4/14/18. Headache Management. Patient with refractory headaches. Headache Management Utilizing an Integrative Approach VITAL BEHAVIORS.

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1 Patient with refractory headaches Headache Management Utilizing an Integrative Approach Karen Williams, DNPc, RN, FNP-BC TNP yr old female with a history of refractory headaches for the last 2 years Migraines since 1990 s- described as posterior pressure, treated with Advil. If untreated will cause photophobia/phonophobia & worse with exertion 2 nd type started 2 years prior. Described as bi-frontal and right eye pressure increases to 4-6/10 and occasion to 8-9/10 w/photo/phonphobia Would occur upon waking up in the morning, worsen with exertion and when dehydrated. Lasting up to 2 weeks and occurring monthly Treated with zomig and advil- with about 1/3 resolved with this Treated in past by a neurologist- MRI of Brain WNL 1 2 VITAL BEHAVIORS Objectives Diagnosis Correctly Discuss the burdens and risk factors associated with headaches Treat Appropriately Headache Management Review tension type headache and migraine Identify appropriate medication treatments and medication overuse headaches Review alternative headache treatments Communicate Effectively Case presentations 3 4 Disclosures Epidemiology of Headaches Off label use of medications The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of the Veterans Affairs, Department of Defense, or U.S. Government Primary headache disorder is estimated to affect 45(+) million individuals in the US (Cleveland Clinic Health Information Center, 2008) World-wide, the percentage of the adult population with an active headache disorder is 46% (Stover, 2007) 42% suffer from tension-type 11% from migraine 3% from chronic daily headache 5 6 1

2 Socioeconomic Types of Headache Disorders Headache is the most common pain-related complaint among workers (Stewart, 2003) One of the most common complaints in the ER, with over 3 million ER visits in 2000 (Stewart, 2003) Most common cause of absenteeism from work and school (Cleveland Clinic Health Information Center, 2008) Primary- not associated with any cause or pathology Migraine, Tension, cluster migraine Secondary- associated with some underlying pathology Traumatic, Drug/substance related, infection, malignancy, vascular (Headache Classification Subcommittee of the International Headache Society, 2013) Estimated $17 billion annually, for the cost of healthcare associated with migraines (Goldberg, 2005) 7 8 Diagnosis Correctly VITAL BEHAVIORS Step 1- Diagnosis the headache Migraine verses Tension Type Chronic Daily Headache Treat Appropriately Communicate Effectively Headache Management Medication overuse Trauma related Disease related Others? 9 10 Tension- Type Headache The most common primary headache Pain is bilateral, often described as pressing, band like or vise-like. In the forehead, temples or back of head and neck Intensity - Mild to moderate Can last from 30 minutes to 7 days Can be associated with photophobia or phonophobia but not both

3 Tension (Continued) Case #1 Often accompanied by fatigue, inadequate sleep Triggered by stress, fatigue or emotional bursts Usually not aggravated by physical activity Usually relieved with OTC analgesics, relaxation, reduction of stress Frequently coexists with migraine (Headache Classification Subcommittee of the International Headache Society, 2013) year old Male High School Student Migraine History of occasional annoying headaches for the last year The last month have increased to almost daily lasting about an hour at a time Described as a band around the head, sometimes accompanied with phonophobia Denies any nausea/vomiting and not worsened by routine physical activities Relieved by Tylenol or OTC NSAIDS Triggers: Stress and inadequate sleep Family history was noncontributory Neurologic exam was normal World wide prevalence of 11% and is the 2 nd most common primary headache (Stovner, et al., 2007) Affecting women 3 times more than men, with a comparison of 17% female vs 6% male (Lipton & Bigal, 2007) Occurs from childhood to adulthood with the peak prevalence occurring in mid-adulthood (Lipton & Bigal, 2007) Migraine Recurrent episodes of generally unilateral (may be bilateral), pulsating/throbbing pain Usually aggravated by physical activity and often relieved with sleep Pain is moderate to severe and debilitating Associated symptoms of nausea, vomiting, photophobia and phonophobia Time frame of 4 to 72 hours, if untreated (Headache Classification Subcommittee of the International Headache Society, 2013)

