OH, MY ACHING HEAD! I HAVE NO DISCLOSURES OR CONFLICTS OF INTERESTS TO DECLARE MANAGING HEADACHE IN THE OUTPATIENT SETTING SECONDARY HEADACHES
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1 1 JUSTIN A. OSSMAN, MD CHATTANOOGA FAMILY MEDICINE UPDATE OH, MY ACHING HEAD! MANAGING HEADACHE IN THE OUTPATIENT SETTING 2 I HAVE NO DISCLOSURES OR CONFLICTS OF INTERESTS TO DECLARE OBJECTIVES International Headache Society (IHS) Classifications Common Headaches Medical and Alternative Therapies Role of Imaging IHS CLASSIFICATIONS PRIMARY HEADACHES Migraine Tension-Type Headache Cluster Headache and other Trigeminal Autonomic Cephalgias Other Primary Headache Disorders 3 4 IHS CLASSIFICATIONS SECONDARY HEADACHES Headache attributed to Trauma Vascular / Non-Vascular Substance or Withdrawal Infection Metabolic Disorder IHS CLASSIFICATIONS TERTIARY HEADACHES Cranial Neuralgias Central and Primary Facial Pain Other Headaches 5 6
2 CHARACTERISTICS Determine if with aura or without aura Lasts 4-72 hours Descriptive terms: Unilateral Pulsating / Throbbing quality Moderate to severe intensity A/w nausea and/or vomiting Photo- / Phonophobia Aggravated with exertional activity Neurovascular headache 5-HT Genetic component Vulnerability > Attack Initiation (Triggers) > Prodrome > with/without Aura > Headache > Resolution > Hangover 7 8 ACUTE Rest Analgesics Antiemetics Triptans Ergotamines Intranasal Lidocaine 4% ACUTE - ANALGESICS OTC Analgesics and NSAIDs NSAID combinations (Anacin, Excedrin) Barbiturate / NSAID combinations (Fioricet) Narcotics Tramadol 9 10 ACUTE - ANTIEMETICS Reglan Promethazine Ondansetron ACUTE - TRIPTANS Almotriptan (Axert): PO Eletriptan (Relpax): PO Frovatriptan (Frova): PO Naratriptan (Amerge): PO Sumatriptan (Imitrex / Treximet / Zecuity): PO, nasal spray, SC, transdermal Rizatriptan (Maxalt): PO, Dissolving wafer Zolmitriptan (Zomig): PO, Dissolving tablet, nasal spray 11 12
3 ACUTE - ERGOT ALKALOIDS Ergotamine (Ergomar): PO Dihydroergotamine (D.H.E. 45 / Migranal): Injectable, intranasal, inhaled (pending FDA approval) PROPHYLAXIS Tricyclic Antidepressants Anti-Epileptics ß-Blockers Ca2+-Channel Blockers NSAIDs Botulinum Toxin A CAM CAM Acupuncture Biofeedback Botox Butterbur Behavioral Tx Feverfew Magnesium CHARACTERISTICS Lasts 30 minutes to 7 days 2 pain characteristics: Pressing or tightening quality Mild to Moderate intensity Bilateral No aggravation w/ routine activity Both: No N/V 1 of Photophobia or Photophobia Physical activity / Yoga Riboflavin (B2) CoQ10 Meditation TENS device TMS Dietary Muscle tension Usually absent any signs of serious underlying condition Trigger control Analgesics +/ Adjuncts Trigger point injections Botulinum toxin A Biofeedback, etc. Physical Therapy Acupuncture 17 18
4 PROPHYLAXIS Amitriptyline Venlafaxine Mirtazapine Trigger Point Injections Behavioral Treatment Acupuncture Physical Tx / OMT TRIGGER POINT INJECTIONS OCCIPITAL NERVE INJECTION Image credits (clockwise from left): burnabyneurology.com, vanderbilthealth.com, intelligentpainsolutions.com CHARACTERISTICS CLUSTER HEADACHE Unilateral in temporal or periorbital area Lasts approx minutes (Untreated) 1 episode QOD to 8 episodes/day Severe pain ( Suicide headache ) Associated Sx: 1 ipsilateral Sx in Eye, Nose, or Face Restlessness or Agitation CLUSTER HEADACHE Vascular dilation Trigeminal nerve stimulation Histamine release Circadian rhythm disturbances Genetics ACUTE CLUSTER HEADACHE Supplemental Oxygen Triptans Intranasal Lidocaine 4% CHRONIC CLUSTER HEADACHE Verapamil Lithium Corticosteroids: PO, Trigger point Deep brain stimulation 23 24
