diagnosis management objectives of headacheswichita.kumc.edu/documents/wichita/familymed... ·...

Diagnosis and Managementof Headaches

Dr. Richard H. LeuVia Christi Family Medicine Residency

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Objectives

• Discuss the diagnosis and managementof the following headache types:

• Tension – type headache• Migraine headache• Menstrual related migraine• Cluster headache

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Headache Spectrum

• TensionMigraine

• How many types ofheadaches do youhave?

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Tension –TypeHeadache

• Most commonheadache in adults

• Approximately 40%of adults will treat atension typeheadache in anygiven year

• Uncommon inchildren or olderadults

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Diagnosis and Management of Headaches Richard Leu, MD

Family Medicine Winter Symposium December 5, 2014

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Characteristics ofTension – Type Headache

• Bilateral• Mild to moderate pain• No aura• Minimal disability• Minimal impact ofexercise

• Occasional light/soundsensitivity

• Scalp or cervicaltenderness

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Migraineurs

• 41% report bilateral pain• 50% report non pulsatingpain

• 75% describe neck pain• 84% identify stress as atrigger

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Pathophysiology ofTension – Type headache

• Heightenedsensitivity of nervecells in the brain

• The “muscular”component is merelya secondaryphenomenon

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Pathophysiology ofTension – type headache

• Many experts feel that episodic tension –type headache may merely reflect amilder or less developed version ofmigraine.

• Tension HA Migraine HA

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Diagnosis ofTension – Type headache

• Diagnosis is definedby the absence offeatures typical ofmigraine or clusterheadache.

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Precipitating Factors ofTension – type headache

• STRESS

• Hunger

• Sleep disruption

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Treatment ofTension – type headache

• Regulate sleep /meals

• Adequate hydration• Exercise 30minutes/day

• Limit alcohol,caffeine and artificialsweeteners

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Treatment ofTension – type headache

• Stress management

• Biofeedback

• Massage therapy

• Physical therapy(Integrative ManualTherapy)

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Acute Treatment ofTension – type headache

• Acetaminophen

• Aspirin products

• Non – steroidal anti – inflammatories

• Limit use to 2 3 days / week to avoid reboundheadache

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Preventive Treatment ofTension – type headache

• Antidepressants (amitriptyline)• Anti – seizure medications (topiramate;valproic acid / divalproex)

• Little scientific evidence to support theuse of anti seizure medications in tension– type headache

• Don’t use muscle relaxants long term

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Migraine

• Migraine is a recurrentheadache that lasts 4 72hours

• 18% of women

• 6% of men

• Under diagnosed andunder treated

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Typical Features of Migraine• Usually one sided

• Pulsating, throbbing,pounding

• Aggravated by routine physicalactivity

• Associated with nausea andvomiting

• Sensitivity to light / noise

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“ ID Migraine “

• Has a headache limitedyour activities for a day ormore in the last 3months?

• Are you nauseated or sickto your stomach whenyou have a headache?

• Does light bother youwhen you have aheadache?

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Migraine

• Aura 15%

• Warning signs 70%– Fatigue– Mood changes– Food cravings– Poor concentration

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Pathophysiology of Migraine

• The nervous system ismore sensitive andvigilant to theenvironment

• Inflammation ofnerves and vessels inthe brain

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Approach to Treatment

• Goal is to give thepatient control overtheir headachesinstead of theheadachescontrolling thepatient’s life.

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Principles of Treatment

• Prevention(prophylacticmeasures)

• Abortive treatment

• Elimination ofintractable migraines

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Preventive Measures

• Diet• Sleep• Exercise• Weight loss• Caffeine regulation• Smoking cessation• Medications

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Diet

• Don’t Skip Meals!!!

• Big Four: chocolate,NutraSweet, caffeineand MSG

• Keep a headachediary

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Sleep

• Goal is 7 8 hrs ofrestful sleep

• Increased frequencywith < 6 hrs of sleep

• Increased frequencywith > 9 hrs of sleep

• Regulate sleep 7days per week

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Disorders of Sleep

• Poor sleep hygiene

• Sleep apnea

• Depression

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Exercise / Weight Loss

• Adipose tissue secretesproteins & hormonesthat help regulateimmunity &inflammation(adiponectin,interleukin 6)

• Dieting and exercise canimprove headaches

• Weight may affectchoice of medications

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CaffeineTwo – edged sword

• 100 – 200 mg = well being• 300 – 400 mg = anxiety, dysphoria• 340 – 750 mg = severe anxiety, panicattacks

• 5 – 10 grams ( 75 cups of coffee ) = lethaldose

• Try to eliminate caffeine use in patientswith severe migraines (taper slowly)

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Caffeine in Medications

• Several medications used for headacherelief contain various amounts ofcaffeine.