4 Case # year old Pediatrician 38 yr old female with reoccurring headaches since high school: left more often than right temporal or occasional bi temporal pressure Nausea occasional vomiting lasting 24 hours Headaches could interfere with her activities including awakening her from sleep Frequency was 1-4 times per month, now weekly OTC s of little help Triggers: Stress and heat, not triggered by menses, foods or alcohol No recent contraceptive use Family history was noncontributory Neurologic exam was normal Step 2 - Headache Evaluation and Diagnosis Accurate and detailed headache history Family Hx, Personal medical Hx, Hx of head trauma, Time frame of headache, age of onset, how frequent, duration, triggers, aggravating factors, co-morbid illnesses, impact on family and work/school Clinical description of the headache: Location, intensity, nature of the pain, preceding symptoms, aura or neurologic symptoms Do they have more than 1 type of headache? Helpful questions Diagnosis of Migraine or TTH Helpful questions: How do headaches interfere with your life? How Frequently do you experience headaches of any type? Has there been a change in your headache pattern over the last 6 months? How often and how effectively do you use medications to treat headaches? (Martin, 2004)

5 Headache Assessment Tools Step 3 - Physical Exam Headache Calendar- iheadache/migrainebuddy (free phone apps) Headache Impact test (6 questions) Helps patients communicate the severity of the headache pain to their provider The Migraine Disability Assessment Questionnaire (5 questions) Measures headache-related disability in: work/school, household and family/social Migraine Specific Quality of Life Questionnaire (MSQ) (14 questions) Role Function-Restrictive Role Function- Preventive Emotional Function 25 Neurological exam: Cranial nerves, Strength, Coordination, DTR s (rule-out papilledema, diploplia, facial weakness, gait disturbances, nuchal rigidity) ROM of neck/palpation of the TMJ and occipital nerves (looking for tenderness or edema, trigger points in paraspinal, shoulder areas)- Blood Pressure: diastolic over 120 mmhg are associated with an increase in headaches Consider CBC, CMP, Thyroid function testing, Vit D level (Looking for treatable cause) (Deluca & Bartleson, 2010) Rule out a systemic illness or other organic cause 26 Trigger points Red Flags SNOOP4 Systemic symptoms or disease (fever, weight loss, jaw claudication) Neurologic signs or symptoms (motor weakness, memory loss, papillary abnormality, sensory loss) Onset sudden (if < 60 sec, called thunderclap headache) Onset before age 5 or after age 50 Pattern change from prior headaches With permission from Sean Riehl Real Bodywork SNOOP4 (continued) Precipitated by Valsalva maneuver- worrisome for underlying vascular lesion Positional headache precipitated by laying down or standing up Papilledema- elevated intracranial pressure (DeLuca & Bartleson, 2010);(Sheller, Vargas,& O neil 2016) Diagnostics for Red Flags Imaging studies: Ct of head, MRI Looking for structural abnormalities Blood chemistries and Blood counts Sed rate should be measured in adults that are 50 and older Lumbar puncture (after obtaining brain imaging): in suspected meningitis, subarachnoid hemorrhage, Pseudotumor cerebri, encephalitis or systemic illness (lupus, sarcoidosis, vasculitis) (Elkind, 2004)

