Headache is one of the most common problems seen in the primary care office. It is often a chronic complaint, not easily managed, and often an unsatisfying experience for families and providers. You can’t cure headache like an ear infection, it will always come back in some form or another. And while headache is technically a neurological problem, at its heart, headache is a chronic pain problem. It is not as glamorous or interesting as many neurological conditions. Many neurologists are not as interested in headache as they are in other conditions. Patients and families are often challenging and the issues are often multi-factorial, comprehensive and complicated. Chronic pain is a field that takes a certain mindset and approach, not for the faint-hearted. I believe that a multidisciplinary wellness approach to care is best, and our job is to guide the families to adopt that approach. This is time consuming, requiring a lot of counselling and coaching, to achieve good results, and most importantly to prevent disability.
Fortunately, for those of us who work in the headache field, there are many wonderful patients and families, more than happy to work as a team to achieve good results. You can have your chronic migraine patient with several comorbidities including inadequately treated psychiatric issues and significant disability as your first patient of the day. Then you can have a patient with episodic migraine or menstrual migraine, with many family members with migraine, has learned their triggers, has a rescue plan, and is doing well overall. It’s really a mixed bag in the headache world, which makes it a bit different than the usual chronic pain patients, especially in pediatrics. It is also more enjoyable.
I think the most important thing is being able to accurately make the diagnosis, identify appropriate treatment, and obtain buy-in from the patients and families to accept the multidisciplinary approach to care. Since I work in a tertiary care outpatient clinic setting, our patients have already been evaluated, tried some medications or treatments, and have not had success. Patients may have had inadequate medication trials, been given incorrect diagnoses and treatments, and establishing trust is difficult. In these days, instant gratification is desired, and this is just NOT a hallmark of headache care. Daily medications can take a month to see effectiveness (or not). Lifestyle changes take time. Learning cognitive behavioral skills take a while to become effective. Establishing a healthy headache lifestyle along with adequate treatment options is a marathon, not a sprint. There’s a lot of trial and error. Without the families’ trust, this journey is made even more difficult.
For the community provider, having some good baseline knowledge of headache, is a great starting point. In the next posts, I will review the primary headache in pediatrics. Learning to recognize the specific headaches and common treatments, both preventive and rescue, is the bread and butter of headache medicine.