• These combination medicationscommonly cause “rebound headaches” ifused more than three days per week

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Smoking

• Smoking increasesfrequency ofheadaches

• Smoking cessation:– Varenicline (Chantix)– Bupropion (Zyban)– Nicotinepatches/gum

– Hypnosis

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Prevention

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When to Consider Preventionwith Medications

• Headache occurs more than 2 days per week• Use of acute medications more than 2 daysper week

• Headache attacks that are disabling despitetreatment

• Prolonged aura, complex aura or migraineinduced stroke

• Patient desires to reduce frequency

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Principles of Prevention

• Reduce frequency of attacks by more than50%

• Start low ; Go slow• Often requires lower dosages• May take 2 3 months to see benefit• Maintain for 6 12 months once 50% reductionachieved, then taper

• Reduces cortical spreading depression (CSD)

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Evidence based Recommendations forPreventive Treatment

• 2012 AHS/AANGuidelines forPrevention ofEpisodic Migraine

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Major Classes of Medications forPrevention

• Beta adrenergicblockers

• Antidepressants• Anticonvulsants(neurostabilizers)

• Calcium antagonists• NSAIDs• Herbal preparations

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Migraine Prevention – Level A(established as effective)

• Valproic acid / Divalproex (Depakote) 4001000 mg/d

• Metoprolol (Lopressor) 47.5 200 mg/d• Butterbur (Petadolex) 75 mg bid or

50 mg bid – tid• Propranolol (Inderal) 120 240 mg/d• Timolol (Blocadren) 10 15 mg bid• Topiramate (Topamax ) 25 200 mg/d

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Butterbur Petadolex• 71% of adults and 77% of children cutmigraine attacks in half after threemonths

• Adults: 75 mg bid with meals or 50 mgtid with meals

• Children: (6 9 yrs) – 50 mg with eveningmeal

• Children: (10 17 yrs) – 50 mg bid withmeals

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Migraine Prevention – Level B(probably effective)

• Amitriptyline (Endep) 25 150 mg/d• Ibuprofen (Motrin/Advil) 200 mg bid• Naproxen (Aleve) 500 mg bid• Magnesium 400 600 mg/d• Riboflavin 400 mg/d• Venlafaxine (Effexor ER) 150 mg/d

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Migraine Prevention – Level B(probably effective)

• Fenoprofen (Nalfon) 200 600 mg tid• Ketoprofen (Oruvail) 50 mg tid• Histamine 1 10 ng subq 2x/week• Feverfew 50 300 mg bid;2.08 18.75 mg tid for MIG 99 preparation

• Atenolol (Tenormin) 100 mg/d

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Migraine Prevention – Level CMigraine Prevention Level C

(possibly effective)

• Carbamazepine (Tegretol) 600 mg/d• Lisinopril (Zestril) 10 20 mg/d• Coenzyme Q10 100 mg tid• Cyproheptadine (Periactin) 4 mg/d• Pindolol (Visken) 10 mg/d• Clonidine (Catapres) 0.075 .15mg/d(patches also studied)

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Migraine Prevention – Level C(possibly effective)

• Candesartan (Atacand) 16 mg/d• Guanfacine (Tenex) 0.5 1 mg/d• Nebivolol (Bystolic) 5 mg/d• Flurbiprofen (Ansaid) 200 mg/d• Mefenamic acid (Ponstel) 500 mg tid

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Migraine Prevention – Level U(inadequate evidence)

• Acetazolamide (Diamox )• Fluvoxetine (Prozac)Indomethacin (Indocin)

• Verapamil (Calan/Isoptin)• Hyperbaric O2• Nifedipine (Procardia/Adalat)• Gabapentin (Neurontin)

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• Fluvoxamine (Luvox)• Protriptyline (Vivactil)• Nicardipine (Cardene)• Nimodipine (Nimotop)• Warfarin (Coumadin)• Aspirin