6 Case # 3 39 year old Designer Female presents to the ER: complains of a severe occipital headache and vomiting Describes it as the Worst headache of her life, stated that is started suddenly after a stressful day at work She had a similar headache 2 days prior but it only lasted a few seconds, then resolved No prior history of a similar headache No prior head trauma, fever, vision changes, photophobia Medical history: 2 normal pregnancies, only taking oral contraceptive for 15 years, no use of illicit drugs, tobacco or alcohol Family history was noncontributory yr old Designer Physical Exam Obese female, mild distress due to pain Pulse- 78, B/P 160/80, Resp-20, Afebrile Head is normal with no tenderness, ENT exam WNL, pupils are small at 2mm but reactive to light with EOM intact, no photophobia or nystagmus. Fundi and optic discs WNL. No neck mass but does have nuchal rigidity Chest/heart exam WNL, lungs clear with normal respiratory effort. Abdomen soft and nontender Neuro exam reveal fully alert, orientated and mildly anxious. Cranial nerves intact, with motor strength symmetrical, DTR s symmetric and brisk without clonus. Cerebellar function and sensory systems are normal CBC, CMP, U/A are WNL Noncontrast Cerebral CT : hyperdensity in the subarachnoid space Step 4- Identify Common Triggers of Migraine Hormonal- menstruation, ovulation, oral contraceptives with estrogen Dietary- ETOH, nitrates, caffeine, aged cheese, MSG, aspartame, chocolate, skipping meals Psychological- stress, anxiety, depression Environmental- glare, flashing lights, strong odors, barometric changes, high altitude Sleep- lack of or too much sleep Drug-related Nitroglycerin, Histamine, Hydralazine, Ranitidine, Estrogen Identify Exacerbating Factors VITAL BEHAVIORS Medication overuse Caffeine overuse Depression/anxiety/stress Increased BMI Suboptimal sleep- < 6 or > 8, Sleep apnea- untreated Low economic status Frequency of baseline headache- greater frequency leads to progression Nutrition/diet- skipping meals Tobacco use Prior head or neck trauma* Any use of barbiturates or opioids can increase chance of CDH, to include Butalbital (Fioricet) (Sheeler et.al, 2016); Murinova & Karshin, 2015) Diagnosis Correctly Treat Appropriately Communicate Effectively Headache Management

7 Step 5- Action Plan Migraine Treatments Preventative Acute treatments Lifestyle modifications Education- on going Realistic expectations Abortive Treatments for Migraine Abortives: First line: NSAIDS/Aspirin or Acetaminophen, (Caffeine + analgesic ) First line if moderate to severe: Triptans (7 types) (Triptan/NSAID) Constrict dilated blood vessels, reduce neuropeptide release and inhibit impulse transmission centrally within the trigeminovascular system Consider the associated symptoms for type of delivery Oral, Subcutaneous injection, Intranasal May need to try several, Individual responses cannot be predicted Ergotamine/Dihydroergotamine (DHE)- Nasal spray, Injection Oxygen inhalation (100%) for cluster migraine (Marmura, Silberstein, & Schwedt, 2015); (Murinova, & Krashin, D. 2015); (Pringsheim, Davenport, Marmura, Schwedt, & Silberstein, 2016); (Silberstein, 2000) Preventative Treatments for Migraines Consider if 4 or more headaches per month, consider co-morbid conditions Propranolol* Topiramate* *FDA approved for migraine prevention Divalproex* Antidepressants TCA s NSAIDS Tizanidine Calcium Channel Blockers- Cluster migraine (Sheeler, et al., 2016); (Marmura, Silberstein & Schwedt, 2015); (Murinova & Krashin, 2015); (Pringsheim, Davenport, Marmura, Schwedt & Silberstein, 2016) Avoid narcotics & benzodiazepines Preventatives (continued) Riboflavin (Vit B2) - Dosed at 100mg, 2 tabs twice per day Magnesium 400mg per day (dose in evening) (Murinova & Krashin, 2015) Calcitonin Gene-Related Peptide (CGRP) Strongly associated with migraine and cluster headache 37 Amino-acid sensory neuropeptide- powerful vasodilator Detected in the trigeminovasclar system Higher concentrations in the blood during a migraine OnabotulinumtoxinA (Botox) * FDA (Sheeler, et al., 2016); (Murinova & Krashin, 2015) Cefaly *FDA Acupuncture - more research showing this to be promising (Coeytaux & Befus, 2016) Occipital Nerve Blocks (Sheeler, et al., 2016); (Murinova & Krashin, 2015) Blockage-? Prevent and/or treat a migraine! "#$ %&' ()*+(h)*%- &)*./ )4 & 6 "#$ %&' )&3)*+7 &)*./ )4 {9: 1213)4}, =/3h +&&)*.%3+&>.%170-%30*) Biofeedback and Cognitive therapy (Sheeler, et al., 2016); (Murinova & Krashin, 2015) (Deen et al., 2017; Hay & Walker, 2017; Krasenbaum, 2017)

