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