Chronic headaches in family practice

More than 11 million people in the United States have moderate or severe migraine resulting in much suffering and millions of lost work days annually. Staying abreast of current advances in headache management is important for family physicians, who care for most headache patients.

MEDLINE files were searched from 1982 to the present using the key words "headache," "migraine," "serotonin," and "cerebral circulation." Also searched were the journals Headache and Cephalalgia and the published proceedings of meetings of the American Association for the Study of Headache, the International Headache Society, and the Migraine Trust.

A new headache classification based on clinical symptoms has been published by the International Headache Society, which clarifies headache diagnoses. Though headaches with serious underlying disease occur only rarely in family practice, physicians must be familiar with the clinical signs indicating the presence of such problems, and any change in or unusual presentation of headache warrants investigation. Headache research has expanded in the past decade, much of which has been directed at raising the standards of treatment. Pharmacologic treatment falls into two categories: acute or abortive treatment and preventive treatment. Analgesic overmedication by headache patients is commonplace and leads to withdrawal symptoms and the development of chronic daily headaches, for which effective treatments are now available at both ambulatory and inpatient levels. At the more basic research level, serotonin receptor studies have provided an impetus for revealing underlying headache mechanisms. A new serotonin agonist, sumatriptan, has proved effective in treating acute migraine and will no doubt be followed by further serotonergic drugs. Patient education, relaxation therapy, and other nonpharmacological approaches, as well as good overall standards of care, are essential ingredients in headache management. Family physicians are well-equipped to offer these approaches to their patients with headache.