Headache Medicine for the Non Neurologist

Transcription

1 Headache Medicine for the Non Neurologist Justin DeLange, DO, FAHS Northern Arizona Healthcare Medical Group- Neurology Objectives At the end of this talk you should be able to: Explain why headache medicine matters Diagnose migraine and diagnose cluster headache Recognize red flag features Know primary work-up for secondary headaches Know available abortive and preventive treatment options for migraine as an outpatient Know why abortive and preventive treatment is important Know management options for headache on an inpatient basis Page 1

2 Lecture Outline Outpatient Management o Migraine o Cluster o Other common headache types Inpatient /ED Management of Migraine Secondary Causes of Headache in the Hospital/ED o Diagnostic o Recognition Disclosures Off-Label: Numerous medications used for headache or migraine do not carry an FDA indication. Financial: none Conflict of interest: none Page 2

3 Why Headache Matters Migraine is a global problem (1 Billion people affected). In the U.S. migraine affects around 12% of the population. 36 MILLION AMERICANS WITH MIGRAINE One in Four Households Prevalence of Chronic Daily Headache: 4% The Numbers Why Migraine Matters The Burden Migraine costs are in upwards of 20 billion dollars a year. This includes office visits, ER visits, medications, and missed work/lost productivity. 4% of all visits to doctor are for headache. World Health Organization places migraine in the Top 10 most disabling diseases on the planet. Pain is not the only disabling factor. o Nausea/vomiting o Aura symptoms o Light/sound/smell sensitivity Page 3

4 Why Migraine Matters in Primary Care The Landmark Study showed 94% of patients complaining in the office to primary care doctors of stable, episodic headaches had migraine or probable migraine. Only 3% had tension-type headache as the primary diagnosis. Migraine causes disability. Tension type headaches do not generally result in disability and seldom do patients with tension type headache seek medical attention. 40% of pts with migraine qualify for preventive treatment BUT only 13% actually get preventive treatment (Lipton RB et al. Neurology; 68: ) Diagnosis/Management of Headaches Outpatient MIGRAINES Page 4

5 Migraine without aura International Headache Society 2013 Diagnostic Criteria A. At least five attacks fulfilling criteria B D B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) C. Headache has at least two of the following four characteristics: o 1. unilateral location o 2. pulsating quality o 3. moderate or severe pain intensity o 4. aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs) D. During headache at least one of the following: o 1. nausea and/or vomiting o 2. photophobia and phonophobia E. Not better accounted for by another ICHD-3 diagnosis. Migraine Diagnosis Simplified Think: PUMA Pulsating Unilateral (60%) Moderate to Severe on pain scale Activity makes worse Other sx s of photophobia, nausea, vomiting, phonophobia, osmophobia. May occur with or without Aura. Page 5

6 More Simplification: ID Migraine Brief Screener Yes or No Answers With your Headaches o 1. Do you have a dislike for light? o 2. Do you have nausea? o 3. Do your headaches have impact on work, home, school, or recreational activities? 2/3 Yes Answers suggest Migraine Sensitivity of 0.81 and Specificity of 0.75 Lipton (2003) Clinical Pearls Regarding Migraine Can be Chronic or Episodic. Response To Triptans or Ergots Not dx Disabling Migraine Red wine Weather Stress Menstrual triggers Aura seen In 20% Bilateral Location In 40% Neck Pain common History of motion sickness Family history Of HA Adapted from Tepper SJ and Tepper DE 2011 and Ward TN 2012 Page 6

7 What is Migraine with Aura? Gradually progressive neurologic impairment that last 5-60 minutes, precedes or coincides with headache, and is completely reversible. o Typical aura may include: Visual Sensory Language o Atypical may include: Weakness Ataxia Prolonged Bulbar symptoms Monocular visual disturbances/blindness Migraine Aura is Important to Recognize Stroke Risk doubled in patients with Migraine with Aura (RR 2.16) OCP (estrogen) + Migraine with aura= fold increase in stroke risk (relative risk) o Absolute risk of stroke is low however o Additive risk not multiplicative OCP (estrogen) + Migraine with Aura + Smoking=DANGEROUS (Odds Ratio 34) Stroke Risk mainly noted in woman less than age 45. Migraine with Aura may also be associated with other cardiovascular disease too. If estrogen needed for compelling indication in patient with migraine with aura patient: lowest dosage recommended. Page 7