5 PROPHYLAXIS CLUSTER HEADACHE Verapamil Corticosteroids Topiramate Melatonin Gabapentin CHARACTERISTICS MEDICATION OVERUSE HEADACHE (MOH) Nearly daily occurrence Diffuse or dull Usually bilateral Headaches worsen as Tx becomes less effective Typical offenders: OTC / Rx analgesics, Caffeine, Sedatives, Ergotamines MEDICATION OVERUSE HEADACHE Increased excitability of neurons 5-HT mediated MEDICATION OVERUSE HEADACHE Stop offending agent Counsel patient HA may worsen Consider alternative methods of Tx ACR APPROPRIATENESS CRITERIA 29 ROLE OF IMAGING CT brain: Acute Worst headache of my life Post-traumatic MRI brain: New or Chronic w/ or w/o new features and neurologic findings 2/2 sinusitis or mastoiditis Suspected temporal arteritis, meningitis / encephalitis IF ONLY IT WERE THIS SIMPLEÁ 30 NO BRAIN, NO HEADACHE. Anonymous
6 TEXT 31 REFERENCES International Headache Society. "Headache Free". R. Cady, M.D.; K. Farmer, Psy.D AmericanHeadacheSociety.org. Cruse DO, Robert. Acute Treatment of Migraine in Children. UpToDate.com. Blau, J.N. Migraine: theories of pathogenesis. The Lancet. Vol. 339, Issue 8803, Reddy, Doodipala. The Pathophysiological and Pharmacological Basis of Current Drug Treatment of Migraine Headache. Expert Rev Clin Pharmacy. 2013;6(3): Loder, Elizabeth. Triptan Therapy in Migraine. N Engl J Med. 2010;363: Silberstein, Stephen. 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;55; Maizels, M.; Geiger, AM. Intranasal lidocaine for migraine: A randomized trial and open-label follow-up. Headache Sep;39(8): TEXT 32 REFERENCES Armstrong, Laura; Gossard, Geraldine. Taking an integrative approach to migraine headaches. The Journal of Family Practice. 2016;65(3): Jackson, JL, et al. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a metaanalysis. JAMA Apr 25;307(16): Paul Millea and Jonathan Brodie. Tension-Type Headache. Am Fam Physician. 2002;66: ,805. Frederick Taylor. Tension-Type Headache In Adults: Acute Treatment. UpToDate.com. Accessed Dec Frederick Taylor. Tension-Type Headache In Adults: Preventive Treatment. UpToDate.com. Accessed Dec Karadas et al. Lidocaine injection of pericardial myofascial trigger points in the treatment of frequent episodic tension-type headache. The Journal of Headache and Pain. 2013;14:44. Jacqueline Weaver-Agostoni. Cluster Headache. Am Fam Physician. 2013;88(2): Gadsby, Peter. Treatment of Cluster Headache. Information for Health Care Professionals. American Headache Society. Robbins, L. Intranasal Lidocaine for Cluster Headache. Headache: the Journal of Headache and Face Pain. 1995;35(2): Srikiatkhachorn, A, et al. Pathophysiology of Medication Overuse Headache: An Update. Headache. 2014;541: American College of Radiology ACR Appropriateness Criteria.
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