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With appropriate diagnosis and treatment, the majority of headache sufferers can look forward to improved management (although not elimination) of their headaches. There remains, however, a group of patients whose headaches do not improve with treatment as expected. In addition to the pain of inadequately relieved headache, these patients are at risk of developing chronic pain syndrome, a condition characterized by significant disability, medication dependence and overuse, depression, and worsening headache.

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Chronic pain syndrome often develops insidiously over time: as a result of the pain and incapacitation of frequent, poorly relieved headaches, patients miss substantial school or work time, and productivity is often reduced even when they are in attendance. Overuse or dependence on medication may result from desperate attempts to remain functional. This leads to secondary problems with rebound headache, altered sleep-wake cycles, or end-organ dysfunction, such as gastrointestinal hemorrhage related to overuse of anti-inflammatory medications, kidney damage from overuse of acetaminophen, sleep disruption related to sedative misuse, and so forth. Sufferers often limit social or leisure activities in order to devote themselves to essential work or school activities, leading to isolation from family or social contacts. Avoidance of physical exertion that may trigger headache not infrequently leads to profound physical deconditioning. In many patients, depression ensues or worsens.

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Once underway, this complex downward spiral is difficult, if not impossible, to address using single-discipline treatment or medication. If the disability resulting from chronic disabling headache could be prevented, tremendous suffering would be avoided. This chapter discusses the magnitude of the problem of refractory headache, suggests ways to intercede in patients currently experiencing refractory headache, and considers how early intervention with appropriate, disease-specific measures might prevent the disaster of chronic headache from developing in many patients.

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Data from the American Migraine Study suggest that 5% of American women and 3% of American men suffer from frequent, severe headaches, defined as headache more than 15 days a month.1 The vast majority can be assumed to have migraine or transformed migraine, with a small number likely experiencing cluster or other less common types of headache. Although tension-type headache in its chronic form can be debilitating, it is far less frequent than migraine among severely disabled patients.

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The gender distribution of headache is not equal, with women more likely than men at all postpubertal ages to suffer from headache, and more likely than men to develop severe, disabling forms of the disorder. Epidemiologic data show that women require more bed rest per attack than do men,2 and are more likely to be moderately or severely disabled as a result of headache. Regardless of gender, the most disabled segment of the headache population accounts for very large percentages of the indirect costs attributed to migraine,3 suggesting that treatment targeted to this group of severely affected patients is highly cost-effective.2

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The level of functioning of patients with chronic headache has been found to ...

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