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Headache Categories• Headache Categories• Migraine Categories• Other Headache Categories• Rare Categories• Chronic Daily Headache

Categories

Non Drug Approaches• Non Drug Approaches• Physical Approaches• Behavioural Treatments• Lifestyle Modifications• Why Patients prefer Non

Pharmacological Methods?

Neuromodulation Devices• gammaCore - new Neuromodulation

Device• Cephaly - FDA Approved

Headache Pearls• various snipits from Headache and

Migraine Centres - World-wide

Headache Medicines• Acute Medicines• Preventive Medicines• Over-the-Counter Medicines

Preventive Drugs for CDH• Antidepressants• Anticonvulsants• Beta Blockers• Calcium Channel Blockers• NSAIDs• Botox

HEADACHECATEGORIES

Common Headache Categories• Tension-type Headache• Medication Overuse Headache

Migraine Categories• Migraine without Aura• Migraine with Aura• Migraine Aura without Headache (neurological symptoms

without a headache)• Menstrual Migraine• Abdominal Migraine

* Please Note: Other very rare migraine types exist, please consult a specialist

Chronic Daily Headaches• Chronic Tension Type Headache• Chronic Migraine• New Daily Persistent Headache• Hemicrania Continua

Uncommon Headache Types• Post Traumatic Headaches (Headaches after Head Injuries) • Myofascial Pain• Headaches due to serious neurological conditions like brain

tumours • Hypnic Headache (which wakes patients from sleep)• Trigeminal Neuralgia (sharp-pain in the face or front of the head) • Headaches attributed to the Temporomandibular Joint (TMJ)

disorders

Rare Chronic Headaches• Chronic Cluster Headache• Chronic Paroxysmal Hemicrania

* a major concern among both Headache Neurologists, Migraine Charities etc., is that by taking acute medicines (any painkillers, triptans, and especially opiates like codeine, morphine, or oxycodone) too frequently, patients often develop Medication Overuse Headache (MOH). It is especially important for people with migraine to not take their acute medicines too often. For more on Medication Overuse Headache see the links below in green

Find Research articles and more about the above categories at: 1) American Council for Headache Education - www.achenet.org/resources/articles/2) The Migraine Trust - www.migrainetrust.org/research-articles3) All classified headache disorders can be located on the ICHD Classification page of the International Headache Society, found at www.ihs-headache.org/ichd-guidelines

Associated SymptomsIt is very common for a migraineur or a headache patient to complain of associated symptoms with their headache pain. The most common symptoms include nausea, light and sound sensitivity, vomiting, dizziness, fatigue, numbness, etc. Keep in mind that these symptoms are very individualistic and affect every person differently. It is also important to note that symptoms can overlap, thereby making them difficult to explain to your physician.

* Please note sinus headache is very uncommon and the diagnosis of sinus headache is commonly given in error. ‘Suspected’ sinus sufferers are very often suffering from a form of migraine. Migraine pain can sometimes present itself in the frontal-nasal area, adding to this confusion.

* Record, and mention any symptoms to your physician as often these are clues as to what headache type they suspect.

Medically reviewed by Dr. Werner Becker, Neuroscience Professor, Foothills Hospital, University of Calgary, Calgary, Alberta

NON DRUG TREATMENTSFOR HEADACHE

Non-Pharmacological ApproachesAlternatives or non-pharmacological approaches are numerous and many patients prefer them to medicines. Proven alternatives include Riboflavin B2, Magnesium, Feverfew (controversial evidence), Coenzyme Q10 (CoQ10), and Butterbur (Petasites Hybridus) (there have been some extremely rare cases of liver toxicity). These are all described in the book Chronic Daily Headache - Chapter 6.

Physical ApproachesPhysical Therapy (physiotherapy) is often used to strengthen neck muscles, or to correct poor posture. Hot or cold packs are common to help ease tender muscles. Neck stiffness is a common complaint from headache and migraine sufferers, and physical therapy can be an effective treatment. Other physical approaches include acupuncture, massage, chiropractic manipulation, and yoga. An older, very thorough book on Alternatives is called “The Headache Alternative” by Dr. Alexander Mauskop from the New York Centre for Headache in New York. Visit www.nyheadache.com, or look for it on Amazon.

Behavioural TreatmentsThese effective treatment strategies are often considered for patients that cannot tolerate medicines or dislike the side affects of medicines. Biofeedback is the #1 behavioural treatment for migraine in the USA, but sadly it does not have a strong presence in Canada. Examples of behavioural treatments include biofeedback, (in Canada we have other relaxation techniques), visual imagery, meditation, cognitive-behavioural/stress-management therapies, psychotherapy and hypnotherapy. Behavioural therapies are usually indicated for children or for women who are pregnant, want to get pregnant or who are breast-feeding. This therapy is generally inappropriate for Chronic Migraine patients, those who take excessive amounts of painkillers, or patients experiencing psychiatric disorders.

