Treating Headache

The proper treatment for your headaches will depend on several factors, including the type, frequency, and cause of your headaches. Not all headaches require medical attention. Treatment may include education, counseling, stress management, biofeedback, medications, and physical therapy education. The treatment prescribed for you will be tailored to meet your specific needs.

Headache education includes identifying and recording what triggers your headache, such as lack of sleep, eating certain foods or additives, caffeine, or stress. Your healthcare provider may give you a headache diary to record the characteristics of your headaches and help you manage headache triggers. Bring the diary with you to all of your doctor appointments; this information will help your healthcare providers correctly treat your headaches.

In addition to medical treatment, your doctor may recommend techniques for managing your headaches at home. Read more about these in the section on managing headaches.

When your doctor starts a treatment program, keep track of the results and how the treatment program is working. Keep your scheduled follow-up appointments so your doctor can monitor your progress and make changes in the treatment program as needed.

This section includes information on treatments for specific kinds of headaches:

• Tension headaches
• Migraines
• Transformed migraines
• Exertional headaches
• Cluster headaches
• Sinus headaches

In addition, you can find information here on treatments that may be used for many kinds of headaches:

• Medications
• Complementary treatments
• Physical therapy
• Treating rebound headaches

Treating tension headaches

Tension-type headaches are treated using several different strategies, including stress management/relaxation training, counseling, biofeedback, and medications. Regardless of the treatment, tension-type headaches are best treated when the symptoms first appear and are mild, before they become more frequent and painful.

• Stress management/relaxation training. Both episodic and chronic tension headaches can be improved by managing stress and practicing relaxation training. Relaxation techniques include deep breathing exercises, progressive muscle relaxation, mental imagery relaxation, and relaxation to music.
• Counseling. It is helpful to recognize and treat the underlying stress and tension that are causing the headaches. Often, people have long forgotten which stressful events initiated their headaches. Counseling can help the person identify his or her headache triggers and learn useful coping methods.
• Biofeedback. Biofeedback is another method of learning how to manage stress. During biofeedback, a series of sensors is connected to your body. The sensors detect changes in physical functions, such as muscle tension and heart rate, and provide immediate feedback through a tone or display on a computer screen. Biofeedback helps you recognize that your body is tense and practice releasing the tension through effective physical skills.
• Trigger-point injection. This procedure is used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. Many times, such knots can be felt under the skin. Trigger points may irritate the nerves around them and cause referred pain, or pain that is felt in another part of the body. A healthcare professional inserts a small needle into the patient's trigger point. The injection contains a local anesthetic that sometimes includes a corticosteroid. With the injection, the trigger point is made inactive and the pain is alleviated.
• Medications. For symptomatic relief of episodic or chronic tension headaches, over-the-counter medications are recommended. Ask your doctor or pharmacist about using acetaminophen (Tylenol), ibuprofen (Advil, Motrin), aspirin, or naproxen sodium (Aleve) to relieve your headaches.

If over-the-counter pain relievers don't help, your doctor may prescribe a medication to reduce the severity and frequency of your headaches. The most effective drug for treating tension-type headaches is often an antidepressant, which provides some relief for about 65 percent of people. Benzodiazepines, butalbital combinations, and narcotics (such as codeine and oxycodone) should be avoided because these medications could become habit forming or addictive.

Keep in mind that medications don't cure headaches and that over time, painkillers and other medications may lose their effectiveness. In addition, all medications have side effects. If you take medication regularly, including products you buy over the counter, discuss the risks and benefits with your doctor. Also, remember that pain medications are not a substitute for recognizing and dealing with the stressors that may be causing your headaches.

This section also contains information on treating tension headaches in children.

Treating tension headaches in children

For occasional symptomatic relief of infrequent tension headaches, over-the-counter (nonprescription) medications are recommended. Ask the advice of your doctor or pharmacist about the use of acetaminophen (Tylenol), ibuprofen (Advil or Motrin), or naproxen sodium (Aleve). The use of aspirin in children under age 14 is not recommended because of aspirin's link with Reye's syndrome, a potentially fatal condition. Also, avoid compounds that contain caffeine.

For relief of chronic tension headaches, daily preventive medications may be prescribed. These medications—which are aimed at reducing both the frequency and severity of the headaches—may include antidepressants, such as amitriptyline hydrochloride (Elavil), and nonsteroidal anti-inflammatory medications (NSAIDs), such as naproxen sodium (Aleve). These medications are not habit forming. Nonpharmacological treatments such as counseling and biofeedback and lifestyle changes regarding sleep, diet, and stress are quite helpful.

Benzodiazepines, butalbital combinations, and narcotics (codeine) should be avoided because these medications could become habit forming or addictive. Overuse of these medications or the daily use of pain-relieving medications can cause analgesic rebound headaches and make the headache worse [headache.treat.rebound].

Treating migraines

The effectiveness of migraine treatment depends on several factors, including whether a patient has identified likely triggers, how successful the patient is in avoiding identified triggers, how proactive the patient is in using treatments such as relaxation or drugs, and how well the patient responds to treatment.

Medications may be prescribed both to relieve symptoms associated with migraines and to prevent migraines from happening.

