The experts are five leading headache specialists. Writing in the April 8 issue of the journal Neurology, they have two words of advice for other doctors. When faced with patients who say nothing helps their headaches, they say: Keep trying.
“Even for the most difficult-to-treat patients, 90% — and up — are very substantially better after a period of good specialty care,” researcher Richard B. Lipton, MD, tells WebMD. “Usually, when the patient says they have tried everything, they either have tried a small fraction of available treatments or have an undiagnosed condition that’s making the problem worse.”
This means that there are lots of people needlessly suffering headache pain, says Lipton, professor of neurology, epidemiology, and social medicine at Albert Einstein College of Medicine in New York.
“We see patients who have suffered for years and years,” he says. “They go to their primary care doctor, try a treatment, and fail. Later they go to a general neurologist, and try and fail. Some 30 years later they turn up in headache specialty practices where they get proper care.”
When to See a Doctor
What do you do when you have a headache? Nearly everybody first tries an over-the-counter headache treatment. If that doesn’t work — or if the headache comes back when the drug wears off — it might be time to get help.
“You should go to a doctor if you have headache red flags,” Lipton says. These warnings include:
A new kind of headache in anyone over the age of 50.
Headaches that become more and more frequent or more and more severe.
Headache together with a fever, a stiff neck, weight loss, or other medical symptoms.
Headache that comes out of nowhere. “If it begins absolutely suddenly; if you go from no pain to severe pain instantly, that is a sign of something bad,” Lipton says.
Headache in people with underlying conditions such as HIV infection or cancer.
You should also see a doctor if you have any kind of head pain that interferes with your life. If a headache interferes with work, study, or your social life, it’s time to get help.
What Kind of Doctor Should I See?
“People who seek medical care for headaches should start with their primary doctor,” Lipton says. “The overwhelming majority of patients can be well managed in primary care settings. Most don’t need neurologists or headache specialists.”
That’s also the experience of Donald B. Penzien, PhD, director of the head pain center at the University of Mississippi Medical Center, Jackson.
“You don’t have to be a rocket scientist to diagnose and treat most headaches,” Penzien tells WebMD. “But it’s not always easy to tell what causes a headache. Your primary care doctor may not have the time or training to delve deeply into it.”
When headache treatment fails to stop pain, he says, it may be time to see a specialist.
“I like to say every doctor treats headache patients. But very few specialize in headache,” Penzien says. “There is a lot to know. If you believe you have a difficult problem, seek out someone who does headache medicine for a living. Your general practitioner, as good a doctor as he or she may be, might not understand.”
Lipton says it’s time to see a specialist if your headache diagnosis isn’t clear.
“If you ask what kind of headache you have and your doctor doesn’t know, see a specialist,” he says. “And some doctors don’t consider treating headache a priority. If your doctor says, ‘Honey, don’t worry, it’s only a migraine,’ go see a specialist. Another reason is if after some period of treatment, you are still experiencing significant pain and disability.”
What Can I Expect from a Headache Specialist?
For many patients, proper care will mean finding the right headache treatment or correcting the dosage and schedule for treatments that haven’t worked before. Much of the time, headache treatment means stopping medicines that are actually causing so-called “rebound” headaches.
“Usually, when the patient says he or she has they have tried everything, they either have tried a small fraction of the therapeutic armamentarium, or they have a condition that’s making things worse — usually overusing medications,” Lipton says. ” Medicines taken to relieve pain can exacerbate headache. People who for years have headache, who take 10 different preventive medicines, haven’t addressed rebounding. It’s one of the most important headache triggers.”
If you take your headache medicine and the headache comes back when it wears off, you may be having rebound headaches. One clue is having a headache when you wake up in the morning.
“About 15% of the time, all we have to do is get patients to quit taking the medicines their primary doctor has been prescribing,” Penzien says. “That is our sole intervention. We just have patients quit taking medicines that make them worse. They usually are prescribed by a doctor that really cares about the patient, but doesn’t understand.”
Problems like this are the first thing a headache specialist looks for.
“There should be some effort to identify headache triggers,” Lipton says. “Every specialist takes a careful headache history to find out what makes a patient’s headache worse. Understanding these factors is an important preventive strategy, because most of these things can be managed.”
The next step is to find drug and non-drug headache treatments that help. Both come in two kinds. Acute headache treatments deal with headaches when they happen. Preventive headache treatments stop or limit headaches before they occur.
“In specialty care, the first objective is to relieve patients’ pain and improve their ability to function,” Lipton says. “In some patients, pain is relatively intractable. Then treatment becomes a rehabilitation strategy. We say, OK, we can’t stop all the pain. What will we do is improve your function in spite of some pain.’ In a small proportion of patients, you need to make this shift. For most, we say ‘Let’s relieve your pain and you can function.’ For others we say, “Let’s work on pain and function in tandem and see how much progress we can make in both areas.”
“The goal is not cure. It is management,” Penzien says. “Patients often give up on us before we give up on them. Once their pain is reduced, they feel as though they can now get on with their lives. But you don’t have to settle for that. We almost always have more tricks up our sleeves.”