Lifestyle ModificationsThese are behaviours that can be easily introduced by the patient - and can be modified at home while waiting on an appointment. Examples include quitting smoking, trigger-avoidance, and incorporating proper sleep habits. These lifestyle modifications have the extra added benefit of being free.

The Following are Reasons why Some Patients prefer Non Pharmacological Treatments

• avoidance of side‐effects that some medicines produce• costs associated with medicine treatments• the sufferer cannot tolerate medications• they have a co- existing illness and the doctor recommends a ‘natural’

treatment• the sufferer ‘feels better’ when pursuing this type of treatment

MEDICINESFOR MIGRAINE

Acute (or Symptomatic)These medicines are generally prescribed to abort (stop) a migraine attack in process. Triptans are migraine-specific acute medicines - examples include almotriptan (Axert), eletriptan (Relpax), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig). Frequent use can lead to another headache type ‘Medication Overuse Headache’. A book on headaches will explain these medicines (and their uses) more fully.

Diclofenac potassium in powder form for oral solution (Cambia) is a fast-acting NSAID recently marketed in Canada for acute migraine in adults.

Over-the-Counter Medicines and OpioidsKnown to most of us as painkillers - these include over-the-counter medicines as well as prescription “opioids” or “narcotics”. Some of them may also contain caffeine. Sufferers often seek them out on pharmacy, supermarket or department store shelves. Frequent use can lead to another headache called ‘Medication Overuse Headache’ (known also as Rebound Headache). Examples of over-the-counter medicines include Acetaminophen (Tylenol), non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen (Advil Migraine), ASA (Aspirin), codeine-containing combination products and others. Visit a headache charity website or a book on headaches, for more information.

Preventative (or prophylactic)These medicines are taken daily to decrease the likelihood of a migraine developing, or to decrease the severity of the pain experienced. Categories include antidepressants, beta-blockers, calcium channel blockers, anticonvulsants, and others including herbal supplements. Chapter 3, 4 in the book ‘Headaches That Persist’ and Chapter 5 in the book ‘Chronic Daily Headache’ describes these medicines in detail. These drugs were usually designed for other ailments and discovered by accident to help alleviate migraine. Both books can be purchased at our website.

* please note that Non-steroidal Anti-inflammatory Drugs (NSAIDs) are used more for Acute migraine treatment, but they are sometimes used preventatively for menstrual migraine.

* for more information on Acute Therapy and Over-the-Counter medicines go here http://www.achenet.org/resources/acute_therapy_why_not_overthecounter_or_other_nonspecific_options/For long term Medication use visit http://www.mhni.com/headache-pain-faq/content-disclaimer/headache-pain-treatment/use-medication

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DEVICES (Drug Free)NEUROSTIMULATIONNeurostimulation Device and Nerve StimulationRecently, there had been an emergence of a few non-invasive nerve stimulators for headache patients. These devices are designed to stimulate nerves associated with a headache and migraine. Examples include Cefaly for migraine and recently in Canada - gammaCore, indicated for both cluster headache and migraines. Larger studies are needed to prove their efficacy. Cefaly is a placed on the sufferers head like a head-band; while gammaCore is held in one hand and the patient stimulates the vagus nerve in the neck region. gammaCore is found effective in treating migraine, cluster and chronic migraines.

gammaCoreThe gammaCore therapy is the first of its kind; a non-invasive vagus nerve stimulator (nVNS) that produces a mild electrical signal to treat migraine and cluster headaches.

• Non-drug therapy. No injecting, inhaling or ingesting.• Flexible treatment option that can be used alone or with your existing treatments.• No surgery. No invasive procedure.• Minimal side effects.• Only available on the recommendation of a physician.

gammaCore is a hand-held, portable device, about the size of a mobile phone that generates a unique electrical signal. A conductive gel is applied on the stimulation surfaces of the device and it is placed on the neck. Each dose takes approximately 2 minutes to administer (you may require more than one dose per treatment).

Early results are encouraging – visit www.gammacore.com

CefalyCefaly is a CE and ISO certified medical device designed to treat and prevent migraine headaches. Cefaly can considerably reduce or replace the consumption of side effect producing medications. Cefaly is the first cranial analgesic electrotherapeutic device to acquire ISO medical certification proven effective on migraine pain with no side effects.

