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HEADACHE
Following closed head injury, headache is the most common and one of the most persistent complaints made to doctors. In TBI patients, effortful concentration often triggers headache, limiting time spent reading, studying or doing cognitive remediation exercises. Headache (especially chronic daily headache and migraine) can be disabling in the absence of medication, since they cause insomnia, fatigue, depression and cognitive decline. Medications which boost serotonin (such as triptans) can reverse or reduce such symptoms in many but not all sufferers. See, Headache 40(8):638-646.

Medication, no matter how potent, is not enough. Chronic headache sufferers must undergo counseling and behavioral change to identify and avoid headache triggers, increase control over headache onset and gain confidence in their own ability to prevent and manage their headaches. See, Headache 40(8):647-655. Patients who have no prevention strategy or those who over-medicate (and thus cause "rebound" headaches) feel themselves at the mercy of their headaches, and tend to feel pessimistic and depressed. Patients who fail to keep headache diaries cannot learn to identify and avoid headaches triggers. For example, headache sufferers who cannot give up red wine, can reduce triggering red wine headache by looking at wine labels and avoiding those which contain sulfites. Working closely with a neurologist who sub-specializes in headache management is critical to recovery from TBI in those patients who suffer intensely from headache. Recent literature indicates that the #1 long term complaint of persons with "mild" TBI is headache.

The choice of medication depends of the cause. The traumatic event which causes the TBI can simultaneously trigger one or more type of headache, including myofascial (from tension in cervical or scalp muscles), cervical (from spinal subluxation or disc herniation in the neck), migraine, cluster and others. For mild to moderate muscle tension headaches, aspirin, ibuprofen or tylenol can help (especially when consumed with a cup of coffee to increase absorption rate in the stomach). Midrin is a good combination pill containing anti-inflammatory and pain medicine with caffeine. For more severe muscle tension headaches, trigger point injections of steroids or Botox along with a more powerful analgesic like Vicodin may be required.

For migrainous headache (one-sided, throbbing headache accompanied by nausea, fatigue and hypersensitivity to light or noise) analgesics are often combined with vaso-constrictors to narrow the dilated blood vessels. These include preparations like Fiorinal. Very severe pain can be medicated with Darvon at home or with DHE-45, Demerol, Stadol or various cortico-steroids at the doctor's office. Intra-nasal administration of lidocaine, a local anesthetic, shows promise for lasting pain relief. A recent study found that some migraine patients benefit from injections of Botox (botulinum toxin) to selected places on the face. Migraineurs with frequent headaches may benefit from prophylatic medications to limit the number of headaches. These include tricyclic anti-depressants (Elavil, Pamelor or Sinequan) and Depakote (a gabapentin preparation used as an anti-convulsant).

A relatively new family of medications called "triptans" (5HT agonists which increase the supply of serotonin) have proven extremely effective in stopping or "aborting" migraines already in progress. These include Imitrex, Amerge, Zomig, Maxalt and Relpax. The triptans are so effective they are being hailed by many neurologists as a near miraculous breakthrough in migraine relief. A key to successful use of triptans is rapid administration. Low dose administration of a triptan during the early phase of a migraine, before it becomes excruciating or incapacitating, appears to work best. Patients with migraine are encouraged to fill out a disability questionnaire (such as the Midas Migraine questionnaire at www.midas-
migraine.net). A 2 year study on treatment of acute migraine conducted between 1997-1999 in 88 clinical centers across 13 countries shows that "stratified care" works much better than "step care" for migraine. In the stratified approach, patients who assess themselves with a high level of disability from migraine, should be placed immediately on triptans. The older approach (based on cost) was to take all migraine patients and bring them up the ranks of medication in step-wise fashion from the cheaper more generic meds to the more expensive, boutique medicines formulated specifically for severe migraine. See Lipton RB et al. "Stratified care vs. step care strategies for migraine" JAMA 2000;284:2599-2605.

Patients who do not respond well to one triptan should not give up. Research shows that non-responders to Imitrex, may respond very well to another triptan due to slight differences in the molecular structure of the medications. Each triptan has its own unique side effect profile. Commonly reported side effects include dizziness, nausea and tiredness. The very newest triptan, to be marketed in the USA in 2001, is almoptriptan or Axert. The studies submitted to the FDA show that Axert has a lower incidence of these side effects than other triptans. When a patient decides to switch from one triptan to another, he should allow 2 weeks off medication before switching to avoid the potentially serious problems that go with mixing medications. Great care should be used with these drugs in anyone with coronary artery disease.

Oral medication is not the only method of aborting a migraine in progress. Inra-nasal administration of lidocaine has proven very effective in some migraine sufferers. Injections of lysine clonixinate (a nicotinic acid derivative marketed under such names as Dolamine, Solnot, Clonix and Deltar) was touted as a highly effective means to control migraine pain at the Winter 2000 Conference of Neurology in Brazil. For patients with acute migraine who are highly nauseated and vomiting, and who cannot tolerate oral medications, intravenous valproate sodium (Depacon) is quite effective and without severe side effects, such as the addiction which accompanies opiate treatments to stop the vomiting. See, Headache 40(9): 720 Oct. 2000. Injections of Botox (killed botulinum toxin) into the scalp muscles has been advocated by some neurologists as an excellent remedy for chronic daily headache with a tension component, since it relaxes the scalp muscles.

Some patients experience their headaches only at night during sleep. These are called "hypnic headaches" and are associated with the REM phase of sleep when serotonin and norepinephrine production cease. Some sufferers of hypnic headaches have OSA (obstructive sleep apnea) and they tend to show improvement with CPAP (continuous positive airway pressure) or surgery of the sinus or throat to remove the obstruction. However, not all hypnic headache sufferers have OSA. For the ones who do not, use of melatonin or Indomethicin has brought some relief. Headache 40(9): 748 Oct. 2000.

Meditation with positive imaging can help tension headache and bio-feedback may help migraine. SSRI antidepressants like Prozac and Zoloft have not been established as effective in relieving migraine. Some cluster headache and migraine patients experience redness, tearing and burning sensations in their eyes during a headache. These patients can benefit from Periactin. People interested in tracking the development of new headache medications may check a new government web site mandated by Congress called www.ClinicalTrials.gov