Continuum : lifelong learning in neurology
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Continuum (Minneap Minn) · Aug 2012
Review Case ReportsNonmedication, alternative, and complementary treatments for migraine.
The efficacy of some nonpharmacologic therapies appears to approach that of most drugs used for the prevention of migraine and tension-type headaches. These therapies often carry a very low risk of serious side effects and frequently are much less expensive than pharmacologic therapies. Considering this combination of efficacy, minimal side effects, and cost savings, medications should generally not be prescribed alone but rather in combination with nonpharmacologic therapies. ⋯ Therapies proven (to various degrees) to be effective for migraine include aerobic exercise; biofeedback; other forms of relaxation training; cognitive therapies; acupuncture; and supplementation with magnesium, CoQ10, riboflavin, butterbur, feverfew, and cyanocobalamin with folate and pyridoxine.
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Medication-overuse headache (MOH) is a chronic daily headache in which acute medications used at high frequency cause transformation to headache occurring 15 or more days per month for 4 or more hours per day if left untreated. MOH is a form of US Food and Drug Administration-defined chronic migraine. This review will describe (1) MOH clinical features and diagnosis, (2) pathophysiology and structural and functional MOH brain changes, and (3) prevention and treatment of MOH. ⋯ MOH development is linked to baseline frequency of headache days per month, acute medication class ingested, frequency of acute medications ingested, and other risk factors. Using less effective or nonspecific medication for severe migraine results in inadequate treatment response, with redosing and attack prolongation, frequently leading to chronification. Use of any barbiturates or opioids increases the transformation likelihood.Patients with MOH can usually be effectively treated. The first step is 100% wean, followed by establishing preventive medications such as onabotulinumtoxinA or daily prophylaxis and providing acute treatment for severe migraine 2 or fewer days per week. Slow wean or quick termination of rebound medications can be accomplished for most patients on an outpatient basis, but some more difficult problems may need referral for multidisciplinary day hospital or inpatient treatments.
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This article covers the clinical manifestations and differential diagnosis of the trigeminal autonomic cephalalgias (TACs). ⋯ TACs are a unique group of primary headache syndromes with individual features and specific responses to treatment that make their identification crucial for optimum management.