Inside Front Cover:

1. Migraine is the most common cause of disabling headache.
2. Migraine can have many clinical presentations and degrees of impact on sufferers.
3. Efficacy of acute treatment is determined largely by choice of medication and timing of intervention.
4. Acute treatment medications should be limited to 2 or less treatment days per week whenever possible.
5. The goal of acute therapy is to safely and completely abort the migraine attack within 2 — 4 hours and preserve the patients ability to function.
6. Prophylactic therapy should be considered when migraine is not well controlled.
7. Lifestyle modifications, education, and patient involvement facilitate therapeutic success.
8. Encourage patients to keep a headache diary to identify risk factors and monitor treatment outcomes.
9. Migraine patients should be scheduled for regular follow-up visits.
10. Primary care can effectively manage most people suffering disabling headache.

First Page: The Primary Care Network is a 501C-3 non-profit organization comprised of over 6,000 clinicians who have demonstrated an interest in the management of disabling headaches by attending a headache management course and by completing follow-up CME articles on the Internet (at www.primarycarenet.org) or in a printed monograph format.

The goal of this publication is to provide a useful, cost effective, and time efficient way to manage patients with a complaint of headaches.

Method:

A. Review of the following guidelines:

1. National Headache Foundation’s Standards of Care for Headache Diagnosis and Treatment
2. Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting

1. Pharmacological Management for Acute Attacks
2. Pharmacological Management for Prevention of Migraine
3. Behavioral and Physical Treatments
4. Neuroimaging in Patients with Nonacute Headache

1. Canadian Guidelines for Headache Management

1. Extract from these guidelines an abbreviated but useful way to manage patients of primary care.
2. Include consensus clinical experience and judgment.

Archie Bedell, MD, PhD

Director, Mercy Health Partners Family Practice Residency Program

Toledo, Ohio

Specialty: Family Practice

Roger K. Cady, MD

Director, Headache Care Center & Primary Care Network

Springfield, Missouri

Specialty: Family Practice/Headache/Pain Management

Merle Diamond, MD

Associate Director, Diamond Headache Clinic

Chicago, Illinois

Specialty: Internal and Emergency Medicine/Headache

Kathleen U. Farmer, Psy.D.