Migraine medications are most effective when used in combination with other approaches, such as dietary and lifestyle changes, exercise, and relaxation therapy. They can be grouped into three different categories, described in this section:

• Symptomatic relief
• Abortive therapy
• Preventive medication

For those with menstrual migraines, a common approach is for the patient to take a nonsteroidal anti-inflammatory drug (NSAID) on a scheduled basis starting two to three days prior to the onset of the menses (or migraine, if predictable) and continue taking it throughout the menstrual flow. More detail can be found in the section on treating migraines in women.

Behavioral techniques can reduce the frequency of the migraines without use of medications. One common method is biofeedback, which involves training individuals to recognize stressful situations and to relax and control the amount of distress they experience. If the migraine begins slowly, many people can use biofeedback to stop the attack before it becomes full blown.

Physical therapy as well as a general aerobic exercise program can provide additional benefits.

Treatment options for cyclic migraines, a form of migraine that occurs in cycles, have included lithium and indomethacin, a nonsteroidal anti-inflammatory drug. Standard antimigraine therapy may be ineffective for cyclic migraine.

All of these treatments should be used under the direction of a headache specialist or physician familiar with migraine therapy. As with any medication, it is important to carefully follow the label instructions and your physician's advice.

This section also contains information on treating migraine headaches in children and in women.

Symptomatic relief for migraines

Symptomatic relief medications are used to relieve the pain and the nausea and vomiting associated with migraine.

Over-the-counter medications are effective for some people. The main ingredients in pain-relieving medications are ibuprofen, aspirin, acetaminophen, naproxen, and caffeine. Be cautious when taking over-the-counter pain relievers, because overuse can cause rebound headaches or a dependency problem. They may also cause stomach irritation and exacerbate nausea and vomiting.

If you are taking any over-the-counter pain medications more than three times a week or daily, it's time to see if your healthcare provider can suggest medications that may be more effective, such as prescription nonsteroidal anti-inflammatory medications (i.e., ibuprofen, naproxen, ketoprofen).

You may also be advised to use antinausea medications to relieve the nausea that accompanies migraines, and sedatives to help you sleep, since sleep relieves migraines.

Since these medications may cause side effects in some people, it's important to consult your doctor about your risks.

Abortive therapy for migraines

Abortive medications, which are used to stop the process causing headache pain, are most effective when used at the first sign of a migraine. By stopping the headache process, abortive medications help prevent the pain, nausea, and light-sensitivity associated with migraine. Abortive medications work by constricting the blood vessels, bringing them back to normal and relieving the throbbing.

Abortive medications include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• The [[triptan medications]] sumatriptan succinate (Imitrex), zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt), almotriptan (Axert), frovatriptan (Frova), and eletriptan (Relpax)
• Ergotamine tartrate and caffeine (Cafergot)
• Dihydroergotamine mesylate (DHE-45, Migranal)

A combination medication (Midrin)

Since these medications may cause side effects in some people, it's important to consult your doctor about your risks.

When migraine headaches last longer than 24 hours and other medications have been unsuccessful in managing the attacks, medication administered in an "infusion suite" can be considered. An infusion suite is a designated set of rooms at a hospital or clinic that is monitored by a nurse and where intravenous drugs are administered. The intravenous drugs are usually able to end the migraine attack. Patients' length of stay at the infusion suite can range from several hours to all day.

Preventive medication for migraines

If your headaches are frequent, long in duration, or particularly disabling, a preventive medication may be warranted. Preventive medications reduce the frequency and severity of the headaches and are generally taken on a regular, daily basis.

Some commonly prescribed preventive medications include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) when taken pre-emptively
• Antidepressant medications such as amitriptyline (Elavil)
• Antihistamines, such as cyproheptadine (Periactin)
• Beta blockers such as propranolol (Inderal)
• Calcium channel blockers such as verapamil (Calan and Isoptin)
• Anticonvulsant medication such as divalproex (Depakote) and topiramate (Topamax)

Up to 70 percent of migraines can be modified with the use of preventive medications. Often, however, a combination of symptomatic and preventive medications may be necessary.

Since these medications may cause side effects, it's important to consult your doctor about your risks.

Treating migraines in women

Hormonal fluctuations can trigger migraines in women; for example, many women experience regular headaches that appear to be related to the drop in their estrogen levels immediately before the start of the menstrual flow. Birth control pills, and hormone replacement therapy during menopause, also can affect the frequency or severity of headaches. Some women get their first migraines while pregnant; in others, migraines go away during pregnancy.

The medications of choice in the treatment of menstrual migraine are nonsteroidal anti-inflammatory medications (NSAIDs). The NSAIDS most often used for menstrual migraine include:

• ketoprofen (Orudis)
• ibuprofen (Advil and Motrin)
• fenoprofen calcium (Nalfon)
• naproxen (Naprosyn)
• nabumetone (Relafen)

Therapy with the NSAID should be started two to three days before the onset of the menstrual flow and continued throughout. Because the therapy is of short duration, the risk of gastrointestinal side effects is limited.

Other medications prescribed include:

• small doses of ergotamine (including Bellergal-S) or a similar compound, methylergonovine maleate (for example, Methergine)
• beta blocker drugs such as propranolol
• anticonvulsants such as valproate
• calcium channel blockers such as verapamil

These drugs should also be started two to three days premenses and continued throughout the menstrual flow.

Because fluid retention is often associated with one's period, diuretics have been used to prevent menstrual migraine. Some physicians may recommend that the patient follow a salt-restricted diet immediately before the start of menses.