8 CGRP Inhibitors Symptom Interaction Monoclonal antibodies Block production of CGRP Reduce level of CGRP released Prevent CGRP from activating Sleep Headache Evidence shows effectiveness- in episodic and chronic migraine Side effects- URI/UTI, fatigue, back pain, N/V arthralgia, injection site pain Less side effects than Topiramate (Deen et al., 2017; Hay & Walker, 2017; Krasenbaum, 2017) Cognitive Irritability/ Mood Preventatives and Co-morbid Conditions Condition Consider Avoid or Caution Depression TCA, SSRI, SNRI Beta Blocker Bipolar Disorder Divalproex,* TCA, SSRI, SNRI Topiramate* Anxiety TCA, SSRI, SRNI, Beta Blocker* Sleep Disturbances TCA, Prazosin, Magnesium Stroke/CVD/Hemiplegic Aspirin, Magnesium Ergot, Triptan Migraine Fibromyalgia TCA, SNRI, Pregablin Beta Blockers Obesity Topiramate TCA, Divalproex, SSRI Epilepsy Topiramate, Divalproex TCA, SSRI, SNRI Raynaud s Phenomenon Muscle Spasms Calcium Channel Blocker Tizanidine, Cyclobenzaprine, Magnesium Beta Blockers, Ergot * FDA approved for migraine 45 Medication Overuse Starting a preventative medication while stopping the offending agent is helpful When weaning off the offending agent a transient increase in headache can occur lasting 2-10 days Consider short course of corticosteroids, NSAIDS, or dihydroergotamine (unless these were the offending agent) Occipital blocks (Sheeler et.al, 2016); Murinova & Karshin, 2015) 46 VITAL BEHAVIORS Education Diagnosis Correctly Treat Appropriately Communicate Effectively Headache Management Headache calendar Sleep hygiene techniques Abstinence/limited alcohol use Proper nutrition/limited caffeine/proper water consumption Coping strategies/journaling/stress management Limited use of abortive medication/avoid overuse headaches Realistic expectations (Sheeler et.al, 2016); Murinova & Karshin, 2015)

9 49 50 (Onabotulinumtoxin A Botox ) Injection Paradigm 31 injections in to 7 muscle groups Additional Modalities When medication is not working or not tolerated Blumenfeld et. al, Headache 2010;50: Occipital Nerve Anatomy

10 Occipital Block Injection Sites Transcutaneous Supraorbital Neurostimulation/ Cefaly FDA approved for prevention of migraine (March 2014) Varying results- need to use it daily for 20 min Currently not covered by Insurance Cost $349.00, pack of 3 electrodes $25.00 (good for 20 treatments each) GON aiming slightly up maintaining a subcutaneous course LOC aiming lateral and up, maintaining a subcutaneous course Cranial Electrotherapy Stimulation Alpha-stim AID Acupuncture FDA approved for treatment of Anxiety, Depression, Insomnia No need to monitor labs/minimal side effects/no dependency Cost savings in reduction of other meds/treatments Qi, or energy, travels along 12 main pathways or meridians within the body Health is influenced by the quality, quantity and balance of our Qi Qi is profoundly disturbed by traumatic stress Cochrane systemic review 2016 Acupuncture should be considered for migraine patients for prevention, particularly if having adverse effects from medications Acupuncture effect size was statically significantly larger in real acupuncture verses sham acupuncture for chronic headaches Acupuncture should be considered for treating episodic or chronic tension headaches (Coeytaux & Befus, 2016) Auriculotherapy/Auricular Acupuncture Relaxation Techniques With permission from Terry Oleson, Ph.D