Administrator, Headache Care Center & Primary Care Network

Springfield, Missouri

Specialty: Health Psychology/Neuropsychology

Chris Friesen, DO

Private Practice

High Ridge, Missouri

Specialty: Family Practice

James Johnson, MD

Private Practice

Edmond, Oklahoma

Specialty: Family Practice

Robert Kaniecki, MD

Director, University of Pittsburgh Headache Center

Assistant Professor of Neurology, University of Pittsburgh

Pittsburgh, Pennsylvania

Specialty: Neurology

Alvin Lake, PhD

Director, Psychology Division, Michigan Head Pain & Neurological Institute

Ann Arbor, Michigan

Specialty: Clinical Psychology

Elizabeth Loder, MD

Medical Director, Pain Management Program, Spaulding Rehabilitation Hospital

Instructor of Medicine, Harvard University

Boston, Massachusetts

Specialty: Internal Medicine

Morris Maizels, MD

Kaiser Permanente Medical Group

Woodland Hills, California

Specialty: Family Practice

Lisa Mannix, MD

Greensboro, North Carolina

Specialty: Neurology/Headache

Vincent Martin, MD

University of Cincinnati

Cincinnati, Ohio

Specialty: Family Practice

Jay Rosenberg, MD

Southern California Permanente Medical Group

Clinical Professor of Neurology, UCSD School of Medicine

San Diego, California

Specialty: Neurology

Curtis P. Schreiber, MD

Director, Medical Programs, Primary Care Network

Springfield, Missouri

Specialty: Neurology

Fred Sheftell, MD

Director, New England Center for Headache

Chief Medical Officer, Primary Care Network

Stamford, Connecticut

Specialty: Psychiatry

Tim Smith, MD

Medical Director, Ryan Headache Center

Director of Clinical Research, Unity Medical Group

St. Louis, Missouri

Specialty: Internal Medicine

Fred Taylor, MD

Headache Specialist, Park Nicollet Clinic Health System

Director, Comprehensive Head and Neck Pain Center

Minneapolis, Minnesota

Specialty: Neurology

Ted Thompson, MD

Family Physician, Gunderson Lutheran

LaCrosse, Wisconsin

Specialty: Family Practice

Jeff Unger, MD

Director, Chino Medical Group Headache Intervention Center

Assistant Professor of Family Medicine, Loma Linda University

Chino, California

Specialty: Family Practice

There are an estimated 28 million migraine sufferers in the United States but less than half are appropriately diagnosed and even less adequately treated. From a public health standpoint, primary care is the only medical specialty in a position to handle the large and growing headache population. Therefore, it is imperative that an effective standard of care be instituted for the primary care clinician.

The Role of Primary Care Clinicians

1. Recognize and prioritize primary headache disorders as important medical problems.
2. Provide effective treatment that preserves the ability to function.
3. Validate the biological basis of headache.

4. Prevent the evolution of inadequately controlled headache to chronic daily headache through appropriate patient management.

Migraine is a heterogeneous condition both in terms of symptomatology and impact on sufferers. Most attacks of migraine produce at least temporary disability despite efforts of self-management. Poorly controlled migraine can become extremely disabling causing frequent disruption of family, social, and work related activities. In fact, a quarter of employed migraineurs indicates that their career development has been negatively affected by migraine.

Few physicians screen for migraine from their patient populations and there are no public health initiatives to encourage screening despite the prevalence, impact, and treatability of the disorder. In fact, it is generally left to the patient to decide when migraine is a significant medical problem worth bringing to the attention of the medical provider. As a consequence, migraine is often mentioned in passing during evaluations of other medical conditions. By the time an individual seeks treatment for a disabling headache, he or she has already failed self-management and is experiencing significant disability.

1. There is no simple test to diagnose migraine. Current diagnostic criteria are symptom based which attempt to isolate various headaches into independent categories. This is time consuming and does not address the impact or treatment needs of the patient.
2. The average time available to a patient visiting a primary care clinician is often less than 10 minutes. Many patients bring multiple problems into an office visit. Thus further obscuring the recognition and impact of headache.
3. Migraine is often misdiagnosed as tension-type or other non-specific headaches. These other headache types rarely produce the level of disability necessary for patients to seek medical evaluation.
4. Treatment paradigms, such as, step care are promoted which mandate less than effective therapies and encourage recidivism. In fact, the average migraineur has failed at 4.6 treatment attempts before finding effective care.
5. Migraine is often viewed as a recurrent acute process rather than a chronic condition.

The sum of these obstacles to care may in part account for the high degree of dissatisfaction with medical care voiced by the headache population.

1. Migraine is a common disorder, affecting 1 out of 9 adults; 1 out of 6 women.
2. Migraine is commonly hidden among other disorders, psychological (depression or anxiety) as well as physical (sinusitis or allergy).
3. The single feature that best defines an acute migraine is interference with daily functioning.
4. A recent large clinical study confirmed a previous retrospective analysis and demonstrated that within the population experiencing migraine, the entire spectrum of disabling headache activity including episodic tension-type headache responds to a triptan. This suggests a common biologic mechanism may underlie both migraine and tension-type headaches. These headaches, though differentiated clinically, may in reality be manifestations of related pathophysiology.
5. From a clinical perspective, strictly defined migraine (International Headache Society-IHS) may be on one end of a spectrum of headache activity and episodic tension-type headache on the other. From the perspective of management and therapy, the focus can shift to the disability or impact that the entire spectrum of headaches makes on an individual’s ability to function normally.
6. In clinical practice, migraine can be defined as a stable pattern of recurrent disabling headaches without evidence of underlying cause. Minor nuances in symptomatology experienced from one headache to the next are less critical than the impact of a headache on the individual.

