When to go to the hospital for a migraine

This article explains when it is appropriate to go to the hospital for a migraine headache.

Headache is one of the most common reasons for an emergency room visit. Some people go due chronic headache or Migraine problems that do not go away with treatment, and in other cases, headache is a symptom of another medical problem.

The best reason for an ER visit is for unusual symptoms that are new to you. You may seek attention to make sure there is no chance of another problem such as aneurysm or meningitis. A severe headache that starts very suddenly (within a second or two) can mean another disorder such as stroke. New symptoms such as a fever, weakness, vision loss or double vision, or confusion are some of most concerning symptoms. If you have a new symptom and serious, life-threatening medical problems such as liver, heart or kidney disease, are pregnant, or have a disorder which affects your immune system such as HIV infection, an ER visit may be more essential.

For many patients, an ER visit for headache or Migraine happens after a long period of severe headache lasting days or weeks. After long time of experiencing severe headache, you may reach the "last straw" and no longer be able to deal with the problem. ER doctors are not specialists in headache and Migraine, and their goals are to make sure there is no serious life-threatening problem and help reduce suffering. Different ER doctors have different ways to treat acute headache and Migraine: there is no universal protocol for emergency treatment of headache disorders.

When going to the ER, be sure to mention:

• your symptoms, including any that are new or unusual for you;
• any medications you have taken, especially in the last few days; and
• if you have had good results from a particular medication regimen, that can be helpful to the ER.

Often ER doctors will want to order tests such as a CT scan of the head or spinal tap to make sure there is no bleeding in the brain, large stroke or meningitis. If you are having your typical severe headache or Migraine, and no new symptoms, the chance these tests will be helpful are extremely low and you have the right to refuse them. (See 5 Things Migraine and Headache Patients and Doctors Should Question.)

The majority of persons coming to an ER for severe headache or Migraine do not get lasting results from the medications given in the ER, so having a good long-term plan and relationship with an outpatient doctor who treats your headache disorder is very important. If you have even occasional long-lasting headaches or Migraines, a good preventive plan is very important, and you should have at least one rescue medication to prevent future ER visits.

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Screening tool available for chronic migraines

This article describes a new screening questionnaire for chronic migraines.

Researchers have developed a new tool that can accurately identify patients with chronic migraine (CM).

The screening questionnaire — called the ID-CM — can potentially be used by physicians or by patients themselves.

"The way we imagine it in clinical practice is that someone completes this questionnaire in a physician's office and it provides a suggestion that the patient may have chronic migraine," said researcher Dawn Buse, PhD, director of Behavioral Medicine, Montefiore Headache Center, Bronx, New York. "The physician would still go through a careful history and physical and complete the diagnostic criteria."

"It may be helpful for people living with chronic migraine who don't realize there's a term for what they're living with," she said. "It might help connect them with specialist health care professionals who can treat them well, and it may help connect them with the right treatment."

The only treatment approved by the US Food and Drug Administration for chronic migraine, defined as having 15 or more migraine days a month, is onabotulinum toxin A (Botox, Allergan Inc), although patients do use other migraine therapies, including triptans.

Dr. Buse presented the research, funded by Allergan, here during PAINWeek.

Rigorous Process

Developing the tool took almost 3 years and involved a rigorous multi-step process. The research team reviewed existing instruments, sought input and consensus from headache physicians and research scientists from around the world, and had a group of people with CM assess the relevance of the questions being developed.

Another important step in the development process was psychometric validation. "This is where we look at someone with chronic migraine, someone with episodic migraine, and someone with no headache and see how well a particular item (for example, whether the pain is pulsating or how often the pain is severe) identifies or separates the different groups," explained Dr. Buse.

As well, headache experts used a semi-structured clinical interview to provide their own diagnosis, which was used as the gold standard. Compared to this gold standard, the screening tool had a sensitivity of 82%, a specificity of 87%, a negative predictive value of 77%, and a positive predictive value of 90%.

Among other things, the final 12-item screening tool asks respondents how often their pain is moderate or severe, how often they're unusually sensitive to light and sound, how often they feel nauseated or sick to their stomach, and how often they worry about missing work, school, or social events because of headaches.

Despite its substantial economic and quality-of-life burden, chronic migraine remains underdiagnosed and undertreated.

Dr. Buse and her colleagues hope to have the screening tool available in the next month or 2 and are working on a manuscript for possible publication.

Findings Relevant

Asked to comment, pain expert Lynn Webster, MD, vice president, scientific affairs, PRA Health Sciences, Salt Lake City, Utah, said he thought Dr. Buse's presentation was "very interesting" and relevant to the average physician who sees many patients with headaches in his or her daily practice.

"An accurate diagnosis is challenging for many physicians and a tool to help make that diagnosis would be welcomed," said Dr. Webster.

The tool appears to be reasonably accurate and sensitive, "which is always a challenge in developing such tools," added Dr. Webster.

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What to do about chronic headaches

This article discusses chronic headaches and what you can do about them.

From drinking too much last night to stressing out about finances or family concerns, there are so many possible causes of the common headache. However, when headaches go from being few and far between to frequent and long-lasting, it may be time to make an appointment to see your primary care physician.

"Practical clinical criteria defines chronic migraine as a headache that occurs greater than 15 days a month with each headache episode lasting longer than four hours for at least three consecutive months," said Dr. Denis G. Patterson, medical director of the Northern Nevada Pain Center and founder of Nevada Advanced Pain Specialists. "It does not matter how severe the headaches are — the medical term for chronic headaches is migraine headache."

