We treat an enormous number of patients with headache. It is important to first determine what the etiology is for headache. A thorough neuro-ophthalmic examination with neuro-imaging is requested. Many of our patients have raised intracranial pressure. These patients have swollen optic discs. These patients headaches can best be treated by first decreasing the intracranial pressure. This is done through a variety of methods including drugs and surgery. Another group of patients have tumors which cause pain either around the eye or in the brain. This is why patients with severe cephalgia require neuro-imaging. The typical neuro-imaging and testing that we perform is an MRI of the brain and orbits. This shows all the nerves from the eye and structures within the brain. This is performed with gadolinium contrast material. A creatinine is performed first to determine if renal function is adequate to handle the gadolinium. Rarely this contrast material has caused kidney changes. We make sure that all patients have normal renal function prior to giving them this drug. If there is no tumor or aneurysm on neuro-imaging, then we consider therapy with medicines.
Different reasons for a headache can lead to different diagnoses and different drug treatments. One group of patients have headaches in the base of the skull and neck. These types of headaches are often treated with a combination of muscle relaxants and anti-inflammatory agents. Patients with severe orbital pain often respond to combination serotonin and norepinephrine reuptake inhibitors. Patients with temporal pain can have giant cell arteritis. These respond to steroids. Those who do not have giant cell arteritis often respond to doses of the neurotransmitter GABA. Patients with pain across their brow can have musculoskeletal type headaches and can respond to Botox in addition to muscle relaxants and strong anti-inflammatory agents such as Naprosyn sodium. If pain is centered in the medial part of the orbit it is often due to a trochleitis. Injections with Kenalog provide excellent pain relief. Pain directly in the eye can be treated with topical prednisolone acetate and homatropine. Retrobulbar pain on eye movements can be a sign of multiple sclerosis requiring intravenous steroid treatment. Pain in the mid-face can be sinusitis requiring antibiotics, Afrin nasal spray, and steroid dose packs.
Those who fall outside of these syndromes often have migraines. These patients’ headaches improve upon rest and removal of light stimuli. Tryptans can relieve them in the short term, however doses with calcium channel blockers, beta blockers and serotonin reuptake inhibitors are often useful. In reality some patients may have over stimulation of the trigeminal nerve. They may respond to neurosurgery.
We handle all of these types of pain syndromes. Patients with chronic pain may require additional narcotics as well as patients in acute pain syndromes. These patients are monitored for any dependency issues. We are happy to evaluate you if you fall into any of these categories.