusion ............................................................................................ 84
Stimulant Use in Migraineurs ...................................................................... 84
Methods ................................................................................................ 84
Results .................................................................................................. 85
Discussion ............................................................................................. 85
Conclusion ............................................................................................ 87
Brief Communication ................................................................................... 88
Frequent Triptan Use: Observations on Safety Issues .......................... 88
Patients and Methods ............................................................................ 89
Results .................................................................................................. 90
Comments ............................................................................................. 92
Migraine Headache Surgery (Letter; February, 2014 Headache) ................ 93
In Defense of Butalbital ............................................................................... 94
Medication Overuse Headache: Inaccurate and Overdiagnosed
L. Robbins, M.D. ......................................................................................... 96
Difficult to Treat Headache: Patient Version ................................................ 97
Outside of Medication .......................................................................... 98
Medication: Selected Outpatient Options ............................................. 98
Botulinum Toxin (Botox) ..................................................................... 99
Polypharmacy: Using Two (or More) Preventives ............................... 99
Daily (or Near-Daily) Triptans ............................................................. 100
Long-Acting Opioids (LAO) ................................................................ 100

Nerve Blocks ........................................................................................ 101
Miscellaneous Medication Approaches ................................................ 102
Conclusion ............................................................................................ 102
Refractory Chronic Migraine: Long-Term Follow-up Using a
Refractory Rating Scale ............................................................................... 103
Introduction .......................................................................................... 103
Methods ........................................................................................................ 104
Design and Patient Selection ................................................................ 104
Refractory Scale ................................................................................... 104
Outcome Measures ............................................................................... 105
Statistics ................................................................................................ 105
Results .......................................................................................................... 105
Discussion .................................................................................................... 107
Comment Observation and Rebuttal ............................................................ 109
Long-Acting Opioids and Headache .................................................... 109
Suggested Readings ..................................................................................... 110
3 Child and Adolescent Headaches .............................................................. 115
Child and Adolescent Headaches ................................................................. 115
Diagnostic Approach ............................................................................ 116
Biopsychosocial Approach ................................................................... 117
Nonpharmacologic Treatments ............................................................. 117
Pharmacologic Treatment ..................................................................... 118
Conclusion ............................................................................................ 121
The Homebound Adolescent Headache Patient ........................................... 121
Role of Therapist Is Key ....................................................................... 122
Mental Health of Parent Is Important ................................................... 122
Ease into a School Program .................................................................. 123
Somatizing Disorders ........................................................................... 123
Summary ............................................................................................... 124
Factitious Disorder in an Adolescent with Headaches ................................. 124
A Case of Mild Factitious Disorder by Proxy ...................................... 124
Introduction .......................................................................................... 124
Diagnosis .............................................................................................. 125
Treatment .............................................................................................. 125
Long-Term Follow-Up ......................................................................... 125
Discussion ............................................................................................. 126
The Participants .................................................................................... 126
Treatment .............................................................................................. 127
Suggested Reading ......................................................................................... 127
4 Cluster Headache ....................................................................................... 129
Cluster Headache ......................................................................................... 129
Specific Characteristics of Cluster Headaches ..................................... 129
Nonmedication Treatment of Cluster Headache ................................... 131

