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For more information about collaborative care , check out Dr . Roger Cady ’ s podcast at www . head achemag . org / ExpertAnswers / ExpertQnA . and a professor of neurology and epidemiology at the Albert Einstein College of Medicine in the Bronx , N . Y ., has identified three key reasons to call in a consult :
1 . The headache diagnosis is in doubt . If a primary care physician is having difficulty determining the type of headache or the reason for the headache , a specialist may be able to help . In some cases , rather than being a primary disorder , a headache could be a symptom of something else . “ If it ’ s a really weird headache that doesn ’ t fit in any of the primary care physician ’ s boxes , that ’ s a reason to see a specialist who may have a few more boxes ,” Dr . Lipton says .
2 . The diagnosis is clear , but optimal treatment is uncertain . A headache patient might have other health issues that complicate care , such as asthma or ulcer disease . Beta blockers cannot be used with asthma , and NSAIDs cannot be used with ulcers , Dr . Lipton says . That eliminates two of the go-to medications for migraine right away . A headache specialist might have additional ideas for treating a patient with this sort of complex medical history .
3 . Initial treatment is unsuccessful , and the patient continues to experience intense symptoms . “ Treatment fails for a number of reasons that specialists are trained to look for ,” Dr . Lipton says . The patient could have more than one headache disorder with overlapping symptoms ; an exacerbating factor , such as obesity , which may predispose him or her to bad headaches that are hard to treat ; or a very powerful trigger factor , such as sleep apnea , that hasn ’ t been identified or addressed . There could also be medication overuse . “ The same medications that relieve symptoms when taken occasionally can become a [ headache ] cause or exacerbating factor if taken too frequently ,” Dr . Lipton says .
This is not to say you should abandon your primary care physician if pain relief isn ’ t instantaneous . But if you ’ re still having disabling headaches after three or four different treatments , it might be time to consider a referral .
“ Sometimes patients are reluctant to ask for a referral because they don ’ t want to insult their general practitioner ,” Dr . Marcus says . “ But the doctor may be relieved to get another opinion if the usual stuff is not working .”
Even though a second opinion might be warranted , it ’ s important not to bounce from doctor to doctor any more than you have to , Dr . Cady notes .
“ What people need is someone who can help them manage their headaches over the long term ,” he says . “ Living with the disease impacts your life for decades , so you want to form a relationship with someone .”
WHAT TO EXPECT FROM SPECIALIZED CARE
Depending on the outlook of your general practitioner , you might not have explored treatment options beyond medication . A headache clinic or specialist can suggest alternatives , such as using biofeedback , trying relaxation techniques , working with a psychologist or getting nutritional advice .
“ Most headache specialists have a menu of resources beyond what ’ s available in primary care — or even from general neurologists , who usually stick to a medical model ,” Dr . Cady says .