migraine and chronic daily headache laurence j. kinsella, m.d., f.a.a.n
TRANSCRIPT
Migraine and Chronic Daily Headache
Laurence J. Kinsella, M.D., F.A.A.N.
You Make the Call: Case 1
37-year-old man with lifelong migraine and develops 6 weeks of unremitting headache (HA)
Bitemporal, throbbing, 3-7/10, morning HA Relieved with acetaminophen/aspirin/caffeine
(Excedrin Migraine®) No visual disturbances, scotomata, nausea,
photophobia 3 months of cyclosporin (Neoral®) for alopecia
universalis
What is the diagnosis?
Audience Question
1. Transformed migraine
2. Medication overuse headache
3. Cyclosporin induced headache
4. Chronic tension type headache
55-year-old woman 10/10 throbbing right periorbital HA awakens her
every night at 3 a.m. Gets relief after 45 minutes with combination of
icepack, T#3 x2, acetaminophen/aspirin/caffeine x2, acetaminophen/pseudoephedrine (Tylenol Sinus®) x2
You Make the Call: Case 2
Diagnosis?
Audience Question
1. Cluster headache
2. Thunderclap migraine
3. Raeder’s Paratrigeminal headache
4. Aneurysmal headache
5. Temporal arteritis
75-year-old woman with right occipital/ burning 8/10 HA, radiating to vertex
No nausea/photophobia/visual disturbances Present for 2 months, constant No relief with over-the-counter medications Exam is normal
You Make the Call: Case 3
Diagnosis?
Audience Question
1. Occipital Neuralgia
2. Cervicocephalgia
3. Temporal arteritis
4. Post herpetic neuralgia
History, History, History
P - Precipitating/palliative factors - diet, exercise, caffeine, OTC drugs
Q - Quality of the pain - burning, aching, stabbing, squeezing, pressure, throbbing
R - Radiation/location of pain
S - Severity - range of pain (least to the most) on analog scale 1-10
T - Temporal factors - what time of day
International Headache Classification
Primary headaches - “benign” disorders Migraine (with and without aura) Tension type (episodic or chronic) Cluster, chronic paroxysmal hemicrania Other benign HA (cough, coital, cold, ice-
pick, exertional HAs)
Headache Classification Subcommittee of the International Headache Society (2004), Cephalalgia 24:1-150
International Headache Classification (Cont.)
Secondary headaches - symptomatic of organic disease or medication overuse Posttraumatic Medication overuse HA Subarachnoid hemorrhage Temporal arteritis Meningitis High pressure/low pressure
Headache Classification Subcommittee of the International Headache Society (2004), Cephalalgia 24:1-150
Cranial neuralgias, nerve trunk pain Headache or facial pain associated with disorders
of the cranium, neck, eyes, nose, sinuses, teeth, mouth or other facial or cranial structures
International Headache Classification (Cont.)
Headache Classification Subcommittee of the International Headache Society (2004), Cephalalgia 24:1-150
Chronic Daily Headache
Not a diagnosis but a category of primary and secondary headache types
> 15 days/month for > 3 months > 4 hours/day 4% prevalence; 5% of all women 40-80% of patients referred to HA centers
Matthew NT et al. (1987), Headache 27:102-106; Colas R et al. (2004), Neurology 62:338-342
Chronic Daily Headache
Subtypes include: Transformed migraine/chronic migraine Chronic tension-type headache New daily persistent headache Hemicrania continua All may be complicated by:
Medication overuse headache
Silberstein SD et al. (1996), Neurology 47:871-875
Transformed Migraine (TM)
> 15 days/month head pain Headache > 4 hours/day At least 1 of:
Previous HA fulfills IHS criteria for migraine Increasing frequency > 3 months
Medication overuse in 80% with TM
Silberstein SD et al. (1996), Neurology 47:871-875; Bigal ME et al. (2002), Cephalalgia 22:432-438
Migraine Without Aura - Common Migraine
Headache has at least 2 of the following characteristics: S = severe UL = unilateral T = throbbing A = activity worsens HA