8 Case A 24-year-old woman presents to her PCP complaining of throbbing, disabling headaches 2 days/month. She notes nausea and photophobia with her attacks Pain is 8/10 and lasts for 6 hours. She notes that Tylenol and Aleve are not helping her headaches. She denies any aura symptoms prior to headache onset. Exam normal What is the diagnosis? Are there any other questions we need to ask? Algorithm for Headache Diagnosis Detailed history and exam Headache Red Flags Present? Yes Exclude Secondary headache using appropriate testing if necessary No Consider Primary HA. Atypical features present? Yes Reconsider Secondary Headache If clearly migraine then imaging is not warranted! No Diagnose primary headache disorder From Wolff s Headache Page 8

9 Make sure you are treating migraine! Secondary Headaches 2SNOOP 4 Headache Red Flags SYSTEMIC SYMPTOMS (fever, weight loss) or SECONDARY RISK FACTORS (HIV, systemic cancer) NEUROLOGIC SYMPTOMS or abnormal signs (confusion, impaired alertness or consciousness) ONSET: sudden, abrupt, or split-second (thunderclap) OLDER: new onset and progressive headache, especially in middle age >50 yr (giant cell arteritis) PREVIOUS HEADACHE HISTORY: first headache or different (change in frequency, severity, or clinical features), POSITIONAL, PAPILLEDEMA, or PRECIPITANTS (cough, sneeze, sex, Valsalva) History must be taken, not just accepted Dodick DW. Adv. Stud Med 2003;3:S Page 9

10 Yellow flags for Secondary Headache Disorders Wakes patient from sleep at night New onset side-locked headache De Luca and Bartleson, Seminars in Neurology, 2010 Physical exam of headache Check Looking for To clue you towards Vital signs Fever, hypertension, obesity Infection, hypertensive HA, pseudotumor cerebri Funduscopy Papilledema Elevated intracranial pressure Cranial auscultation Orbital bruits Vascular malformation, thyrotoxicosis Palpate temporal arteries Inspection and palpation of HEENT Neurologic examination Tenderness, nodularity, absence of temporal pulse Lymphadenopathy, meningismus, inflamed mucosa, TMJ tenderness Horner s syndrome, facial numbness, neurologic deficit Giant cell arteritis Infection, TMD Carotid dissection, intracranial lesion Adapted from Smith JH Page 10

11 If Red Flags Present? Need Imaging! MRI Brain in nonemergent (outpatient) settings If Thunderclap headaches are present then vessel imaging (MRA head/neck or CTA head/neck) is necessary! CT Head and/or MRI Brain in emergent settings Case After a thorough history and examination you determine that she has not red flags or atypical features. She is asking for further treatment. What should we recommend for treatment? Page 11

12 Acute Pharmacotherapy for Migraine Guidelines published showing evidence base for acute migraine therapies. (Marmura M, Silberstein SD, Schwedt TJ. Headache. 2015;55:3 20) Answers the question of which medications are effective in acute migraine treatment. Acute treatment is very important as ineffective acute treatment chronic migraine (Lipton et al. Neurology 2014) Acute medications not only help pain but also help migraine-associated disability. Acute Pharmacotherapy for Migraine Strength of Evidence Level A: established as effective (First Line agents) Acetaminophen 1000 mg for nonincapacitating attacks. DHE Nasal Spray 2mg DHE Pulmonary inhaler 1 mg Aspirin 500 mg Diclofenac 50, 100 mg Ibuprofen 200, 400 mg Naproxen 500, 550mg Note: Opiates/Opioids should never be used as a first line agent! Marmura M, Silberstein SD, Schwedt TJ. Headache. 2015;55:3 20. Page 12

13 Acute Pharmacotherapy for Migraine Strength of Evidence Level A: established as effective (First Line agents) Triptans Almotriptan-Expensive, but less side effects Eletriptan-Expensive, Quick and Effective Frovatriptan-Expensive, long-acting (not quick) Naratriptan-cheap, long-acting (not quick) Rizatriptan-cheap, Quick and Effective Sumatriptan-cheap, quick, most side effects. Injectable form is gold standard but side effects. Zolmitriptan-consistent, quick Sumatriptan/naproxen-expensive, more effective than sumatriptan alone. Use full doses! Marmura M, Silberstein SD, Schwedt TJ. Headache. 2015;55:3 20. Acute Pharmacotherapy for Migraine Strength of Evidence Level A: established as effective (First Line agents) Triptans Almotriptan-Expensive, but less side effects Eletriptan-Expensive, Quick and Effective Frovatriptan-Expensive, long-acting (not quick) Naratriptan-cheap, long-acting (not quick) Rizatriptan-cheap, Quick and Effective Sumatriptan-cheap, quick, most side effects. Injectable form is gold standard but side effects. Zolmitriptan-consistent, quick Sumatriptan/naproxen-expensive, more effective than sumatriptan alone. Use full doses! Marmura M, Silberstein SD, Schwedt TJ. Headache. 2015;55:3 20. Page 13

