References:Headaches(Chinese Version)
Headaches and the Workplace / School
American Council for Headache Education http://www.achenet.org
Many women with headache are overwhelmed by the strain of (1) holding down a demanding job, (2) meeting family obligations, and (3) taking care of personal health and needs. Patients with very severe headaches may consider cutting back on work load or even quitting work altogether as a way of helping their headaches. Often they assume that if they do not have work to worry about, their headaches will improve. However, pain and headache experts in the field find that quitting work is not necessarily the answer for everyone.
Depending on the type of work, some modifications can be made in the workplace that might help reduce the impact of a stressful job on one's headaches. For many patients, slight modifications in the workplace can reduce the frequency and severity of attacks. For example, some of these include:
The way people are treated at work can make a big difference in how successful they are able to manage their headaches while maintaining a job. Employers need to realize that headaches are a legitimate medical problem and that headaches are more common in women than men. Some employers may "make light" of worker's headache complaints. Historically, employers take seriously some medical problems that are more common in men, such as heart attacks, prostate trouble, and high blood pressure. It is not unreasonable to ask that a chronic headache condition also be taken with the same consideration. Simple workplace modifications like telephone headsets to reduce neck strain, replacing headache-provoking fluorescent lights with incandescent lights, and allowing sufferers to take regular breaks and meals can make big differences in coping with job stresses and preventing headache.
The doctor also may be willing to make a request that may help reduce some of the work stress (sitting instead of standing, modified lighting, noise control, etc). Giving up work completely is rarely necessary or advisable for the majority of headache patients. Headache patients need to learn how change of environmental factors can make a difference in their job stress and triggering or exacerbating headaches. In most cases, this can be done without significantly disrupting others.
All things considered, work actually provides benefits that are important for many people who suffer from headache. Going to a job on a regular basis is a reason to get up, get dressed, interact with people, earn financial rewards, build self esteem, and maintain independence. Personal reward, feeling of accomplishment, and being proud of one self is an important part of good well-being and can be a rewarding part of one's job. For most people, earning money and performing well at work provides an important self-esteem boost and helps people feel useful. Importantly, work provides a beneficial routine and structure to our lives.
Some patients who give up because they think their headaches will be cured and are surprised to find that their headaches did not go away. Once they have quit working, many find that there is no reason to get up in the morning, and some tend stay in bed most of the day. This disrupts sleep-wake cycles, and some people may stay up watching late-night television while their family and friends sleep. During the day they are tired, they may not bother to get dressed, and they quickly lose touch with friends and activities. For many of these individuals, depression may set in, and with others, they focus (some even perseverate) on their headache pain and medication use. For some patients that quit working because of their headaches, this downward spiral of inactivity, depression and worsening headache is not at all uncommon.
Remaining involved in life, even if it means altering one's work schedule, changing jobs or taking up volunteer work is often a better choice than dropping out entirely. For the majority of headache sufferers, quitting work is not the solution to managing headaches.
Over the last 10 to 15 years, headache sufferers have benefited from a new generation of headache drugs that are faster-acting with fewer side effects. However, some people, like Leslie, still have headaches that are so severe or pro-longed that they can't be adequately controlled by these medications. Others get good results with drugs such as DHE or the triptans, but their headaches are so frequent that they find they are taking these medicines several times a week.
If you are losing too much of your life to frequent or severe headache attacks, there are other options for managing your headaches. Instead of taking medication as needed, to control the pain and other symptoms of a headache attack, you can try one of a number of medicines that can reduce the number of headaches you experi-ence stopping headaches before they strike.
Stopping versus Preventing Headache
Most of the familiar headache drugs¡ªover-the-counter pain relievers, NSAIDs, ergotamine, DHE, and triptans¡ªare used only to stop (abort) a headache attack that is already in progress or about to begin. These drugs, known as abortive medications, are not only ineffective but counter-productive if taken on a daily or near-daily basis. You should never take them ¡°just in case¡± because you are worried that you might get a headache attack.
In contrast, preventive medications are taken daily to prevent headaches from occurring. These medications do not eliminate headaches altogether. When successful, they reduce the number of headaches that do occur. Oftentimes these headaches are less severe and more easily controlled with abortive medications.