And at least 1 of the following during headache: N = nausea or vomiting S = sensitivity to light/sound
Mnemonic: SULTANS
Headache Classification Subcommittee of the International Headache Society (2004), Cephalalgia 24:1-150
Diagnostic Criteria for Migraine With Aura (Classic Migraine)
At least 2 attacks Aura must exhibit at least 3 of the following
characteristics: Fully reversible Gradual onset Lasts less than 60 minutes Followed by headache within 60 minutes HA may begin before or simultaneously with the aura Normal neurologic exam and no evidence of organic
disease that could cause headaches
Headache Classification Subcommittee of the International Headache Society (2004), Cephalalgia 24:1-150
Migraine: Abortive Therapy
Aspirin/APAP/caffeine (Excedrin®) Sumatriptan (Imitrex), zolmitriptan (Zomig®),
rizatriptan (Maxalt®) Isometheptene/dichlo/apap (Midrin®) Ergot tart/caffeine (Cafergot®) Butalbital NSAID Do not exceed 2-3 days treatment in 1 week
rebound
Silberstein SD (2000), Neurology 55(6):754-762
Individual Attacks at Home
ED management of migraine is ineffective
57 patients in ED 95% met migraine
criteria (SULTANS) by questionnaire
Only 32% given a dx of migraine
59% “cephalgia”, “HA NOS”
65% txed with “migraine cocktail”- benadryl, reglan, toradol
24% opioids Only 7% given specific
Tx- triptan, DHE 60% had HA 24 hrs
later
Headache 2003;43:1026-31.
Migraine: Abortive Therapy
Dihydroergotamine mesylate (DHE 45) .5-1 mg q 8 hrs
Metoclopramide (reglan) 10 mg IV
Dexamethasone (Decadron) 16-24mg IV x1
Reduces recurrent HA at 72 hours
Sumatriptan (SC Imitrex®) 4-6 mg SQ, 5 mg Nasal
Ketorolac injection (Toradol®) 15mg IV/IM
Emergency Room
Cochrane Review: Steroids and Migraine. BMJ 2008 Jun 14; 336:1359
Silberstein SD (2000), Neurology 55(6):754-762
ED Management of Migraine
Prochlorperazine (Compazine®) 10 mg IV vs. metoclopramide* (Reglan®) 20 mg IV
Both given with 25mg IV diphenhydramine (Benadryl®) Randomized, controlled trial; 77 patients Mean VAS change of 5.5 vs 5.2 Similar at 2 and 24 hours later Compazine assoc with non-statistical increase in side
effects
A randomized controlled trial of prochlorperazine versus metoclopramide for treatment of acute migraine.
Ann Emerg Med. 2008; 52(4):399-406
Triptans
Major advance in migraine therapy 5-HT1B/1D agonists Vasoconstriction All act by suppressing nausea, confusion,
autonomic dysfunction and pain associated with migraine attack
Differ only in pharmacokinetics
Johnston MM, Rapoport AM. Triptans for the management of migraine. Drugs. 2010 Aug 20;70(12):1505-18
Triptans List
Sumatriptan 25-100 mg po/6 mg sq/5 mg nasal at HA onset, rpt 1 hr sq, 2 hr po/nasal
Zolmitriptan 2.5-5 mg Rizatriptan 10 mg SL Eletriptan (Relpax®), frovatriptan (Frova®),
almotriptan (Axert®), others
Johnston MM, Rapoport AM. Triptans for the management of migraine. Drugs. 2010 Aug 20;70(12):1505-18
Migraine Prophylaxis
-blockers (C): propranolol LA (Inderal-LA) FDA 60 mg qd, timolol 20 mg qd FDA
Anticonvulsants: topiramate FDA (Topamax®) (was C, now D- 3/28/11 due to cleft palate) 25-100 mg bid Lower toxicity than divalproex (Depakote®),
no weight gain
Tricyclics antidepressants (D): nortriptyline (Pamelor®) 10-60 mg
NSAID: naproxen sodium (Anaprox DS®) (C) (menstrual migraine - 550 mg bid x 10 days)
Silberstein SD (2000), Neurology 55(6):754-762
First Line (Pregnancy Class)
Migraine Prophylaxis
Divalproex (Depakote®) (D) FDA Gabapentin (Neurontin®) (C) Baclofen (Lioresal®) (C) “MigreLief”1,2 $20 /60 pills
Riboflavin (Vitamin B2) 400 mg/day (A) Magnesium oxide 360 mg/day (B) Feverfew 100 mg/day
Petadolex 1 tid (Butterbur extract) (A)
Other Options
1Pfaffenrath V, Wessely P, Meyer C, et al. Magnesium in the Prophylaxis of Migraine - A Double-Blind, Placebo-Controlled Study. Cephalalgia 1996;16:436-40.