14 Acute Pharmacotherapy for Migraine Triptans Different Modalities/Delivery: Consider alternate route if patient has bad nausea Tab All triptans Disintegrating tab Zolmitriptan rizatriptan Nasal Spray Sumatriptan zolmitriptan Injectable Sumatriptan Iontophoretic Patch (FDA warning: skin burns!!!) pulled off market Sumatriptan Intra-nasal powder (breath-powered) now FDA-approved Sumatriptan Contraindications to triptans Known or suspected ischemic heart disease Cerebrovascular disease Peripheral vascular disease Uncontrolled HTN Severe hepatic disease Use of ergot-alkaloid or other 5-HT 1 agonist (i.e. a different triptan) within preceding 24 hours Patients should avoid sumatriptan, rizatriptan, and zolmitriptan within 2 weeks of MAO inhibitor use (phenelzine) Hemiplegic attacks Typically avoid during pregnancy (FDA Category C) Page 14

15 Acute Pharmacotherapy for Migraine DHE Nasal Spray DHE Nasal Spray is often overlooked and is useful if patient does not respond to triptans or NSAIDs. Does not need to be dosed at the onset of the attack to be effective. Drawbacks: Taste, medication going down the back of the throat. Can be expensive depending on patient s insurance. Contraindications to DHE Black box: Serious/life-threatening peripheral ischemia has been associated with the coadministration of DHE with potent CYP3A4 inhibitors including protease inhibitors and macrolide antibiotics Coadministration with other pressor/vasoconstrictive medications Hypersensitivity to ergot alkaloid products Myocardial infarction Uncontrolled hypertension, ischemic heart disease, angina Cerebrovascular disease, peripheral vascular disease Onset of chest pain following test dose Other ergot or 5-HT derivatives (triptan) within last 24 hr Pregnancy and lactation (FDA Category X) Prolonged hypotension, shock Sepsis Severely impaired liver/renal function Following vascular surgery Hemiplegic/basilar migraine Page 15

16 Acute Pharmacotherapy for Migraine Anti Emetics Good for Rescue when nothing else is helping. May help keep patient out of the ED. May also help headache too! Prochlorperazine 5-10 mg PO x1 (or suppositories at 25 mg PR x1) Metoclopramide 10 mg PO X1 Promethazine mg PO x1 Metoclopramide and Prochlorperazine have best evidence in setting of migraine (IV forms). Watch for EPS! Should only be used for Rescue therapy! Ondansetron if unable to tolerate anything else or has tremor history. Primer on Acute Treatment In absence of vascular disease, consider migraine specific medication (e.g. triptans, DHE) For Triptans should be dosed at headache ONSET. Try adding NSAID with Triptans at onset for synergy or for breakthrough pain. NSAIDs do not need to be taken at headache onset to be effective Significant nausea?: try triptan injection or disintegrating tabs or nasal spray If no response to Triptans, Try NSAIDs alone or DHE nasal spray. Try to limit abortive medications to no more than 2 days/week (no more than 9 days/month) to avoid analgesic or triptan overuse headache. Make sure patient has antiemetics for Rescue therapy (may help with headache along with nausea) Page 16

17 Preventive Therapy for Migraine o When to Initiate Migraine Prophylaxis: >3 migraine days/month >2 migraine days/week Abortive medication overuse Severe disability from headaches Patient preference Abortive medication side effects Atypical cases: Hemiplegic Migraine, Prolonged aura, Brainstem aura. Preventive Therapy for Migraine o Preventive therapy helps to avert chronification of migraine. o Start Low and go slow o 2-3 month trial o Reassure patient they are not married to a certain drug. If side effects or no response after 2-3 months then try another drug. o Realistic Goals: Goal is less disability, halving of frequency, and less abortive med usage. Page 17