In general, there is little overlap between these two categories of headache medicines. Most abortive medications will actually cause headaches if they are used too often. Likewise, preventive medicines are generally useless if they are only taken during a headache attack. They need to be taken on a regular basis in order to work.
When are Preventive Medicines Used?
Preventive medications are generally reserved for people whose headaches are either frequent or severe or both. In most of these situations, the drug is taken daily on a long-term basis. Preventive drugs are also helpful for people who get their headaches at predictable times. For example, women with menstrual migraine or people with cluster headache that occurs at predictable seasons of the year can start taking a preventive medication in advance of their headache-prone time to reduce the risk of severe headaches.
The goals of headache prevention are:
The Headache Preventative Drugs There are several types or classes of headache preventive medications. With the exception of methysergide, all these drugs were originally developed for treating other conditions, such as high blood pressure, seizures, or depression, and only later discovered to be effective for headache as well.
| Class | Medications | Special Considerations |
| Beta blockers: Prescribed for hypertension (high blood pressure), angina, cardiac arrhythmias (abnormali-ties of the heart’s electrical system), heart attack, and tremor; propranolol and timolol also approved for migraine | Propranolol (Inderal) Timolol (Blocadren) Metoprolol (Lopressor) Nadolol (Corgard) Atenolol (Tenormin) |
Should not be used in patients with emphysema, chronic bronchitis, asthma or diabetes; used with caution in patients with depression; may limit athletic performance |
| Anticonvulsant: Treats migraine, seizures, and bipolar disorder (manic depression) | Divalproex sodium (Depakote) | Blood tests before therapy and periodically during treatment are recommended |
| Tricyclic antidepressants: Relieve depression | Amitriptyline (Elavil, Etrafon, Limbitrol) Nortriptyline (Pamelor, Aventyl) Doxepin (Sinequan), Protriptyline (Vivactil), Desipramine (Norpramin), Imipramine (Tofranil) |
Should not be used in patients with specific heart rhythm abnormalities, prostate problems, or glaucoma |
| Calcium channel blockers: Prescribed for angina, cardiac arrhythmias (abnormalities of the heart's electrical system), hypertension (high blood pressure) | Verapamil (Calan, Isoptin) Diltiazem (Cardizem) Nimodipine (Nimotap) |
Not prescribed for people with certain types of heart disease |
| Nonsteroidal anti-inflammatory drugs (NSAIDs): Relieve pain and inflammation resulting from many different conditions | Naproxen sodium (Anaprox) Ketoprofen (Orudis) |
Ulcers or bleeding of stomach lining may occur with long-term use of NSAIDs; not prescribed for people with aspirin sensitivity or asthma |
| Serotonin antagonist: Prescribed for migraine or cluster headache | Methysergide (Sansert) | Rare risk of fibrosis (scar tissue on internal organs); should not be used by patients with coronary artery disease, angina or Raynaud's disease |
| Serotonin and histamine antagonist: Prescribed for migraine in children | Cyproheptadine (Periactin) | Avoid use during asthma attacks |
It's generally not possible to predict which medication will work best for an individual. For this reason, selection of a headache preventive medicine is often guided by any other health conditions a patient may have. For example, a beta blocker would be a good drug to try for someone with high blood pressure, while a tricyclic antidepressant would generally be avoided for someone with a history of heart disease. Divalproex sodium would be the obvious choice for someone with migraine and bipolar disorder, though it also works for people who only have migraine.
Cost is another factor to consider in selecting a headache preventive. Not all patients have prescription plans, and even those who do may find it difficult to get reimbursed for drugs that are used off-label, that is, prescribed for a condition that is not included in the FDA-approved indications. Propranolol, timolol, divalproex sodium and methysergide have been approved for prevention of migraine by the FDA. All of the other current headache prevention drugs are prescribed off-label. The monthly cost for headache prevention drugs can range from $4.35 for the antidepressant amitriptyline to $270.00 for the calcium channel blocker nimodipine. While no one should be denied an effective treatment on the basis of cost, it makes good sense to first try less costly drugs that have a proven track record, unless the individual has other medical conditions that limit treatment options.