11 Mobile Apps Mobile APPS Breath2Relax Virtual Hope Box Mindfulness Coach -TSWF-AIM-Client-Handout-Aug2016-web.pdf Checklist for providers to recommend specific apps or websites Square Breathing Peppermint oil H O L D INHALE EXHALE H O L D Well tolerated- used for aromatherapy, topical use, enema Helpful for: Tension headache Irritable Bowel Non-ulcer dyspepsia Nausea Relaxes smooth muscle/relieves colonic spasms with barium enemas KDW Health Management LLC Peppermint oil Lavender When ingested side effects- allergic reactions, heartburn, perianal burning, blurred vision, nausea/vomiting May inhibit cytochrome P450 1A2 system Contraindicated - Hiatal hernia, severe GERD, gallbladder d/o, caution with pregnancy and breast feeding. (Has been used to trigger menstruation) Should not be used near the face of infants due to potential to cause bronchspasms (Briggs, 2016); (Kliger & Chaudhary, 2007) Thought to act on the limbic system, when inhaled, especially on the amygdala and hippocampus- Safety concerns- short term safe, need long term studies, some concern for gynecomastia when applied to skin. Some GI upset when ingested Do not ingest during pregnancy or breastfeeding Helpful for- Anxiety Depression Insomnia No potential for drug abuse (Koulivand, Ghadiri & Gorji, 2013)

12 No one cares how much you know, until they know how much you care Theodore Roosevelt Empathetic Listening Case Presentation Headache Syndrome Migraines + new onset headaches for 2 years Background Social & Medical History 44yr old female with a history of refractory headaches for the last 2 years Migraines since 1990 s- described as posterior pressure, treated with Advil. If untreated will cause photophobia/phonophobia & worse with exertion 2 nd type started 2 years prior. Described as bi-frontal and right eye pressure increases to 4-6/10 and occasion to 8-9/10 w/photo/phonphobia Would occur upon waking up in the morning, worsen with exertion and when dehydrated. Lasting up to 2 weeks and occurring monthly Treated with zomig and advil- with about 1/3 resolved with this Treated in past by a neurologist- MRI of Brain WNL 44 yr old female/married/home-maker/ Graduated High School- some college No Tobacco/ Occasional ETOH/Occasional caffeine/diet balanced/elliptical 3 x s per week Enjoys travel, reading and volunteering Migraines, Right shoulder arthritis, Cervical DDD, low back pain Hx of fall while skiing 2006 with tailbone fx, right shoulder injury and concussion Allergic to Sulfa Surgical- none Family hx- Migraines- Mother & Father

13 Significant Exam Findings Treatment Normal Neurologic exam Bil occipital tenderness Pulling sensation to right of C4 to C7 with rotation of head to left MRI of c/spine- DDD with disc protrusion Topiramate titration/maintain zolmitriptan Botox Headaches improved at f/u but still with multiple headaches Consult to neurosurgeon- stable- consult to PT Occipital blocks & auricular acupuncture at f/u with dramatic reduction in headaches B/P elevated and switched Topiramate to Propranolol 80 LA 2 nd & 3 rd rounds of Botox Maintained on Propranolol 80LA Continued control of headaches to one per month and occasional occipital headache Overjoyed at having this treated! Summary VITAL BEHAVIORS Step 1- Diagnosis the headache or headaches- Tension and Migraine are the most common primary headaches Diagnosis Correctly Step 2- Accurate and through headache history Step 3- Physical exam/ rule out systemic illness Step 4- Identifying triggers and exacerbating factors Treat Appropriately Headache Management Step 5- Action Plan- Acute, preventative, lifestyle modifications, education is a key component (Realistic Expectations) Communicate Effectively Headache table Migraine Tension-Type SAH Location Unilateral Bilateral Occipital Intensity Moderate to Severe Mild to Moderate Severe/ Worst HA of life Duration 4 to 72 hours 30 mins to 7 days Sudden/rapid onset Sentinel HA may be seconds to minutes Quality Pulsating Pressure/Tightening Thunderclap Associated Symptoms Nausea, vomiting, photophobia, phonophobia Photophobia or phonophobia ( but not both) N/V, Photophobia, Neck stiffness, seizures, LOC, COMA Female: Male ratio 3 : : 1 Higher in females, African and Asian heritages 77 Headache table Migraine Tension-Type CDH Location Unilateral Bilateral Varies Intensity Moderate to Severe Mild to Moderate Mild to severe Duration 4 to 72 hours 30 mins to 7 days Minutes to hours. 15 or more headache days per month for 3 months or more Quality Pulsating Pressure/Tightening Varies depending the type of primary headache Associated Symptoms Nausea, vomiting, photophobia, phonophobia Photophobia or phonophobia ( but not both) Look for medication over use, exacerbating factors Female: Male ratio 3 : : 1 No preference 78 13