Medications for Cluster Headache ....................................................... 131
First-Line Cluster Abortive Medications .............................................. 131
Second-Line Cluster Abortive Medications ......................................... 133
Preventive Therapy for Cluster Headaches .................................................. 135
Preventive Medications (See Table 4.2) ............................................... 135
Sample Case History ............................................................................ 138
Treatment Plan ...................................................................................... 138
Results .................................................................................................. 138
Discussion ............................................................................................. 139
5 Psychological Comorbidities ..................................................................... 141
Anxiety in a Headache Patient ..................................................................... 141
What Is Anxiety? .................................................................................. 142
Types of Anxiety ................................................................................... 142
Posttraumatic Stress Disorder ............................................................... 144
The Limbic System ............................................................................... 144
Treatments of Anxiety in Pain Patients ................................................ 145
Medications for Anxiety ....................................................................... 145
The Major SSRIs .................................................................................. 147
The Major SNRIs ................................................................................. 150
Conclusion ............................................................................................ 151
Attention-Deficit Hyperactivity Disorder and Patients with Pain ................ 152
Diagnosis of ADHD in Adults .............................................................. 152
ADHD and Impairment ........................................................................ 153
ADHD and the Patient With Pain ......................................................... 154
ADHD Medications .............................................................................. 154
Nonmedication Treatments ................................................................... 155
Conclusion ............................................................................................ 155
Personality Disorders and the Bipolar Spectrum: Recognition
and Management in a Pain Clinic Setting .................................................... 155
Introduction .......................................................................................... 155
Personality Disorders at a Clinic .......................................................... 156
Pain and Personality Disorders ............................................................. 158
Bipolar Disorder ................................................................................... 159
Conclusion ............................................................................................ 161
Suggested Reading ......................................................................................... 162
6 Case Studies ................................................................................................ 165
An Interactive Case History of Chronic Migraine: Part 1 ............................ 165
Psychological Aspects .......................................................................... 165
Initial Prescription ................................................................................ 167
Heather’s Second Visit, 6 Weeks Later ................................................ 169
Summary ............................................................................................... 170
Two Weeks Later: A Call from Heather ............................................... 170

An Interactive Case of Chronic Migraine: Part 2 ......................................... 171
What Treatment Options Should Be Considered? ................................ 171
What Medication Changes Should Be Considered? ............................. 173
What Other Medication Options Should Be Considered? .................... 174
Role of Genetic Resilience ................................................................... 175
Conclusion ............................................................................................ 175
An Interactive Case History: Part 3 ............................................................. 176
History .................................................................................................. 176
What Treatment Options Should Be Considered? ................................ 177
How does Pregnancy Affect Treatment? .............................................. 177
Stress at Home ...................................................................................... 179
At this Point, Would you Consider Botulinum Toxin
or Occipital Nerve Blocks? .................................................................. 179
What Treatment Should Be Considered? ............................................. 180
Weaning off OTC Pain Medications .................................................... 180
Conclusion ............................................................................................ 181
Suggested Reading ......................................................................................... 183
7 Miscellaneous .............................................................................................. 185
Case Studies in NDPH: New Daily Persistent Headache ............................ 185
Introduction .......................................................................................... 186
Onset and Symptoms ............................................................................ 186
Diagnosis .............................................................................................. 186
Pathophysiology ................................................................................... 186
Epidemiology ....................................................................................... 187
Triggering Events ................................................................................. 187
Treatment .............................................................................................. 187
Long-Term Prognosis ........................................................................... 188
Conclusion ............................................................................................ 188
The Immune System and Headache ............................................................. 188
Calcitonin Gene-Related Peptide ......................................................... 189
Cytokines .............................................................................................. 189
Tumor Necrosis Factor ......................................................................... 190
Adiponectin .......................................................................................... 190
Glia and Headache ................................................................................ 191
Mast Cells ............................................................................................. 191
Seasonal Allergies and Headache ......................................................... 192
Conclusion ............................................................................................ 192
Weight Loss .................................................................................................. 193
Exercise: Just do Something and Have Fun!! .............................................. 194
Supplements for Good Health (in Headache Patients) ................................. 194
Chaos (Nonlinear Dynamics) and Migraine ................................................ 196
Background ........................................................................................... 197
Chaos and the Nervous System ............................................................ 197

Chaos at the Ionic Level ....................................................................... 198
Chaos at the Neuronal Level ................................................................ 198
CSD and Chaos ..................................................................................... 199
Sensitization ......................................................................................... 199
Controlling Chaotic Dynamics ............................................................. 200
Practical Applications ........................................................................... 200
Conclusion ............................................................................................ 201
Suggested Reading ....................................................................................... 201
Index .................................................................................................................. 205