The advisory committee consensus is that migraine can be recognized in clinical practice by exploring the following four questions:

1. How do headaches interfere with your life?

Headaches that produce significant disability should be considered migraine until proven otherwise. Allowing a patient to explain the impact of headaches helps define disability, establishes rapport, and directs therapeutic interventions. For example, headaches that restrict important activities such as work or home responsibilities suggest a need for aggressive therapy whereas headaches with less impact may be adequately treated with OTCs. In this way, the physician provides the tools for managing the spectrum of headache activity and paves the way for patient-centered care. In the long run, the physician manages the patient rather than just headaches.

2. Has there been any change in your headache pattern over the last six months?

An affirmative answer demonstrates the need for a more in-depth evaluation while a negative response reassures the physician and patient that serious underlying disease is unlikely.

 

3. How frequently do you experience headaches of any type?

This information alerts the physician to chronic headache disorders and migraine transformation. Frequent headaches raise the issue of adding a migraine preventive to the patient’s treatment regimen. The question will also differentiate migraine from cluster headache.

4. How often and how effectively do you use medication to treat headaches?

Adding questions about prodrome, aura, postdrome, family history, and menstrual association can further reassure the patient and physician. Scheduling follow-up visits allows the physician to identify the rare secondary cause of headaches, assess treatment response, screen for co-morbidities, such as depression or irritable bowel syndrome, and monitor use of medication.

Migraine is a recurrent self-limited neurological event characterized by headache and other systemic symptoms. The creation of an acute treatment strategy for migraine involves five steps:

1. Identify components of migraine physiology that allow for intervention as early as possible in the migraine process.
2. Select the best pharmacological options for each patient.
3. Instruct patients on the proper use of their medications
4. Encourage use of a headache diary to monitor treatment and medication usage.
5. Provide information resources for patient education (see back cover).

The primary reason a patient sees a physician for migraine is to secure effective pharmacological intervention for the treatment of acute migraine. Fortunately, there is a wide range of drugs available for treatment of acute migraine. Therefore, it is advisable that a provider targets medications to specific phases of migraine pathophysiology.

The cascade of neurological changes that constitutes an acute attack of migraine generally occurs in a predictable fashion. Appreciating the clinical evolution of the migrainous process is the key to a rational pharmacological approach. Clinically, an acute attack of migraine can be divided into five phases: prodrome, aura, headache, resolution, and postdrome. Therapeutically, these can be grouped into pre-headache (prodrome and aura), headache, and post-headache (postdrome). Conceptualizing these three phases helps the selection of the most effective pharmacological approach.

The pre-headache phase may be characterized by non-specific symptoms, such as fatigue, mood disruption, muscle pain, or food cravings or focal neurological symptoms of an aura. Many patients are not aware of these symptoms until they’ve been educated about prodromes. For example, cervical muscle tension may be part of prodrome yet is often misinterpreted as being a tension headache. Food craving may result in chocolate consumption and be interpreted as a migraine trigger. However, for many patients, pre-headache is an individualized pattern that carries the indisputable message that a migraine is imminent. Prodrome precedes the onset of migraine in 50% or more of migraine attacks. Presumably, these symptoms result from neurochemical disruption of CNS homeostasis. Many of these symptoms continue during the headache phase of migraine, but are generally overshadowed by the drama of head pain.

Several theories suggest that the pre-headache phase results from an imbalance of neuromodulating transmitters such as serotonin and/or dopamine. In simplified terms, dopamine represents an excitatory side of neuromodulation while serotonin represents the inhibitory side of the equation. Prodromal symptoms relate to excess dopamine stimulation decreases in serotonin activity.

