So You Think You Have Tried Everything, Do You? Then Think Again. Part IV

When everything in Tiers I and II have failed, we are halfway there.  Here are some of the things to try at this next level.

Abortive / Symptomatic-Pharmacological Treatment Tier IV

Intravenous Infusions 

The role for IV therapy in headache treatment is in one of several situations including the following;

1)      The first is where someone has entered a cycle of very severe and daily headaches,

2)      Where the preventatives have not been working and we need a way to break a prolonged cycle,

3)      Where someone is in rebound headaches and needs help cutting back on the rebounding medications.


IV treatments include one or a combination of several medications that might include;

1)      DHE -45 (dihydroergotamine),

2)      An anti-emetic such as metoclopramide,

3)      Magnesium,

4)      Depacon® (IV form of Depakote)

5)      Others






Pros: These IV solutions can be very effective in treating headaches even when all else has failed.




The hope is that these will give lasting benefit. Sometimes they only help for days, which is not worth the effort. It is expensive to do IV therapy., but IV medications can have more of a side effect.


Arranging IV meds can be difficult. We are working on creating an IV center as part of the Pacific Rim Headache Center. But until that is up and running, we have to rely on home infusion services.

Chronic Daily Opioids 

This is the intentional prescription of daily narcotics to treat the headaches.

Pros:For some people, this is the only avenue left for help.



The cons are many.  For one, it is a given that if you take these narcotics on a daily basis, you become addicted.  That addiction can complicate a person’s life.


In some studies, the daily prescribing of narcotics didn’t improve the overall quality of a person’s life but lessened it.


Daily narcotics, by law, must be given at special pain clinics and those are sometimes hard to find.


Pain medication can cause rebound headaches and over time, the headache condition actually worsens.  This is why many headache clinics don’t think there is a place for daily narcotics, while some do.



Prevention Non-pharmacological / Tier IV

Supplements No additional ones to add at this level

Nerve stimulation


Either two point (bi-occipital) or four point (bi-occipital + bi-greater orbital) nerve stimulation. These procedures also go by names such as the “Reed Procedure” or the “Omega Procedure.”

Pros:The limited studies done so far show that these tend to be highly effective even for patients who have failed everything else.  However, they don’t work for everyone.



These are invasive procedures requiring wires to be connected directly to the nerves under the skin and then wearing a stimulator that has been surgically implanted. The procedure is expensive, my estimate is $10-20,000 and may not be covered by your insurance.

Headache Surgery 

This is a procedure where a surgeon cuts away tissue from around nerves outside the cranium.

Pros:The plastic surgeons who do these procedures claim to have a very good response.  However, there has only been one study done so far.  If this did work, it would be a permanent solution to the headaches. We are working with a plastic surgeon in Anacortes who can do the decompression procedure.



These procedures have not been approved by the American and International Headache Societies due to lack of evidence. These procedures can be expensive and insurance companies do not cover them.



Prevention Pharmacological / Tier IV

Daily Triptans Pros:There have been a couple of studies looking at the benefit of using daily triptans, such as naratriptan, as headache preventatives and they seem to support their benefit.  Many patients report that these are the only thing that gives them relief.  We have pretty good data on the use of daily triptans and they appear to be safe. However, long term studies have not been done yet to establish compete safety.


Triptans can cause rebound headaches, where the headaches actually worsen with their frequent use.  The next major problem is that triptans are expensive and insurance companies usually only pays for 12-18 per month.

Inpatient (Quaternary) Treatment Centers Pros:These are hospital-based treatment centers that offer intense, round the clock, headache diagnosis and treatment. The staff at these centers are all highly trained in headache treatment, which separates them from a usual hospital stay.  Most of them have demonstrated effective treatment, even in patients who have failed other treatments. It is also an excellent place to be wean off, in a compassionate way, medications that might be causing rebound headaches.


Because insurance companies pay poorly for this important service, there are only a few such centers in the U.S. so it requires travel.  We work with the first one ever developed, Michigan Headpain and Neurologic Institute, in Ann Arbor, Michigan.  These programs can be expensive. If they have had any criticism it is the fact that the patient can do better in that controlled environment, but then might deteriorate when they are in their home setting.