The medication Lupron affects hormone levels and is used only when all other treatment methods have been tried and been unsuccessful.

Migraines may also be associated with hormone replacement therapy taken during menopause. For patients who need to continue post-menopausal estrogen supplements, the patient should be started on the lowest dose of these agents, on an uninterrupted basis. Instead of seven days off the drug, the patient should take it on a daily basis. By maintaining a steady dose of estrogen, the headaches may be prevented. An estrogen patch (such as Estraderm) may be effective in stabilizing the levels of estrogen.

During pregnancy, no treatment is recommended to treat migraines. Medication therapy used to treat migraines can affect the uterus and can cross the placenta and affect the baby, so these medications should be strictly avoided during pregnancy. A mild analgesic, such as acetaminophen, can be used for pain. It is imperative that pregnant women suffering from headaches discuss the safety of headache medications with their obstetricians and headache specialists.

Treating migraines in children

Fifty percent of children and adolescents report migraine improvement within six months of beginning treatment. However, in about 60 percent of adolescents who experience their first migraine as an adolescent, the migraines continue off and on for many years.

Some children and adolescents with migraines don't experience headache relief despite trying many of the currently available medications. If this is the case for your child, ask your doctor about possible participation in a clinical trial. Clinical trials provide access to drugs not yet approved by the Food and Drug Administration. Such drugs are available only through doctors and healthcare organizations that have agreed to participate in the clinical trials. Your doctor will help determine if your child is an appropriate candidate for this type of research study.

Many migraine medications have not been approved by the FDA for use in children and adolescents with headaches.

This section contains more information:

• for parents of young children
• for parents of adolescents

Treating migraines in young children

For young children with infrequent migraines, symptomatic medications are useful:

• Simple analgesics: pain-relieving medications, such as ibuprofen or acetaminophen, but not aspirin (which is associated with a serious condition known as Reye's syndrome in children)
• Antiemetics: medications that relieve nausea and vomiting
• Sedatives: medications that help a child sleep (sleep relieves migraine)

For young children with frequent migraines, preventive medications may be prescribed.

While not FDA approved for use in children, they are often prescribed "off label":

• Cyproheptadine, propranolol, tricyclics, calcium channel blockers, or anticonvulsants
• A combination of symptomatic (from list above) and preventive medications

Treating migraines in adolescents

For adolescents with infrequent migraines (with or without aura), these medications can be useful:

• Analgesics: pain-relieving medications (remember that aspirin is dangerous in children)
• Antiemetics: medications that relieve nausea and vomiting
• Sedatives: medication that helps a patient sleep (sleep relieves migraine)
• Abortive medications including:
  —Triptans (Imitrex, Zomig, Amerge, Maxalt, Axert, Frova, and Relpax)
  —DHE-45 , given nasally, subcutaneously, or intravenously
  —A combination medication (Midrin)
  —Ergotamine tartrate and caffeine (Cafergot)
• A combination of symptomatic and abortive medications

Sedatives and abortive medications aren't approved by the FDA for use in people under age 18.

For adolescents with frequent migraines, these medications (not FDA approved for kids) can be tried:

• Preventive medicines such as propranolol, tricyclic antidepressants, calcium channel blockers, or anticonvulsants
• A combination of abortive and symptomatic medications

When headaches—and especially migraine headaches—last longer than 24 hours and other medications have been unsuccessful in managing the attacks, medication administered in an "infusion suite" can be considered. An infusion suite is a designated set of rooms at a hospital or clinic that is monitored by a nurse and where intravenous drugs are administered. The intravenous drugs are usually able to end the migraine attack. Patients' length of stay at the infusion suite can range from several hours to all day.

For adolescents with severe migraines that do not respond to other medications and last more than 24 hours, these abortive medications (not FDA approved for kids) can be prescribed:

• Triptans, given by injection
• DHE-45, given nasally, subcutaneously, or by intravenously
• Anticonvulsants, given by infusion
• Sedatives, given by infusion
• Antiemetics, given by infusion
• Others, such as magnesium or nonsteroidal anti-inflammatory drugs

Treating transformed migraines

Many people who have migraines notice that their headaches are becoming less severe but more frequent, possibly as a result of regular use of medication. These chronic migraines are known as transformed migraines. Treatment is complicated because the chronic nature of the headaches often leads people to overuse analgesics, both prescription and over the counter. They may use these drugs daily, even on days when they don't have a headache. This puts the patient at risk for building up a tolerance to the drugs. Additionally, patients who use large amounts of analgesics that contain caffeine will experience withdrawal headaches.

In many cases, patients suffering from transformed migraines have other health problems, such as hypertension (high blood pressure) and depression, which complicate treatment. Seeking an experienced, multidisciplinary healthcare team to coordinate treatment is essential to success.

Treating exertional headaches

Most exertional headaches, which occur during exercise, are benign and respond to usual headache therapy. In many patients, headaches disappear spontaneously. Indomethacin, a nonsteroidal anti-inflammatory drug, can be used chronically or before specific activities that trigger the headaches. If indomethacin is taken chronically, monitoring for side effects is mandatory.

Treating cluster headaches

Cluster headache sufferers generally must take preventive medication when they enter a cluster period unless the cluster periods last less than two weeks. Some medications used in the prevention of these headaches include calcium channel blockers, verapamil, lithium carbonate, divalproex sodium, corticosteroids, methysergide, melatonin, and topiramate.