The therapeutic implications of understanding prodromes are enormous. If interventions are instituted during this phase, the headache itself may be averted. Many patients have discovered this through experience and report that if they take medications at the "right point in time," they can avert an impending migraine. Common prodromes include changes in energy level, alterations of sensory processing or cognition, food craving, and tender muscles in the head and neck.

The headache phase of migraine is characterized by headache which typically begins as mild pain and escalates to moderate or severe throbbing pain. Associated with the headache are numerous symptoms reflecting disruption of the central nervous system. These include sensory disruption, nausea and/or vomiting, mood disruption, cognitive disruption, and muscle tenderness in the head and neck, and autonomic disruptions. This symptom complex is frequently severe enough to produce significant disability and approximately one thirds of attacks result in confinement to bed. Generally, an attack of migraine lasts between 4 and 72 hours but may be shorter especially in children and adolescents.

Numerous factors need to be considered when developing a treatment strategy for the headache phase of migraine. The time from onset until peak intensity of pain or the presence of significant nausea generally determines the need for rapid acting interventions. Several options exist, such as using a parenteral formulation to circumvent the GI system, timing pharmacological intervention to precede the onset of significant GI symptoms, or adding an antiemetic prior to or with medication. In addition, important personal or work activities may affect treatment need. These are best managed when patients have multiple treatment options available to them.

Several clinical studies have demonstrated that triptans have significantly better efficacy taken when pain is mild as compared to moderate to severe. It would appear from this data and clinical experience that the more intense the headache phase has become prior to onset of therapy, the less likely a patient is to experience an abortive response to triptans.

The post-headache phase is characterized by lingering associated symptoms without headache. Most commonly this includes GI symptoms with a queasy, sick stomach and food intolerance, decreased concentration and occasional cognitive difficulties, sore muscles and general an overall sense of fatigue. This can last up to 48 hours.

Patients need to understand the evolution of their migraine attacks over time. By specifying certain medications for the various phases of migraine, patients can prevent or avoid much of the disability associated with migraine. In the long run, self-management integrated with effective pharmacology is the most effective form of therapy

Acute treatment is defined as an intervention aimed at aborting the migrainous process that is imminent or once it has started.

1. Safely abort the symptoms of migraine.
2. Prevent or stop disability and maintain function.
3. The medication accomplishes these goals within 2 hours of initiating therapy.

Effective therapy is attainable in a majority of patients even though these goals may not be attained in all patients or for every migraine attack.

1. Early intervention with appropriate medication offers the best opportunity for accomplishing the goals of acute treatment. Treatment with triptans initiated during pre-headache phase may prevent up to 60% of predicted attacks and decrease the severity of attacks that do occur. There is a growing and substantial body of evidence suggesting that early intervention during mild headache with triptans can abort headache in 80 - 90% of attacks within 2 —4 hours with lower recurrence, less disability, and fewer adverse events.²¹ Non-triptans may be equally effective in selected patients if used early in the migraine process but clinical trials supporting this have not been done.
2. People with migraine frequently experience a variety of clinically distinct headache patterns. Many of these have the potential to produce disability. These headaches may not in all instances fulfill IHS criteria for migraine yet if a persons suffers migraine their spectrum of headache is likely responsive to intervention with triptans.
3. Therapy that fails to eliminate the symptoms of migraine or ineffective therapy encourages medication over-use which in turn can result in episodic migraine evolving into chronic daily headache.
4. The goal of acute therapy is to tailor intervention to an individual’s needs and provide therapy that maintains or returns the patient to full function. Unfortunately, despite the best therapeutic plan, not all headaches will always respond. For that reason, it is important to provide a rescue plan for some patients.

1. Encourage patient participation in management.
2. Though rare, secondary headaches must be considered even after the diagnosis of migraine is made.
3. Migraine sufferers may have more than one headache presentation. Avoid defining these presentations as fundamentally different headaches without clear diagnostic evidence, such as sinus headache, muscle-tension headache.
4. Educate patients about early intervention and disability prevention rather than promote a treatment model that rescues patients once the migraine has become disabling.
5. With varying treatment needs, more than one therapy may be required.
6. Additional therapeutic options may be required to address medical factors, such as nausea/vomiting, or patient commitments, such as work, family activities, or special programs.

