HMFP Comprehensive Headache Center Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Instructor in

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2 HMFP Comprehensive Headache Center Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Instructor in Anesthesia and Neurology Harvard Medical School

3 Limited time to cover a huge amount of material A high-speed approach to clinical headache management Not a presentation of the latest research Will cover principles and treatment options Patient education is the most valuable treatment modality Flexibility is essential

4 Anxiety, depression, bipolar disorder, borderline personality disorder Stress is a consistent/common headache trigger 1) Psychotherapy/cognitive behavioral therapy 2) Biofeedback 3) Yoga/meditation 4) Exercise 5) Pain psychology

5 3 months or longer of taking acute medication more than twice a week 1) Limit acute medication use to no more than twice a week (identify an appropriate alternative) 2) Begin headache prevention 3) Taper the overused medication (washout can take several months)

6 1) Consistent sleep schedule (treat insomnia) 2) Regular meals with healthy snacks 3) Limit caffeine use 4) Stress management 5) Obesity

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8 Prevention indicated if a patient is experiencing two or more headaches a week Be aware of medication failures (inadequate treatment trials) Headache prevention can take 2-3 months to work and doses must be adequate Titrate dose slowly Combination therapy

9 Standard of therapy for many chronic medical conditions (diabetes, hypertension, HIV) Targets multiple pathophysiologic mechanisms Can address comorbidities such as depression, anxiety, bipolar disorder, insomnia Use non-pharmacologic methods as well

10 Beta-blocker plus TCA (depression and insomnia) Beta-blocker plus SNRI (depression and fibromyalgia) Beta-blocker plus topiramate (obesity) Topiramate plus tizanidine (insomnia) Personal preference

11 1) Topiramate: dose 50 mg bid. SE s include paresthesias, decreased appetite, cognitive dysfunction, kidney stones. Teratogenic (D) and can interfere with birth control. Especially useful in chronic migraine. FDA approved for episodic migraine. 2) Tizanidine: dose 6-8 mg/bedtime. SE s include sedation, rare transaminitis, nightmares. 3) Verapamil: dose 360 mg/day. SE s include hypotension, edema, constipation.

12 4) Valproate: dose 1,000 mg daily. SE s include gastric distress, hair loss, weight gain, tremor, rare transaminitis. Teratogenic (X for migraine prophylaxis, D for other indications). Effective in chronic daily headache. FDA approved for episodic migraine. 5) Amitriptyline: dose mg/bedtime. SE s include sedation, dry mouth, weight gain.

13 6) Propranolol: dose mg/d. SE s include hypotension, exercise intolerance, fatigue, depression. Contraindicated in asthma. FDA approved for episodic migraine. 7) Botulinum toxin Type A: dose 155 units every three months. Well-tolerated. Often used in combination therapy. FDA approved for chronic migraine. Insurance approval can be problematic. 8) Gabapentin: dose mg/d. Few side effects/drug interactions.

14 9) Pericranial nerve blocks. 10) Nutraceuticals (nutrition/pharmaceutical) 1) Riboflavin (Vitamin B2): dose 400 mg/d. 2) Magnesium (citrate): dose 600 mg/d.

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16 Acute treatment should be kept to no more than twice a week Treat early Tailor treatment: injectable therapy for rapid onset headaches; intranasal, injectable, or rectal routes for headache with severe nausea/vomiting Consider combinations: Triptan plus NSAID, Triptan plus antiemetic, combination of all three

17 It may not be possible to completely abort every headache (functionality) Less convenient but more effective nonoral medications may be necessary (nonoral formulations are generally more effective)

18 1) NSAIDs: ibuprofen ( mg), naproxen sodium ( mg), flurbiprofen (100 mg), ketoprofen (50 mg), indomethacin (25-50 mg oral, 50 mg suppository). SE s include gastrointestinal bleeding, nausea, abdominal pain, renal disease, heart attack, and stroke. 2) Dihydroergotamine: intravenous, intramuscular, subcutaneous: mg at headache onset; intranasal: 0.5 mg in each nostril, repeat in 15 minutes. Useful if combined with an NSAID or antiemetic. SE s include nausea, vomiting, muscle cramping.

19 3) Triptans: sumatriptan (oral, nasal spray, injection, transdermal), zolmitriptan (oral, nasal spray), rizatriptan (oral), naratriptan, frovatriptan, eletriptan, almotriptan (oral). SE s include chest discomfort and dizziness. Can combine with an NSAID. Contraindicated in patients with known cardiac disease, uncontrolled hypertension, and pregnancy. Insurance limitations. Serotonin syndrome.

20 4) Dopamine antagonists: a) prochlorperazine 5-10 mg po tid or 25 mg rectally; sedation and akathisia; b) metoclopramide 5-10 mg po tid, less sedating and well-tolerated; c) promethazine mg po or rectally tid; sedation. Keep use to twice a week or less to prevent dystonia and dyskinesia. 5) Corticosteroids: useful for prolonged or severe headaches. Decadron 4 mg tid for 2-3 days, prednisone taper. Limit use to every three months.

21 6) Opioids: Controversial and very limited use for headache. Strict parameters when used in patients with true contraindications to appropriate therapy. Can be used in pregnancy. 7) Butalbital combination products: Avoid, please. Or use with strict limitations, if at all. 8) Acetaminophen: useful when combined with an antiemetic. Safe in pregnancy.

22 Diphenhydramine/hydroxyzine Dopamine antagonists Intranasal lidocaine Intravenous magnesium sulfate Occipital nerve blocks

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