18 Preventive Therapy for Migraine o Try to kill two birds with one stone if possible. Topiramate for the obese patient Propranolol for the anxious or tremulous patient Amitriptyline for the insomnia patient. Depakote or Topiramate for the Bipolar patient Propranolol, Metoprolol, or Atenolol in the hypertensive patient Amitriptyline in the fibromyalgia or chronic pain patient. Preventive Therapy for Migraine AAN Guidelines for Migraine Preventive Therapy o FIRST LINE! o Level A: Meds with established efficacy (should be offered) o Topiramate mg/daily o Metoprolol mg/daily o Propranolol mg/daily o Level B: Meds are probably effective (should be considered) o Amitriptyline mg/daily Page 18

19 Preventive Therapy for Migraine AAN Guidelines for Migraine Preventive Therapy o SECOND LINE! o Level A: Meds with established efficacy (should be offered) o Divalproex sodium or sodium valproate 250 mg-1500 mg/daily o Level B: Meds are probably effective (should be considered) o Venlafaxine 37.5 mg-225mg/daily o Atenolol mg/daily Preventive Therapy for Migraine AAN Guidelines for Migraine Preventive Therapy: Vitamins, Supplements, and Herbal Therapies o Level A: Meds with established efficacy o Petasites (Butterbur): no longer safely recommended due to liver toxicity issues! o Level B: Meds are probably effective (should be considered) o Magnesium o Feverfew o Riboflavin Page 19

20 Preventive Therapy for Migraine onabotulinumtoxina o If patient has had 15 or more headache days/month for at least 3 months=chronic Migraine o If Chronic migraine patient has tried two or three different preventives and is still having 15 or more headache days/month then onabotulinumtoxina may be indicated o OnabotulinumtoxinA is only FDA-approved medication for Chronic Migraine o Refer to Neurology or Headache Specialist. Addressing Risk Factors for Developing Chronic Migraine Medication overuse Attack frequency Obesity Head Injury Snoring Caffeine Depression Allodynia Anxiety Other chronic pain Page 20

21 New and Emerging Migraine Treatments Transcranial Magnetic Stimulation* Non-invasive Vagal nerve stimulation for Cluster and Migrane* Trigeminal nerve stimulation* Sumatriptan intranasal powder* CGRP monoclonal antibodies (Awaiting FDA approval) Photos credit: National Headache Foundation *FDA approved New and Emerging Migraine Treatments Transcranial Magnetic Stimulation* Non-invasive Vagal nerve stimulation for Cluster HA* Trigeminal nerve stimulation* Sumatriptan intranasal powder* CGRP monoclonal antibodies (Awaiting FDA approval) Photos credit: National Headache Foundation *FDA approved Page 21

22 New Migraine Preventives: Monoclonal Antibodies to CGRP Erenumab (fully human) Eptinezumab (humanized) Galcanezumab (humanized) Fremanezumab (humanized) Indication EM, CM EM, CM EM, CM, CH EM, CM, CH Dosing Monthly SC Q 3 month IV Monthly SC Monthly or Q3 month SC; IV load for CH Target CGRP Receptor CGRP peptide or ligand Developmental Status Submitted to FDA; Target Action date: 5/17/2017 Submission in Late 2018? CGRP peptide or ligand Submitted to FDA; Target Action Date: 10/11/2018 (est.) CGRP peptide or ligand Submitted to FDA; Target Action Date:? Adapted from SJ Tepper 2017 New Migraine Preventives: Monoclonal Antibodies to CGRP Erenumab (fully human) Eptinezumab (humanized) Galcanezumab (humanized) Fremanezumab (humanized) Indication EM, CM EM, CM EM, CM, CH EM, CM, CH Dosing Monthly SC Q 3 month IV Monthly SC Monthly or Q3 month SC; IV load for CH Target CGRP Receptor CGRP peptide or ligand Developmental Status Submitted to FDA; Target Action date: 5/17/2017 Submission in Late 2018? CGRP peptide or ligand Submitted to FDA; Target Action Date: 10/11/2018 (est.) CGRP peptide or ligand Submitted to FDA; Target Action Date:? Adapted from SJ Tepper 2017 Page 22

23 CGRP Monoclonal Antibodies 50% Responder Rate: ~40%-50 (similar to current preventives) Onset of Effect: days (same day response noted for eptinezumab IV) Current Migraine preventive therapies take weeks-months to have effect. Image credit: Practical Neurology Nov/Dec 2017 Diagnosis/Management of Headaches Outpatient CLUSTER HEADACHE Page 23