Because of the brief duration of an attack, treatment to abort these headaches is difficult. Oxygen inhalation by facial mask can be used at the first signs of a cluster attack and has been used successfully in aborting an acute cluster headache. Sumatriptan (Imitrex) injections are often prescribed for the acute treatment of cluster headaches. Other choices include zolmitriptan tablets and ergotamine preparations. Some patients have gained some relief with the use of intranasal applications of a local anesthetic agent, such as lidocaine. But often the acute headache has disappeared before the patient arrives at the emergency department or physician's office to receive treatment.

Surgical intervention may be considered for people with chronic cluster headaches who have not been helped with standard therapy.

All of these treatments should be used under the direction of a physician familiar with cluster headache therapy.

Treating sinus headaches

Usually, sinusitis is treated with medicines that get rid of the infection and establish drainage of the blocked sinuses. Antibiotics are typically recommended to eliminate specific bacteria that are causing the infection. Sometimes, in the case of complicated infections, surgical procedures may be necessary to establish adequate drainage of the infected sinuses.

Decongestants and antihistamines reduce swelling in the blocked channels that communicate between the nose and sinuses. Decongestants also help relieve headache symptoms because they constrict blood vessels that cause headache pain. However, decongestant use can be habit forming. If your headaches seem to be relieved by decongestants but you do not have an acute sinus infection, you may actually have a migraine or tension-type headache.

Other medications to treat sinus infections include analgesics (pain-relieving medications) and vasoconstrictors. Corticosteroids may be prescribed for some people when the pain continues after the use of analgesics. When an allergen is causing the sinus flare-ups, preventive allergy therapy is often needed.

Although allergies may lead to sinusitis, it is a misconception that allergies directly cause headaches. Allergies and headaches generally must be treated separately.

Medications

Headache medications can be grouped into three different categories: those that provide symptomatic relief, abortive therapy (intended to stop the process that results in a headache), and preventive therapy. Each type of medication is most effective when used in combination with management techniques such as dietary and lifestyle changes, exercise, and relaxation therapy.

Medications that promise symptomatic relief address the headache pain or the nausea and vomiting associated with migraine. These may include simple analgesics, ibuprofen or acetaminophen, antiemetics or sedatives. Many of these are available over-the-counter, while others require a prescription.

Important: If symptomatic relief medications are used frequently for headaches that are severe enough to interfere with functioning, you should consult your healthcare provider about preventive headache medications. Overuse of symptomatic medications can actually cause more frequent headaches or worsen headache symptoms.

Abortive therapy is most effective when used at the first sign of a migraine to stop the process that causes the headache pain. These drugs may also be given for cluster headaches. Abortive medications include: triptans such as sumatriptan succinate (Imitrex) and zolmitriptan (Zomig), dihydro-ergotamine mesylate (DHE-45, Migranal), a combination medication (Midrin), and ergotamine tartrate and caffeine (Cafergot).

Preventive therapy is used to treat very frequent tension headaches and migraines, the combination of both types of headaches, and cluster headaches. Most of these medications require a prescription. Drugs are aimed at reducing both the frequency and severity of the headaches and include:

• nonsteroidal anti-inflammatory (NSAID) medications
• antidepressants
• antihistamines such as cyproheptadine
• beta blockers
• calcium channel blockers
• anticonvulsant medications
• lithium

Many combination headache medications include caffeine, which can make other medications more effective.

Pregnant women are advised to avoid any medication due to its potential effect on the fetus, although a mild analgesic for pain, such as acetaminophen (Tylenol), can be safely used. A woman who suffers from headaches during her pregnancy should discuss other treatment options with her obstetrician.

This section contains more information on:

• over-the-counter pain medication
• triptans
• antidepressants
• beta blockers
• calcium channel blockers
• the muscle relaxant baclofen (Lioresal)
• caffeine
• anticonvulsants
• lithium

Over-the-counter pain medication

Nonprescription pain relievers such as acetaminophen and ibuprofen have been demonstrated to be safe when used as directed. Keep the following precautions in mind:

• Know the active ingredients in each product. Be sure to read the entire label.
• Do not exceed the recommended dosage on the package. It is easy to overmedicate yourself.
• Check with your doctor before taking products containing, aspirin, ibuprofen, or naproxen sodium if:
  — You have a bleeding disorder
  — You have asthma
  — You have recently had surgery or dental surgery or are about to have surgery
  — You have ulcers or kidney or liver disorders
  — You already take any nonsteroidal anti-inflammatory medications such as ibuprofen or naproxen sodium.
• Check with your doctor before taking acetaminophen-containing products if you have kidney or liver problems.

Triptans

Triptans are approved by the Food and Drug Administration for the treatment of acute migraine attacks and are the most useful class of abortive agents. The subcutaneous injection form of sumatriptan (Imitrex) has also been used successfully for the treatment of cluster headache attacks. Triptans are taken when a headache starts, to stop the process that causes the headache. They work by reducing the size of enlarged blood vessels in your head. Options include zomitriptan (Zomig), naratriptan (Amerge), sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), eletriptan (Relpax), and frovatriptan (Frova).

