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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.