Volume 100, Issue s9

Migraine headaches are a common medical problem that physicians frequently encounter in their practice. They can be disabling, leading to the individual's suffering if not treated appropriately and quickly. There is a variety of medications and treatment approaches that can be used to relieve pain and any associated symptoms. New medications have become available in recent years to aggressively treat migraine headaches. Called "triptans," these medications have been designed to specifically treat an acute migraine attack and can be effective if used early and properly. Many medications are also available to treat symptoms associated with migraines. Patient education, along with nonpharmacologic approaches, is an element of effective treatment. Biofeedback, relaxation, and physical techniques can be effective adjunctive options. Although nonprescription medications can be helpful initially, more specific treatment is often required. Opioids, phenothiazines, ergotamine, and the triptans are generally used in patients with difficult migraines. The newer agents, the triptans, offer new hope in aggressively treating this painful condition that often has an impact on individuals and their families.

Cervicogenic headache is a chronic, hemicranial pain syndrome in which the sensation of pain originates in the cervical spine or soft tissues of the neck and is referred to the head. The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve converge with sensory fibers from the upper cervical roots. This convergence of nociceptive pathways allows for the referral of pain signals from the neck to the trigeminal sensory receptive fields of the face and head as well as activation of the trigeminovascular neuroinflammatory cascade, which is generally believed to be one of the important pathophysiologic mechanisms of migraine. Also relevant to this condition is the convergence of sensorimotor fibers of the spinal accessory nerve (CN XI) and upper cervical nerve roots, which ultimately converge with the descending tract of the trigeminal nerve. These connections may be the basis for the well-recognized patterns of referred pain from the trapezius and sternocleidomastoid muscles to the face and head. Diagnostic criteria have been established for cervicogenic headache, but presenting characteristics of this headache type may be difficult to distinguish from migraine, tension-type headache, or paroxysmal hemicrania. This article reviews the clinical presentation of cervicogenic headache, its proposed diagnostic criteria, pathophysiologic mechanisms, and methods of diagnostic evaluation. Guidelines for developing a successful multidisciplinary pain management program using medication, osteopathic manipulative treatment, other nonpharmacologic modes of treatment, and anesthetic interventions are presented.

Chronic recurrent headache affects 45 million Americans. Despite recent advances in medical modes of therapy for headache, the underlying pathophysiology for the condition is not yet fully understood. Like other conditions for which we have no objective markers for disease, nor a clear understanding of pathophysiology, psychologic causes are suspected. Although mounting evidence suggests a biochemical basis for headache, many clinicians still believe that psychologic influences may contribute to maintaining headache chronicity. Nonpharmacologic and psychologic treatment modalities such as biofeedback and cognitive/behavioral therapy may be successfully used as part of a comprehensive treatment program to give patients a greater sense of control, reverse anticipatory anxiety, and improve functioning and quality of life.

Headache can be caused by a multitude of factors, but experienced physicians accustomed to treating patients with headache are adept at making an accurate diagnosis. Occasionally, however, a patient has an unusual presentation of headache or facial pain. In these cases, it can be difficult to classify the etiology of the headache despite the performance of a thorough physical examination and the acquisition of appropriate diagnostic tests. Awareness of some of the otolaryngologic diseases that can manifest as facial pain or headache may help the physician better diagnose and treat this complex problem.