Headaches: An Approach to Evaluation & Management

Transcription

1 Florida Osteopathic Medical Association 17 th Annual Primary Care & Cardiovascular Symposium Headaches: An Approach to Evaluation & Management Kenneth Hentschel, DO, PhD, FAANEM St. Vincent s Spine & Brain Institute

2 Disclosures I have no financial relationships that impact on this activity

3 Learning Objectives To identify patients at risk of having secondary headache disorders To select appropriate tests for patients with features of secondary headache disorders To prescribe patient-specific acute and transitional headache therapies To identify and treat patients who may benefit from headache prophylactic therapy

4 Relevance Acute headache is a common chief complaint in the emergency department or the primary physician's office Acute headache can be a sign of serious underlying disease with high morbidity and mortality

5 Overview Definitions: Primary & Secondary Headaches Secondary Headache Identification Primary Headache Treatment Principles Stratified Acute Therapies Preventative Therapies Summary Case for Applied Principles Status Migrainosus ED Treatment

6 Approach to Acute Headache First goal is to differentiate between primary and secondary headache disorders A PRIMARY headache is a condition whereby headache as a symptom has no identifiable underlying disease state Examples: migraine, tension or cluster headaches. A SECONDARY headache is a disease state whereby the headache is a secondary manifestation of an underlying pathology Examples: Hemorrhage, abnormal ICP, infection, neoplasm, inflammation, infarction

7 Secondary Headache Disorders Hypertensive crisis Subarachnoid hemorrhage Cerebral infection Cerebral venous sinus thrombosis Cervical artery dissection Complicated sinusitis Intracranial hemorrhage Ischemic infarction Spontaneous intracranial hypotension Subdural hematoma Brain tumor Giant cell arteritis Pituitary apoplexy Obstructive hydrocephalus Epidural hematoma Intracranial aneurysm Intracranial AVM

8 Risks for Secondary Headache A change from the usual Headache character First headache, particularly (in patients >50 yo) Worst headache Side-locked, invariable Persistent headache or nonresponsive headache Positional headache Fever, nuchal rigidity associated features Loss of consciousness, altered level of awareness associated features Focal neurologic signs as accompaniments Papilledema on examination Jaw claudication and visual loss

9 Approach to Acute Headache BEWARE, the location and character of headaches are nonspecific BEWARE, since the pathophysiology of headache is a common final pathway, primary or headache disorders may present similarly BEWARE, people with known primary headaches (migraines) may develop a secondary headache disorder, so remain vigilant

10 Pathophysiology Primary headache Ex. Genetic Secondary headache Ex. Hemorrhage Spreading wave of cortical excitation/depression Decreased serotonergic activity at hypothalamus/brainstem Sensitization of trigeminal pain pathways HEADACHE

11 Labs Testing for Secondary Headache CBC (infection, myelodysplasia) Coag panel (coagulopathy) ESR, CRP (arteritis) Drug screen (Sympathomimetics) Radiography CT head without contrast (acute hemorrhage) MRI brain (hemorrhage, infarct, neoplasm, infection) CTA/MRA head, possibly neck (Vascular lesions) Lumbar puncture/csf evaluation Opening pressure (Pseudotumor, low pressure headaches) Cell counts (Infection, hemorrhage) Cultures (Infection) Cytology (neoplasm)

12 Principles of Primary Headache Therapy Early treatment is the goal. All headache therapies are more effective when used earlier. Headaches are like house fires, they are easier to put out early on. Therapies with faster onset of action can be more efficacious Injection > nasal spray > solubilized powders > gelcaps > tablets Consider comorbidities and accompanying symptoms as you tailor headache therapies Two medications used together can be synergistic, more effective than either alone

13 Principles of Primary Headache Therapy Stratified approach: The medication chosen is based upon the attack severity and characteristics First tier: Lower potency agents, often available over-the-counter, for lower severity benign headache Lower cost; similar efficacy sometimes if used early Second tier. Moderate to severe headaches, or headaches refractory to first tier treatments. Often migraine specific therapies (triptans) Third tier: Severe, uncontrolled rescue therapy. May contain combinations of medications for highest potency, possibly controlled substances if necessary

14 1st Tier Acute Primary Headache Therapy Acetaminophen 1000 mg PO (NTE 4g/d) Hepatic; Non-NSAID Aspirin mg PO (NTE 4g/d) NSAID; Gastritis Ibuprofen 400 mg PO (NTE 2400mg/d) *** Moderately efficacious; short half-life. NSAID; less gastritis Naproxen sodium mg PO (NTE 1375mg/d) *** Moderately efficacious; long half-life; NSAID; favorable cardiovascular profile Diclofenac potassium 50 mg PO (NTE 150mg/d) Moderate-highly efficacious; NSAID; Rapid onset Ketorolac 10 mg PO (NTE 40mg/d); 30mg IM/IV (NTE 120mg/d)

15 2nd Tier Acute Primary Headache Therapy Indication: Used for headaches of moderate to severe intensity or for headaches refractory to tier 1 agents Triptans are the mainstay of therapy in patients free of vascular disease Unlike other therapies, triptan dosing should be high range Do not Start low and go slow Instead, Put the fire out Insurance contracts may limit your (initial) choice Document treatment failures or limitations

16 2nd Tier Acute Primary Headache Therapy Sumatriptan 100mg PO*** 6mg SQ highest efficacy (if tolerated); Fastest onset 20mg NS Rizatriptan 10mg (ODT) PO longer half-life for rebound HA Zolmitriptan 2.5mg (ODT) PO 5mg NS Frovatriptan 2.5mg PO longer half-life for rebound; menstrual Almotriptan 12.5mg PO best tolerated for sensitive patients Naratriptan 2.5mg PO Eletriptan 40mg PO most efficacious among PO; long half life