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• Omega 3 acid (Lovaza)• Acenocoumarol (Sintrom)• Cyclandelate• Picotamide• Bisoprolol (Zebeta)

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Migraine Prevention(probably ineffective)

• Clomipramine (Anafranil)

• Clonazepam (Klonopin)

• Acebutolol (Sectral)

• Lamotrigine (Lamictal)

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Migraine Prevention(probably ineffective)

• Montelukast (Singulair)

• Nabumetone (Relafen)

• Oxcarbazepine (Trileptal)

• Telmisartan (Micardis)

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Migraine Prevention

• In one study, 3 mg of melatonin taken 30minutes before bedtime for threemonths decreased the number ofmigraines by almost 2/3 and reducedseverity by half.

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Side –effects of Melatonin

• The side – effects noted in this studyincluded :

• Excessive sleepiness• Hair loss• Increased sexual libido

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Botox• Approved by FDA fortreatment of chronicmigraines in adults

• Children age > 10with chronicheadaches have hadexcellent results

• Cost is a drawback –must code as chronicmigraine (346.70)

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Principles of AbortiveTherapy

• Use the mosteffective therapy atthe onset of themigraine

• Must always havemedication withyou!

• Try to limit acutetreatments to 3x perweek

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Common Abortive Medications

• NSAIDs• Aspirin• Combination analgesics with caffeine• Triptans• Antiemetics (often used in combinationwith NSAIDs or Triptans)

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Triptans

• Use with Naproxen500 mg at onset ofmigraine

• Use mostappropriate deliverymode

• Failure = noresponse to threedifferent triptans

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Triptans

• May use Triptanswith SSRIs (inform ptof symptoms ofserotonin syndrome)

• Treat the headache;not the aura

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Evidence based Recommendations forAcute Treatment of Migraine

• Triptans as initial treatmentfor moderate to severemigraine – Grade A

• Triptans as initial treatmentfor migraine of any severitywhen nonspecific treatmenthas failed – Grade C

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• DHE nasal spray formoderate to severemigraine Grade A

• DHE (IM,SC) for moderate tosevere migraine – Grade B

• DHE ( IV ) plus antiemetic (IV ) for severe migraine –Grade B

• Ergotamine (Ergomar) formoderate to severemigraine – Grade B

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• Metoclopramide (Reglan)IV / IM to control nausea –Grade C

• Metoclopramide (Reglan)IV as monotherapy formigraine pain relief – GradeB

• Prochlorperazine(Compazine) IV, IM, PR formigraine in appropriatesetting – Grade B

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• Acetaminophen notrecommended – Grade B

• NSAIDs and combinationanalgesics with caffeine asfirst line treatment formild moderate attacks –Grade A

• Corticosteroids(dexamethasone 16 mg IVor PO) for rescue therapyfor status migrainosus –Grade C

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Abortive Therapy

• WHO lists aspirin as an essential medicationfor treatment of migraine in adults

• FDA – approved dose for migraine is 1000 mgfor a one time administration in 24 hours;limit use to max of 3x/week to preventrebound headaches

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Economic MigraineTreatment

• Prevention:• 1. Lifestyle changes• 2. Melatonin 3 mg 30 minutes before hsAbortive Therapy:

• 1. ASA 1000 mg plus metoclopramide;prochlorperazine or promethazine at onset ofmigraine

• 2. limit use to once in 24 hours ; max of 3x perweek

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Difficult to Treat Migraines

• DHE (Migranal) nasalspray– One spray each nostril– May repeat in 15 mins.– Max: 4 sprays / attack6 sprays / 24 hrs8 sprays / week

– Use with an antiemetic

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Intractable Migraine• Inflammation !!!