Most headaches and migraines involve the trigeminal nerve. Its superior branch ends at the exit of the eye socket, underneath the skin of the forehead.An adhesive electrode is positioned on the forehead and Cefaly connects to this. Through the electrode, Cefaly generates precise micro-impulses in order to stimulate the nerve endings of the trigeminal nerve.

Neurostimulation of the trigeminal nerve with Cefaly® produces a relaxing effect. Regular repetition of this relaxing effect helps reduce the number of attacks of headache and migraine. Cefaly is the first external trigeminal neurostimulator. Cefaly works by stimulating the trigeminal nerve utiliz- ing an electrode that is applied to the forehead. This is where the two essential branches of the trigeminal nerve (supratrochlear and supraorbital) extend fur- thest to the surface of the skin. Cefaly is designed and developed in accordance with the strictest quality standards eliminating all possible short-term and long-term dangers.

Cefaly is an innovative, lightweight and extremely cost effective pain relieving solution. Its self adhesive electrode is placed directly on to the forehead. Worn conveniently like a pair of eyeglasses, Cefaly connects to the electrode and begins its subtle treatment. For a full detailed step by step guide on how to use Cefaly www.cefaly.ca/site/userguide.

For more information visit www.cefaly.ca or read about us in MacLeans Magazine at www.macleans.ca/society/health/two-shocks-and-call-me-in-the-a-m/

* Cephaly has Food and Drug Administration (FDA) Approval

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Reviewed by Irene Worthington, Pharmacist with interest in Headache, Sunnybrook Health Sciences Centre, Toronto, ON and lead author of Canadian Headache Society’s Acute Migraine Guidelines and co-author of Prophylactic Migraine Guidelines. She is a published author and member of the Board of Directors of Headache Network Canada.

DRUG CLASS CDH TYPE ADVERSE FFECTSAntidepressantsNortriptyline or amitriptyline

Chronic tension-type headache

• Drowsiness, dry mouth, possible weight gain

AnticonvulsantsTopiramate

Chronic migraine • Weight loss, nausea, tingling, cognitive effects, dizziness, tremor, drowsiness

Beta BlockersPropranolol

Chronic migraine • Depression occasionally, reduced exercise tolerance, slow heart rate, sleep disturbance

• Avoid in patients with asthma

Calcium Channel BlockersVerapamil

Chronic migraine • Constipation, swelling in hands/feet

NSAIDSIndomethacin

Hemicrania continua

• Occasional stomach irritation• Can cause stomach/intestinal bleeding

Botulinum Toxin InjectionBOTOX® onabotulinumtoxinA

Chronic migraine • Eyelid drooping

PREVENTATIVE DRUGS USED TOTREAT CHRONIC DAILY HEADACHE

HEADACHE PEARLS• AccordingtotheWorldHealthOrganization,ChronicHeadachesareaveryseriouspublichealthproblem(WorldHeadacheAlliance,England)

• TheWorldHeadacheAlliancesuggeststhatMedicationOveruseHeadacheismostoftencausedbyergots,followedbyanalgesics.Triptanswerelesslikely(WorldHeadacheAlliance,England)

•WendyThomas-ChiefExecutiveoftheMigraineTrustinEnglandisasked“willweeverfindacureformigraine?”,andherreplyis“Yes,butwejustdon’tknowwhenyet”.Sheadds“wehaverecentlyseeninthelastyear-theevolutionofnewstimulationtreatments”,butfurtheradds“largercontrolledstudiesareneededtoprovetheirefficacybutshealsoremindsusthat“MedicalResearchhasdeliveredcuresandeffectivetreatmentsformanyconditionsanddiseases.”(TheMigraineTrust,England)

•Weatherchangescanbefurtherbrokendownasbarometricpressures(altitude),brightsunlight,andinwesternCanada-theChinookwinds.Stormfrontscanalsobeanaggravatingfactor.(HeadachesThatPersist-Book,London,Canada)

• AlthoughCDHpatientsareoftenthemostdifficulttodealwith,accuracyindiagnosisandperseveranceintreatmentcanleadtosignificantimprovementsinvirtuallyallcases(TheMigraineTrust,England)

• Anotherpossiblecauseofdailyheadpainisaproblemwiththeupperneckandcervicalspine,especiallyafteraninjury.Itis,however,stillcontroversialastojusthowoftenthiscausesdailyheadache.Headinjuriescanalsocauseadailyheadachesyndrome.(HeadacheNetworkCanada,Toronto)

