ปวดศ รษะมา 5 ป ก นยาแก ปวดก ย งไม ข น นพ.พาว ฒ เมฆว ช ย โรงพยาบาลนครราชส มา

Transcription

1 ปวดศ รษะมา 5 ป ก นยาแก ปวดก ย งไม ข น นพ.พาว ฒ เมฆว ช ย โรงพยาบาลนครราชส มา 1

2 CONTENT Chronic Daily Headache Medical Overused Headache Management

3 Headaches are one of the most common symptoms List of differential diagnoses over 300 different types and causes Cause of most headaches can determined by a careful history and neurologic examination Neurol Clin 1996;14:1-2. 3

4 3026 neuroimaging scans patients with headache and normal neurologic examination is quite low; brain tumors, 0.8% arteriovenous malformations, 0.2% hydrocephalus, 0.3% aneurysm,0.1% subdural hematoma, 0.2% strokes, 1.2% 1440 scans of patients with migraine: brain tumor, 0.3% arteriovenous malformation, 0.07% saccular aneurysm, 0.07% White matter abnormality reported on MRI in all types of migraine, range from 12% to 46% Neurol Clin 1996;14:1-2. 4

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6 Consider Headache Prophylactic Therapy Patient s condition and related disorder

7 emegal lery.co m

8 CONTENT 1 Chronic Daily Headache

9 headache 15 d/mo, for at least 3 months lasting more than 4 hours CDH has 4 subtypes: Chronic Daily Headache (CDH) Definition: Chronic migraine CDH New daily persistent headache Hemicrania continua Chronic tension type Headache 2011;51 Suppl 2:

10 Chronic Migraine Unilateral or bilateral Pulsating in quality Moderate to severe intensity Worse by routine activity Hemicranial Continua Unilateral Daily and continuous Without pain free period Moderate intensity but sometime severe Indomethacin-response New Daily Persistent Headache New onset (within 3d) Persistent Character of pain not making diagnosis Chronic Tension Type Bilateral location Pressing/tightening (non-pulsating) Mild to moderate intensity Not worsen by routine activity N Engl J Med 2006;354: Cephalgia 2004;24:

11 Chronic Daily Headache (CDH) 15 days a month more than 4 hours a day If it lasts less than 4 hours a day Trigeminal Autonomic Cephalalgia (TAC) TACs include Episodic & Chronic cluster headache Episodic & Chronic paroxysmal hemicrania SUNCT Hypnic headache J Headache Pain 2007;8:

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13 2 Medical Overused Headache CONTENT

14 Regular overuse for 3 months of one or more drugs for acute headache treatment (depending on the medication) 10 d/mo 15 d/mo Duration Ergotamine Paracetamol Triptan NSAIDs 3 months Opioids Combinations The International Classification of Headache Disorders 3rd edition 14

15 In a study on episodic migraine (n=532) 1-year incidence of chronic headache was 14% Higher preponderance in woman higher headache frequency at baseline taking greater amounts of analgesics Poorer quality of life (Measured by scales: higher score on MIDAS: Migraine disability assessment scale) MOH Introduction & Epidemiology

16 Characters of MOH Occur daily or nearly daily Vary in severity, type and location from time to time Low threshold for head pain (physical or mental effort) Withdrawal symptoms occur when stop pain medication (need medications) Improvement of headache occurs after stop medications Prophylactic medications ineffective while taking excess amounts of pain relief drugs

17 MOH is 3 rd most common form of headache (following TTH and migraine) Unclear pathophysiological mechanism All analgesic drugs can inducing MOH Characters of MOH Drug withdrawal is the most effective treatment Early initiate adequate prophylactic treatment regimens

18 Diagnostic Criteria for Medications-overuse Headache (MOH) Headache present 15d per month Regular overuse for 3 months of one or more drugs for acute headache treatment (depending on the medication) Headache develop or markedly worsened during medication overuse Headache resolve or improved from previous pattern within 2 months after stop of overused medication The International Classification of Headache Disorders 3rd edition 18

19 3 Management CONTENT

20 Patients should be advised to Correction for Expectation Maintain a regular lifestyle, with adequate sleep, meals, exercise, and manage stress. Any identifiable Trigger should be avoided Taper overused medication/caffeine over 4-6 wk Add preventive medications Treatment of MOH Out patient

21 Treatment of MOH In patient Abrupt drug withdrawal is the treatment of choice for MOH Fluid replacement Antiemetic Analgesic Prednisolone 60 mg in d1 taper by 20 mg q 2d total 6d Start preventive medications simultaneously

22 Reduce - attack frequency, severity, and duration - acute medication use and prevent MOH - unnecessary medical care Improve - responsiveness to acute attack - QOL GOAL of Preventive treatment

23 Principle of Prophylactic Initiated with first line medications Initiated with lowest effective dose and increased slowly until clinical benefits are achieved without any adverse events Adequate trial 2-3 months should be given to each drug Use of a long-acting formulation may improve compliance Br J Pharmacol 2001;132:

24 Principle of Prophylactic Combination of first line drugs should be tried before advancing to 2 nd line drug (in case of monotherapy are ineffective) Lack of response to several prophylactic drugs remain use of medication overuse should be suspected Gradual withdrawal should be considered after 6 to 12 months of effective prophylaxis, Br J Pharmacol 2001;132:

25 Treatment of MOH Medications Dosage TRICYCLIC ANTIDEPRESSANT Amitriptyline mg/d Nortriptyline mg/d BETA-BLOCKER Propranolol mg/d ANTIEPILEPTICS Topiramate mg/d Valproate mg/d Gabapentin mg/d CALCIUM CHANNEL BLOCKER Flunarizine 5-10 mg/d Verapamil mg/d Am Fam Physician 2006;73:

26 Neurology 2012;78:

27 BOTULINUM TOXIN for Chronic Migraine Totally 155 u

28 Non-pharmacologic Prevention Adequate hydration Adequate sleep Managing stress, anxiety, depression Exercise Behavioral therapy Other relaxation Acupuncture Transcutaneous Electrical Nerve Stimulation (TENS) Br J Pharmacol 2001;132:

29 March 2014, the FDA approved the first device for the preventive treatment of migraine for adults Supraorbital Transcutaneous Stimulator 29