2Schoenen J, Lenaerts M, Bastings E. High-dose Riboflavin as a Prophylactic Treatment of Migraine: Results of an Open Pilot Study. Cephalalgia 1994;l14:328-9
Transformed Migraine/Status Migrainosus
Unremitting headache > 72 hours fulfilling criteria for migraine
80% associated with medication overuse
Transformed Migraine/Status Migrainosus
Withdraw all medication Raskin protocol: DHE IV 0.5 mg/metoclopramide
(Reglan®) 10 mg IV q 8 hours for 3 days1
Dexamethasone (Decadron-LA®) 10-24 mg IV x1 Dexamethasone (Decadron®) 2 mg bid for 3-5 days Prednisone (Deltasone®) 60 mg daily for 3-5 days
BMJ 2008 Jun 14; 336:1359
Am Fam Physician. 2011;83(3):271-280.
1Raskin NH (1986), Neurology 36(7):995-997
Treatment
*FDA boxed warning 2/26/09 – Long-term or high-dose use of metoclopramide has been linked to tardive dyskinesia.
Complicated Migraine
Persistent neurologic residue of a migraine attack
Migraine with dramatic focal neurologic features (include ophthalmoplegic, hemiplegic, basilar migraine)
Chronic Daily Headache
Subtypes include: Transformed migraine/chronic migraine Chronic tension-type headache New daily persistent headache Hemicrania continua All may be complicated by:
Medication overuse headache
Silberstein SD et al. (1996), Neurology 47:871-875
Chronic Tension Type HA
Head pain > 15 d/mo for at least 6 months Last hours, or may be continuous Pressing, tightening quality Mild-to-moderate intensity Bilateral, often occipital/posterior May have mild nausea, photophobia Do not fulfill migraine criteria Consider other causes: ICP (Intracranial Pressure), SDH (Subdural Hematoma), CO
poisoning
Tension-Type Headache (TTH)
Considered the most common HA type (ICHD)
30-78% prevalence Squeezing, band-like or global headache Environmental stressors May or may not limit function
Headache Classification Subcommittee of the International Headache Society (2004), Cephalalgia 24:1-150
TTH Frequent overlap with other HA subtypes
Migraine Medication overuse
Ask about over-the-counter medication especially those with caffeine (Excedrin/Anacin/APC)
How many cups/pots of coffee/tea daily? How many 2-liter bottles of soda?
Chronic Daily Headache Subtypes include
Transformed Migraine/Chronic Migraine Chronic Tension Type Headache New Daily Persistent Headache Hemicrania continua All may be complicated by:
Medication Overuse Headache
Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised HIS criteria. Neurology 1996;47:871-875
New Daily Persistent HA > 3 mo, daily within 3 days of onset 82% recall exact day of HA onset Bilateral, pressing quality Mild-moderate Nausea, photophobia MRI, MRV to exclude venous thrombosis LP with opening pressure to exclude intracranial
hypotension
Li, D & Rozen, TD (2002). "The clinical characteristics of new daily persistent headache." Cephalalgia 22 (1), 66-69.
Cerebral Venous Thrombosis
54 yo M with new onset headaches, syncope with exertion
Sudden onset bi-occipital HA 8/10 aching without relief, worsened supine
Exam normal, except loss of venous pulsations.
MRI normal, MRV abnl. IV Venogram shows
stenotic left lateral sinus.
Chronic Daily Headache Subtypes include
Transformed Migraine/Chronic Migraine Chronic Tension Type Headache New Daily Persistent Headache Hemicrania continua All may be complicated by
Medication Overuse Headache
Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised HIS criteria. Neurology 1996;47:871-875
Hemicrania Continua
Cluster variant Unilateral pain without side-shift Daily and continuous Moderate to severe At least 1 of:
Conjunctival injection or lacrimation Nasal congestion or rhinorrhea Ptosis or miosis
Complete response to indomethacin
Cluster Headache
Uncommon (69/100,000) Men:women 6:1 Headaches begin 20-50 years of age (mean 30) High incidence of smoking, Peptic Ulcer Disease
(PUD) Familial cases unusual
Cluster Headache (Cont.)
