Disclosures. Objectives 11/10/2017. Research funding: Consultant and advisory: NIDILRR Wadsworth Foundation. Allergan Amgen Lilly Teva

Transcription

1 AHS Scottsdale Headache Symposium 2017 Long Term Management of Posttraumatic Headache Sylvia Lucas MD, PhD, FAHS Clinical Professor of Neurology & Neurological Surgery Adjunct, Rehabilitation Medicine University of Washington Medical Center Harborview Medical Center UW Sports Concussion Clinic Seattle, Washington November 18, 2017 Disclosures Research funding: NIDILRR Wadsworth Foundation Consultant and advisory: Allergan Amgen Lilly Teva Objectives To recognize clinical characteristics or types of posttraumatic headache (PTH) To identify risk factors for development of PTH To assess co-morbid conditions associated with PTH To apply treatment protocols for management optimization 1

2 Epidemiology of TBI Headacheis the most common physical symptom after TBI (Walker et al. 2005; Dikmen et al. 2010). 2.5 million traumatic brain injuries (TBI) per year in US ( annualized data; Faulet al, 2010). Data do not include outpatient or office visits, military data or those not seeking care. 75% of TBIs are mild TBI (mtbi). Possibly up to 3.8 million injuries per year among 44 million children and 170 million adults who play organized sports (likely underestimated for failure to recognize or minimize injury (Daneshvar et al. 2011). Prevalenceof PTH in prospective cohort studies ranged from 30-60% at 1 month after injury and 26-65% 1 year after injury in civilian any intensity TBI (Dikmen et al. 2010, Faux & Sheedy 2005; Hoffman et al. 2011; Lieba-Samal2011; Lucas et al. 2014; Stovneret al. 2009; Barlow et al. 2010; Eisenberg et al. 2013). Higher symptom burden in those with 2 or more concussions (Mannixet al. 2014). 80% Prevalence of New or Worse Headache in the Year after TBI 70% 60% 50% 56% 63% 69% 58% 40% 30% 40% 37% 33% 34% Moderate to Severe TBI Mild TBI 20% 10% 17% 17% 0% Pre-Injury Baseline 3 Months 6 Months 12 Months (Hoffman et al. 2011; Lucas et al. 2014) International Classification of Headache Disorders-3 rd edition (beta version) 5. Headache attributed to trauma or injury to the head and/or neck Acute vs. persistent headache (less than vs. greater than 3 months) Acute headache is reported to have developed within 7 days after injury, regaining consciousness or discontinuation of medication impairing ability to sense headache (delayed-onset headache in Appendix) Moderate or severe vs. mild traumatic injury to the head There are no specific headache features known to distinguish the subtypes of 5. Most of these resemble tension-type headaches or migraine. Diagnostic criteria might include type, subtype or phenotype of the headache (e.g. migraine, tension-type) 2

3 Classification of New or Worse Headache Baseline 3 Months 6 Months 12 Months Mod/Sev Mild Mod/Sev Mild Mod/Sev Mild Mod/Sev Mild Migraine/ Probable Migraine 54% 46% 63% 38% 67% 35% 61% 42% Tension 7% 9% 13% 16% 14% 19% 14% 18% Cervicogenic 10% 6% 5% 10% 2% 9% 5% 6% Unclassifiable 29% 38% 20% 35% 17% 37% 20% 34% (Lucas et al. 2012; Lucas et al. 2014) Frequency of Headache by Classification Several per week 1 per week/mo <1 per month 0 Moderate/Severe Mild Pain and Headache Impact 5 years after Moderate to Severe TBI Discrete Mixture Modeling was used to estimate trajectory groups based on both pain rating (1-10) and impact score using HIT-6 (36-78) HIT-6 scoring: 49 or less=no impact 50-55=some impact 56-59=substantial impact 60 or over=severe impact 3

4 Chronic Improving Worsening Minimal Chronic Worsening Minimal Factors Related to Trajectory Membership Chronic Pain Female Injured by violence Unemployed prior to injury History of headache or mental health problem Chronic Impact Female Injured by violence Unemployed prior to injury History of headache 4

5 70 Self-Report of Treatment in those with mtbi (DiTommaso, Hoffman, Lucas et al. Headache; 2014) 60 Number of Participants Months 6 Months 12 Months 0 STRATEGIES FOR PTH TREATMENT Establish PTH phenotypes Educate patients on concussion Modify behaviors that worsen Headache (poor sleep, screen time, intense exercise) Set realistic expectations Identify co-morbid conditions Acute treatment for headache (decrease intensity improve daily function) Preventive treatment for headache (decrease frequency and Intensity). Re-evaluate often Management of PTH is empiric No Class I studies Class II: manual spine therapy vs cold packs Effect of decrease in headache intensity at 5 weeks lost after 8 weeks (Jensen et al. 1990) Class III (retrospective) at least 1 month of valproic acid 44% had 24-50% improvement (chiropractic, NSAIDs, analgesics and PT allowed) Retrospective chart analysis of 100 active duty Soldiers Triptans effective in migraine phenotype; topiramate had significant reduction in headache frequency 35% responder rate 5

6 Treatment of Chronic Posttraumatic Headache with OnabotulinumtoxinA: Open Label Pilot Study Headache Diary and Outcome Measures Screening 1 st injection 2 nd injection 3 rd injection Final visit Headache Rate Mean (SD) % Headache Days Mean number 83 (21) 25 days 67 (28) 20 days 47 (31) 14 days 49 (34) 14 days Average pain (0-10) 5.2 (1.5) 4.5 (1.6) 4.9 (1.5) 4.6 (1.4)) MIDAS 89 (51) 79 (53) 43 (42) 19 (17) 21 (18) HIT-6 (36-78) 65 (4) 66 (4) 62 (4) 59(6) 59 (7) Lucas, 2017 (AHS 59 th Annual meeting PS14) Subjects Reporting Headache, Depression, Both or Neither over One Year after mtbi Baseline N=212 Year 1 N=187 Headache only 112 (52%) 81 (43%) Depression only 8 (4%) 4 (2%) Headache and Depression 23 (11%) 46 (25%) Neither 69 (33%) 56 (30%) RRthat subjects with headache will be depressed *** RR that subjects with depression will have headache *** *** p<0.001 TREAT THE TYPE Evaluate clinical features of PTH and treat as a primary headache disorder Prior history of headache or family history of headache may make it more likely to respond to the treatment but this needs further study Severity of headache may determine need for non-specific vs specific migraine therapy Frequency may determine need for preventive therapy Recognize co-morbid conditions (consider when choosing preventive therapy) Need to consider severity of TBI and cognitive impairment in the individual with PTH and choose therapy accordingly Multidisciplinary approach may be beneficial CBT, TBI psychologists, TBI associations and support groups, concussion specialists 6

7 Conclusions HA is a significant problem after TBI Relative frequency of HA did not appear to decrease significantly over time, even five years after injury HA prevalence and impact on daily life remained consistently high over five years Headache type, when classifiable, was most frequently consistent with migraine or probable migraine over five years Clinicians should provide ongoing treatment for HA after TBI Treatment studies are needed to determine whether frequency, severity, and impact of HA after TBI can be decreased with effective pharmacologic or nonpharmacologic methods. Thank you! 7