Prodrome

1. Non-pharmacological: Biofeedback, exercise, withdraw from stress.
2. Oral triptans: The role of triptans during prodrome is evolving. Data are available to support the following approaches:

Naratriptan 1 mg bid Predictable menstrual migraine

Begin 2 days prior to predicted migraine; treat for 5 days.

Sumatriptan 25 mg tid Predictable menstrual migraine

Begin 2 days prior to predicted migraine; treat for 5 days.

Naratriptan 2.5 mg Well-defined prodrome

Single dose; repeat if headache begins.

*The Advisory committee believes that all other triptans will be effective in these roles.

3. NSAIDs: Although no clear-cut evidence, consensus considers NSAIDs a reasonable option for a well-defined prodrome.

 

Mild Headache

1. Triptans (Typical dose)

Oral: Sumatriptan 25-100 mg (50 mg)

Zolmitriptan 2.5-5.0 mg (5 mg)

Naratriptan 1.0 - 2.5 mg (2.5 mg)

Rizatriptan 5-10 mg (10 mg; 5 mg if on propranolol)

Nasal: Sumatriptan 20 mg (20 mg)

Pending Approval:

Eletriptan

Almotriptan

Frovatriptan

2. Isometheptene compound (2 STAT at onset; 1 q 30 min prn continued HA; max 5 per headache)

3. OTC combination (ASA + acetaminophen + caffeine)
4. Full dosage of rapid acting NSAIDs

1. Oral triptans(see above)
2. Nasal triptans (see above)
3. Subcutaneous triptan

Sumatriptan (6 mg sc)

4. OTCs (see above)

If headache progression is rapid or associated with significant nausea, the use of intranasal or subcutaneous formulations is preferred.

1. Subcutaneous triptan (see moderate/severe)
2. NDAID — Ketolorac 30-60mg IM
3. D.H.E. 45 — 0.5 —1mg IM/IV q8h PRN
4. Narcotics

1. OTCs (see above)
2. NSAIDs (see above)

1. Headache frequency is more than twice a week.
2. Despite acute treatment, recurring migraines are significantly interfering with the patient’s daily routines.
3. Contraindication to, failure or overuse of, or adverse events with acute therapies.
4. Presence of complex auras (basilar or hemiplegic), prolonged aura, or migrainous infarction.
5. Patient preference

1. Reduce attack frequency, severity, or duration.
2. Improve responsiveness to treatment of acute attacks.
3. Improve function and reduce disability.

1. Maximize compliance by discussing with the patient the rationale for a particular treatment, when and how to use it, and common adverse events.
2. Address patient expectations. Discuss expected benefits and the need to give each medication an adequate trial. For most medication, a 4-6 week trial should be given and then the dose should be escalated in a stepwise fashion until improvement occurs, side effects develop, or the dose reaches the maximum that the physician is comfortable with.
3. If a successful dose is found, consider a taper in 6-12 months if headache pattern has been controlled.
4. Create a formal management plan incorporating behavioral and/or manual therapies and acute therapy elements.
5. Avoid interfering medications, such as acute medication or decongestants used more frequently than 2-3 days per week.
6. Consider comorbid conditions and their treatment in the selection of a particular agent.
7. Compliance may improve with the use of long-acting formulations.

1. Monitor headache frequency, severity, duration, and the use, efficacy, and side effects of acute treatment medication through headache diaries.
2. Headache diaries are an essential element of prophylactic programs.