Triptans come in several forms: tablet, nasal spray, and injection. Your doctor will decide what dose to give you and will tell you how many doses you can safely take in one 24-hour period. Do not take more than your doctor says is safe. You may find that your headache worsens briefly before the pain is relieved. If you are treating more than two headaches per week with a triptan, call your doctor.

You should not use triptans if you have uncontrolled high blood pressure, a history of heart attack, heart disease, cerebrovascular disease, peripheral vascular disease, liver or kidney dysfunction, or if you are pregnant.

Common side effect include:

• A feeling of pain or tightness in the chest or throat
• A general feeling of warmth or flushing
• A feeling of heaviness in the extremities, especially the arms
• A tingling or burning sensation in the neck, head, or face
• Dizziness or lightheadness

Antidepressants

Your doctor may prescribe an antidepressant to help prevent your headaches. Antidepressants work by altering the levels of certain neurotransmitters, chemicals that carry messages between neurons in the brain.

Important: All antidepressants carry the risk of inducing hypomania in people with unrecognized bipolar disorder. Ungoverned treatment of an undiagnosed depression has resulted in rare cases of suicide.

This section contains more information on:

• Tricyclic antidepressants, the main treatment for depression in the 1960s through the 1980s. They are often prescribed for other conditions, including insomnia, bulimia, and headaches.
• Newer antidepressants, known as selective serotonin reuptake inhibitors (SSRIs)
• Other new antidepressants

Tricyclic antidepressants

Your doctor may prescribe a tricyclic antidepressant to help prevent your headaches. These drugs have been shown to be effective in preventing both migraine and tension-type headaches. They work by increasing the levels of the neurotransmitters serotonin and norepinephrine within the brain.

Generic and brand names of some tricyclic antidepressants used for headaches include amitriptyline (Elavil), desipramine (Norapramin, Pertofrane), doxepin (Sinequan, Adapin), imipramine hydrochloride (Tofranil, Janimine), nortriptyline (Pamelor, Aventyl).

The doses of tricyclic antidepressants used to prevent headaches are much lower than those used to treat depression. However, this drug might have beneficial effects on mood, sleep, appetite, libido, and memory, in addition to controlling your headaches. This drug is taken at night to prevent daytime drowsiness. This drug usually takes three to six weeks to become effective. Therefore, you should take it for at least two months to determine its effectiveness. Your dosage will be determined by your doctor.

Side effects are common during the first two weeks of treatment, then usually subside. They include constipation, dry mouth, and sedation and are more common with amitriptyline than with other tricyclic antidepressants, especially in the elderly population.

If you experience blurred vision, rapid heartbeat, orthostatic hypotension (a drop in blood pressure and a feeling of dizziness when you stand up quickly), or difficulty urinating, call your doctor. Before taking the drug, tell your doctor if you have narrow-angle glaucoma or a history of heart disease, kidney disease, thyroid problems, or seizures. Also, notify your doctor if you have taken an MAO inhibitor, such as Nardil, within the past 14 days.

Selective serotonin reuptake inhibitors (SSRIs)

Your doctor may prescribe a selective serotonin reuptake inhibitor (SSRI) to help prevent your headaches. SSRIs have shown some effect in preventing migraine and tension-type headaches in some people, especially chronic headaches. The drug might have beneficial effects on mood, appetite, and memory. Generic and brand names of some SSRIs given to prevent headaches: fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).

SSRIs usually take several weeks to become effective. Therefore, you should take them for at least a month to determine their effectiveness. Usually, patients take this medicine in the morning to prevent insomnia. Your dosage will be determined by your doctor. Tell your doctor if you have a history of seizures, bipolar disorder, kidney disease, or suicidal tendencies.

Side effects include nausea during the first week of therapy. After the first week, most patients note a change in appetite, and 5-to-10-pound weight gain is common. Some people note an increased energy level. If the increase is too great, people sometimes complain of anxiety, insomnia, diarrhea, or sexual dysfunction. Call your doctor if you develop a rash while taking an SSRI.

Other antidepressants

Bupropion (brand name Wellbutrin or Zyban), trazodone (Deseryl), and venlafaxine (Effexor) have all been shown to be effective in preventing both migraine and tension-type headaches in small studies. Since they are antidepressants, they may also have beneficial effect on mood, appetite, and memory. All three of the drugs take two to four weeks to become effective, so you should take them for at least two months to find out if they are effective.

Bupropion. Before taking the drug, notify your doctor if you have a history of seizures or eating disorders. Common side effects include insomnia, excitement or anxiety, nightmares, dry mouth, and changes in appetite or weight. Less common side effects include drowsiness, frequent urination, difficulty urinating, constipation, blurred vision, or excessive sweating. If you experience a rash, seizures or tremors, or loss of coordination or loss of consciousness, call your doctor immediately. This generally does not occur at low doses.

Trazodone. Common side effects include drowsiness (so best to take it at bedtime), nausea (which can be avoided by taking the medicine with food), diarrhea, excitement or anxiety, insomnia, nightmares, dry mouth (chewing sugarless gum or candy will help prevent this), increased sensitivity to sunlight, changes in appetite or weight, and sexual dysfunction. If you develop a rash, call your doctor. If you are a male, notify your doctor if you develop a prolonged or inappropriate erection.