Abrupt onset of pain, builds in 2-15 minutes
Pain is excruciating, severe (deep, constant, stabbing, explosive or pulsatile)
Location: in and around 1 eye
Unilateral, usually same side
Patient up and pacing due to pain
Cluster Headache (Cont.)
Duration: 30 minutes - 2 hours 75% of attacks between 9 p.m.-10 a.m.1
Awakens from sleep 1-2 clusters per year, 4-8 weeks or longer
1Russell D (1981), Cephalalgia 1:209-216
Cluster Headache
Lacrimation Blocked nostril Rhinorrhea Conjunctival injection Temporary ipsilateral Horner’s (2/3) Sweating of forehead Pallor or flushing Nausea Bradycardia
Associated Symptoms and Signs
Other Cluster Variants
Chronic paroxysmal hemicrania Multiple short, severe HA occurring daily Short episodes of cluster 1-2 minutes Average 14 daily
SUNCT (Short-Lasting, Unilateral, Neuralgiform headaches with Conjunctival injection and Tearing)
30-100 attacks daily Usually < 30 seconds Responds to indomethacin
Cluster Headache: Treatment
Stop smoking
Prophylactic treatment of chronic cluster
Indomethacin (Indocin®) 75 mg SR, 25-100 mg tid
Avoid over age 60 Lithium carbonate 300-900 mg daily Methysergide (Sansert®) 2-8 mg daily Propranolol, Nifedipine (Procardia®), verapamil
(Calan®)
Silberstein SD (2000), Neurology 55(6):754-762
Cluster Headache: Treatment (Cont.)
Abortive therapy Rectal ergot for nocturnal attacks 100% oxygen Sumatriptan injection Prednisone or dexamethasone: burst and
taper
Silberstein SD (2000), Neurology 55(6):754-762
Chronic Daily Headache
Subtypes include Transformed Migraine/Chronic Migraine Chronic Tension Type Headache New Daily Persistent Headache Hemicrania continua All may be complicated by:
Medication Overuse Headache
Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised HIS criteria. Neurology 1996;47:871-875.
Medication Overuse Headache
Prevalence 1-2% Morning headaches Chronic daily headache > 15 days/month Simple analgesics > 15 days/month Ergots, triptans, opioids, combo NSAIDS > 10
days per month Most have baseline migraine HA
Dodick DW (2006), N Engl J Med 354(2):158-165; Zwart JA (2003), Neurology 61:160-164
Medication Overuse Headache
Stop all OTC analgesics, caffeine consumption Wean butalbital, opioids, benzodiazepines Ketorolac PO 60 mg x1, 10 mg q 6 hours x 3
days Tizanidine (Zanaflex®) 2-8 mg tid1
May require hospitalization Raskin protocol: DHE 0.5-1 mg IV q 8 hours/
metoclopramide 10 mg for 3 days
Treatment
1Saper JR et al. (2002), Headache 42(6):470-482
Steroids ineffective for MOHNeurology 2007
Randomized controlled trial of 100 patients 51 rcvd prednisone 60 mg taper, 49 placebo No change in mean HA (MH) severity or frequency
Boe, M. G. et al. Neurology 2007;69:26-31
©
“Sinus Headaches”?
Over-diagnosed and over-treated Not a recognized form of HA by the IHS except in setting
of acute bacterial sinusitis 74% fulfill IHS migraine criteria 45-50% of asymptomatic adults have evidence of sinus
mucosal thickening or edema Utility of routine CT sinuses not established
Gupta M, Silberstein SD. Expert Opin Pharmacotherapy 2005;6:715-722.
Mehle ME, Kremer PS. Sinus CT scan findings in “sinus headache “ migraneurs. Headache 2008;48:67.
How often is “Sinus” Headache Really Migraine?
