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HeadacheManagementMulti-ModalityApproach

KarenWilliams, MSN,RN, FNP-BCTempleVA

Neurology/Headache Clinic

Patientexperience• 51yr oldmalewithahistoryofrefractoryheadachesfor20+yrs

(since1992)

• Started withparachutejump,hardlanding,hitheadtotheleft,hadLossofConsciousness-

• DescribedasLefthemicranial throbbing/achingassociatedwithphotophobia/phonophobia,Nausea/Vomiting&worsewithexertion.Ratedas10/10

• Occurring2-4timespermonthlasting3-6days

Disclosures• Off label useofmedications

• Theviews expressed in this presentation are those of theauthor anddonot reflect theofficial policyof theDepartment of theVeterans Affairs,Department ofDefense, orU.S.Government

Objectives

• Epidemiology/Socioeconomics ofheadaches

• Briefly describe themostcommon types ofheadaches

• Review essentials ofevaluation

• Review treatments

• Case presentation

Epidemiology ofHeadaches

• Primary headache disorder isestimated toaffect45(+)million individualsin theUS1

• World-wide, the percentageof theadult population with anactiveheadache disorder is46%2

– 42%suffer fromtension-type– 11%frommigraine

– 3%fromchronic dailyheadache

Socioeconomic

• Headache is themostcommon pain-related complaint among workers3

• Most commoncauseofabsenteeism fromworkandschool 1

• Oneof themost commoncomplaints in theER, with over3million ERvisits in 20003

• Estimated $17 billion annually, forthe costofhealthcare associated withmigraines4

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Types ofHeadacheDisorders

• Primary- notassociated with anycause orpathology– Migraine, Tension, cluster migraine

• Secondary- associated with some underlying pathology– Traumatic, Drug/substance related, infection, malignancy, vascular

Tension- TypeHeadache• Themost commonprimary headache

• Pain isbilateral, often described as pressing, band–like orvise-like. In theforehead, temples orbackofhead andneck

• Intensity - Mild tomoderate

• Can last from30minutes to7days

• Canbeassociated with photophobia orphonophobia but notboth

Tension (cont)• Oftenaccompanied by fatigue, inadequate sleep

• Triggered bystress, fatigue oremotional bursts

• Usually not aggravatedbyphysical activity

• Usually relieved with OTCanalgesics, relaxation, reduction of stress

• Frequently coexists with migraine2

Migraine

• World wide prevalence of11%and is the2nd most commonprimaryheadache2

• Affecting women 3times more thanmen, with acomparison of17%femalevs6%male6

• Occurs fromchildhood toadulthood with the peakprevalence occurring inmid-adulthood6

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Migraine(cont)

• Recurrent episodes ofgenerally unilateral (maybebilateral),pulsating/throbb ing pain

• Usually aggravatedbyphysical activityand often relieved with sleep

• Pain ismoderate tosevereanddebilitating

• Associated symptoms ofnausea, vomiting, photophobia andphonophobia

• Time frameof4 to72hours, ifuntreated

MigrainewithAura

• Aura- aconstellation ofvisual andsensory symptoms thatoccur justbeforeorat theonset ofamigraine

• Visual aura (mostcommon)- blind spots, flashes oflight, zigzag lines

• Sensory aura- numbness or tingling ofanarmor face

• Reversible aphasia

• Duration of symptoms of1hour, but motor symptoms canlast longer2

CommonTriggersofMigraine

• Hormonal-– menstruation, ovulation, oral contraceptives with estrogen

• Dietary-– ETOH,nitrates, caffeine, agedcheese, MSG, aspartame, chocolate,

skipping meals

• Psychological-– stress, anxiety,depression

CommonTriggersofMigraine(Cont)

• Environmental-– glare, flashing lights, strongodors, barometric changes, highaltitude

• Sleep-– lackofor too muchsleep

• Drug-related –– Nitroglycerin, Histamine, Hydralazine, Ranitidine, Estrogen

HeadacheEvaluationandDiagnosis

• Accurate andthrough headache history

– FamilyHx,Personal medical Hx,Hx ofhead trauma, Time frameofheadache, ageofonset, how frequent, duration, triggers, aggravatingfactors, co-morbid illnesses, impacton family andwork/school

– Clinical description of theheadache: Location, intensity, nature ofthepain, preceding symptoms, auraorneurologic symptoms

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Helpfulquestions Diagnosis ofMigraineorTTH

• Helpful questions:– Howdoheadaches interfere with your life?

– HowFrequently doyouexperience headaches ofany type?

– Has there beenachange inyourheadache pattern over the last6months?