Beta blockers such as propranolol, nadolol, and timolol are frequently prescribed preventive drugs for migraine. They are good choices for people with high blood pressure, since one drug can treat two conditions. Beta blockers have been around for a long time and have a very good record for safety. Side effects may include fatigue and cold hands and feet; vivid dreams, sleeplessness or depression are less common but have also been reported. Let your doctor know if side effects are causing problems for you, but don’t stop the medicine or skip doses until the two of you have had a chance to discuss the issue. Side effects generally improve with continued treatment and can often be minimized by lowering the dose and then increasing it gradually.
Divalproex sodium was first developed as a treatment for seizure disorders and later proven to be an effective preventive treatment for migraine. In fact, it is one of the better studied headache preventive drugs. People with migraine take smaller doses than those needed to control seizures, so side effects are generally milder when the drug is used for headache control. The most common side effects at the lower doses are nausea, queasiness, fatigue and drowsiness. These side effects tend to disappear with continued treatment. As a safety measure, liver function is sometimes monitored with periodic blood tests.
Tricyclic antidepressants are also effective options, particularly for people who have both migraine and tension headaches or who are also prone to depression. Dry mouth, weight gain and drowsiness are the most common side effects, but these tend to improve after a few weeks of treatment. Usually the doses needed to treat headache are lower than those needed for depression, so the side effects are often less noticeable. If weight gain or sedation becomes a problem while taking amitriptyline, some of the other drugs in this class of medicines, such as protriptyline, are less likely to have these effects and could be tried instead.
A newer class of antidepressants called SSRIs or selective serotonin reuptake inhibitors are sometimes used for prevention of migraine. SSRIs such as fluoxetine (Prozac), venlafaxine (Effexor), and sertraline (Zoloft) produce fewer side effects than the tricyclic antidepressants, so they are a reasonable option for headache patients who also have problems with their mood. Sometimes headache can occur as a side effect of SSRIs. Some people are offended when their doctor suggests taking an antidepressant to treat their headaches, assuming the doctor thinks their headaches are a psychological problem.
However, antidepressants can be effective in controlling headache for people who are not at all depressed, just as beta blockers are effective for headache sufferers who do not have high blood pressure, and divalproex sodium is an effective headache treatment for people who have no history of seizures. If you have had any problems with depression or anxiety, it is best to mention this to your doctor, since some other headache preventive drugs can produce depression as a side effect.
The calcium channel blocker verapamil is an effective preventive treatment for cluster headache, a relatively rare headache disorder involving severe but brief episodes of one-sided head pain that occur in clusters then disappear for months to years. Verapamil is somewhat less effective when used for migraine prevention, but it might be a reasonable choice for patients with high blood pressure who have side effects with beta blockers. Constipation is the most common side effect. The other calcium channel blockers are also sometimes used for migraine prevention, but their effectiveness has not been demonstrated in formal studies.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen or ketoprofen are sometimes prescribed as preventive drugs for migraine. Headache sufferers should never attempt to treat on their own by taking daily doses of over-the-counter equivalents such as Aleve, Actron, Orudis, or ibuprofen (Advil, Motrin, Nuprin). At the wrong doses, daily NSAIDs can result in a drug-rebound headache that returns as each dose wears off. NSAIDs are often good choices for women with menstrual migraine. In this situation they are taken only during the headache-prone days of each cycle. Stomach irritation can occur as a side effect of NSAIDs, and there is a risk of ulcers and bleeding of the stomach lining with long-term use.
Methysergide is one of the oldest and still most effective drugs for migraine prevention. However, it has side effects that limit its usefulness. It has been known to cause scar tissue to form on the heart or other organs as a very rare but serious complication of long-term use. Patients who are prescribed methysergide must stop the drug for three to four weeks after every six-month course of treatment in order to avoid this complication. More common side effects include nausea or vomiting, diarrhea, heartburn, and stomachache.
Cyproheptadine is an antihistamine but it also acts on the serotonin system, which is known to have a role in migraine and cluster headache. It is commonly used to treat childhood migraine and is generally given at bedtime. The most common side effects are an increase in appetite and weight gain.
