Coexistent Headache and Chronic Pain
by R. Steven Singer, MD
 Patients presenting with both headache and chronic pain may find
that their condition provides a complexity that neither the clinical management of
headache nor general management of pain is equipped to handle alone. The practical reality
of today’s medicine is that there is little overlap between the two specialties. As a
result, the patient may find great difficulty in finding a practice that will commit to
the patient’s medical management. On the one hand, a headache specialist/neurology
office may lack knowledge about pain literature or common pain complaints, may be
uncomfortable with the demand/need of opiates for chronic pain, or may lack the procedures
or time for frequent office calls and interactions that a typical pain patient requires.
On the other hand, the pain management office may not be knowledgeable about unique
headache/ migraine considerations in prescribing medications or find that initial
evaluations for chronic pain are complicated by the overlay of headache.
Other concerns include the potential for misdiagnosis when, in actuality, brain disease
is present. Yet despite the trepidation that these practitioners may have, patients with
coexistent headache and chronic pain are common in the medical office and may be
successfully managed. The following discussion provides insights into the variation of
presentation and potential treatment modalities.
Chronic Intractable Headache
Every headache clinic has a small percentage of patients who are essentially intractable
and are often referred to basic pain management with chronic narcotics as the primary form
of treatment. This may include patients with chronic migraine, post-craniotomy patients,
trigeminal neuralgia and other more obscure conditions. These are patients who have failed
all the usual and customary forms of headache treatment. There is general agreement in the
headache literature that opioids rarely conquer the problem of chronic headache entirely
as tolerance and analgesic rebound issues intervene. Further, severe headaches may come
through baseline chronic analgesic medications and these patients often require some
breakthrough medication such as another opioid or a triptan.
Please refer to the Nov/Dec 2003 issue for the complete text. In the event you need to order a back issue, please click here.
— Nov/Dec 2003
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