Management of refractory headache is a challenge for most neurologists. Success may depend as much on the clinician's approach to the patient as to the pain condition. Speaking at the 14th Congress of the International Headache Society (IHS) in Philadelphia earlier this month, Joel R. Saper, MD offered recommendations for identifying underlying contributing factors among patients with refractory headache. Below are some of his observations and suggestions.

No Simple Algorithms
In the case of chronic headaches, specific stressors may contribute to the pain that patients experience, and there is no simple algorithm or single medication suitable to address headaches and the underlying stressors that contribute to them, Dr. Saper reminds. It's not a simple case of treating the diagnosis. Each case may be complicated by the patient's personality, other medications he or she is using, and individual stressors. Barriers to pain control may be physiological and/or psychological, Dr. Saper says.

To identify patients with medication overuse headaches (MOH) or rebound headache, consider headache frequency. Although IHS guidelines released in 2006 provide a monthly guide, Dr. Saper considers weekly frequency of headaches: two to three per week.

The management of Medication Overuse Headache includes discontinuation of offending medications, the use of preventive therapies, and in many cases introduction of behavioral therapy, Dr. Saper says. Yet, not all patients respond. Emerging data suggest there could be a role for high estrogen levels and associated obesity in headache. Adiposity is associated with inflammation, he says, but it remains unclear what effect, if any, estrogen modulation has on headaches.

There is also evidence that headaches may be more common in patients with obsessive compulsive disorders or tendencies and may be associated with borderline personality disorder or bipolar disorder. For some of these patients, pain serves a “purpose,” such as communicating, controlling, punishing, protecting, or even empowering, Dr. Saper says.

Dr. Saper even reports that in one patient with a history of refractory headaches, he diagnosed an underlying eating disorder long overlooked by multiple other physicians. Treatment for the disorder was instituted. Focus on the Patient

Clinicians should recognize that most refractory headache patients are emotionally stable and committed to getting better, Dr. Saper stressed in his presetation. It appears however, that there may be a subset of refractory headache patients who are affected by psychological disorders that hinder their recovery. These cases are no doubt challenging. Neurologists should be attentive to these potential cases and alert to underlying diagnosis be prepared to offer patients support and additional healthcare resources to help them overcome headache pain.