Morris Levin

Nerve blocks in the treatment of headache

SummaryNerve blocks and neurostimulation are reasonable therapeutic options in patients with head and neck neuralgias. In addition, these peripheral nerve procedures can also be effective in primary headache disorders, such as migraine and cluster headaches. Nerve blocks for headaches are generally accomplished by using small subcutaneous injections of amide-type local anesthetics, such as lidocaine and bupivicaine. Targets include the greater occipital nerve, lesser occipital nerve, auriculotemporal nerve, supratrochlear and supraorbital nerves, sphenopalatine ganglion, cervical spinal roots, and facet joints of the upper cervical spine. Although definitive studies examining the usefulness of nerve blocks are lacking, reports suggest that this area deserves further attention in the hope of acquiring evidence of effectiveness.

A Retrospective, Comparative Study on the Frequency of Abuse in Migraine and Chronic Daily Headache

Objective.—To assess and contrast the relative frequency of a past history of physical and/or sexual abuse in patients with chronic daily headache (CDH) versus migraine.

EVALUATION AND MANAGEMENT OF HEADACHE IN THE EMERGENCY DEPARTMENT

In the ED, correct diagnosis is the necessary foundation on which specific therapy is based. There is no substitute for obtaining a thorough history and examining the patient competently. Patients with a past history of primary headaches, such as migraine, also may be afflicted with (new) secondary headaches. Although efficiency is desirable from the perspective of ED management, a thoughtful approach complemented by the judicious selection of tests is compatible with that goal as well as achieving the desired outcome of accurate diagnosis and relief of pain. Arrangements for long-term follow-up are important.

Three common neuralgias. How to manage trigeminal, occipital, and postherpetic pain.

PREVIEW The pain experienced by patients with trigeminal, occipital, or postherpetic neuralgia is often severe, chronic, and difficult to treat. In this article, Drs Ashkenazi and Levin outline the pathologic mechanisms of pain in these common neuralgias and discuss individually tailored pharmacologic and surgical approaches to their treatment.

Opioids in Headache

Opioid analgesics have long been used to treat head pain of various types. This has been increasing to a significant degree over the past 25 years because of a trend for more liberal use of opioids in non‐malignant pain. Opioid treatment for acute headache, as well as prophylactically for refractory chronic headache, is controversial. There are a number of adverse effects associated with acute and chronic opioid treatment. Tolerance, dependence, and addiction are prominent issues. This article attempts to analyze the benefits and disadvantages for opioids in the management of migraine and other headache disorders, relying on known properties of this class of medication as well as clinical data. It will mainly focus on 2 topics: the use of opioid medication for the acute treatment of migraine attacks and continuous prophylactic use for refractory chronic migraine.

Defining refractory migraine: Results of the rhsis survey of american headache society members

Objectives.— To gauge consensus regarding a proposed definition for refractory migraine proposed by Refractory Headache Special Interest Section, and where its use would be most appropriate.

Pharmacological prevention of migraine

#### Summary points People who have migraine experience intermittent attacks of unilateral, pulsating, and moderate to severe headache with associated nausea or photophobia and phonophobia (or all these symptoms). These attacks typically start before the age of 40, often in childhood or teenage years, and occur most commonly from the second to the fourth decade of life.1 Attacks may be infrequent or frequent. Chronic migraine is diagnosed when attacks regularly occur on more than 15 days a month. Box 1 shows the International Headache Society’s classification criteria for migraine without aura. #### Box 1 International Headache Society’s classification criteria for migraine without aura1 At least five attacks fulfilling criteria A-C Recent population studies have shown the worldwide prevalence of migraine to be greater than 10%. The prevalence of migraine in the United States has been estimated at 18% for women, 6% for men, and 12% overall.2 3 Migraine clearly affects women more than men, and its aetiology also seems to have a hereditary component. The World Health Organization ranks migraine 19th on the list of diseases worldwide that cause disability.w1 In spite of recent advances in treatment options for migraine, both acute and preventive, these treatments continue …

An Analysis of Cluster Headache Information Provided on Internet Websites

Objective.— To evaluate the quality of websites providing cluster headache information for patients and healthcare providers.

The International Classification of Headache Disorders, 3rd Edition (ICHD III) – Changes and Challenges

In order to effectively study and manage headache disorders, diagnosis is essential. In both research and clinical arenas, separating secondary causes from primary headache disorders is a crucial first step, followed by further specificity within these broader categories. Historical approaches to classifying headache disorders culminated in the International Classification of Headache Disorders (ICHD), completed and published in 1988. This was revised as the International Classification of Headache Disorders, 2nd Edition (ICHD II) in 2004. The International Headache Societys Subcommittee on Classification began work on the 3rd edition in 2010, and has just published this online and in the journal Cephalalgia. The diagnostic criteria for more than 200 causes of headaches are based upon evidence when available, and fortunately, recent research in the field of headache medicine has produced data applicable to the refinement of classification of a number of primary and secondary headache disorders. Some areas, however, await further study, making classification more challenging. This article will attempt to provide an overview of the rationale behind the ICHD, a guide to its use, and a summary of important diagnostic features of the primary and secondary headaches, particularly where these have changed significantly in the ICHD III from ICHD II.

Refractory headache: classification and nomenclature.

There are a number of reasons to attempt to define and classify refractory headache disorders. Particularly important are the potential benefits in the areas of research, treatment, and medical cost reimbursement. There are challenges in attempting to classify refractory forms of headaches, including the lack of biological or other objective markers and a lack of consensus among practitioners as to what qualifies as refractoriness, or even if a separate category for refractory migraine and other refractory headaches needs to be established. A definition of refractory migraine has been proposed by Schulman et al in this issue (“Defining Refractory Migraine [RM] and Refractory Chronic Migraine [RCM]: Proposed Criteria for the Refractory Headache Special Interests Section of the American Headache Society”), which should be tested for validity and usefulness. It seems reasonable to consider adding this defined syndrome to the International Classification of Headache Disorders, second edition (ICHD‐II). In this article, options for adding refractory headache syndromes to the ICHD are discussed with pros and cons for each. Two “best” options for adding the disorder “refractory migraine” to the ICHD are presented along with an illustrative case example.