Venlafaxine. Before taking the drug, tell your doctor if you have cardiovascular disease, high blood pressure, a history of seizures, or bipolar disorder or if you have recently had a heart attack. Side effects are common during the first two weeks of treatment, then they usually subside. Common side effects include nausea (which can be avoided by taking the medicine with food), drowsiness (so best to take it at bedtime), excitement or anxiety, increased sensitivity to sunlight, changes in appetite or weight, sexual dysfunction, and constipation.

Beta blockers

Some of the beta blockers used to treat high blood pressure have also been approved by the Food and Drug Administration for the treatment of migraine headaches. Others that are not specifically approved for migraines may still be prescribed for this purpose.

Because beta blockers affect blood pressure, be sure to tell your doctor if you have asthma, chronic obstructive pulmonary disease, congestive heart failure, heart block, low blood pressure, slow heart rate, impaired kidney function, diabetes, heart disease, liver or kidney disease, or thyroid problems. Be sure to tell your doctor about any other drugs you are taking, including over-the-counter medicines and herbal products. Also tell your doctor if you expect to get pregnant or if you are pregnant or breastfeeding.

Beta blockers may take a few weeks to be effective. Continue taking the drug exactly as instructed, even after the symptoms go away, and do not stop taking it without talking to your doctor first. When these drugs are abruptly stopped, patients may feel anxious, have rapid heart rates, and feel palpitations and chest pain.

Although side effects are difficult to predict, the most common side effects are:

• Sleep disturbances
• Nausea
• Dizziness
• Sexual dysfunction
• Cold hands and feet
• Slower heart rate (even during exercise)
• Fatigue

Call your doctor immediately if you develop a rash; difficulty breathing; fainting or severe dizziness; slow, fast, or irregular heartbeat; swelling of hands, feet, ankles, or lower legs; or any other symptoms that cause concern. Call, too, if any of your side effects change in intensity.

Calcium channel blockers

Calcium channel blockers, used in the treatment of several heart-related disorders, have not been approved by the Food and Drug Administration for treatment of headaches. However, they have been studied for vascular headaches and have been shown to be effective in preventing migraine as well as cluster headaches. They are widely used for headache treatment and work by unknown mechanisms. Some calcium channel blockers prescribed for headaches are verapamil (Calan, Covera, Isoptin, Verelan), nimodopine (Nimotop), and diltiazem (Cardizem, Dilacor).

A calcium channel blocker may take two to four weeks to be effective. Be sure to continue taking it as instructed by your doctor, even after symptoms disappear. Do not stop taking a calcium channel blocker without first talking to your doctor, as you could make your condition worse. Avoid grapefruit and grapefruit juice, which may interfere with absorption.

Side effects may include nausea, dizziness, constipation, difficulty urinating, and fatigue. Call your doctor immediately if any of your side effects change in intensity or if you experience any other symptoms that you think could be caused by this medicine.

Baclofen (Lioresal)

This muscle relaxant acts on the nerves of the spinal cord, decreasing the number and severity of muscle spasms and relieving pain. Your doctor may prescribe Lioresal to help treat your tension-type headaches. It's important to take the drug exactly as prescribed by your doctor, even after symptoms have disappeared—and to talk to your doctor before giving up the medication. Stopping abruptly may cause hallucinations and seizures.

Although side effects from baclofen are uncommon, they may include:

• Drowsiness
• Nausea
• Dizziness
• Weakness
• Confusion
• Headache
• Insomnia
• Rash
• Constipation

Call your doctor immediately if any of your side effects change in intensity, or if you experience difficulty breathing, seizures, develop a rash, or feel extremely tired or weak.

If your doctor suggests baclofen, let him or her know if you have any drug allergies or any history of kidney disease, epilepsy, ulcer disease, stroke, rheumatic disease, cerebral palsy, Parkinson's disease, or any psychiatric conditions. Tell your doctor if you are pregnant, plan to become pregnant, or are breastfeeding. Tell your doctor of any other prescription, over-the-counter, herbal, or vitamin products you are taking.

The pros and cons of caffeine

Caffeine can be a double-edged sword: It can serve as a treatment for some people with headaches, or, in some cases, people who are dependent on it can get headaches from having too little. The important thing to remember is that, for unknown reasons, caffeine has analgesic properties and, used carefully, can be one of the most effective remedies. And while caffeine-containing medications can be beneficial, these medications, combined with caffeine from other sources, make you more vulnerable to a rebound headache, a condition that develops from the overuse of any headache medication.

Caffeine is a common ingredient in many prescription and over-the-counter headache medications, including Excedrin, Midol, and Cafergot. Because analgesics work more quickly and more efficiently with caffeine, patients are able to take less medication and feel relief sooner. By taking less medication, the patient reduces the risk for potential side effects and reduces the risk of habitual or addictive usage. Caffeine additives make pain relievers 40 percent more effective.

Caffeine is also found in beverages, including anything with chocolate, regular and diet cola and other sodas (like Mountain Dew or Surge), chocolate or coffee liqueurs, and of course coffee and tea. Even caffeine-free and decaffeinated beverages contain small amounts of caffeine. All chocolate-containing foods have caffeine, too.

Caffeine withdrawal from normal caffeine usage is rare. However, with excess use—more than 500 mg daily (approximately 5 cups of coffee) over a long period of time—sudden cessation could cause symptoms of withdrawal, including headaches. Patients can avoid caffeine withdrawal by limiting their daily consumption and by gradually decreasing consumption rather than ending use abruptly.