– Howoften andhow effectivelydoyouusemedications totreatheadaches?7

HeadacheAssessment Tools

• HeadacheCalendar- iHEADACHE (freephone app)

• Headache Impact test (6questions)– Helps patientscommunicatetheseverity of theheadache paintotheirprovider

• TheMigraine Disability Assessment Questionnaire (5questions)– Measures headache-related disability in:work/school,householdandfamily/social

• Migraine SpecificQuality of LifeQuestionnaire (MSQ) (14questions)– RoleFunction-Restrictive– RoleFunction- Preventive– EmotionalFunction

PhysicalExam

• Neurological exam:Cranial nerves, Strength, Coordination, DTR’s (rule-outpapilledema, diploplia, facialweakness, gaitdisturbances, nuchal rigidity)

• ROM ofneck/Palpation of theTMJandoccipital nerves (looking fortenderness oredema, trigger points inparaspinal, shoulder areas)-

• Blood Pressure: diastolic over120mmHgareassociated with an increaseinheadaches

•Rule out a systemic illness or other organic cause

RedFlagsAssociated withSecondaryHeadaches

• Systemicsymptoms ordisease (fever, weight loss, jawclaudication)

• Neurologic signs or symptoms (papilledema, motor weakness, memoryloss, papillary abnormality, sensory loss)

• Onset sudden

• Onset beforeage5orafterage50

• Pattern change fromprior headaches

DiagnosticsforRedFlags

• Imagingstudies: Ctofhead, MRI– Looking forstructural abnormalities

• Blood chemistries andBlood counts– Sed rateshould bemeasured inadults thatare50andolder

• Lumbarpuncture (afterobtaining brain imaging): in suspected meningitis,subarachnoid hemorrhage, Pseudotumor cerebri, encephalitis or systemicillness (lupus, sarcoidosis, vasculitis)7

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MigraineTreatments TreatmentsforMigraine

• Abortives:– First line:NSAIDSorAcetaminophen

– First line ifmoderate tosevere:Tripitans• Constrict dilated blood vessels, reduce neuropeptide release andinhibit impulse transmission centrally within the trigeminovascularsystem

– Ergotamine/Dihydroergotamine (DHE)

– Oxygen inhalation (100%) forcluster migraine8

PreventativeTreatmentsforMigraines

• Consider if4ormoreheadaches per month, consider co-morbidconditions– Propranolol*– Topiramate*– Divalproex*

– Antidepressants – TCA’s– NSAIDS– Calcium Channel Blockers- Cluster migraine

*FDAapproved formigraine prevention

Preventives(continued)

• Riboflavin (Vit B2) - Dosed at100mg, 2tabs twiceper day

• Magnesium 400mgperday (dose inevening)

• Botox*• Cefaly*

• Acupuncture

• Occipital NerveBlocks

• Biofeedback and Cognitive therapy

Headache

EpisodicHeadache•Characterize type•Abortivetherapy

•Maximum 6 doses/week

ChronicDailyHeadache•> 15HAdayspermonth•Analgesic rebound•Prophylaxisiskey

Abortive ProphylaxisOnset of action ~4wks

Avoidnarcotics&Benzos

NSAIDs•GI sid eeffects

Ibup ro fenNap ro xen Sod iumAcetaminophenAsp irin

Triptans• Con traind icated in p atien tswith CAD

Imitrex in j/o ral/NSZomig o ral/NSMaxalt/Relp ax/AxertAmerge/Fro va

CombinationMedications• R isko fW/D

Fio ricetFio rin alExced rin

Beta & AlphaBlockersP rop rano lo l -h elp w/an xietyP razo sin - h elp w/Nigh tmares and po ssib lyETOHabu se

Anti-depressants•May imp rove mood• Imp roves sleep

To fran i l /No rtrip tyl l in e/Amitryp ti l l in eVen lafaxin e/Du lo xetin eP aro xetin e/Fluo xetin e/M irtazap in eTrazodone

AEDS•Neu ropath icp ain

Gabapen tin

•Mood lab i l i tyValp ro ic acidTop irimate

AlternativesP romethazin eMeto clop ramideP ro ch lo roperazin eOndan setronTizan id in eOccip i tal b lo ckAcupun ctu re

CAMB io -feedbackVit B2 /MagnesiumAcupunctu reBOTOXPT/Ch irop racticCefalyCES-Alpha-stim

Sleep Headache

Irritability/Mood

Cognitive

Symptom Interaction

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Education

• Headachecalendar• Sleep hygiene techniques

• Abstinence/limite d alcohol use• Proper nutrition/limite d caffeine/proper water consumption• Coping strategies/Journaling/St ress management• Limited useofabortive medication/avoid overuse or rebound

headaches

• Realistic expectations

OccipitalNeuralgia:themigrainelookalike(sorta)

