Intractable Headache

Intractable headache is “doctor speak” for that headache that just doesn’t seem to go away, no matter what you and your doctor do. The headache may be migraine or another kind of headache, or a combination of two or more different headache types. Regardless of the cause, it is a relentless, seemingly untreatable headache.

What is going on in your head when the pain is so resistant to treatment?

It seems as if EVERYTHING seems to trigger the headache and nothing seems to help. Surprisingly, we don’t have a complete understanding of what changes are taking place in the brain of someone in this situation. We think that the brain of someone with constant, treatment-resistant pain actually processes information differently from the way people who don’t have constant pain. There is very exciting research going on looking into these changes, but we don’t have definite answers yet. Like a car engine, you have to understand how it works before you can understand what is wrong with it, and you have to understand what is wrong with it before you can fix it. So that is where we are regarding the big picture.

In the meantime, what do we do about this intractable headache? Let’s break it down the way a headache specialist does:

Someone comes to the office and says, “I have this constant headache and nothing helps,” and they have a list of all the diagnoses they have been given and all the medicines and other things they have tried. The first question is: Do we have the right diagnosis? In other words, just what kind of headache are we dealing with? We divide headaches into two huge categories to start with:

  • Primary Headaches (meaning headaches that are not due to another cause like a brain tumor or an infection or another medical condition).
  • Those that are due to some underlying condition are called Secondary Headaches. Usually, secondary headaches are ruled out early on by imaging studies and lab tests. So most intractable headaches turn out to be primary headaches.

Of all the primary headaches, the most common ones to become intractable are migraine and tension-type headaches. However, there are other primary headaches that can be chronic and daily which can mimic migraine or tension-type. If that happens, then patients with these other conditions may receive the wrong treatment, and the headache will become intractable. So, headache specialists watch for this possibility and rule out other chronic daily headaches like hemicrania continua, new daily persistent headache, and post-traumatic headaches.

There is another, very important category, though. That category is made up of patients who have both an underlying primary headache and then, on top of that, have a secondary headache (a headache due to something else). The most common example of this is medication overuse headache. In this situation, someone has a primary headache like migraine, and then (often with the help of a well-meaning doctor) ends up using acute medications too often. Then, the brain gets used to these acute medications and starts to think they are part of the normal brain chemistry.

Not only do the medications become less effective, but when they wear off between doses, and the brain thinks there is something wrong or missing and sends out pain messages.  For the majority of these patients, the only solution is to both stop the use of the “offending” medication AND address the treatment of the underlying headache type.

So how do we approach the “intractable headache?” Once we are sure we have the right diagnosis, we develop a treatment plan to address the problem. There are two important things to keep in mind:

  1. In most cases, there will not be a cure. So the expectation should be to decrease the frequency and severity of the headaches. In other words, to get back to having milder and less frequent headaches. If the expectation is a cure (i.e. no headaches at all), you will likely be disappointed.
  2. In most cases, it takes a while for headaches to become intractable, usually months or even years. So, it will take a while to get back out of the situation. Rarely will it be a simple matter of a new pill or different device.

The best view of addressing intractable headache is to identify factors that are contributing to the headaches (it is rarely just one thing). This may be a combination of changing (stopping or starting) medications, identifying lifestyle decisions that may be contributing (spending days in bed, non-scheduled eating patterns, lack of exercise, etc.) and introducing new therapies that help to regain control over triggers.

In summary, intractable headache is not a unique headache type. Typically it is an episodic (occasional) headache that for a variety of reasons spins out of control. The solution is to break down the headache into those things you can control (medications, life-style, triggers) and systematically work through the process of putting them in order. This is neither easy nor obvious in most cases and the help of a qualified headache specialist, pain psychologist, physical therapist, nutritionist and others can make all the difference, not to forget the support of an educated and caring family.

Robert P. Cowan, MD, FAHS, FAAN

© 2014 Robert Cowan – Present. Last updated May 14, 2014.