Treating Persistent Headaches
By Ali Ahsen Shah, MD, MS
Persistent headaches often present a challenge for clinicians to manage. Headaches that occur on a daily or near daily basis for 15 days or more a month are painful and debilitating for patients. This is particularly true of headaches of cervicogenic origin, which present as chronic hemicranial pain that is referred to the head from either bony structures or soft tissues of the neck.
Up to 50 million Americans suffer from chronic headaches, and about 15 percent of the U.S. population suffers from debilitating migraine headaches. The vast majority of patients with headache that persists have a primary headache syndrome.
A migraine is an inherited condition manifesting as sensitivity to afferent stimulation. Patients become sensitive to light, sounds, smells and head movement during attacks.
A tension headache is a featureless headache not having the characteristic nauseam, photophobia or phonophobia characteristic of a migraine. Cervicogenic headache, more common in females, has neck involvement that is typically unilateral, moderate to severe nonthrobbing and nonlancinating pain originating from the neck, with marginal effect from indomethacin, ergots or sumatriptan (which can be diagnostically confirmed by anesthetic block).
Headache etiology can range from traumatic injury (such as from a motor vehicle accident) to infections or be secondary to inflammatory processes. Analgesic overuse or substance abuse may be the culprit, but sometimes headache is just plain unexplained. Patient habits also may contribute to persistent headaches.
Headaches can simply be a nuisance or they may be life threatening. In the case of the latter, clinicians should know these warning signs, which deserve prompt attention: fever; pronounced change in pain character or timing; neck stiffness; pain associated with cognitive dysfunction; pain associated with neurological disturbance such as clumsiness or weakness; or pain associated with local tenderness, such as of the temporal artery.
It is important to differentiate cervicogenic headache from a migraine. A cervicogenic headache typically will not respond to the traditional migraine pharmacologic therapy, such as ergotamine or sumitriptan, but it may respond to NSAID therapy and physiotherapy.
A biomechanical approach to cervicogenic headache is taken at the Good Shepherd Spine & Joint Center. The approach used to manage cervicogenic headaches includes: taking a careful history; studies of neck posture, levels of muscle tenderness and range of motion; and the identification of myofascial trigger points. Imaging procedures are not confirmatory but can provide supportive information.
The goal is to rule out many other potential causes of head pain, such as tumors, malformations, arthropathies, herniated discs or spinal nerve compression. Once that is completed, an effective, individualized treatment plan is developed for each patient.
Ali Ahsen Shah, MD, MS, is a physical medicine and rehabilitation physician at the Good Shepherd Spine & Joint Center. Dr. Shah specializes in the non-surgical treatment of spine and joint pain and headaches. He sees patients at Good Shepherd’s Health & Technology Center in Allentown and at Good Shepherd Rehabilitation–CedarPointe in South Whitehall Township.