• Occipital pain thatmayormaynotbeononeside &sudden inonset

• Sharp, shooting pain radiating fromthebackof thehead into the templesand forehead

• Pain aboveandbehind the eye

• Nausea when thepain is severe

• Pain transiently relieved byoccipital block2

OccipitalNerve Anatomy

Common causes

• Entrapment of theoccipital nerves by theneckandscalpmuscles 9-11

• Trauma:Fall,MVC, blow to thehead, whiplash

• Seatbelt use:Right occipital pain indrivers and left inpassengers due toseatbelt 12

OccipitalBlockInjectionSites

GONaimingslightlyupmaintainingasubcutaneouscourseLOCaiminglateralandup,maintainingasubcutaneouscourse

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Additional Treatments• NeckRange ofMotion exercises

• Ice/heat to thebackofthe head

• Nervemodulating medications (Gabapentin, Topamax, Depakote)

• NSAID,Lidocaine gel toneckarea,Epsom salt bath

• Breathing/relaxation techniques

• PT/Chiropractic manipulation ofthe neck

AdditionalModalities

Whenmedication isnotworking ornot tolerated

Botox Injection Paradigm:31Injection SitesAcross7MuscleAreas

BOTOX* P rescrib in g In fo rmation ,Feb ruary 2 0 1 4 ;2 .B lumen feld ,Heada ch e. 2 0 1 0

Trancutaneous SupraorbitalNeurostimulation/Cefaly

• FDAapproved forprevention ofmigraine (March2014)• Varying results- need touse it daily for20min• Currently notcoveredby Insurance

– Cost $349.00, packof3electrodes $25.00 (good for20treatmentseach),2AAA batteries

CranialElectrotherapyStimulationAlpha-stim

• FDAapproved for treatment ofAnxiety, Depression, Insomnia

• Utilized inover70VA’s and in theDoD

• Cansee reduction ofanxiety in1st treatment, maytake3-4weeks forPTSD/Depression

• Noneed tomonitor labs/minimal side effects/no dependency

• Cost savings in reduction ofothermeds/treatments

Acupuncture

Qi, orenergy, travels along12main pathways ormeridians within thebody

Health is influenced by thequality, quantity andbalance ofour Qi

Provides power for– Growth andDevelopment– Movement

– Maintenance ofbody temperature– Protection against illness– Regulation

Qi is profoundly disturbed by traumatic stress

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DifferentTypesofAcupuncture

• Traditional Chinese Acupuncture (TCM)

• Medical Acupuncture

• Japanese Acupuncture

• Korean Hand Acupuncture

• Scalp Acupuncture

• Auricular Acupuncture andAuriculotherapy

• Veterinary Acupuncture

MedicalAcupuncture• Simplified version ofTCM frequently addresses more acuteissues.

• 300-500 hours of training.

• Physician, Nurse Practitioners andPhysician Assistants using this modality.

• Added treatment modality inWestern medicine – gaining momentum inmilitary andVA facilities forpain treatment, PTSD/mood disorders, headinjury

Auriculotherapy/Auricular Acupuncture

With permiss ion from Terry Oleson, Ph.Dwww.auriculotherapy.org

CasePresentation

Posttraumaticheadaches

Veteran with20+yearsactiveduty

Background• 51yr old malewith ahistory of refractoryheadaches for20+yrs (since

1992)

• Startedwith parachute jump, hard landing, hit head to the left, hadLossofConsciousness-

• Described asLefthemicranial throbbing/aching associated withphotophobia/phonophob ia, Nausea/Vomiting &worse with exertion.Rated as10/10

• Occurring 2-4 times permonth lasting 3-6days,daily mild headache

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Background(continued)• Triggered bylight

• Treatedwith Imitrex 100mg/ Fioricet- notusually helpful. Layingin adark,quiet room

• Preventative: Depakote500mg2 tabs

• Interferes completely with activities when hewould haveanattack

• Past treatments: Nortriptyline, Inderal, Verapamil, Topamax, Maxalt,Zomig- none helpful. Botox- reducednumber &severity

SocialHistory• 51yrold male- Retired fromArmyafter20yrs asE7 (SergeantFirst

Class) MOSTransportation/Snipper, 5deployments toOIF/OEF

• Married, 2children/BA inGeneral studies

• Tobacco- 3cigarettes /NoETOH/NoCaffeine/Diet balanced/Walking &household duties/No current hobbies

• Spiritual affiliation- Baptist

• Current stressors: things hehasgone through “ I had todosomebadthings Doc”

MedicalHistory• Migraines, OSA, HTN,PTSD,Diabetes, Ataxicgait, testicular crush injury

• 3concussions with LOC,2paratrooping, 1 IEDblast, multiple dazed withhard landing