Dexamethasone 8mg /16 mgIM, IV or oral as a singledose

Prednisone 50 mg daily x 3days

Methylprednisolone(Solumedrol) 80 mg IM

Ketorolac (Toradol) 60 mg IM

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Intractable Migraine

• 5 day Dexamethasone taper:

• Use 0.75 mg tablets

• Take two tablets twice daily x 2 days

• Take one tablet twice daily x 1 day

• Take one tablet daily x 2 days

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Steroids in Pregnancy

• Steroids should not beused in patients lessthan 10 weeks gestationdue to increased risk ofcleft palate

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Intractable Migraine(ER or Infusion Center)

• D.H.E. 45 1 mg IV ; dilute in 50ml of NS and run in over 30minutes; don’t use if pt. took atriptan within 24 hours; alwaysuse with an antiemetic ( mayrepeat in 1 hour x 2 doses; max of3 mg/attack and 6 mg / week)

• Magnesium sulfate 1 gram IV ;dilute in 50 ml of NS and run inover 30 minutes; may repeat in 812 hours

• Caffeine sodium benzoate 500mg IV; dilute in one liter of NSand run in over one hour

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Intractable Migraine(ER or Infusion Center)

• Valproic acid/Divalproex(Depacon) – 500 – 1000 mgIV; dilute 1:1 with NS andrun in over 15 minutes

• Antiemetics – IV

• Diphenhydramine(Benadryl) 25 – 50 mg IV

• Hydromorphone (Dilaudid)2 mg IV

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Infusion Center Protocol

• IV caffeine sodium benzoate 500 mg in one liter ofNS over one hour

• Prochlorperazine (Compazine) 10 mg IV• Diphenhydramine (Benadryl) 50 mg IV• Dexamethasone 8 or 16 mg IV upon completion ofcaffeine infusion and discharge to home

• Limit to 2 – 4 times per month• Use Dexamethasone only 1x/month

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Infusion Center Protocol

• Infuse one liter of NS over one hour• Magnesium sulfate – 1 gm diluted in 50 ml of NS andinfuse over 30 minutes

• Metoclopramide (Reglan) 10 mg IV• Hydromorphone (Dilaudid) 2 mg IV• Dexamethasone 8mg or 16 mg IV upon completionof infusion

• May use 2 4x /month• Use dexamethasone only 1x/month

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Inpatient Treatment

• IV antiemetic followedby D.H.E. 45 0.5 1 mgIV

• Repeat every 8 hours x3 days

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Outpt. Modification ofInpatient Protocol

• IV/IM antiemetic• DHE 45 – 0.5 mg IV diluted

in 50 ml of NS and infuseover 30 minutes; start 20minutes after antiemetic;don’t start if pt took atriptan in previous 24 hours

• Give twice daily (8 hoursapart) for three consecutivedays if needed

• May use up protocol up to2x per month (at least oneweek apart)

• Often will give 5 daydexamethasone taper withfirst protocol for the month

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MRI/MRAIndications

• New onset headache < age 5 or > age 50• Exacerbation of headache with physicalactivity

• A change in patient’s headache pattern• Patients with a past history of cancer orimmunosuppression

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Menstrual – Related Migraine

• Pure menstrual migraineis uncommon

• 60% of migraineurs haveattacks related to menses

• MRM – attack occurs 2days before and up to 2days after the menses

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Treatment of Acute Attacks of MRM

• Behavioral management– avoid triggers

• NSAIDs• DHE – nasal spray, IM, SC• Triptans• Acetaminophen/ASA/Caffeine

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Intractable Acute Attacks of MRM

• Analgesics

• Corticosteroids

• Any of previousinfusion centerprotocols

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Preventive Treatment for MRMLevel A

Level A: established as effective

Should be offered to patients requiringprophylaxis

Frovatriptan (Frova) – 2.5 mg bid for 5 daysperimenstrually (loading dose was used)

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Preventive Treatment for MRMLevel B

• Level B: probably effective• Should be considered for patients requiringprophylaxis

• Naratriptan (Amerge) – 1 mg bid for 5 daysperimenstrually (no loading dose)

• Zolmitriptan (Zomig) – 2.5 mg bid or tid for 5days perimenstrually (no loading dose)

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Preventive Treatment for MRMLevel C

• Level C: possibly effective

• May be considered for patients requiringprophylaxis

• Estrogen – 1.5 mg estradiol in gel (EstroGel)daily x 7 days perimenstrually

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Preventive Treatment for MRM(expert opinion)

• Start Naproxen 500 mgbid with food two tothree days before onsetof menses and continuethrough the menses

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Preventive Treatment forMRM

• Melatonin levels have been shown to bedecreased during menses in women withmenstrual migraine