24 Cluster Headache Most severe pain a patient can experience other than childbirth and/or passing kidney stones Part of a group of headache known as trigeminal autonomic cephalalgias (TACs) o TACs=typically short, severe unilateral headaches with autonomic features Any headache meeting criteria for a TAC or cluster headache needs imaging o Pituitary lesion? o Dissection? o Posterior fossa lesion? o Hypothalamic lesion? Suspect Cluster? MRI Brain w/wo contrast Consider Vessel imaging Photo: National Library of Medicine (NIH); Medline Plus Cluster Headache International Headache Society Criteria 2013 A. At least five attacks fulfilling criteria B D B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting minutes (when untreated)1 C. Either or both of the following: 1. at least one of the following symptoms or signs, ipsilateral to the headache: a) conjunctival injection and/or lacrimation b) nasal congestion and/or rhinorrhoea c) eyelid oedema d) forehead and facial sweating e) forehead and facial flushing f) sensation of fullness in the ear g) miosis and/or ptosis 2. a sense of restlessness or agitation D. Attacks have a frequency between one every other day and eight per day for more than half of the time when the disorder is active E. Not better accounted for by another ICHD-3 diagnosis. Simplified Diagnosis o Think SSS (sharp, short, severe) minutes o Most likely in V1 (trigeminal) or C2 (occipital distribution) o Attack frequency: QOD to 8/day o EtOH trigger common o Agitation/Restlessness in 90% o Circadian/circannual periodicity ( alarm clock periodicity ) o Autonomic symptoms: ptosis, miosis, tearing, rhinorrhea, nasal congestion, conjunctival injection, diaphoresis Stillman 2011 Page 24

25 Abortive o Oxygen L/min via NRB mask x15 minutes o Sumatriptan 6 mg SC Oral triptans suboptimal in cluster! o DHE injection or nasal spray o Sumatriptan or zolmitriptan nasal spray Preventive o Verapamil mg/d o Sodium valproate mg/d o Topiramate mg/d o Melatonin 9-25 mg daily Cluster Headache Treatments Bridging (pain relief while waiting for preventive to kick in ) Prednisone mg/d tapered over 14 days Greater occipital nerve block Diagnosis/Management of Headaches Outpatient OTHER HEADACHE TYPES Page 25

26 Other Common Headache Types Tension-type Headache Usually does not present to clinic (not disabling) unless chronic Typically bilateral, pressure-like No migrainous features o No nausea and vomiting o May have photophobia or phonophobia but not both! Activity does not make worse Treatment o Amitriptyline is preventive of choice if bothersome. o NSAIDs for abortive care Post-Traumatic Headache New-onset headache that appears after head injury, concussion o MRI Brain needed +/- vessel imaging Treat the phenotype o Migrainous o Cluster o Tension-type Diagnosis/Management of Headaches Inpatient/ED MIGRAINES Page 26

27 Inpatient Treatment Principles ED/Inpatient Place the patient in a darkened, quiet room Provide reassurance Treat fluid depletion Treat nausea and vomiting!!! Implement treatment with parenteral medication Use non-dependence producing agents when possible (no opioids if possible) Utilize doses which are likely to be effective Inpatient Treatment Principles ED/Inpatient Do not restrict antiemetics just to patients with nausea o Dopamine-blockade may be implicated in migraine relief Use migraine-specific therapy (DHE, Triptans) o But 50% of patients presenting to ED in 1 study had a potential contraindication to migraine-specific therapy (Friedman et al. Headache 2009) Response to therapy is not a diagnostic tool! Page 27