• Inapatientwithanormalneurologicalexamandnoothercomplaints,thesolesymptomofheadacheisrarelyrelatedtoabraintumour.Typicalbraintumourheadachesare“tension-like”,achinginnature,andcanoccurintermittentlywithagradualonsetandresolutionoverafewhours.(MichiganHeadache&NeurologicalInstitute,Michigan)

•WhenapatientisexperiencingMedicationOveruseHeadache,successfulhomedetoxificationoftenconsistsofanumberofstrategiesincludinggradualtaperingofthemedicationbeingoverused.Thiscanbechallengingandmanypatientsresistthisforfearofheadachesreturningorbeinguncomfortablewhenmedicinesarewithdrawn.Additionallypatienthabitsaredifficulttobreak,andsometimespsychotherapyiswarranted(AmericanHeadacheSociety)

•Manyindividualswithmigrainesuffertheirfirstheadachesaschildrenoradolescents.Overtime,headachesmaybecomemoresevereorfrequent,withsomeindividualshavingheadachesincreasetoadailyoccurrence.Thisincreaseiscalled“headacheprogressionortransformation.”Transformationinthiscasemeansaturnorchangetomoreheadaches.Agoalofcurrentheadacheresearchistounderstandthereasonsforthisprogression.Mightthischangebelargelyduetophysical,environmentalorinheritedtendenciesorsomecombination?(AmericanCouncilforHeadacheEducation)

• Headacheisanalmostuniversalexperience;mostofushavesomekindofheadacheatsometimeinourlives.Theclassificationsystemofheadachesusedbythemedicalprofessionisoneofthelongestinmedicine,withmanytypesandcauses.(TheMigraineTrust,England)

HeadacheBookstoHelpyouThebook-HeadachesThatPersist-isinnumerouslibraries.SuggesttoyourlibrarytopurchaseChronicDailyHeadache.

International

Headache NeurologistInterview with

Joel R. SaperM.D., F.A.C.P., F.A.A.N

HEADACHEFrequent, Continuous & Chronic Headaches

G. Brent Lucas B.A.

Your #1 Guide to Chronic Headaches

Headache Glossary Included - Compare Your Symptoms

www.headache-help.org

G. Brent Lucas B.A.

CHRONIC DAILY HEADACHE www.headache-help.org

Help for Headaches - www.headache-help.org www.headache-help.org

ISBN 978-0-9809559-1-0Canada - $19.95 • US - $19.95 • UK - £11.77

Published in Canada by:

“It’s like having a Sun-Burn all day, every day!”Headache, in its chronic or continuous form, presents a challenge to both the treatingphysician and the patient. If a headache patient complains of a myriad of symptoms, for their doctor, the problem becomes more complex.

- Dr. Joel Sapper, MHNI

Brent Lucas lives in London, Ontario and has a particular interest in headache/migraines & disability issues. He USED to suffer from chronic headaches. His focus is on helping others through education, and teaching sufferers how to help themselves – which patients can do in numerous ways.

CHRONIC or FREQUENT HEADACHES

• Insufficient training in medical school (Drs. Saper, Lay 2011)• Some patients have 2 or more headache types which can make diagnosis and effective

treatment very difficult.• Co-existing conditions such as depression, anxiety, sleep disorders, etc.(an entire

chapter is devoted to co-existing conditions)• Lack of awareness & education means that many patients treat themselves with OTCs

which can lead to MOH, which can make other migraine-specific medicines ineffective.• Improper treatment of migraines can lead to chronic migraine.• Chronic or frequent headaches can often be resistant to treatment.

What can YOU do?

Reasons why a Headache remains a Complex Problem, for Some:

• Keep a detailed diary and bring it to your doctor for analysis. Find out where to find one free.• Practice good ‘Headache Hygiene’ – explained in chapter 8 • Apply relaxation training to lower your sensation to pain. Suggestions inside• Learn about various chronic or frequent headaches and compare those symptoms to

YOUR symptoms and bring them your doctor. • Become more adherent about what is asked of you by your doctor. With your doctor’s help,

bring your chronic headache pattern, back to an episodic or occasional headache pattern; which makes them more manageable and/or treatable.

• Where can I find info specific to CDH Types?• My chronic headaches just began one day. Why?• Are chronic headaches treated with medicines,

alternatives, both?• There are some newer headache categories discussed

in this book. What are they?• I heard of the International Headache Society,

Classification Guidelines for Headache. Is it free to access for both doctors & patients? (see Appendix ii)

Answers to questions like these:

Headaches BookCover-9.indd 1 13-04-29 4:08 PM

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HEADACHEMEDICALLY REVIEWED

From ‘Type to Treatment’