Headache myths revealed: Unravel some common misconceptions
Myth 1: You can tell if a patient has a brain tumor by what headache they have.
"There’s a lot of talk about what kind of headache you get from a brain tumor but there’s no truth to that," says Michael Callaham, MD, FACEP. Studies have shown that it’s difficult to determine the cause of headache from a description of the headache, he explains.
"Obviously if they say the headache feels like it’s right in their left frontal sinus and they have mucus dripping out of their nose and are tender over the sinus, you might be able to diagnose sinusitis," says Callaham. "But for generalized headaches, you need to focus on severity and how different it is from previous headaches."
Timing of a headache is also not an indication of its cause, stresses Callaham. "Morning headache pain being associated with tumor is an old belief which has been disproved," he says.
Myth 2: Don’t go by pain scales alone. "Some people are dramatic and will say that every headache feels like 300 pounds of TNT that just went off," says Callaham. "But if it’s like that every time, it is consistent. Whereas someone else may be stoic but still can have bleeding or a tumor. So you can’t make an assessment based on how the patient is reacting."
When patients are asked to describe their pain on scale of 1 to 10, their answers may be misleading. "Some patients who don’t appear to be in any distress at all may be snoozing on a gurney, but claim their pain is a 10," says Callaham. "Others may say it’s a score of 3 or 4, but they also say they’ve never had pain before higher than a one-half."
Ask patients to compare pain scores with their other headaches, says Callaham. "If they have headaches once a month and they’re usually a 9 or 10, that is consistent. But if they say they’ve never had one worse than a 2 before, then of course you need to figure out what is different—is it just more severe, or different in some way?"
If it isn’t immediately clear, then you should err on the side of caution, advises Callaham. "Some patients aren’t good at describing things. I’ve been in situations where several nurses and doctors all have a different impression," he says. "If you spend a few minutes arguing with each other about whether a chest pain patient has a heart attack, you better act as if they do. It’s the same thing with headaches: If you are confused, you better act as if it’s serious."
Myth 3: Patients with a subarachnoid bleed will be groggy, confused, or comatose. "That’s not true," says Callaham. "Typically patients have a small warning bleed first. That is the nurse’s chance to save this patients’ life. The patient will usually be completely mentally intact with no obvious symptoms."
Myth 4: Giving a headache patient a placebo will determine whether the headache is serious. "People misunderstand the placebo effect," says Callaham. "They have this mistaken idea that if they give a patient Imitrex and the headache goes away, then it proves that it was a migraine."
Actually, placebos work for all types of headaches, stresses Callaham. "There are plenty of case reports in the literature of thorazine relieving pain caused by meningitis, subarachnoid bleeding, and brain tumors. Imitrex works well in relieving headache caused by carbon monoxide poisoning. If a headache goes away with any particular treatment, that proves nothing about its cause."
Clinicians tend to think that patients who respond to placebos are whiners and drug seekers, says Callaham. "But actually the patient with the highest response to the placebo effect is a person like the typical doctor or nurse—well educated, hard working, compulsive, and professional," he notes.
Response to placebo doesn’t mean the patient is faking it, says Callaham. "It doesn’t mean the response is not real or in your head, it just means that something in your brain releases substances that make you feel better," he explains. "People think, this guy’s faking, let’s give him placebo and if it goes away it proves he was faking. It doesn’t prove any such thing at all. All it proves is the patient believes in you, because that’s where most of the placebo effect comes from."
Myth 5: Headache patients are often drug seekers. It’s a mistake to assume headache patients are drug seekers, says Patricia Masson, RN, MSN. "It’s a very painful disease. If patients are having more than two or three headaches a month that debilitate them, they should be considered for chronic, daily therapy for prevention," she stresses.
There is a small percentage who are repeat visitors abusing pain medicine, and are usually asking for Demerol, says Callaham. "But most of these patients are not seeking narcotics. They just want pain relief so they can go back to work, and are not getting it through other methods of treatment," he adds.
Some patients may be addicted to medications through no fault of their own, Masson notes. "There are patients out there who have become addicted because of the type of medication the patient is on. The time to put them through withdrawal is not when they are seeking help in the ED," she says.
Sometimes the primary care physician isn’t managing the patient to the best of his or her ability, and encourages patients to go the ED, says Callaham. "It’s also our job to get plugged back into primary care. You don’t want to just give them a shot of Demerol and send them out the door so they can come back a month later."
Myth 6: Headache patients don’t belong in the ED. "Sometimes ED staff react as though headache patients shouldn’t be in the ED because they don’t have a life-threatening problem. That is failing to understand what our job really is. If you had a splitting headache in the middle of the night and couldn’t sleep, you’d want relief too," says Callaham.
Still, some patients are repeaters. "A very small percentage comes in regularly. But that small group is very frustrating because each one could account for 20 visits each year. Also, many of these patients make multiple visits to multiple hospitals," Callaham notes.
At UCSF Medical Center, patients are told that if they come in with a chronic pain problem, they will be treated once and then instructed to establish a relationship with one of the medical staff, Callaham explains. "There is no reason to treat patients in the ED on a chronic basis if they don’t have a primary care physician associated with our hospital, unless they are visiting from another part of the country," he says. "If the patient is associated with another hospital, why aren’t they going to that hospital? The answer to that is usually because they have abused it."