28 Inpatient/ED Treatment Migraines Migraine specific treatments Inpatient Triptans Sumatriptan 6 mg SC (Max 12 mg/24 hours) Side effects: injection site reaction, paresthesias, hot/cold sensation, chest pressure/pain/tightness, dizziness, flushing, limb pain, vasoconstriction, and nausea. Ergotamine derivatives Dihydroergotamine mesylate (DHE) 0.5 mg 1 mg IV ( Max 2 3 mg/24 hours) (May be dosed every 8 hours in hospital) Side effects: paresthesias, dizziness, flushing, nausea/vomiting, diarrhea, dyspnea, rash, diaphoresis, elevated blood pressure, anxiety, and vasoconstriction. For DHE: pretreatment with anti-emetic +/- diphenhydramine often needed! Inpatient/ED Treatment Migraines Migraine specific treatments Inpatient Triptans Sumatriptan 6 mg SC (Max 12 mg/24 hours) Side effects: injection site reaction, paresthesias, hot/cold sensation, chest pressure/pain/tightness, dizziness, flushing, limb pain, vasoconstriction, and nausea. Ergotamine derivatives Dihydroergotamine mesylate (DHE) 0.5 mg 1 mg IV ( Max 2 3 mg/24 hours) (May be dosed every 8 hours in hospital) Side effects: paresthesias, dizziness, flushing, nausea/vomiting, diarrhea, dyspnea, rash, diaphoresis, elevated blood pressure, anxiety, and vasoconstriction. **AHS Guidelines for Acute Migraine in ED (2016): Should Offer For DHE: pretreatment with anti-emetic +/- diphenhydramine often needed! Page 28

29 Inpatient/ED Treatment Migraines Nonspecific Migraine treatments Inpatient Antiemetics (D 2 Antagonists) Chlorpromazine mg IV/IM Prochlorperazine 10 mg IV/IM ** Promethazine 25 mg IM Haloperidol 5 mg IV in 500 ml normal saline over 20 minutes Droperidol 2.5 mg IV Metoclopramide 10 mg IV/IM Side effects: drowsiness, dizziness, blurred vision, akathisia, dystonia, parkinsonism, fluid retention (metoclopramide), QT prolongation (Droperidol has Black Box warning due to risk of QT prolongation*), neuroleptic malignant syndrome, hypotension (especially chlorpromazine) Inpatient/ED Treatment Migraines Nonspecific Migraine treatments Inpatient Antiemetics (D 2 Antagonists) Chlorpromazine mg IV/IM Prochlorperazine 10 mg IV/IM ** Promethazine 25 mg IM Haloperidol 5 mg IV in 500 ml normal saline over 20 minutes Droperidol 2.5 mg IV Metoclopramide 10 mg IV/IM** **AHS Guidelines for Acute Migraine in ED (2016): Should Offer Side effects: drowsiness, dizziness, blurred vision, akathisia, dystonia, parkinsonism, fluid retention (metoclopramide), QT prolongation (Droperidol has Black Box warning due to risk of QT prolongation*), neuroleptic malignant syndrome, hypotension (especially chlorpromazine) Page 29

30 Inpatient/ED Treatment Migraines Nonspecific Migraine treatments Inpatient Antiepileptics Valproate sodium mg IV (one time dose) Side effects: drowsiness, asthenia, nausea/vomiting, injection site reaction, dizziness, hepatotoxicity, hyperammonemia, pancreatitis. Useful for patients with cardiovascular or cerebrovascular contraindication to triptans, DHE. Inpatient/ED Treatment Migraines Nonspecific Migraine treatments Inpatient Antiepileptics Valproate sodium mg IV (one time dose) Side effects: drowsiness, asthenia, nausea/vomiting, injection site reaction, dizziness, hepatotoxicity, hyperammonemia, pancreatitis. **AHS Guidelines for Acute Migraine in ED (2016): May Offer Useful for patients with cardiovascular or cerebrovascular contraindication to triptans, DHE. Page 30

31 Inpatient/ED Treatment Migraines Nonspecific Migraine treatments Inpatient NSAIDs Ketorolac 30 60mg IV/IM Side Effects: GI bleeding, GI ulceration, dyspepsia, abdominal pain, nausea, vomiting, injection site reaction, bleeding, rashes, nephrotoxicity, cardiovascular risk, anaphylaxis. Useful for Break through pain while inpatient Inpatient/ED Treatment Migraines Nonspecific Migraine treatments Inpatient NSAIDs Ketorolac 30 60mg IV/IM Side Effects: GI bleeding, GI ulceration, dyspepsia, abdominal pain, nausea, vomiting, injection site reaction, bleeding, rashes, nephrotoxicity, cardiovascular risk, anaphylaxis. **AHS Guidelines for Acute Migraine in ED (2016): May Offer Useful for Break through pain while inpatient Page 31