17 3rd Tier Acute Primary Headache Therapy Indication: Used for severe headaches; rescue therapy 2 medications used together can be synergistic, more effective than either alone Naprosyn sodium + TRIPTAN Naprosyn long half-life; Sumatriptan fast onset Diclofenac potassium + TRIPTAN Diclofenac powder very fast onset; Frova long half-life BEWARE Cyclobenzaprine + TRIPTAN may provoke serotonin syndrome Altered mental status, tremor, autonomic instability

18 3rd Tier Acute Primary Headache Therapy 2 medications used together can be synergistic Metoclopramide (10mg ODT) + TRIPTAN Use if significant nausea; prokinetic/gi; poss EPS side effect (tardive dyskinesia) Dexamethasone (4mg PO) + TRIPTAN Dex if component of inflam (eg cervicogenic); caution if DM DHE (0.5mg each nostril q15m, NTE 4 uses/6h; NTE 4mg/d) Back box warning for periph ischemic from DD interxn with macrolides: Azithromycin, clarithromycin, erythromycin, telithromycin, fidaxomicin Butalbital/acetaminophen/caffeine (50/300/40; 1-2 tabs PO q6h; Bu NTE 300mg/d) Opioids/Barbiturates Not recommended for regular use Agents tend to be lower potency Agents tend to produce rebound headaches Agents can lead to dependency

19 Headache Preventative Therapy Indication: Severe primary HAs occurring 2-4x/mo or more; disabling, causing significant impairment of ADLs Goal: decrease frequency and severity of acute HAs 50% Over time may increase efficacy of primary acute HA treatments Slow onset, usually takes weeks to 1 month to work Education; set expectations Start dosing low, titrate to lowest effective dose slowly Choose agent based upon patient comorbidities/characteristics

20 Headache Preventative Therapy Level A Evidence Topiramate 25mg po QHS*** [Goal dose mg PO BID] Associated with Weight loss: Anticonvulsant AE: cholelithiasis, metallic taste, paresthesia; slowed cognition Metoprolol Tartrate 25 mg PO BID; NTE 200 mg/d May also palliate HTN, tremor Avoid in reactive airway disease AE: fatigue, dizzy, bradycardia Propranolol HCl ER 80 mg ER PO QD Valproic acid 250 mg PO BID May palliate labile mood; anticonvulsant Avoid in young females (teratogen, alopecia, wgt gain) AE: tremor, hepatoxicity

21 Headache Preventative Therapy Level B Evidence Amitriptyline mg PO QHS*** May palliate Sleep, pain, mood AE: wgt gain, dry mouth Venlafaxine 37.5 mg PO Qam ER preparation better tolerated; goal 75mg ER PO QAM May also palliate mood AE: insomnia Atenolol 50mg PO QD Better tolerated than propranolol Same precautions

22 Headache Preventative Therapy Alternative Agents May use as preventative therapy or as an adjunct Feverfew mg PO QD Riboflavin (vitamin B2) 400 mg PO QD Coenzyme Q mg PO QD Magnesium citrate 300 mg PO BID Butterbur 75 mgpo BID

23 Summary Remain vigilant and recognize the patients with less common secondary headache disorders among the common primary headaches Perform additional testing when necessary to evaluate patients suspected of having secondary headache disorders

24 Summary In patients with primary headache disorders, educate regarding multimodal therapeutic plan, which could include preventative and stratified acute therapies Tailor the therapies for the patient's unique comorbidities and characteristics Encourage her regular routine of sleep, exercise and diet. Instruct the patient's to track headache severity, frequency and response to therapy for tailored plan of care

25 Case 34-yo female with episodic HAs since teens, variable location, severity 7 10/10, frequency 5/mo, duration hours -all day. Associated features: mild nausea without vomiting, and scintillating visual display. Provocation with stress or insomnia. Normal neurologic exam. PMH: asthma, controlled. Head CT was normal. She previously tried sumatriptan 50mg PO, which was helpful temporarily, but she developed recurrent headache.

26 Case No red flags for secondary headache disorder Prevention therapy: amitriptyline 25 mg nightly Palliates headache, sleep, inexpensive; SLOW onset Stratified acute primary headache therapy: First tier: Naprosyn sodium 500 mg PO BID PRN Second tier: Eletriptan 40 mg PO PRN Longer half-life to combat rebound Third tier: as above, add metoclopramide 10 mg PO Palliates HA, nausea and synergistic w prior meds Education, education, education

27 Status Migrainosis 1. NS 1L, IV, ml/min 2. Diphenhydramine mg IV 3. Metoclopramide 10mg IV 4. Magnesium sulfate mg IV 5. Ketorolac 30mg IV 6. Options; choose one: i. Valproic acid 500mg IV ii. Levetiracetam 500mg IV iii. Methylprednisolone 200mg IV 7. DHE 0.5-1mg IV (if no triptan in last 24h) *Meds given in succession, separated by minutes. *SL Orr et al. Canadian headache Society systemicatic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia 2015; 35 (3):

28 References WJ Becker. Acute Migraine Treatment. American Academy of Neurology Continuum (Minneapolis MN) 2015;21(4): Practical Neurology, by Jose Biller. 4 th Edition. Lippincott, Williams & Wilkins, Philadelphia PA Chapter 20: Approach to the patient with acute headache, by DL Gordon, pp

29 Thank You Kenneth Hentschel, DO, PhD, FAANEM St Vincent s Spine & Brain Institute Office phone: General neurology or subspecialty referrals: doctor.hentschel@gmail.com