1. Beta-adrenergic blocking agents

First-line: propranolol (20-160 mg/day), timolol (10-30 mg/day)

Second-line: atenolol (25-100 mg/day), metoprolol (50-100 mg/day), nadolol (20-120 mg/day)

2. Tricyclic antidepressants

First-line: amitriptyline (10-100 mg/day)

Second-line: nortriptyline (10-150 mg/day), protriptyline (5-30 mg/day)

3. Anticonvulsants

Behavioral therapy should be part of managing all headache patients. It can come in small installment with words of encouragement or formalized consultations. Whenever possible, behavioral therapy should be proactive and not instituted after "everything" has failed.

A migraineur is born with a more sensitive nervous system. For confidence in being able to manage migraine, a person needs to learn to recognize cues that indicate their system is at risk and to know what to do to reestablish equilibrium. Inherent in this concept is the migraine threshold.

The central nervous system constantly adjusts to changes in the external and internal environment. If demands placed on the nervous system exceed its ability to make these adjustments a migraine occurs. The migraine threshold is this theoretical line between physiological adjustment and the initiation of migraine. The migraine threshold is largely determined by genetic factors. However three other factors appear to lower the threshold for migraine. These include overuse of acute treatment medication (analgesic rebound headache), frequent uncontrolled attacks of migraine (kindling), and psychological assaults.

The factors that put the nervous system at risk for an attack of migraine are often stereotypic and predictable. Modification of these factors or learning to respond differently to them can reduce the frequency and impact of migraine. A month-long diary of headaches is the most effective tool for identifying these precipitating events and risk factors (see Table 1). An individual can counter these risk factors with activities that protect the nervous system from exceeding the migraine threshold (see Table 2).

Numerous studies support the use of biofeedback to prevent migraine. The majority of patients in primary care can teach themselves to relax and warm their finger temperature by listening to soothing music for 10 minutes once or twice a day. This process is especially effective for children and migraineurs who are considering pregnancy.

Biofeedback is the process of bringing involuntary physiological functions under voluntary control. Finger temperature, for instance, is a reflection of the body’s level of vigilance. The average finger temperature is 85 degrees F. As the stress response builds in the body, the finger temperature decreases. When the finger temperature is chronically low (below 80 degrees F), the body is in the survival mode, usually signifying that the individual has lost the ability to relax and re-create. Biofeedback trains the nervous system to shutout stimulation. Through biofeedback, the individual steps back from daily concerns, and focuses on returning the body to homeostasis, through calming, relaxing music and/or visualization. As this occurs, the finger temperature rises. The goal is 96 degrees F.

Coping Skills: Due to the sensitivity of the migraineur’s nervous system, there is an alertness to the feelings of others. Often, migraine sufferers feel responsible for another’s distress or apathy. Once they understand their sensitivity, they realize that they have a choice and they can decide to shut out others’ demands without feeling guilty. The coping skills that headache sufferers generally find useful include cognitive restructuring, assertiveness training, and identifying goals.

Cognitive Restructuring: Negative self-talk is an automatic private conversation that goes on inside a person’s mind in response to an occurrence in the environment. Often these negative evaluations of oneself are unconscious. Under guidance from a psychologist or counselor, the individual identifies negative self-talk and changes the disparaging remarks to positive messages. Through this process, the individual becomes in touch with both mind and body and as a result, has more control over health.

Assertiveness Training: Certain individuals believe that saying "no" or standing up for themselves will lead to rejection, abandonment, or an aggressive confrontation. Differentiating assertiveness from aggressiveness is a step-by-step process:

1. Identify when a behavior is being asked that the person does not want to do, which is usually signaled by feelings of guilt, anxiety, ignorance, or dread.
2. Practice saying "no" in unimportant situations, such as in a supermarket.
3. Say "no" to those who will be understanding, such as a friend.
4. Finally, say "no" to the person who demands behaviors that you don’t want to do.

Identifying Goals: Once assertive behavior is learned, the person needs to establish goals rather than rely on others to dictate behavior. Goals need to be written down and divided into a time frame, such as within 1 week, 1 month, 6 months, 1 year, and 5 years.