Vitamin, herbal, and mineral supplements, particularly riboflavin, feverfew, and magnesium, may also be prescribed to aid in headache control. It is not a good idea to take megadose vitamins on your own because excessive doses of some vitamins (vitamin A, for example) can cause headaches. The herb feverfew was shown to be moderately effective in migraine prevention in several studies; it’s important to find a reliable source, since herbal remedies sold in capsule form may be stale and lacking in potency.
Before You Start
It's important to know that preventive medicines usually do not succeed in preventing headaches altogether. Instead, the goal often is to reduce headache frequency. The headaches that do occur may be less severe and more easily con-trolled by abortive drugs like DHE or a triptan.
Preventive medicines are ineffective if the individual is using pain relievers or other headache abortive drugs on a daily or near-daily basis. Overuse of pain relievers, ergotamine or triptans can result in a daily headache that cannot be treated except by stopping the overused medication. The daily headaches tend to improve some weeks to months after the medication is stopped. Unfortunately, the headaches may become more intense when the medication is withdrawn. Preventive medicines can be very helpful in getting the individual through that withdrawal period, but they will not work unless the overused medication is stopped completely.
Birth control pills may sometimes increase headache frequency, and preventive medicines are generally ineffective in controlling headaches related to birth control pills. If you suspect your headaches are intensified by your oral contraceptives, discuss the possibility with your doctor. You may want to try a non-hormonal method of birth control for a few months to see if the headaches might improve on their own.
What to Expect
Once you start a headache preventive medicine, you may not notice a real improvement for as long as two or three months. If you don't see an improvement within that time period, don't be discouraged because there are still other medications to try. Some people who have limited improvement or side effects with one medication will do very well with another. Some doctors prefer to start preventive drugs at a low dose and build up the dosage gradually, because side effects tend to be less of a problem with this "start low-go slow" strategy. This approach takes more time, but it can be very helpful in selecting the right dose for a given individual.
It's often difficult to remember to take a pill or capsule every single day, particularly when you haven't yet noticed an improvement in your headaches. But, unless you take all the medication as directed, you may never find out whether it could help you. If you do miss some of your doses, be honest with your doctor about the problem. The two of you might want to try one of several different "reminder" systems that help people keep track of daily medications. Most pharmacies and drug stores have pill containers labeled for the days of the week that can help you keep on schedule.
Tracking Results
Whenever possible, it¡¯s a good idea to keep a headache calendar or journal before and after starting a preventive medication. In your journal, you should record all your headaches, their intensity, their duration and their type (if you have more than one type or pattern of headache). Write down all the drugs and the doses you take for each headache and also note down whether they helped the headache or not. A before-and-after picture of headache frequency and severity is really quite important for deciding whether the medication is doing its job. If you set your expectations too high, hoping you will be one of the lucky ones who have almost no headaches and no noticeable side effects, you may miss seeing a more subtle improvement - for instance, you might have one-third fewer headaches and you may be taking about half as much medication for them as you used to. If you and your doctor then decide to try another dose or a different drug, you will have a benchmark so that you can make comparisons to say which is better, Treatment A or Treatment B.
A headache journal is also an excellent tool for developing non-drug prevention strategies. For this purpose, you should also record all medications you take for any reason (some drugs can cause headache as a side effect) and any suspected triggers, such as alcohol, MSG (monosodium glutamate), excessive caffeine/ caffeine withdrawal, muscular tension, poor posture, extra stress or tension at work or home, changes in weather patterns, flashing lights or strong odors, or any of the possible food triggers. While some triggers, such as weather changes, are impossible to control, many others can be minimized or avoided altogether.
Over the Long Term
Most people will continue to have some headache attacks while taking preventive medication. These attacks can be treated with "back-up" abortive medications such as over-the-counter pain relievers (if effective), ergotamine tartrate, DHE or triptans. Check with your doctor before assuming it¡¯s okay to use whatever is in your medicine cabinet. Certain preventive and abortive drugs can interact with each other either in a positive way -- they have synergistic or additive effects in improving headache control -- or a negative way -- they interact to increase side effects or risk an overdose. Your doctor will know which headache abortive drugs can be safely used with your preventive medication.