Anticonvulsants

Anticonvulsants such as divalproex sodium, sodium valproate, valproic acid, and topiramate are used to control seizures in epilepsy. Common brand names include: Depakote, Depakene, and Topamax.

These medicines also been proven effective against migraine headaches. Valproic acid, for example, works by increasing the levels of the neurotransmitter GABA in the brain. That decreases painful nerve impulses to certain areas of the brain.

It's important to follow the directions on the prescription label carefully. If there is any part you do not understand, ask your doctor or pharmacist.

Although side effects of anticonvulsants are difficult to predict, common ones include drowsiness, nausea, fatigue, confusion, a weight gain, hair loss, liver dysfunction, inflammation of the pancreas, and bone marrow suppression. Exposure to anticonvulsants early in pregnancy may result in birth defects.

Call your doctor immediately if you notice:

• Severe dizziness
• Severe vomiting
• Abdominal pain
• Yellowing of the skin
• Increased bruising
• Malaise
• Blood in the urine or stool.
• You are pregnant

Lithium

Lithium is classified as an antidepressant and mood stabilizer, but it has also proved to be very effective at preventing cluster headaches. It works within the brain to correct chemical imbalances of the neurotransmitters serotonin and norepinephrine. (You might note an added benefit of improved mood, ability to concentrate, and sleep while taking this medicine.) Common brand names include Lithium Carbonate, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs, Lithium Citrate, and Cibalith.

It may take your doctor a few weeks to figure out an effective dose. Never abruptly stop the medicine if you feel it is not helping; instead, notify your doctor and discuss a dosage adjustment. You may need to have blood levels drawn to determine the level of drug in your system.

Common side effects include:

• Increased thirst
• Nausea or loss of appetite
• Diarrhea
• Metallic taste in your mouth
• Fatigue
• Fine hand tremors
• Uncoordination or abnormal movements of arms and legs

Most of these symptoms will lessen as your body adjusts to the medicine, although some elderly patients might be extremely sensitive to the effects of lithium. Call your doctor if you develop a skin rash, generalized itching, blurred vision, clumsiness, staggering, hand tremor, confusion, giddiness, muscle twitching, ringing in the ears, increased output of diluted urine, or cold intolerance. Also call if you take or plan to take thyroid medication.

Do not take aspirin, nonsteroidal inflammatory medicines, or diuretics (water pills) with lithium. Do not follow a salt-restricted diet while on lithium, as it may increase the likelihood of potentially dangerous side effects. Do not take lithium if you are pregnant or plan to become pregnant. Lithium is excreted in breast milk.

Complementary treatments

Sometimes, people who suffer from chronic headaches turn to complementary treatments for relief. It's important to know that few approaches have been studied, and many therapies require multiple sessions and may take longer to work than traditional drug-based therapy. It's also important to find a trustworthy, certified, practitioner. Don't hesitate to ask your doctor to refer you to a qualified alternative health practitioner. In fact, ask your doctor to help coordinate your program of care.

Hypnosis uses a blend of relaxation, imagery, and the power of suggestion to achieve a heightened sense of relaxation. Headache relief may be achieved through deep relaxation and posthypnotic suggestion.

Massage helps to reduce stress and relieve tension. It is especially effective for relieving tight, tender muscles in the back of your head, neck, and shoulders. While massage might provide relief from headache pain—especially headaches caused by tension—its value has not been fully determined.

Chiropracty is a form of treatment involving spinal manipulation that has been claimed to alleviate migraine and tension headaches. The theory, which is unproven, is that pain is caused by abnormal motion and irritation to the neck muscles, nerves, and other tissues; manipulation may alleviate the pain by restoring normal mobility and function. There is not as much scientific evidence supporting chiropractic manipulation for headaches as there is for other alternative approaches. Furthermore, excessive manipulation may cause additional problems. Ask your primary care physician if this therapeutic approach is suitable for you.

Some studies have shown that lavender, ginger, peppermint, and wintergreen oils might help relieve some headaches. You might get relief simply by smelling the oil, or by applying it to the nape of your neck and your temples. On the other hand, some odors may increase or provoke nausea if used during migraine attacks.

This section provides further information on:

• Biofeedback
• Acupuncture and acupressure
• Vitamins and herbal products

Biofeedback

Biofeedback helps a person learn stress-reduction skills by providing information about muscle tension, heart rate, skin temperature, and other vital signs as the person attempts to relax. A biofeedback unit processes electronic signals from the body and "feeds back" the information to the user in the form of sounds or graphs on a computer screen. By teaching people how their bodies respond in stressful situations and allowing them to gain some control over certain bodily functions that cause tension and physical pain, biofeedback can help many headache sufferers stop an attack before it becomes full-blown.

Biofeedback training usually requires several sessions with a skilled biofeedback therapist. Some companies, however, make some simple biofeedback devices for self treatment at home. These devices can be helpful for some people.

The equipment used in biofeedback includes:

Electromyograph (EMG). This measures the electrical activity in the muscles to determine the amount of muscle tension. Small, flat metal sensors, called electrodes, are attached to the skin (usually on the forehead). The electrodes measure the electrical activity in the muscles directly underneath the electrodes and in adjoining muscles. The forehead muscle, for example, is connected with the jaw, neck, shoulder, and scalp muscles. The electrical activity of the muscles will be measured and displayed as numbers or electrical waves on a screen that the person can view. The forehead muscle is often used for relaxation training because tension in this area can lead to tension headaches.

