Faculty Disclosures. Learning Objectives

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1 Case Study 1 and Q & A Content developed by: Lawrence C. Newman, MD, FAHS Donna Gutterman, PharmD Faculty Disclosures LAWRENCE C. NEWMAN, MD, FAHS Dr. Newman has received consulting fees and/or honoraria from Allergan, Inc., Labrys Biologics, NuPathe, and Zogenix. Dr. Newman is on the speaker bureaus for Allergan, Inc. and Zogenix. DONNA GUTTERMAN, PHARMD Dr. Gutterman has received consulting fees and/or honoraria from NuPathe, Teva Pharmaceuticals, Dr. Reddy Pharmaceuticals. Learning Objectives At the conclusion of this talk, participants will be able to: 1. Screen for secondary headache disorders using the SNOOP 4 paradigm 2. Evaluate the need for ancillary testing in patients presenting with headache 3. Order and analyze appropriate test results in patients in whom headache patterns have changed 1

2 Terri, Age year history of migraine without aura Typically associated with her menstrual cycle Stress and changes in weather are triggers Terri Presents with.. Daily headache Increasing in frequency for the last 4 months Headache Frequency: September December September October November December 2

3 What else would you like to know? What Else Would You Like To Know? Is this different than her prior attacks? What Else Would You Like To Know? Pain is generalized, dull, and associated with nausea Awakens with headache every morning for past 2 months Only pain-free time was during a ski trip 2 weeks ago Medical and neurological exams (while pain-free) are normal 3

4 What Else Would You Like To Know? cont. Is this different than her prior attacks? Are there other features associated with these new attacks... Photo-, phono-, or osmophobia? Autonomic signs? Weakness, numbness, speech disturbances? Systemic signs/symptoms? Symptoms of allodynia? Do the HAs remit spontaneously? How does she treat the HA? Yes No No Generalized weakness Fatigue Hurts to brush hair I don t know; I always treat them Sumatriptan 6 mg sc almost every morning for the past 2 months Previously used OTC aspirin/acetaminophen/caffeine tablets Next Steps? Diagnose Chronic migraine with MOH* Limit acute treatment Sumatriptan 2 days/week Begin prevention Follow-up Topiramate 25 mg hs and titrate up to 100 mg hs 1 month *Medication Overuse Headache 1-Month Follow-Up No improvement Daily headache persists On days without sumatriptan notes that headache spontaneously remits while at work Fatigue, nausea, and weakness persist all day Exam still normal 4

5 Terri s Headache Diary ARS Question What is the most appropriate next step with this patient? A. B. Imaging C. Blood work D. All of the above 5

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8 Boyfriend, with whom she lives, has same symptoms 8

9 Boyfriend, with whom she lives, has same symptoms Consultation was called...with a plumber Boyfriend, with whom she lives, has same symptoms Consultation was called...with a plumber Boyfriend, with whom she lives, has same symptoms Consultation was called...with a plumber Hot water heater has a leak 9

10 Carboxyhemoglobin level Boyfriend, with whom she lives, has same symptoms Consultation was called...with a plumber Hot water heater has a leak Boyfriend, with whom she lives, has same symptoms Consultation was called...with a plumber Hot water heater has a leak Carboxyhemoglobin level 10% Carbon Monoxide Toxicity Carbon monoxide (CO) is a colorless, odorless gas CO binds to hemoglobin >200 times higher affinity than oxygen so even small concentrations can result in significant levels of carboxyhemoglobin (HbCO) CO toxicity causes impaired cellular oxygen delivery and utilization Ernst A et al. NEJM. 1998;339:

11 CO Toxicity CO has its most profound impact on the organs with the highest oxygen requirement Brain Heart Kidney Headaches occur at levels around 10% Levels of 50 70% may cause: Seizure Coma Death HbCO levels often do not reflect the clinical picture Ernst A et al. NEJM. 1998;339: Symptoms of Acute CO Poisoning Malaise, flulike symptoms, fatigue Dyspnea on exertion Chest pain, palpitations Lethargy Confusion Depression Impulsiveness Distractibility Hallucination, confabulation Agitation Nausea, vomiting, diarrhea Abdominal pain Headache, drowsiness Dizziness, weakness, confusion Visual disturbance, syncope, seizure Fecal and urinary incontinence Memory and gait disturbance Bizarre neurologic symptoms, coma Ernst A et al. NEJM. 1998;339: Physical Findings of CO Poisoning Heart Tachycardia Hypertension or hypotension Hyperthermia Tachypnea Skin Classic cherry red skin is rare (ie, "When you're cherry red, you're dead ) Pallor is present more often Eyes Flame-shaped retinal hemorrhages Bright red retinal veins (a sensitive early sign) Papilledema Homonymous hemianopsia Lungs Noncardiogenic pulmonary edema Neurologic / Psychiatric Memory disturbances (most common), including retrograde and anterograde amnesia with amnestic confabulatory states Emotional lability Stupor, coma, gait disturbance, movement disorders, rigidity 11

12 Exclude Secondary Headache History and examination Assess for worrisome signs and symptoms Look for atypical features Screen for Red Flags SNOOP 4 Yes? Evaluate for Secondary Headache S Systemic symptoms (weakness, fatigue, nausea) N Neurologic symptoms or signs O Onset: abrupt, peak <1 min O Older: >50 (GCA; glaucoma, cardiac cephalalgia) P Previous headache history (symptoms changed over the past 4 months) P Postural, positional P Precipitated by Valsalva, exertion P Papilledema (pulsatile tinnitus, diplopia, transient visual obscurations) P Progressive (intractable) Dodick DW. Adv Stud Med. 2003;3: Pitfalls in This Case Remember SNOOP 4 : Systemic features o Generalized weakness o Fatigue o Nausea Change in headache pattern/history Don t be fooled by response to treatment Medication overuse doesn t always cause Medication Overuse Headache Lipton RB et al. Headache. 1997;37:

Faculty Disclosures. Learning Objectives. Acute Treatment Strategies

Faculty Disclosures. Learning Objectives. Acute Treatment Strategies WWW.AMERICANHEADACHESOCIETY.ORG Acute Treatment Strategies Content developed by: Lawrence C. Newman, MD, FAHS Donna Gutterman, PharmD Faculty Disclosures LAWRENCE C. NEWMAN, MD, FAHS Dr. Newman has received