Back Pain. John W. Engstrom, MD December 15, Disclosures. A Primary Care Approach to Headache. Headache Goals

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1 Disclosures Nothing to declare --- or --- Significant ownership interests Consulting, speaker bureaus, honorarium, grants Link to Harrison s Chapter on Headache: on/education.html A Primary Care Approach to Headache John Engstrom, MD April 27, 2012 Headache Goals Objectives: Know risk factors by history and exam for serious causes of headache Know how to diagnose migraine and tension-type headache Know how to treat migraine -Remove environmental triggers -Acute headache treatment -Chronic headache treatment Headache: Risk Factors for Serious Cause - History Postural Headache-supine (Inc CSF pressure) or standing-low CSF press (awakened from sleep) Worst headache ever, first severe headache New headaches, but not old headaches Onset after age 55 Known systemic illness, sweats

2 Headache: Risk Factors for Serious Cause - Examination Documented fever, Afib, new MAP > 140 (220/120) Systemic signs-wt loss, adenopathy, organomegaly With new focal neurologic symptoms/signs (see migraine accompaniments below) Specific signs-temporal artery tenderness, stiff neck Headache-The Origin of Pain Pain-sensitive: scalp, intracranial arteries, dura, dural sinuses, periosteum Not pain-sensitive-brain parenchyma, choroid plexus, ependyma lining the ventricles CNS autonomic system-cranial nerve V, trigeminal ganglion, and specific brainstem nuclei Migraine is a brain disorder Common Headaches Primary-the headache is the disorder (e.g.- migraine, tension-type headache, overlap of both) Secondary-headache secondary to exogenous factors (e.g.-systemic infection, head trauma, glaucoma, meningitis, sinusitis) Headaches from brain tumors, subarachnoid hemorrhage, epidural/subdural hematomas rare Tension-Type Headache Band-like headache pain; mechanism unclear Not related to nervous tension No nausea, vomiting, photophobia, phonophobia, throbbing, or aggravation with movement Episodic or chronic (>15 days per month) Acute Rx-NSAIDs, ASA, acetaminophen Chronic-Amitryptyline (10-75 mg/night) Other migraine Rx not effective

3 Migraine-Definition Episodic headache with associated features Nausea, vomiting, scalp tenderness, photophobia, light-headedness in > 50% Visual disturbances, paresthesias, vertigo > 30% Altered mentation, diarrhea, fortificat spectra > 10% Classic-With warning sensory or visual symptoms Common-no warning or aura Prevalence-15% women, 6% men in one year Migraine-Helpful Diagnostic Features Headache lasting 4-72 hours with a normal examination and no secondary cause plus: Two or more: unilateral pain, throbbing, increased by movement, moderate or severe intensity At least one: nausea, vomiting, photophobia, phonophobia Diurnal periodicity-predominance at a specific time of day favors migraine Migraine-Visual Accompaniments are Positive Visual Phenomena 40% of patients, may move across field of vision Stars, spots, circles, geometric shapes, sparkles, broken glass-may be bright, pulsing, colored Altered, distorted shapes- metamorphopsia Larger or smaller objects- macropsia, micropsia May occur without headache Episodic dark visual loss-distinguish from TUA Migraine-Sensory Accompaniments are Positive Sensory Phenomena 1/3 of patients Paresthesias most common; never decr sensation Sensory symptoms with seizure spread over seconds and last seconds, not minutes May affect inside of mouth in migraine, not TIA Patients with vascular risk factors-may be difficult to distinguish from TIA

4 Principles of Migraine Management Set realistic expectations Remove environmental triggers when possible Consider meds for acute Rz, avoid side-effects Consider meds for hedache prophylaxis, avoid side-effects Migraine Management-Setting Realistic Expectations Goal: Decrease frequency and severity of headaches, not complete cessation of headache Good news: broad menu of management options Titrate primarily to functional goals, not pain Incr med toxicity risk with HA cessation as goal After a reasonable trial of medication, discontinue medications that don t work well Patient Education: Migraine Management-Remove Environmental Triggers Avoid excess caffeine or alcohol Remove triggers known to cause the patient s symptoms (e.g.-chocolate, wine, noise, light, etc.) Avoid sleep deprivation or excess Avoid skipping meals Migraine Management-Acute Treatment Best results with treatment at onset of the attack If repeat treatment needed after one hour, then initial dose should be increased for later attacks For mild headaches, has the patient already established efficacy with simple analgesics? Can removal of triggers reduce the frequency or severity of headaches?

5 Migraine Management-Acute Treatment- Medications (see Harrison s chapter) Sumatriptan 50 mg or 100 mg po Early nausea, sumatriptan nasal spray 20 mg Early emesis, sumatriptan 25 mg PR or 6 mg SC Menses-related headache-ergotamine po at night to prevent and triptans or DHE for symptoms Rapid onset of symptoms-sumatriptan 6 mg SC Alternatives: Midrin, ergotamine Migraine Management-Prevention To patient: Need to stay on medication long enough to assess efficacy against the background fluctuation in headache frequency and severity Adequate trial may take 1-3 months Increase dose if partial response only Select a drug by anticipating possible side effects Migraine Management- Prevention Medications I Propranolol mg po bid Amitryptyline mg po qhs (use nortriptyline in elderly-reduce anticholinergic side-effects) Topiramate mg/day (wt loss, glaucoma, alt MS, renal stones) Valproate mg po bid (wt gain, tremor, hair loss, hematologic/liver function abnl, fetal) Migraine Management- Prevention Medications II Gabapentin mg total dose divided tid (dizziness, sedation) Methysergide 1-4 mg/day (drowsiness, leg cramps, hair loss, retroperitoneal fibrosis; drug holiday for one month every 6 months) Do not use: Verapamil-controlled trials unconvincing SSRIs-controlled trials show no effect