32 Inpatient/ED Treatment Migraines Nonspecific Migraine treatments Inpatient Corticosteroids Dexamethasone mg IV (prevents recurrence) Side effects: nausea, vomiting, dyspepsia, dizziness, mood swing, insomnia, anxiety, hypertension, hyperglycemia, avascular necrosis of bone (rare) Others Magnesium sulfate 1 2 g IV (for MwA, light/sound phobia) Side effects: hypotension, flushing, drowsiness. Inpatient/ED Treatment Migraines Nonspecific Migraine treatments Inpatient Corticosteroids Dexamethasone mg IV (prevents recurrence) Side effects: nausea, vomiting, dyspepsia, dizziness, mood swing, insomnia, anxiety, hypertension, hyperglycemia, avascular necrosis of bone (rare) Others Magnesium sulfate 1 2 g IV (for MwA, light/sound phobia) Side effects: hypotension, flushing, drowsiness. **AHS Guidelines for Acute Migraine in ED (2016): Should Offer Page 32

33 Diagnosis/Management of Headaches Inpatient SECONDARY HEADACHES Algorithm for Headache Diagnosis Detailed history and exam Headache Red Flags Present? Yes Exclude Secondary headache using appropriate testing if necessary No Consider Primary HA. Atypical features present? Yes Reconsider Secondary Headache If clearly migraine then imaging is not warranted! No Diagnose primary headache disorder From Wolff s Headache Page 33

34 Secondary Headaches 2SNOOP 4 Headache Red Flags SYSTEMIC SYMPTOMS (fever, weight loss) or SECONDARY RISK FACTORS (HIV, systemic cancer) NEUROLOGIC SYMPTOMS or abnormal signs (confusion, impaired alertness or consciousness) ONSET: sudden, abrupt, or split-second (thunderclap) OLDER: new onset and progressive headache, especially in middle age >50 yr (giant cell arteritis) PREVIOUS HEADACHE HISTORY: first headache or different (change in frequency, severity, or clinical features), POSITIONAL, PAPILLEDEMA, or PRECIPITANTS (cough, sneezing, sex, Valsalva) History must be taken, not just accepted Dodick DW. Adv. Stud Med 2003;3:S Serious Secondary Causes of Headache Subarachnoid hemorrhage (SAH) Giant cell arteritis Cerebral venous sinus thrombosis Cervical artery dissection Reversible cerebral vasoconstriction syndrome Hypertensive emergency Acute strokes: hemorrhagic or ischemic Pituitary apoplexy Adapted from: Bounes and Edlow, Eur Review Med Pharm Sciences, 2011 Mass lesions o Tumor o Abscess (including parameningeal infections) o Intracranial hematomas (parenchymal, subdural, epidural) o Colloid cyst of 3rd ventricle Meningitis and encephalitis Idiopathic intracranial hypertension Spontaneous intracranial hypotension Carbon monoxide poisoning Cardiac cephalalgia Acute narrow angle closure glaucoma Page 34

35 Serious Secondary Causes of Headache Subarachnoid hemorrhage (SAH) Giant cell arteritis Cerebral venous sinus thrombosis Cervical artery dissection Reversible cerebral vasoconstriction syndrome Hypertensive emergency Acute strokes: hemorrhagic or ischemic Pituitary apoplexy Adapted from: Bounes and Edlow, Eur Review Med Pharm Sciences, 2011 Mass lesions o Tumor o Abscess (including parameningeal infections) o Intracranial hematomas (parenchymal, subdural, epidural) o Colloid cyst of 3rd ventricle Meningitis and encephalitis Idiopathic intracranial hypertension Spontaneous intracranial hypotension Carbon monoxide poisoning Cardiac cephalalgia Acute narrow angle closure More common glaucoma causes of thunderclap headache Aneurysmal Subarachnoid Hemorrhage Thunderclap headache, seizures, meningismus, altered consciousness Sensitivity of CT for detecting aneurysmal SAH within 6 hours=92-100% If CT negative and SAH suspected then LP indicated o o Should be performed as soon as possible Looking for xanthochromia Spectrophotometry J. van Gijn, and G. J. E. Rinkel Brain 2001;124: Oxford University Press 2001 Page 35

36 Aneurysmal Subarachnoid Hemorrhage MRI Brain useful in patients who present days after sx onset o o FLAIR, GRE sequences sensitive for SAH MRI more sensitive than CT outside acute phase Blood vessel imaging needed to look for aneurysm o CTA o MRA If negative then invasive angiography indicated J. van Gijn, and G. J. E. Rinkel Brain 2001;124: Oxford University Press 2001 Tx: CCBs Reversible Cerebral Vasoconstriction Often recurrent Thunderclap HA over a period of 1-2 weeks o With or without focal Neuro Sx s Monophasic course Vessel imaging=reversible beading/vasospasm o Normalization within 12 wks. MRI may show ICH, infarcts, PRES CSF normal or near normal Syndrome (RCVS) Image credit: The Lancet Neurology , DOI: ( /S (12) ) Image Copyright 2012 Elsevier Ltd Page 36