However, if you find you are still using these drugs on a frequent basis (more than 1-2 times per week), your preventive medicine is not providing enough benefit and you should see your doctor to discuss the dosage, other prevention measures, or a change to a different medication.
Preventive medications only work if they are taken consistently as prescribed. However, long-term treatment doesn't mean "for life." Headaches tend to have a variable pattern, getting worse or improving for no apparent reason. While preventive drugs do not "cure" headaches, they can help a person get through a particularly bad cycle of worsening headache. Many doctors will try tapering the preventive medication after six months to a year of treatment, to see if the underlying headache pattern may have improved.
Health Care Policy for Headache Treatment in Women: A Call to Action
Headache is three times more common in women than in men during the middle age, adult years.
The highest prevalence for headache in women is during the middle years (30-50 years of age)- a period of their lives when they are trying to build a career and raise a family. This differs from other chronic diseases that are equally common in men and women and that present later in life (such as diabetes or high blood pressure). Goals of treatment among these disorders differ. For example, for diseases that present later in life (when many are retired), goals of treatment may not focus so heavily on the impact medications have on work, family, and social life. For headache, given the prevalence, severity of illness, associated disability, and time when it presents during a female patient's lifetime, it is clear that advocating for the best available treatment for headache is a political issue that should be of concern to all women.
Treating diseases like high blood pressure and diabetes is done early because it makes clinical sense and saves "dollars and cents." Lowering blood pressure and keeping blood sugar under control costs money but prevents development of more expensive problems like heart attack, stroke, and blindness. For diabetes and high blood pressure, insurance companies, health maintenance organizations (HMOs) and employers agree that these disorders need to be treated early and aggressively because of the cost-benefits and improved quality of care. However, similar treatment strategies (early, aggressive therapy) for other conditions not usually considered life-threatening, such as headache, are not clearly supported by health care organizations.
One reason that health care organizations do not support the concept of "early and aggressive treatment" for headache is that the "financial benefits" (cost benefits) are less obvious. Newer medications like the triptans work better, are faster, and cause less fatigue than older medications (such as barbiturate-caffeine-aspirin combinations, opiates, and ergotamine combinations). One problem is that new medications are more expensive.
Nonpharmacological techniques for treating headache, such as biofeedback or relaxation training, also appear to be expensive in the short term, and insurance or HMOs are often reluctant to pay for these options. For women who may wish to become pregnant, and who need or want to avoid using medication, however, such economizing may not make personal sense. Some patients do not receive adequate therapeutic benefit from traditional headache medications, while others need to use nonpharmacological techniques to help the medicine work. Unfortunately, nonpharmacological techniques are often not broadly available. In other cases, payers are not motivated to pay for nonpharmacological techniques because the "cost benefit" for these procedures has not been established; some health care organizations are not convinced that nonpharmacological technique will save them money.
Health care organizations need to maintain at least a financial balance and hopefully earn a profit; therefore, "cost management" is built into their restrictions for care that are placed on the patients and physicians. The business concept may resemble: "If there are several different medications that work (eventually), then prescribe the least expensive one." For these large health care businesses, the loss of function, time from work, and lost from family is not factored into defining "successful migraine management." In this light, "patient priorities" and "health care company priorities" are at odds.
In an effort to address the cost-benefits of more expensive therapies (i.e., triptans) for migraine, outcomes studies are underway.
One recent study involved patients enrolled in an HMO who were allowed to use sumatriptan for treatment of migraine. During the course of the study, patients reported fewer migraine-related disabilities. Patients taking sumatriptan also had lower migraine severity scores, and they used fewer healthcare resources. Specifically, the total migraine healthcare costs were 41% lower after starting treatment with sumatriptan. This study also shows that patient satisfaction is an important factor defining treatment success. Patient satisfaction is directly related to the level of disability in addition to pain relief. Successful migraine treatment parameters are evident when considering:
Customer service, quality guarantee or product satisfaction are all concepts people expect when shopping for cars, houses, and even day care centers for their children. However, people are not use to "shopping for healthcare." Perhaps during the new millennium, health care organizations will become more competitive and support treatment strategies to help patients and health care providers effectively manage headache. In turn, the headache sufferer certainly can be more demanding about getting their health care needs met, and they also can be more selective about health care choices.