Preventing Headaches and
Reducing their Impact

Gary E Cordingley, MD, PhD
Do you find yourself treating one headache after another?  Do headaches interfere
with your usual activities?  Do your treatments cause annoying or impairing
effects of their own?  If your answer to any of these questions is yes, then you
should consider a preventive treatment.
Whether speaking of migraines, tension-type headaches or other recurring head pains, it's safe to say that the
best headache attack is the one you don't have.  Even if you have found an effective treatment for resolving a
headache that is already underway, there is nothing about today's as-needed treatment that will keep next
week's attack from occurring.

Headache treatments come in two forms—abortive and preventive.  The abortive form is familiar to most
people.  It means something you do to get rid of a headache that has already started.  Usually it consists of an
over-the-counter or prescription medication, but in some cases, a non-drug approach works.  By contrast, a
preventive treatment is something you do every day with the goal of keeping some future attacks from even
starting.  These, too, can involve drug and non-drug strategies.

Billions of dollars are spent each year on abortive remedies.  For the most part, they are dollars well spent.  
And for people who have infrequent headaches that are rapidly and reliably resolved by an abortive treatment,
a preventive treatment might be needless.   

But if attacks are frequent, hard to resolve, interfere with usual activities—or side-effects from the abortive
treatment interfere with usual activities—then a preventive treatment should be considered.  Employing a
preventive remedy does not preclude also using an abortive measure: each can be part of an integrated plan.

Before discussing specific treatments for specific headache types, let's consider the impacts of recurring
headaches.  The more obvious impact is the sheer unpleasantness and suffering involved in an attack.  
However, another impact—though less obvious—is in its own way just as important.  And that is the associated
disability or loss of function that comes with an attack.

If a headache attack is severe, then whatever else was planned for that day goes out the window—it's just not
going to happen.  If an attack is moderate in intensity, then usual activities might be possible, but occur more
slowly, less efficiently, or require more effort to produce.  This, too, represents headache-associated disability.

An increasing trend in the field of headache management is for practitioners to address their patients' loss of
function as well as their pain and suffering.  Drs. Richard Lipton and Walter Stewart designed a questionnaire
to estimate headache-associated disability, called the
MIDAS (Migraine Disability Assessment) scale which can
also be used for non-migraine headaches.

Measuring and then re-measuring MIDAS is one method for judging if a preventive treatment is effective.  But
to accurately detect the effectiveness (or lack of effectiveness) of a preventive headache treatment there
should also be some sort of day-by-day recording system.  

It might be as minimal as a check-mark on the calendar for each day with any symptoms.  Another system is to
summarize at the end of each day that one day's headache-impact by selecting one of the following four
descriptions—none, mild, moderate or severe.  Numerically inclined people can assign scores of 0-3 to these
choices and then run averages and other statistics for each calendar month.

For people with recurring or continuous pain there is a tendency to live moment-to-moment without a view of
the longer-term pattern.  A recording system helps capture the big picture.  It would be a mistake to judge the
effectiveness of any treatment by what happened with symptoms in just the last few days.  Generally, a month
or longer is required to judge fairly and accurately.

So now that we have decided to consider a preventive treatment for our headaches and have put in place a
system for measuring the treatment's outcome, what specific remedies are available?

It depends, of course, on the kind of headaches being treated.  Let's discuss two of the most common types—
migraine and tension-type headaches.

For prevention of migraine, the best-studied and most effective drug treatments are available by prescription
only in the U.S.  These include propranolol (brand name Inderal), amitriptyline (Elavil), divalproex (Depakote)
and topirimate (Topamax).  

Riboflavin (vitamin B2) at 400 milligrams per day was shown in one controlled study to have migraine-
preventing actions.  (At this dose—far higher than what is needed to treat vitamin deficiency—riboflavin should
be considered a drug rather than a vitamin.)  The herb feverfew has also shown benefit in controlled trials, but
it is important to remember that this, too, is a drug and can have side-effects.  As is the case with other drugs, it
should not be used during pregnancy.

Non-drug strategies of proven effectiveness in migraine prevention include therapist-supervised programs of
stress management, relaxation, biofeedback and cognitive-behavioral therapy.  Studies of acupuncture have
shown mixed results.  Avoiding individually determined
triggers for attacks carries no risk and can reduce attack

For tension-type headaches amitripyline is the best-studied drug for prevention of attacks.  Note that this drug
is also a leading treatment for migraine, so people unlucky enough to have both kinds of headaches can obtain
benefit from just one drug.  Unfortunately, even at the low doses used for headache prevention, amitriptyline
can cause daytime drowsiness (even when administered at bedtime) or annoying oral dryness.  Because of
this, substitution of a better-tolerated, though less-studied drug in amitriptyline's family (tricyclic
antidepressants) is sometimes required.  Tizanidine (Zanaflex) has also shown benefit in controlled trials.

Non-drug strategies for tension-type headache have also been proved effective.  These include similar
behavioral interventions to those mentioned for migraine—stress management, relaxation, biofeedback and
cognitive-behavioral therapy.

It would be wonderful if preventive treatments stopped headaches entirely.  If they did, a measurement system
would not be necessary.  But a more realistic goal for preventive treatment is to reduce overall headache
symptoms by at least half, or to an extent that an individual patient finds meaningful.  When this occurs, a
preventive approach can be a valuable addition to a program of headache management.

(C) 2005 by Gary Cordingley