6 Headache Challenges: The Incomplete Historian Keep a headache diary-patient (best) or caregiver Frequency of acute attacks Record accompanying symptoms for diagnosis Record possible triggers in real time Record time between aura and headache-consider using info to treat during the aura Record time of onset-if a pattern, consider Rx one hour prior to anticipated onset of symptoms Headache Challenges: Too Many Options Use parenteral or nasal route if typical attack includes nausea or vomiting Removal of environmental triggers and use simple analgesics first-simple solution is best Know how to use 2-3 acute treatments and 3-4 prophylactic treatments Post-Traumatic Headache After head trauma or systemic infection (viral) Associated dizziness, vertigo, conc/memory Neurologic exam and brain imaging normal Rarely subdural hemat, carotid dissection, SAH May last weeks, months, 3-5 years; disability Treatment options: amitryrptyline or nortriptyline, topiramate, gabapentin, valproate New Daily Persistent Headache Ddx-subarachnoid hemorrhage, low CSF pressure, high CSF pressure, post-traumatic, chronic meningitis May be benign and onset of migraine or tensiontype headaches

7 Postural Headaches Normal Brain MRI-Axial View T2 High CSF Pressure Due to disrupted CSF flow or reabsorption Brain MRI often reveals the etiology; communicating hydrocephalus vs. non-communicating Worsen in supine position (e.g.-awaken at night), but may also awaken with increased pco2 Measure CSF opening pressure, if LP safe after CNS imaging Hydrocephalus-Brain MRI Axial T2 Postural Headaches Low CSF pressure Onset within 1-2 minutes after sitting or standing Resolution within 1-2 minutes supine Refractory to all pain medications Most common post-lp, but any spinal CSF leak CSF opening press low-lack of CSF flow/slow flow Diagnosis by history and sagging brain on MRI Treatment: bedrest 3-7 days; blood patch if persists

8 MR findings rapidly correct after treatment of SIH Cluster Short attacks of retro-orbital or periorbital pain Associated with autonomic symptoms-nasal congestion, tearing, or conjunctival injection Periodicity-daily attacks occur at about the same hour each day Duration of a flare may be 6-8 weeks per year Patients have the urge to move, unlike migraine PRE-THERAPY POST-Blood patch Cluster Headache-Acute Treatment Acute Rx-High flow (10-12 L/min) oxygen for minutes Need Rx with rapid onset since pain peaks quickly Alternatives: Sumatriptan SC 6 mg/intranasal 20 mg Use the time of onset to begin treatment before symptoms recur (e.g.-if symptoms begin at 1:45 PM, then begin treatment at 1:30 PM) Oxygen at home? Cluster Headache-Chronic Treatment Chronic-choice depends on duration of bouts (e.g.-daily headache for a week vs. 6 weeks) 1 week: prednsione 60 mg po for 7 days, then taper off over 3-4 days. 6 weeks or more: Lithium mg/day Verapamil, topiramate, methysergide, gabapentin

9 Cough and Exertional Headache May be the sign of an aneurysm, carotid stenosis, or vertebrobasilar disease Consider MRI with intracranial and extracranial MRA if patient at risk or Consider head CT with CTA to look at posterior, anterior, intracerebral circulation Cough-Chiari malformation? Cough Headache Triggers: coughing, sneezing, straining, or laughing Usually lasts several minutes and then resolves Primary (no etiology found) is a benign disorder Treatment: Indocin po tid Prevention: suppress stimuli or pretreat Exertional Headache Clinical features Triggered by exercise; may be pulsatile Lasts few min-24 hours; bilateral Espec heavy exertion; hot weather or high altitude Treatment Acute attacks-indocin ( mg/day) Prevention-Indocin, ergotamine, DHE nasal spray Sex Headache Occur irregularly and infrequently Benign, reassurance May cease if discontinue sexual activity Prevention Propranolol mg/day Diltiazem 60 mg tid Ergotamine or Indocin min before sex

10 Distinctive Head Pain: Trigeminal Neuralgia Symptoms-Paroxysms of sharp, repetitive stabbing pain in the cheek, lip, or chin Triggers-minor sensory stimulation including eating, touching the face, brushing teeth, wind Diagnosis-exclude sensory loss on the face by exam to pin or light touch; exclude other cranial nerve involvement or refer to neurologist Exclude dental disease-periapical abscess Distinctive Head Pain: Trigeminal Neuralgia Treatment Often exquisitely sensitive to carbamazepine Begin 100 mg/day and increase weekly to at least 50% reduction of symptoms Symptom control for at least one month, then can discuss taper Alternatives: oxcarbam, lamtorigine, phenytoin Surgery if meds fail: microvasc decompression Medication Overuse Headache Medications that alter the pattern of head pain are an iatrogenic problem when the headache persists Functional status of some patients improves when medications are decreased (opiates, barbiturates) Medication overuse may lead to rebound headaches when stopped or decreased in dose Outpatient tapers may be accompanied by daily NSAID use (e.g.-ibuprofen or naproxen bid) Medication Overuse Headache: Inpatient Treatment Remove acute analgesics + detoxify Medically Refractory Headache dx is socially acceptable and many insurance plans will pay Common offenders-opiates, barbiturates (butalbital in Fioricet), benzodiazepines Given antiemetics and fluids, clonidine for opiate withdrawal, compazine for nausea and sleep IV DHE or ASA (United Kingdom) for acute HA

11 Headache Summary Exclude worrisome etiologies Primary-Tension-type and Migraine predominate Secondary-viral syndromes and post-traumatic majority of secondary causes Recognize distinctive head pain patterns that make the diagnosis and dictate treatment Be able to address environmental triggers, acute treatment, and chronic prophylaxis for migraine