• Allergic toSimvastatin

• Surgical- testicular crush

• FamilyHx- Mother- cancer, Fatherdied ofnatural causes

• Hadgone through vestibular and ocular-motor rehab forconcussions in2009

SignificantExamFindings• Neurologic examWNL, excepthasdiplopia inall rightperipheral gazes and

lefthead tilt

• Leftoccipital tenderness

• Teeth with signs ofbruxism

• CTofhead– WNL

• Wearing of sunglasses andhat in the examroom- extremephotophobia allthe time

Treatment• Education on findings, treatment considerations toinclude Acupuncture,

Botox, Occipital blocks

• Selfhelp strategies to include, ice to thebackofthe head, Breathing andneckexercises, Magnesium 400mg.Stopdaily useofFioricet

• Encouraged tocontinue with Mental health

• Startedwith acupuncture, occipital blocks andBotox (perheadacheprotocol andadded Masseters)- reduced migraines to4per week, shorterinduration and resolving with Imitrex, resolving daily mild headache

Treatment(continued)• Alpha-stim Aid introduced when becameavailable in theheadache clinic,

3months after1st appointment. Helped with further reduction ofanxiety

• After 2rounds ofBotox, daily useofalpha-stim andstopping his Fioricet,henoted heno longer needed towearsunglasses, migraines improving

• Migraines now 2per month, resolved afterabout 40 minutes with Imitrex100mgandalpha-stim aid

• “Ayearago itwas rough, but this program is ablessing, youchanged mylife! “

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Summary• Tension andMigraine are themost commonprimary headaches

• Rule outa systemic illness orother organiccause

• Treat themostdisturbing symptoms first

• Education is akeycomponent

• Hx of traumamay increase yoursuspicion ofoccipital neuralgia

HeadachetableMigraine Tension-Type OccipitalNeuralgia

Location Unilateral Bilateral OccipitalIntensity ModeratetoSevere Mild toModerate Mild tosevere

Duration 4to72 hours 30mins to7days Minutes tohoursPaintransientlyrelievedbyoccipitalblock

Quality Pulsating Pressure/Tightening Sharp,throbbing,pressure

AssociatedSymptoms

Nausea,vomiting,photophobia,phonophobia

Photophobia orphonophobia (butnotboth)

Painbehind theeyes,nauseawhenpainsevere,photophobia

Female:Maleratio 3:1 1.3:1 Nopreference,seenoftenafterhead/necktrauma

1. TheCleveland Clinic Health Foundation. Overview ofheadache inadults. Cleveland Clinic Health Information Center website. Accessed Feb122008

2. Stovner LJ,etal. TheGlobal Burden ofheadache:A Documentation ofHeadachePrevalence andDisability Worldwide. Cephalgia 2007;27:193-210.

3. Stewart WF, etal. LostProductive Time andCost Due toCommon PainConditions in theUSWorkforce. JAMA 2003;2902443-2454.

4. Goldberg LD.Thecostofmigraine and its treatment.AM JManag Care2005:11(2 suppl): 562-567.

5. HeadacheClassification subcommittee ofthe International headacheSociety.The International Classification ofheadacheDisorders:2ndedition. Cephalagia 2004;4Suppl 1:9.

6. Lipton RB, Bigal ME, etal. Migraine prevalence, disease burden, and theneed forpreventive therapy.Neurology 2007; 68:343-349.

References References(con’t)7. Martin V, Elkind A.Diagnosis and classification ofprimary headache

disorders. In:Standards ofCare forHeadache Diagnosis andTreatment.Chicago I ll:National headache Foundation 2004;4-18.

8. Silberstein SD.Practiceparameter:evidence-based guidelines formigraine headache (anevidence-based review): reportof theQualityStandards Subcommittee ofthe American AcademyofNeurology. Neurology 2000;55-754

9. Bogduk N.Theneckandheadaches. Neurol Clin 2004;22:151.10. Boes, CJ,Copobianco, DJ,Cuter, FM, etal. Headacheand other

craniofacial pain. In:Neurology inclinical practice, Bradley, WG, Daroff,RB, Fenichel, GM,etal (Eds), Butterworth Heinemann, Philadelphia, PA2004;2055.

References(con’t)11. Ashkenazi A, LevinM.Threecommonneuralgias. Howtomanage

trigeminal, occipital, and postherpetic pain.Postgrad Med 2004;116:16.12. Zasler N:Neuromedical Diagnosis andManagement ofPostconcussive

Disorders. In:HornL,Zasler N, (EDS).Medical Rehabilitation oftraumaticBrain Injury.Philadelphia, Pa:Hanley&Belfus 1996;145-148.

KarenWilliams,MSNCRNP

karen.williams1@VA.gov254-743-2759