14 Headache table Migraine Tension-Type Occipital Neuralgia Location Unilateral Bilateral Occipital Intensity Moderate to Severe Mild to Moderate Mild to severe Duration 4 to 72 hours 30 mins to 7 days Minutes to hours Pain transiently relieved by occipital block Quality Pulsating Pressure/Tightening Sharp, throbbing, pressure Associated Symptoms Nausea, vomiting, photophobia, phonophobia Photophobia or phonophobia ( but not both) Pain behind the eyes, nausea when pain severe, photophobia Female: Male ratio 3 : : 1 No preference, seen often after head/neck trauma References 1. Becker, W. J. (2015). Acute migraine treatment in adults. Headache: The Journal of Head and Face Pain, 55(6), Briggs, P. (2016). Inhaled peppermint oil for postop nausea in patients undergoing cardiac surgery. Nursing, 46(7), Coeytaux, R. R., & Befus, D. (2016). Role of acupuncture in the treatment or prevention of migraine, tension-type headache, or chronic headache disorders. Headache: The Journal of Head and Face Pain, 56(7), Deen, M., Correnti, E., Kamm, K., Kelderman, T., Papetti, L., Rubio- Beltrán, E., On behalf of the European Headache Federation School of Advanced Studies (EHF-SAS). (2017). Blocking CGRP in migraine patients a review of pros and cons. The Journal of Headache and Pain, 18(1), 96. References (continued) 5. De Luca GC, Bartleson JD. When and how to investigate the patient with headache. Semin Neurol. 2010; 30: Goldberg LD. The cost of migraine and its treatment. AM J Manag Care 2005:11(2 suppl): Hay, D. L., & Walker, C. S. (2017). CGRP and its receptors. Headache: The Journal of Head and Face Pain, 57(4), Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders:3 rd edition (beta version). Cephalagia 2013; 33(9): Kligler, B., & Chaudhary, S. (2007). Peppermint oil. American Family Physician, 75(7), References (continued) 10. Koulivand, P. H., Ghadiri, M. K., & Gorji, A. (2013). Lavender and the nervous system. Evidence-Based Complementary & Alternative Medicine (ecam), 2013, Lipton RB, Bigal ME, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007; 68: Marmura, M. J., Silberstein, S. D., & Schwedt, T. J. (2015). The acute treatment of migraine in adults: The american headache society evidence assessment of migraine pharmacotherapies. Headache: The Journal of Head and Face Pain, 55(1), Martin V, Elkind A. Diagnosis and classification of primary headache disorders. In: Standards of Care for Headache Diagnosis and Treatment. Chicago Ill: National headache Foundation 2004; References (continued) 14. Murinova, N., & Krashin, D. (2015). Chronic daily headache. Physical Medicine and Rehabilitation Clinics of North America, 26(2), Sheeler, R. D., Garza, I., Vargas, B. B., & O'Neil, A. E. (2016). Chronic daily headache: Ten steps for primary care providers to regain control. Headache: The Journal of Head and Face Pain, 56(10), 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; Stewart WF, et al. Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce. JAMA 2003; Stovner LJ, et al. The Global Burden of headache: A Documentation of Headache Prevalence and Disability Worldwide. Cephalgia 2007; 27:

15 References (continued) 19. Pringsheim, T., Davenport, W. J., Marmura, M. J., Schwedt, T. J., & Silberstein, S. (2016). How to apply the AHS evidence assessment of the acute treatment of migraine in adults to your patient with migraine. Headache: The Journal of Head and Face Pain, 56(7), The Cleveland Clinic Health Foundation. Overview of headache in adults. Cleveland Clinic Health Information Center website. Accessed Feb Karen Williams, DNPc, RN, FNP-BC