Preventing Headaches and Reducing their Impact


Do you find yourself treating one headache after another? Do headaches interfere with your usual activities? Do your treatments cause annoying or impairing effects of their own? If your answer to any of these questions is yes, then you should consider a preventive treatment.

Whether speaking of migraines, tension-type headaches or other recurring head pains, it’s safe to say that the best headache attack is the one you don’t have. Even if you have found an effective treatment for resolving a headache that is already underway, there is nothing about today’s as-needed treatment that will keep next week’s attack from occurring. Headache treatments come in two forms—abortive and preventive. The abortive form is familiar to most people. It means something you do to get rid of a headache that has already started. Usually it consists of an over-the-counter or prescription medication, but in some cases, a non-drug approach works. By contrast, a preventive treatment is something you do every day with the goal of keeping some future attacks from even starting. These, too, can involve drug and non-drug strategies.

Billions of dollars are spent each year on abortive remedies. For the most part, they are dollars well spent. And for people who have infrequent headaches that are rapidly and reliably resolved by an abortive treatment, a preventive treatment might be needless. But if attacks are frequent, hard to resolve, interfere with usual activities—or side-effects from the abortive treatment interfere with usual activities—then a preventive treatment should be considered. Employing a preventive remedy does not preclude also using an abortive measure: each can be part of an integrated plan.

Before discussing specific treatments for specific headache types, let’s consider the impacts of recurring headaches. The more obvious impact is the sheer unpleasantness and suffering involved in an attack. However, another impact—though less obvious—is in its own way just as important. And that is the associated disability or loss of function that comes with an attack.

If a headache attack is severe, then whatever else was planned for that day goes out the window—it’s just not going to happen. If an attack is moderate in intensity, then usual activities might be possible, but occur more slowly, less efficiently, or require more effort to produce. This, too, represents headache-associated disability.

An increasing trend in the field of headache management is for practitioners to address their patients’ loss of function as well as their pain and suffering. Drs. Richard Lipton and Walter Stewart designed a questionnaire to estimate headache-associated disability, called the MIDAS (Migraine Disability Assessment) scale which can also be used for non-migraine headaches. Measuring and then re-measuring MIDAS is one method for judging if a preventive treatment is effective. But to accurately detect the effectiveness (or lack of effectiveness) of a preventive headache treatment there should also be some sort of day-by-day recording system. It might be as minimal as a check-mark on the calendar for each day with any symptoms. Another system is to summarize at the end of each day that one day’s headache-impact by selecting one of the following four descriptions—none, mild, moderate or severe. Numerically inclined people can assign scores of 0-3 to these choices and then run averages and other statistics for each calendar month.

For people with recurring or continuous pain there is a tendency to live moment-to-moment without a view of the longer-term pattern. A recording system helps capture the big picture. It would be a mistake to judge the effectiveness of any treatment on what happened with symptoms in just the last few days. Generally, a month or longer is required to judge fairly and accurately.

So now that we have decided to consider a preventive treatment for our headaches and have put in place a system for measuring the treatment’s outcome, what specific remedies are available?

It depends, of course, on the kind of headaches being treated. Let’s discuss two of the most common types—migraine and tension-type headaches.

For prevention of migraine, the best-studied and most effective drug treatments are available by prescription only in the U.S. These include propranolol (brand name Inderal), amitriptyline (Elavil), divalproex (Depakote) and topirimate (Topamax). Riboflavin (vitamin B2) at 400 milligrams per day was shown in one controlled study to have migraine-preventing actions. (At this dose—far higher than what is needed to treat vitamin deficiency—riboflavin should be considered a drug rather than a vitamin.) The herb feverfew has also shown benefit in controlled trials, but it is important to remember that this, too, is a drug and can have side-effects. As is the case with other drugs, it should not be used during pregnancy.

Non-drug strategies of proven effectiveness in migraine prevention include therapist-supervised programs of stress management, relaxation, biofeedback and cognitive-behavioral therapy. Studies of acupuncture have shown mixed results. Avoiding individually determined triggers for attacks carries no risk and can reduce the attack rate.

For tension-type headaches amitripyline is the best-studied drug for prevention of attacks. Note that this drug is also a leading treatment for migraine, so people unlucky enough to have both kinds of headaches can obtain benefit from just one drug. Unfortunately, even at the low doses used for headache prevention, amitriptyline can cause daytime drowsiness (even when administered at bedtime) or annoying oral dryness. Because of this, substitution of a better-tolerated, though less-studied drug in amitriptyline’s family (tricyclic antidepressants) is sometimes required. Tizanidine (Zanaflex) has also shown benefit in controlled trials.

Non-drug strategies for tension-type headache have also been proved effective. These include similar behavioral interventions to those mentioned for migraine—stress management, relaxation, biofeedback and cognitive-behavioral therapy.

It would be wonderful if preventive treatments stopped headaches entirely. If they did, a measurement system would not be necessary. But a more realistic goal for preventive treatment is to reduce overall headache symptoms by at least half, or to an extent that an individual patient finds meaningful. When this occurs, a preventive approach can be a valuable addition to a program of headache management.

By Gary Cordingley

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