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Treatment Failure has Many Causes, Most
of Which can be Corrected |
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BY DON SCHRADER
Contributing Writer |
CHICAGO
(ECCC)— Failure of headache treatment can arise
from a multitude of potential sources, which should be
identified and addressed promptly, Dr. Richard Lipton, said
April 13 at the annual meeting of the American Academy of
Neurology.
“Headache patients who consult neurologists usually have not
responded to over-the-counter treatments and to primary care
therapy,” said Dr. Lipton, professor of neurology at Albert
Einstein College of Medicine and director of the Montefiore
Headache Center in New York. “They often say they have tried
everything and nothing works.”
Principal reasons for treatment failure include incomplete or
incorrect diagnosis, exacerbating factors that are overlooked,
and inadequate pharmacologic or nonpharmacologic treatment.
Incomplete or incorrect diagnoses fall into three broad
categories: A secondary headache disorder goes undiagnosed; a
primary headache disorder is misdiagnosed; and two or more
headache disorders coexist and one goes unrecognized.
A detailed history and physical examination of a headache
patient should begin with consideration of red flags: signs and
symptoms of an underlying disorder that is causing headache. The
presence of a red flag suggests a secondary headache, and some
of the easily overlooked sources of secondary headache include
medication overuse, giant-cell arteritis, sphenoid sinusitis,
cardiac cephalgia, Lyme disease, and opportunistic infection.
If no red flags exist, attention should shift to diagnosis of a
primary headache syndrome. However, the focus should return to
secondary headache if the pain has atypical features:
inconsistent with accepted diagnostic categories of primary
headache; the pain does not respond to treatment; the headache
profile changes.
Some of the more commonly overlooked primary headaches are
hemicrania continua, paroxysmal hemicrania, and hypnic headache.
Incomplete diagnosis can occur when migraine coexists with
hemicrania continua or cluster and trigeminal neuralgia occur
together.
When considering primary headache, Dr. Lipton approaches the
differential diagnosis from the perspective of headache
frequency and duration: short duration headache (<4 hours
duration); recurrent-long duration (duration ≥4 hours, frequency
≤15 days/month); and chronic daily headache (duration ≥4 hours,
frequency ≥15 days/month).
Recurrent, short-duration headaches can be further separated
into several subtypes: those associated with pain in the first
branch of the trigeminal nerve (trigeminal autonomic cephalgias);
pain triggered by specific events or activities (cough,
exertion, sex, or sleep); “other,” which includes stabbing and
tension-type headaches.
Exacerbating factors can figure into the evaluation and
management of patients with existing chronic daily headache and
those with episodic migraine that might be at high risk for
progression.
“For patients who already have chronic daily headache, we want
to eliminate exacerbating factors and identify factors that lead
to remission,” said Dr. Lipton. “For patients with episodic
migraine, we want to identify those who are at high risk for
progression and then prevent that from happening.”
Prominent risk factors for progression to chronic daily headache
are increased attack frequency, obesity, medication overuse,
stressful life events, snoring, and allodynia.
With regard to medication overuse as a cause of headache
transformation, the risk of progression to chronic daily
headache is influenced by the type of medication used. As the
number of days a patient uses barbiturates in a month increases,
so does the likelihood of transformation to chronic daily
headache. The risk is further increased by the patient’s
baseline headache frequency, said Dr. Lipton.
On the other hand, increasing use of nonsteroidal
anti-inflammatory drugs decreases the risk of headache
progression. However, the protective effect diminishes as
baseline headache frequency increases.
“If you have a headache frequency of less than 10 days a month,
taking nonsteroidals appears to be protective against the
transition from episodic to chronic migraine, but once the
headaches become frequent enough, it’s too late,” said Dr.
Lipton. “The nonsteroidals cease to be protective and actually
become a risk factor for progression.”
As a source of failure of preventive therapy, inadequate
pharmacotherapy can occur as a result of the wrong drug, an
excessive starting dose, an inadequate final dose, inadequate
duration of treatment, and patient noncompliance.
With respect to inadequate pharmacotherapy as a cause failure of
acute treatment, “the fundamental issue is to understand the
reason for the patient’s dissatisfaction,” said Dr. Lipton.
“Does it represent lack of initial effect, headache recurrence
after an initial effect, or side effects?”
All therapies work better when given early in the course of a
headache syndrome. Abundant evidence from clinical trials have
identified inappropriate timing of therapy, especially delayed
initiation, as a frequent cause of treatment failure, said Dr.
Lipton.
The patient might require an antiemetic, and some patients may
require nonoral therapy, he added.
“Nonoral treatments are dramatically underutilized,” said Dr.
Lipton. “Gastric paresis is part of the migraine attack. Someone
who vomits can’t use an oral medication. Nasal sprays,
injections, and suppositories all are well worth using.”
Unrealistic or overly optimistic expectations reduce the
likelihood that patients with headache will be satisfied with
their therapy.
As a final consideration, treatment failure can reflect patient
dissatisfaction with therapy, which often can only be addressed
by encouraging reasonable expectations.
“The formula for satisfaction is reality divided by
expectations,” said Dr. Lipton. “If we let patients know what to
expect therapeutically, they may well be more satisfied with
what we offer them.” |
| Copyright 2008 Elsevier Custom Conference Coverage. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the copyright owner. No responsibility is assumed by the Publisher for any injury and/or damage to persons or property as a matter of products liability, through negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the medical sciences, the Publisher recommends that independent verification of diagnoses and drug dosages should be made. Opinions expressed in this publication are those of the original authors and do not necessarily reflect those of the Publisher, the sponsor, or the editors. Elsevier assumes no liability for any material published herein. |
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