37 Internal Carotid or Vertebral Artery Dissection May present with or without thunderclap headache o Often after head/neck trauma Neck pain (often unilateral) common Stroke symptoms often present MRI Brain w/o contrast to check for infarct MRA head/neck or CTA head/neck Dissection may be a Cluster HA Mimic! Cerebral Sinus Thrombosis Usually presents with new chronic daily headache 5% may present with Thunderclap headache May also present with weakness, seizures, AMS, visual issues (papilledema). Suspect with Risk Factors: o Pregnancy o Dehydration o OCP use o Venous thrombosis history o Children, young adults, women>men Diagnosed with MRV or CTV Page 37

38 Spontaneous Intracranial Hypotension Postural Headache o o Worsens within 15 minutes of sitting or standing Improves when recumbent Thunderclap headache in 15% Auditory muffling, tinnitus, dizziness, blurry vision common May occur from LP, trauma, or connective tissue disease Spontaneous Intracranial Hypotension MRI shows pachymeningeal enhancement, subdural hygromas, and/or brain sagging. CT or MRI myelogram may be needed to localize site of leak Treatment is blood patch Page 38

39 Giant Cell Arteritis New onset headache in patient above age of 50 Jaw claudication Temporal artery tenderness New visual disturbances Polymyalgia rheumatica sx s Fever or anemia ESR and/or CRP elevated Photo: uveitis.org Headache: The Journal of Head and Face Pain Volume 55, Issue 6, pages , 11 MAR 2015 DOI: /head fig-0003 Giant Cell Arteritis Temporal Artery Biopsy is diagnostic Steroids should not be delayed to avoid ischemic complications o Vision loss is irreversible Prednisone 60 mg daily ASA 81 mg daily should also be started o Wide spread vasculitis of medium to large vessels Page 39

40 Conclusion Migraine is a disabling, genetic brain disease History is EVERYTHING in headache medicine Be wary of red flag symptoms (2SNOOP4) Migraine specific abortive therapy should be used when possible o Triptans or DHE if no risk factors o NSAIDs may be used for synergy with migraine specific therapy Migraine preventives are underutilized and important Utilize Parenteral, non-opioid treatment in the hospital/inpatient setting for migraine when possible Be on the lookout for secondary causes of headache in the ED/Hospital/Outpatient o Thunderclap Headache may herald an ominous cause!!! Questions? Page 40

41 Pregnant Migraineur? No preventives if possible. Magnesium 350 mg (FDA recommends no higher) Propranolol FDA Category C-lowest dose possible if needed. Amitriptyline (no more than 50 mg) FDA Category C -lowest dose possible if needed. Abortives: Tylenol Tylenol/Caffeine Metoclopramide 10 mg PRN (use sparingly) Naproxen or Ibuprofen in 1 st and 2 nd Trimesters only! Prednisone (not in 1 st Trimester) Avoid opiates/opioids or butalbital if possible! Triptans are Category C and use as a third line agent should only be considered if nothing else is helping. Registry data showing sumatriptan may be safe. DHE is Category X and is always contraindicated!!! Consensus Statements on OCP use in Migraine with Aura European community: More restrictive of OCP use in migraine. ACOG position: no OCPs in a patient with migraine with aura above 35 year old. IHS position: individually assess and evaluate risk for stroke in each patient WHO: women with migraine with aura should not use OCPs. Page 41

42 In the clinic or at home: Rescue Plan to Keep Out of ED! Initial Therapy First dose of triptan And/Or NSAID Back-up Therapy Repeat dose of triptan. Also try NSAID for breakthrough pain if not given initially. Rescue Therapy Trying to keep out of ED Prochlorperazine PO or PR (or other antiemetic of your choice) Indomethacin 50 mg PR Ketorolac mg IM or PO Consider steroids If Fails If Fails Consider non-oral meds in patients with severe nausea/vomiting. Injections/Nasal spray Stop Status Migrainosus treatment if headache-free for 24 hours. Adapted from Kriegler 2011 Adapted from Whyte, Headache 2010; Turkewitz. Self-administration of parenteral ketorolac for head pain. Headache, 1992 Page 42