• Melatonin may be helpful in the prevention ofmenstrual related migraine

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Hormonal Treatment in MRM

Menstrual migraines aretriggered by drops inestrogen

Don’t be overly concernedabout using a low – dose(20 mcg of ethinyl estradiol)OC in women with migraineif they are under 35 yrs;have normal BP ; don’tsmoke and do not have anaura

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Hormonal Treatment of MRM• Use a 20 mcg ethinyl

estradiol mono – phasicOCP for 3 4 monthsconsecutively; then off for 1week using syntheticconjugated estrogen A(Cenestin) 0.9 mg daily asan estrogen supplementduring the week off theactive pills

• Repeat cycle

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Hormonal Treatment of MRM

• Levonorgestrel/ethinyl estradiol (LoSeasonique) withsynthetic conjugated estrogen A (Cenestin) 0.9 mgdaily during the 13th week (week off between 12week cycles of LoSeasonique)

• May use extended regimes using ethinylestradiol/norelgestromin (OrthoEvra patch) or ethinylestradiol/etonogestrel (NuvaRing)

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Cluster Headache

• Attacks frequently occurat night

• One to severalheadaches / day

• Short duration (30 – 45minutes); rarely lastover 4 hours

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Cluster Headache

• Describes headachepattern

• Clusters can last days tomonths

• Remission (often foryears)

• Seasonal (spring or fall)

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Cluster Headache

• Men/Women = 5:1• Onset 20 – 40 yrs of age• Always one – sided(behind eye)

• Excruciating pain (hotpoker in eye)

• Patient paces

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Cluster Headache• May have flushing offace, tearing, nasalcongestion or runnynose

• Pupil may contract

• Eyelid may be swollenor droop

• “Lower half syndrome”– cheek and mouthaffected instead of eye ,temple and forehead

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Treatment ofCluster Headache

• Avoid alcohol

• Avoid use of nitrates ifpossible (lower dose)

• Avoid food triggers thatcontain tyramine–cheeses, citrus fruits,chocolate, processedmeats, MSG, nuts,seeds and peanutbutter

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Abortive Therapy forCluster Headache

• Classic abortive therapyis inhalation of 100%oxygen ( 7 – 15 liters bymask for 15 minutes)

• Sumatriptan injection ishighly effective

• Zomig nasal spray (10mg ) achieved relief in30 minutes in 61% ofpatients in one study

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Abortive Therapy forCluster Headache

• Ergotamines (orally,sublingual, IM, nasalspray or suppository)

• Nasal lidocaine – 4%solution; soak 2cotton applicatorsand advance into thenose; blocks thesphenopalatineganglion

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Preventive Therapy forCluster Headache

• Preventive therapy is used to reducefrequency, duration, intensity and interruptthe cluster cycle

• Daily treatment is begun at the onset of a newcycle

• It does not prevent future clusters sotreatment is tapered gradually over 2 4 weeksafter the last attack

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Preventive Medications forCluster Headache

• Lithium carbonate (notwell tolerated)

• Verapamil (up to 1200mg / day) combinedwith topiramate,depakote or lithium

• Steroid taper• Ergotamine• Melatonin – 9 – 12 mg

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References• NHF Head Lines (national headache foundationpublication):– July/Aug 2004 No 139 Jan/Feb 2006 No148– Nov/Dec 2004 No 141 Mar/Apr 2006 No 149– Mar/April 2005 No 143 Nov/Dec 2007 No 159– May/June 2005 No 144 Jan/Feb 2008 No 160– Sept/Oct 2005 No 146 May/June 2008 N0 162– Nov/Dec 2005 No 147 Mar/April 2009 N0 167

– Headache Update 2011 – Diamond Headache Clinic– Research and Educational Foundation – 7/2011 in Orlando,Florida

– “Clinical Inquiries” – The Journal of Family Practice Mar2005 Vol 54 No 3

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References

• National Guideline Clearinghouse–www.guideline.gov

• Neurology 2000; 55: 754 763• “Effective Treatment of Migraine” –Postgraduate Medicine; April 2004 Vol 115

• “Migraine in Special Populations” –Postgraduate Medicine; April 2004 Vol 115

• 2012 AHS/AAN Guidelines for Prevention ofEpisodic Migraine: Results

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References

• Head Wise Vol 3, Issue 1; 2013• (www.headaches.org)

• Head Wise Vol 3, Issue 2; 2013• (www.headaches.org)

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