From the Guidelines
Intractable headache refers to a severe, persistent headache that does not respond to standard treatments or medications, significantly impacting a person's quality of life and daily functioning. These headaches are resistant to conventional therapies and continue despite multiple treatment attempts. According to the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1, intractable headaches often require a multidisciplinary approach for management. The guideline highlights the importance of considering the patient's headache type, comorbid conditions, and values and preferences when crafting a treatment plan.
Some key points to consider in the management of intractable headaches include:
- The use of preventive medications, such as topiramate, valproate, or amitriptyline, which have shown statistically significant reductions in mean monthly migraine days 1
- The potential benefits of nerve blocks, such as greater occipital nerve blockade, which has been shown to improve pain in some patients with migraine 1
- The role of neuromodulation techniques, although the evidence for these is currently limited and more research is needed 1
- The importance of a comprehensive treatment plan, potentially including lifestyle modifications, behavioral therapies, and rehabilitation interventions, such as physical therapy and aerobic exercise 1
It is essential to note that the management of intractable headaches should be individualized and tailored to the specific needs and circumstances of each patient. Patients with intractable headaches should be evaluated by a neurologist or headache specialist who can develop a comprehensive treatment plan and provide ongoing support and guidance. As stated in the guideline, the goals of treating acute migraine include rapid and sustained alleviation of pain and most bothersome symptom and restoration of function 1, and the management of intractable headaches should prioritize these goals while also considering the patient's overall quality of life and well-being.
From the Research
Definition of Intractable Headache
- Intractable headache refers to a persistent headache that is difficult to treat or fails to respond to standard and/or aggressive treatment modalities 2.
- The terms refractory headache and intractable headache have been used interchangeably to describe this condition 2.
- Intractable headaches can be debilitating, often leading to significant distress, prolonged medical treatment, and unanticipated hospital admissions 3.
Characteristics of Intractable Headache
- Intractable headaches are characterized by their resistance to medical management, resulting in significant headache-related disability 2, 3.
- The level of headache-related disability and the intended intervention (clinical or research) are important factors to consider when defining intractability 2.
- Intractable headaches can be primary, such as migraines, tension headaches, and cluster headaches, or secondary, attributed to injury or infection 3.
Treatment of Intractable Headache
- Various treatments are available for intractable headaches, including interventional strategies such as trigger-point injections, peripheral nerve stimulators, or peripheral nerve and ganglion blocks 3.
- Occipital nerve stimulation has been shown to be a safe and effective treatment option for medically intractable chronic cluster headache 4, 5, 6.
- Other treatments, such as erector spinae plane blocks, may also be effective in managing intractable secondary headaches 3.