What is the treatment for intractable headaches?

Treatment of Intractable Headache

For intractable headaches, first-line treatment should include systemic corticosteroids, particularly intravenous corticosteroids, combined with antiemetics to treat accompanying nausea and improve gastric motility. 1

First-Line Treatment Options

• Intravenous corticosteroids are the mainstay of treatment for status migrainosus (severe, continuous migraine lasting up to one week) 1
• Antiemetics such as metoclopramide or prochlorperazine should be administered concurrently to treat nausea and improve gastric motility 1, 2
• Initial management should include IV fluids for hydration along with the corticosteroids and antiemetics 1
• Parenteral NSAIDs such as ketorolac can be effective due to their relatively rapid onset of action and six-hour duration 1

Second-Line Treatment Options

• If inadequate response within 1-2 hours to first-line treatments, add parenteral NSAIDs such as ketorolac 1
• Subcutaneous sumatriptan may be used, particularly when patients cannot take oral medications due to vomiting or when they rapidly reach peak headache intensity 1, 3
• For refractory cases, consider IV magnesium sulfate 1
• Intravenous dihydroergotamine (DHE) with metoclopramide every 8 hours has shown efficacy in terminating cycles of intractable migraine 4

Third-Line Treatment Options

• Opioid analgesics such as meperidine may be required for severe intractable headache that doesn't respond to other treatments 1
• Butorphanol nasal spray can be considered when other treatments fail 1

Important Considerations and Cautions

• Non-oral routes of administration are preferred when significant nausea or vomiting is present 1, 2
• Narcotic use should be limited and carefully monitored as it can lead to dependency, rebound headaches, and eventual loss of efficacy 1
• Monitor for medication overuse, which can worsen the condition and lead to chronic daily headaches 1
• Sumatriptan carries risks including chest/throat/neck/jaw pain, cerebrovascular events, and serotonin syndrome, especially when combined with SSRIs or SNRIs 3, 5
• Significant elevation in blood pressure, including hypertensive crisis, has been reported with triptans 3

For Persistent Intractable Headaches

• Consider preventive therapy to avoid recurrence 1
• Recommended first-line agents for prevention include propranolol (80-240 mg/d), timolol (20-30 mg/d), amitriptyline (30-150 mg/d), divalproex sodium (500-1500 mg/d), and sodium valproate (800-1500 mg/d) 6
• For highly refractory cases, neuromodulation techniques such as occipital nerve stimulation have shown efficacy in multiple studies 7, 8, 9
• Occipital nerve stimulation has demonstrated a 46.1% improvement in attack frequency for intractable chronic cluster headache with an overall response rate of 52.9% 8

Non-Pharmacological Approaches

• Relaxation training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive-behavioral therapy may be effective in preventing migraines 6
• Behavioral therapy such as relaxation or biofeedback may be combined with preventive drug therapy to achieve additional clinical improvement 6
• Exercise has been shown to be effective for the prevention of migraine; exercising for 40 minutes three times a week can be as effective as relaxation therapy or topiramate 6
• Patient education is essential - patients should understand that migraine is a neurological disorder with a biological basis that may require a multimodal approach to therapy 6

Special Situations

• In patients with cardiovascular disease, avoid triptans and consider NSAIDs or antiemetics as primary therapy 1
• For pregnant patients, acetaminophen and antiemetics are preferred; avoid NSAIDs and triptans 1
• In cases where medication overuse is contributing to intractable headaches, discontinuation of the overused medication is essential, though this may temporarily worsen symptoms 1