4
8
8
80
0 20 40 60 80 100
Schreiber CP, et al. Arch Intern Med. 2004;164:1769-1772
Subject (%)
Migraine with or w/oAura (IHS 1.1, 1.2)
Migrainous (IHS 1.7)
Episodic Tension-type (IHS 2.1)
Other
Recurrent episodes (at least 6 in the past 6 months)No fever or purulent discharge
No history of abnormal sinus radiographs
Treatment of Transformed Migraine and Medication Overuse Headache
Education, close followup for 8-12 weeks Lifestyle changes: caffeine, smoking, sleep Behavioral therapy Abrupt withdrawal of analgesics except:
Barbiturates: wean over 1 month Opioids: clonidine withdrawal
Dodick DW (2006), N Engl J Med 354(2):158-165
Bridging Medications for Outpatient Treatment
Tizanidine 2-6 mg po TID Baclofen 10-20mg TID Hydroxyzine 25-50mg PO, IM NSAIDS (Naproxen 500 mg, Ketorolac 10-30 po) Dihydroergotamine 0.5-1 mg nasal, IM, subq Antiemetics: metoclopramide 10-20 mg
Intravenous Therapies for Intractable Headaches
IV DHE 1 mg (FDA)/ Reglan 10 mg q8 x 3 days
IV DHE 3mg/L NS over 24 hrsx3
IV decadron 12-24 mg IV x1
IV Magnesium 1 gm x 1 IV depacon 250 mg q
12 hr IV Keppra 500 mg q
12 hr Propafol, others
Saper J. Intravenous management of intractable headache. American Academy of Neurology Course. 2010
Emerging Therapies
• Calcitonin gene-related peptide (CGRP) antagonists Olcegepant (Phase II) Telcagepant (withdrawn due
to increased LFTs)
• Combinations
• Sumatriptan and naproxen (Treximet®) - (FDA)
• Anticonvulsants Pregabalin Zonisamide Levetiracetam Lacosamide Carabersat lamotrigine
Arulmozhi DK et al. (2009), Vascul Pharmacol 43(3):176-187; Rapoport AM, Bigal ME (2005), Neurol Sci 26(suppl 2):S111-S120; Available at:
www.clinicaltrials.gov
Physical Examination
Blood pressure Funduscopy: papilledema in idiopathic
Intracranial hypertension, tumor; subhyaloid hemorrhage in SAH
Temporal artery tenderness: temporal arteritis Neck stiffness, Kernig’s/Brudzinski’s, orbital
tenderness: meningitis
SAH = subarachnoid hemorrhage
Worrisome HA Red Flags
Systemic symptoms: fever, weight loss
Neurologic symptoms or signs: confusion, depressed alertness or consciousness
Onset: sudden, abrupt, split-second
Older: new HA > 50 years old - temporal arteritis
Previous HA history: change in usual HA pattern - change in frequency, character, severity
Secondary risk factors: HIV, cancer
“SNOOPS”
Headaches to be Considered for Emergency Referral
Abrupt onset of “the worst HA of my life” Change in an established HA pattern Headache plus:
Stiff neck Fever Confusion, alteration of consciousness Focal neurologic signs Inability to walk
Headaches to be Considered for Emergency Referral (Cont.)
Any patient over 50 years old with new onset of headaches Get a sedimentation rate (ESR)
Headaches that last more than 72 hours
Summary
Chronic daily headache is common Transformed migraine, tension type and cluster variants Medication overuse HA is seen in all subtypes History is critical SULTANS and SNOOPS
Questions from the Audience?
References1. Dodick DW. Chronic Daily headache. NEJM 2006;354:158-165.2. Headache Classification Subcommittee of the International Headache
Society (2004), Cephalalgia 24:1-1503. Edlow JA. Diagnosis of subarachnoid hemorrhage in the emergency
department. Emerg Med Clin North Am 2003;21:73-87.4. Silberstein SD. Practice parameter: evidence-based guidelines for
migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000 Sep 26;55(6):754-62.
5. Freitag FG. Acute treatment of migraine and the role of triptans. Curr Neurol Neursci Rep 2001;1:125-132.
6. Silberstein SD, Liu D. Drug overuse and rebound headache. Curr Pain Headache Rep 2002;6:240-247.
7. Snow V, et al. pharmacologic management of acute attacks of migraine and prevention of migraine headache.Ann Intern Med 2002;137:840-849.
8. Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised HIS criteria. Neurology 1996;47:871-875