Headache Treatment Options

The management of your headaches and facial pain may include both nonmedical and medical treatments. Nonmedical treatment includes keeping a headache diary, making life style changes, avoiding factors that may trigger your headache.

We offer an array of specialized and advanced treatments for headache that may not be commonly available.

Headache Medications

Most medications that are taken as needed to treat individual headache attacks, but you may also need to take medications on a scheduled basis to reduce the frequency of your headaches. Medications for treating the acute headache stage belong to several classes.

• Oxygen is used to treat cluster headaches.
• Local anesthetics (applied in the nose) treat many headache and facial pain disorders.
• Analgesics, such as the non-steroidal anti-inflammatory drugs (naproxen sodium, diclofenac and ketorolac), are used to treat migraine and other headaches.
• Triptans, which include seven different medications, come in oral, nasal and injectable routes of use.

You may benefit from preventive medications if you suffer from frequent headaches or headaches that interfere with your schooling, work or social activities. You may also benefit if you are at risk for developing medication overuse from taking your as-needed medications too frequently.

The choice of preventive medication is based on the individual. Factors including the best medical evidence, your specific diagnosis, patient preference, other medical conditions and experiences with prior medications are all taken into consideration. The medications used to prevent headaches come from various classes. Many were initially developed to treat other medical conditions and were subsequently found to be effective at preventing headaches, including:

• Medications also used to prevent seizures (antiepileptics), such as topiramate, valproate and carbamazepine
• Medication also used to treat elevated blood pressure (antihypertensives), such as metoprolol, propranolol and verapamil
• Medications also used to treat depression and anxiety, such as amitriptyline, nortriptyline, protriptyline, imipramine and venlafaxine

Certain vitamins, supplements and herbal medications may also help prevent migraine attacks. Some of these, such as magnesium, riboflavin, feverfew and special extracts of butter bur root may be as effective as prescription medication. While these are available over-the-counter, we strongly recommend that you first discuss these options in detail with your treating provider before starting.

Biologics and Injections to Treat Headache

Among the newest treatments in headache are biologics.

BOTOX Injections

OnabotulinumtoxinA injections are a safe and effective treatment for a specific form of migraine called chronic migraine. The injections are administered in the office by your headache medicine provider. The injections are administered in seven different muscle groups in the head and neck region every 12 weeks.

Calcitonin Gene-Related Peptide Monoclonal Antibodies

Calcitonin gene-related peptide (CGRP) is a substance thought to play a role in the development of migraine. CGRP monoclonal antibodies are a new generation of medications specifically developed to block the effects of CGRP and thereby prevent migraine attacks. There are currently three FDA approved CGRP monoclonal antibodies available for the treatment of migraine — erenumab, fremanezumab and galcanezumab. These medications are self-administered shots taken once monthly, or, in the case of fremanezumab, three injections once quarterly. These are injections that are under the skin (subcutaneous).

Procedures to Treat Headache

In certain situations, selected procedures may be the best option for the treatment of headache or facial pain.

Sphenopalatine Ganglion Blocks

The sphenopalatine ganglion (SPG) is a structure containing nervous tissue located in the back of the nasal cavity. The SPG contains nerve fibers traveling to another structure in the brainstem called the trigeminal nucleus which is involved in the sensation of pain in the head and face. Blocking this structure with an anesthetic (numbing medication) can provide relief from certain facial pain and headache disorders including migraine.

The procedure we perform is needleless. A small soft plastic catheter (tube) is placed in the nasal cavity. The sphenopalatine ganglion is sprayed with an anesthetic, and the catheter is withdrawn. This procedure may be repeated on a scheduled basis depending upon the specific condition being treated and your response to the treatment.

Nerve Blocks

Nerve blocks — with or without a cortisone-related medication — can be administered in the occipital nerves at the base of the skull and in the upper neck. While they are primarily used for the treatment of occipital neuralgia, they can prevent cluster headaches and some migraines, and can also stop a prolonged migraine attack. Other than pain from the injections side effects are rare, the benefit can be immediate with extended duration. On occasion, the patient will have pain localized to their temples or forehead, and local nerve blocks can be placed there as well. These are similar to the occipital nerve blocks, but carry a risk of cosmetic effects such as dimpling of the injection area that may slowly resolve.

Nerve Stimulation

Occipital nerve stimulation involves an implantable device that is attached to nerves in the upper neck. It has been used as a treatment for chronic migraine and can be done by our Froedtert & MCW neurosurgery and pain medicine physicians. Its benefits may diminish over time and obtaining insurance coverage for this expensive procedure is difficult.

Vagal nerve stimulation was developed as an implanted device for seizures but also used for migraine and depression. While it is still used for seizures, the costs and high side effect rate never led to this being common for the other conditions. Recently a device for stimulating the vagus nerve in the neck for treatment of cluster headaches has been developed that uses a handheld device that is applied to the skin. It is useful to stop many cluster headache attacks and may help reduce the frequency of cluster headaches. While it is approved by the FDA, insurance coverage is still challenging to achieve. It is less likely to produce side effects than the older implanted devices.