Acupuncture/Acupressure: Using fine metal needles or mechanical pressure, the acupuncturist manipulates energy called Chi to help the individual return to a balanced state.

Manipulative Procedures: A skilled practitioner moves joints or muscles in an effort to relieve tension and promote normal joint mechanics. When muscle tension precedes or accompanies the headache or when there has been an injury to the neck or head or spine, manipulative therapies may help alleviate the circuitry of pain.

Massage: A massage relaxes the body and releases stress buildup in muscle tissue.

Riboflavin (200-400 mg per day)

Vitamin B Complex (1 tablet per day).

Magnesium (500-750 mg per day)

Feverfew/Valerian Root (one capsule 3-4 times per day for one month. If effective, the dosage may be slowly decreased if desired.)

Aspirin: one per day

The treatment need of the migraine population varies widely from occasional office visits to prolonged hospitalizations. Most migraine sufferers can be managed within the scope of office-based primary care. However at times, resources beyond those typically found in primary care must be utilized. This section explores situations and resources available for managing of these patients.

CT is adequate for neuroimaging of nonacute headache with worrisome signs.

Recommended if:

1. It will lead to change in management.
2. The individual is significantly more likely than anyone else in the general population to have a significant abnormality.
3. It makes sense on an individual basis.

Worrisome Features:

1. Abnormal neurological examination
2. Headache worsened by Valsalva maneuver
3. Headache wakes person from sleep
4. New headache in person older than age 50
5. Progressively worsening headache

There are two major reasons for referral of headache patients. Neurological referral may be indicated in certain cases for diagnostic evaluation. This may be necessitated when the headache pattern is inconsistent with migraine or there is a need for reassurance by either patient or provider. Examples of appropriate consultation might be patients with atypical or prolonged aura, complicated migraine (basilar, hemiplegic, ophthalmoplegic) or if the diagnosis is uncertain.

Some complex patients have concomitant medical issues that may benefit from referral to other specialists such as internal medicine, nephrology, psychiatry or psychology.

When assistance in headache management is needed it is best to seek out a headache specialist. Headache specialists often have diverse backgrounds such as neurology, anesthesia, internal medicine, and family practice. Interest in headache management is actually more important in selecting a headache specialist than is their board certification. Sharing management of complicated cases with a headache specialist can often improve outcomes.

In-patient care is infrequently required for headache patients. Exceptions include patients with unrelenting migraine (status migrainosus) and patients who need monitoring during drug detoxification. One approach that had been helpful for many patients with status migrainosus is known as the Raskin protocol. Successful in-patient programs commonly employ an interdisciplinary approach, including psychology, biofeedback, education and social services.

In this era of managed care it not uncommon for third parties to intervene in the management of headache. Often this intervention is intended to reduce the cost of treatment to the health plan with dollar savings as the main objective rather than improving patient outcomes. The primary method of achieving the goal of reducing pharmacy cost is to mandate a step care approach of treatment despite mounting evidence that stratified care is more effective than step care.

In order to achieve the best outcomes for patients it is important for clinicians to:

1. Be the patient’s advocate.
2. Establish alliances with employers who have a vested interest in maintaining employee function and reducing work absenteeism.
3. Encourage third party payers to attend to the indirect costs of headache and the expense of repeated treatment failure.
4. Educate managed care and third party payers to the increased long term costs of poorly controlled headache and the value of effective early intervention.

1. Eat breakfast. Predictable mealtimes.
2. Wake up at the same time each morning.
3. Exercise at least 3 times a week.
4. Biofeedback daily: balance internal physiology and listen to your body.
5. No smoking, no caffeine after 4 pm, no artificial sweetener.
6. Learn headache pattern.
7. Pamper self during stressful times.
8. Resolve disputes: forgive, release, resolve.
9. Accept imperfection as human.
10. Play is as important as work.