To prevent that abuse, the medical staff member provides a written treatment plan for appropriate ED visits. "The treatment plan will never include more than one ED visit per month, and sometimes not even that often," says Callaham. "That eliminates a lot of the abuse right there."
For the first visit, the patient is given the benefit of the doubt and treated. "But at that point, we tell them, I understand you have had severe headaches for 10 years, but the ED is not the place to treat chronic pain. So we want you to have a relationship with a primary care doctor.’"
Still, even the most aggressive medical therapy doesn’t work well enough for some patients, so allowances are made in those cases, says Callaham. "If the patient comes back, we can check their written protocol, which is on file," he explains. "If they don’t have a protocol on file, we’ll see them and assess their emergency. But we do not treat their pain or give them narcotics."
Myth 7: Demerol is the best treatment for headache. Demerol is the most frequently abused treatment for headache, says Callaham. "It’s not a particularly effective treatment for headache. We no longer use Demerol in the ED, and the moment we got rid of it, certain patents never came back. We don’t use Demerol because we think it’s too easily abused. We have better alternatives that are just as strong and long lasting, such as morphine, fentanyl, and oral agents."
Still, Demerol is a popular drug. "Whole generations of doctors have been trained to give it automatically instead of morphine, for no particular reason," notes Callaham. "If you read pharmaceutical books, you won’t find anything that says Demerol is better than these other drugs. It gives people a bigger rush, which is why they abuse it more."
Myth 8: Giving narcotics to headache patients will make them addicts. "Giving big doses of narcotics doesn’t make anybody addicted. If you take people who don’t have an affinity for these drugs, and pump them full of morphine for weeks, physiologically they will be addicted, and feel crummy like they have the flu, but nobody gets addicted for that reason," says Callaham. "If someone has a severe headache, and nothing else works, it wouldn’t worry me to give a big dose of morphine."
The small percentage of headache patients that are addicted usually ask for Demerol, notes Callaham. "These patients have had migraines for years and say the only thing that works for them is Demerol, and they come in regular as clockwork every two weeks. They are addicted to Demerol, but it’s the personality type, not the drug itself," he says.
Myth 9: If it’s not the worst headache of your life, it’s nothing serious. "That is not necessarily the case, because everyone’s pain threshold is different," says Gerardi. "People with migraines actually have a higher risk of meningitis. So if a patient has a migraine and fever, it doesn’t mean they don’t have meningitis. You’ve got to evaluate them like anyone else."
Headaches with moderate pain must be taken seriously, stresses Callaham. "The headaches I worry about people missing are not the spectacular, severe pain ones, but the not-so-impressive ones that are reported as moderate pain, which they may not work-up," he says. "That is a big mistake. Tumors, infection, subarachnoid bleeds, and even meningitis can present with headache that is not extremely severe."
Myth 10: If a patient gets better with an antiemetic such as Compazine, they don’t have a subarachnoid bleed. "There are studies that show that patients can get a leaking aneurysm and the pain goes away after a little leak and doesn’t persist," says Gerardi. "People think that since the pain went away, they are not obligated to do a further workup such as a spinal tap. However, the only way to fully rule out a subarachnoid bleed is with both a CT and a lumbar puncture."
CTs tend to be more sensitive early on. "Studies show that if the patient presents within the first 12 hours of the headache, CT scans are almost 95% sensitive for picking up a subarachnoid bleed," says Michael Gerardi, MD, FAAP, FACEP. "But if the headache is going on for two or three days, sensitivity of the CT scan drops off. So you are more obligated to do a lumbar puncture in that situation."
The severity of the pain will not determine whether the patient has a subarachnoid bleed, stresses Gerardi. "You may think that since the headache has been going on for three days and it’s not a thunderclap headache, it’s not a subarachnoid bleed, but that’s not true at all," he says.
Myth 11: Headache patients should not be given pain medication. "There’s been a bias against giving pain medications to patients with headaches," says Gerardi. "People are reluctant to give anything for pain because they don’t want to alter the patient’s mental status. Giving pain medicine is not going to significantly alter subsequent exams."
If a spinal tap is necessary, patients will need to be given pain medication anyway, notes Gerardi. "If you have to do a spinal tap, you may as well give them something for pain and make them comfortable. If you are thinking about not doing a tap or CT, then you have to carefully watch them. Otherwise, you may as well give them something for pain," he says.
For more information about management of headaches, contact the following:
• Michael Callaham, MD, UCSF Stanford Health Care, Herbst Emergency Service, 505 Parnassus Ave., L-138, San Francisco, CA 94143-0208. Telephone: (415) 665-3999. Fax: (925) 253-9577. E-mail: firstname.lastname@example.org
• Ann Dietrich, MD, FACEP, Columbus Children’s Hospital, Department of Emergency Medicine, 4th Floor, Education Bldg, 700 Children’s Drive, Columbus, OH 43205. Telephone: (614) 722-4385. Fax: (614) 722-4380. E-mail: email@example.com
• Michael Gerardi, MD, FAAP, FACEP. Morristown Memorial Hospital. Telephone: (973) 971-5044. E-mail: firstname.lastname@example.org
• Patricia Masson, RN, MSN. Partners Neurology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. Telephone: (617) 724-9957. Fax: (617) 726-2353.