According to Patterson, who is board-certified in pain medicine and physical medicine and rehabilitation, common headache triggers include hormonal changes in women, stress and changes in sleep patterns. Certain foods, such as alcohol, aged cheeses, chocolate, aspartame, too much caffeine, monosodium glutamate, processed and salty items, also may set off headaches. Among other potential triggers are bright lights, loud sounds, unusual smells, changes in the weather or barometric pressure, intense physical exertion or sexual activity.

"The causes of chronic headaches are not well understood," Patterson said. "Medical experts believe that genetics and environmental factors seem to both play a role."

No matter the cause, if you find that you're hampered by headaches a little too often, experts suggest first making an appointment with your primary care physician. If unable to alleviate the headaches, this doctor may then refer you to a headache specialist, such as a neurologist or pain management physician.

"A physician trained in treating headaches will likely diagnose the condition on the basis of your medical history, a review of your symptoms, and a physical and neurological examination," said Patterson, who specializes in common and complex neurological disorders, as well as musculoskeletal issues. "Your doctor may also recommend a variety of tests to rule out other possible causes for your pain if your condition is unusual, complex or suddenly becomes severe."

As for treating chronic headaches, there are quite a few options for today's patients. Your doctor may advise starting with noninvasive and nonpharmacological solutions to see if the migraines can be reduced naturally. For example, you may be encouraged to engage in muscle relaxation exercises and commit to getting enough sleep. Other treatment options may involve alternative medicine, such as acupuncture or massage therapy.

Pain-relieving medications or preventive medications also might be prescribed to address chronic headaches. Finally, certain patients may need injections to ease or prevent the pain. This might involve the use of nerve blocks, nerve stimulators or Botox injections.

"Botox is the first and only preventive treatment approved by the FDA for adults with chronic migraine," Patterson said. "It may reduce the number of headache days a month and/or decrease the severity of headache episodes."

Without treatment, the frequent pain of chronic headaches can lead to decreased quality of life. If you find that your headaches go beyond the occasional hangover or tension-filled day, reach out for relief.

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Study: Complementary & Alternative Medicine Use In Youth With Recurrent Headaches

A new study published in Pediatrics claims that children with chronic recurring headaches, especially those with another chronic condition, are more likely to use complementary and alternative medicine.

OBJECTIVE: To identify prevalence and patterns of complementary and alternative medicine (CAM) use among youth with recurrent headaches (HA) and evaluate associations with co-occurring health problems and limitations as well as with the use and expenditures for conventional medical care.

METHODS: Variables were constructed for youth aged 10 to 17 by using linked data from the 2007 National Health Interview Survey and the 2008 Medical Expenditures Panel Survey. Bivariate, logistic, and 2-part regression analyses were used.

RESULTS: Of the 10.6% of youth experiencing HA, 29.6% used CAM, rising to 41% for the many HA sufferers who also experienced difficulties with emotions, concentration, behavior, school attendance, or daily activities. Biologically based products (16.2%) and mind-body therapies (13.3%) were most commonly used, especially by the 86.4% of youth with HA experiencing at least 1 other chronic condition. Compared with non-CAM users, youth with HA who used CAM also had higher expenditures for and use of most types of conventional care.

CONCLUSIONS: CAM use is most common among youth with HA experiencing multiple chronic conditions and difficulties in daily functioning. Associations among CAM use, multiple chronic conditions, and higher use of conventional care highlight the need for medical providers to routinely ask about CAM use to meet the complex health needs of their patients and facilitate the optimal integration of care. Research is needed to identify models for coordinating complementary and conventional care within a medical home and to understand the health benefits or risks associated with CAM use in conjunction with conventional treatments for patients with HA.

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Long-term treatment for headache sufferers

Electric stimulation of the peripheral nerve has shown long-term effectiveness for reducing the intensity of headaches for chronic headache sufferers.

For the more than 45 million Americans who suffer from chronic headaches, relief may be on the way in the form of an electric pulse, according to a study presented at the ANESTHESIOLOGY™ 2013 annual meeting. Electric stimulation of the peripheral nerve reduced average headache intensity by more than 70 percent.

With electric stimulation of the peripheral nerve, a thin insulated wire is implanted in the back of the head (occipital nerve) or in the forehead above the eyebrow (supraorbital nerve) and delivers electric pulses to block pain. The study looked into the safety and long-term usefulness of this treatment.

"Despite advances in headache treatment over the past two decades, many people do not get adequate pain relief from current treatments, or they cannot tolerate the side effects of the medications," said Billy K. Huh, M.D., Ph.D., professor and medical director of the Department of Pain Medicine at The University of Texas MD Anderson Cancer Center, Houston, and adjunct professor of the Department of Anesthesiology at Duke University Medical Center, Durham, N.C. "This treatment offers hope to those patients and a chance for a major improvement in quality of life."

The study monitored 46 patients who received peripheral nerve stimulation between 2005 and 2012. Follow-up phone interviews were conducted to determine subsequent headache intensity, frequency of headaches per month, complications and overall satisfaction with the treatment.

The study found that both headache intensity and frequency decreased significantly. The average headache intensity was reduced by more than 70 percent. The average number of "headache days" decreased from 28 to 14 per month. Ninety percent of patients were satisfied with the treatment, with one reporting more than eight years of reduced headache intensity and frequency.

A drawback of the treatment is its relatively high level of complications, which include electrode migration, equipment problems and infection. The study authors state that as physicians gain experience with implantation techniques, complications will decrease.

"This is a real breakthrough for chronic headache sufferers," explained Dr. Huh. "For patients with no other options to relieve their pain and suffering, this treatment is a way for them to get their life back."

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