Temperature trainer. This device produces a digital readout of temperature, similar to the readout of the time given by a digital watch. There is also a sound that rises in pitch as the temperature increases. The temperature measuring sensors are attached to the fingers of your dominant hand. Skin temperature of the hands and feet vary according to the activation of the sympathetic nervous system. High activation—a stress response—produces cool or cold skin. Low activation—a relaxation response—results in warm skin temperature.

Heart rate monitor. Your heart rate is monitored by a photocell sensor (plethysmograph) attached either to your fingertip or earlobe. This sensor picks up changes in heart rate, measured in beats per minute (BPM). These sensors are identical to the ones found in training spas and gymnasiums when using the treadmill, exercise bicycle, and other machines for improving cardiovascular fitness.

Acupuncture and acupressure

Acupuncture is an ancient Chinese system of healthcare that involves the insertion of very fine, sharp needles into certain points of the body. There are nearly 12,000 "acupoints" along the body's 14 major meridians, or energy-carrying channels. Sixteenth-century Chinese doctors used the term "ch'i" (pronounced "chee") to describe the energy that circulates through meridians. The belief is that illness or pain is caused by a disruption of ch'i, leading to an imbalance of energy that can be corrected by acupuncture.

It is thought that stimulation of the acupuncture points results in the release of endorphins, the body's natural pain reliever. Among other benefits, researchers have found that acupuncture might possibly provide relief from chronic headache pain. In a treatment series, the acupuncturist uses different combinations of points, different needling techniques, or both. If you choose this form of therapy, make sure your practitioner is certified and that clean, sterile needles are used. Acupressure follows the same principles as acupuncture but replaces needles with the application of physical pressure.

There are 6,500 licensed acupuncturists in the United States, and 3,000 doctors who perform acupuncture as part of their medical practice. The World Health Organization currently recognizes more than 40 medical problems, ranging from allergies to AIDS, that can be helped by acupuncture treatment.

Vitamins and herbal products

Unlike medications, herbal products do not undergo vigorous clinical study and review by the Food and Drug Administration, so you should always approach them very cautiously. Not all herb products are safe, and more research—especially in children—is needed to find the proper dose, define who can benefit, and to identify any side effects. There is some scientific evidence showing that the mineral magnesium given daily either alone or with a daily dose of riboflavin (also known as vitamin B2) can reduce migraine frequency. Ask your doctor about this treatment option.

The following herbal products have been used to treat headache or for pain relief:

• Feverfew: the best studied herbal for headache; has shown value in preventing and treating migraine headache and may also be helpful in cluster and menstrually related headaches.
• Cayenne (capsaicin): the "hot" in hot peppers. It has been used topically to provide pain relief; there is some evidence of its effectiveness in cluster headache.
• Chamomile tea: has sedative effects and relaxes the body; has been used to ease the nausea of migraine.
• Dandelion: contains magnesium and vitamin B, which is helpful for headache prevention.
• Ginger: an anti-inflammatory that might offer some benefit for migraine.
• Gingko: has been shown to increase blood flow to the brain and reduce platelet clumping.
• Stinging nettle: is an anti-inflammatory; has been used to relieve chronic headache.
• Willow bark: used to relieve pain.

It's important to tell your doctor if you decide to try herbal remedies. Some products interfere with the actions of both prescription and over-the-counter medications and should not be taken together with them.

Physical therapy

Physical therapy can be very helpful for headaches that originate in the muscles or joints of the neck (also called cervicogenic headaches). Patients who have migraines or tension-type headaches may have their headache pain brought on by neck strain and therefore may benefit from physical therapy. Physical therapy must be considered an essential part of any program that addresses chronic pain.

Treating rebound headaches

Some of the medications used for headaches, taken in large amounts, can actually increase the frequency of headaches, resulting in the transformation of episodic headaches to chronic ones; these are sometimes called "rebound" headaches. They are similar to, but less severe than, those for which the medication was taken. The rebound headaches may last for days. The mechanisms are not fully understood. Medication overuse is most likely to occur in patients with chronic tension headaches.

Commonly used medications that can bring on rebound headaches include many medications usually thought of as safe, including aspirin, sinus relief medications, acetaminophen, ibuprofen, sedatives for sleep, ergotamine preparations, codeine and related narcotic preparations, and over-the-counter combination headache remedies. Continued use of these medications may eventually lead to the development of low-grade headaches that just will not go away. Some people who never knowingly suffered from headaches can develop chronic daily headaches by overusing analgesics for other problems.

When these chronic daily headaches occur, many patients react by taking larger or more frequent doses of the medication. But that not only exposes the patient to a higher level of the medication's toxicity but also makes the situation worse. Patients may find themselves taking the medication constantly for months because they continue to find short-term relief, although the headache inevitably returns. The medication may wear off during sleep, waking the patient in the middle of the night with a new headache.

Usually, discontinuing the medication will bring back headaches that can be controlled with carefully administered pain relievers. Patients taking large doses of sedative hypnotics, sedative-containing combination headache pills, or narcotics may need to be admitted to the hospital so they can recover under supervision.