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My Head Still Hurts

What To Do When Headache Treatments Don't Work

What Kind of Doctor Should I See? continued...

When headache treatment fails to stop pain, he says, it may be time to see a specialist.

"I like to say every doctor treats headache patients. But very few specialize in headache," Penzien says. "There is a lot to know. If you believe you have a difficult problem, seek out someone who does headache medicine for a living. Your general practitioner, as good a doctor as he or she may be, might not understand."

Lipton says it's time to see a specialist if your headache diagnosis isn't clear.

"If you ask what kind of headache you have and your doctor doesn't know, see a specialist," he says. "And some doctors don't consider treating headache a priority. If your doctor says, 'Honey, don't worry, it's only a migraine,' go see a specialist. Another reason is if after some period of treatment, you are still experiencing significant pain and disability."

What Can I Expect from a Headache Specialist?

For many patients, proper care will mean finding the right headache treatment or correcting the dosage and schedule for treatments that haven't worked before. Much of the time, headache treatment means stopping medicines that are actually causing so-called "rebound" headaches.

"Usually, when the patient says he or she has they have tried everything, they either have tried a small fraction of the therapeutic armamentarium, or they have a condition that's making things worse -- usually overusing medications," Lipton says. " Medicines taken to relieve pain can exacerbate headache. People who for years have headache, who take 10 different preventive medicines, haven't addressed rebounding. It's one of the most important headache triggers."

If you take your headache medicine and the headache comes back when it wears off, you may be having rebound headaches. One clue is having a headache when you wake up in the morning.

"About 15% of the time, all we have to do is get patients to quit taking the medicines their primary doctor has been prescribing," Penzien says. "That is our sole intervention. We just have patients quit taking medicines that make them worse. They usually are prescribed by a doctor that really cares about the patient, but doesn't understand."

Problems like this are the first thing a headache specialist looks for.

"There should be some effort to identify headache triggers," Lipton says. "Every specialist takes a careful headache history to find out what makes a patient's headache worse. Understanding these factors is an important preventive strategy, because most of these things can be managed."

The next step is to find drug and non-drug headache treatments that help. Both come in two kinds. Acute headache treatments deal with headaches when they happen. Preventive headache treatments stop or limit headaches before they occur.

"In specialty care, the first objective is to relieve patients' pain and improve their ability to function," Lipton says. "In some patients, pain is relatively intractable. Then treatment becomes a rehabilitation strategy. We say, OK, we can't stop all the pain. What will we do is improve your function in spite of some pain.' In a small proportion of patients, you need to make this shift. For most, we say 'Let's relieve your pain and you can function.' For others we say, "Let's work on pain and function in tandem and see how much progress we can make in both areas."

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