Short Clinical Guidelines: Headache, Key Points for Diagnosis and Treatment

Transcription

1 Clinical Highlights 1. Headache is diagnosed by history and physical examination with limited need for imaging or laboratory tests. 2. Warning signs of possible disorder other than primary headache are: Subacute and/or progressive headaches that worsen over time (months) A new or different headache Any headache of maximum severity at onset A headache that wakens you from sleep Headache of new onset after age 50 Persistent headache precipitated by a Valsalva maneuver Evidence such as fever, hypertension, myalgias, weight loss or scalp tenderness suggesting a systemic disorder Presence of neurological signs that may suggest a secondary cause Seizures 3. Migraine-associated symptoms are often misdiagnosed as sinus headache by patients and providers. This has led to the underdiagnosis and treatment of migraine. 4. Appropriate pharmacological or analgesic treatment of acute headache should generally not exceed more than two days per week on a regular basis. More treatment other than this may result in medication-overuse chronic daily headaches. 5. Disability from headaches is an important issue for migraineurs. 6. All patients should be considered for prophylactic therapy. 7. Migraines occurring in association with menses and not responsive to standard cyclic prophylaxis may respond to hormonal prophylaxis with the use of estradiol patches or estrogen-containing contraceptives. 8. Women who have migraines with aura have a higher risk of stroke with the use of estrogen-containing contraceptives. Headaches occurring during perimenopause or after menopause may respond to hormonal therapy. 9. Most prophylactic medications should be started in a low dose and titrated to a therapeutic dose to minimize side effects and maintained at target dose for 8-12 weeks to obtain maximum efficacy. 10. Consider referral to addictive medicine program if appropriate. Treatment Goals 1. Increase the accurate diagnosis of headaches 2. Increase the functional status of those with migraine 3. Increase the rate of treatment plans or adherence to plan for mild, moderate and severe headaches for migraineurs 4. Reduce the use of opiates and barbiturates for the treatment of primary headache 5. Increase education for patients with primary headache 6. Increase appropriate prophylactic treatment based on headache type (i.e., migraine, cluster, menstrual-associated) 7. Increase appropriate acute and prophylactic treatment for migraineurs based on level of severity (i.e., mild, moderate, severe) Effective date: August, 2007 Page 1

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5 Drug Notes Side Effects Contraindications Acetaminophen Hypersensitivity to acetaminophen Acetaminophen / Aspirin/Caffeine Acetominophen/aspirin mix with caffeine added Aspirin Gastrointestinal * Active peptic ulcer Chlorpromazine (CPZ) injection Thorazine Dexamethasone Decadron DHE (dihydroergotamine mesylate) D.H.E. 45 Type of tranquilizer and anti-psychotic medication used to treat migraines and nausea Anti-inflammatory and steroid medication Type of drug used to treat migraine, rebound, or cluster headaches Drowsiness, extrapyramidal * symptoms Cushingoid * Chest tightness, tingling, nausea disease Hypotension *, previous adverse reaction Ischemic heart disease *, uncontrolled hypertension *, vasospastic angina *, advanced peripheral vascular disease *, pregnancy, ischemic cerebrovascular disease * Nasal spray Migranal Ergotamine by mouth Cafergot Type of drug used to treat migraine, rebound, or cluster headaches, constricts blood vessels, improves blood vessel tone Nasal congestion, throat discomfort, nasal irritation, nausea Chest pain, tingling, nausea See DHE * injection Ischemic heart disease *, uncontrolled hypertension *, vasospastic angina *, advanced peripheral vascular disease *, pregnancy, ischemic cerebrovascular disease * Rectal suppository Cafergot Chest pain, tingling, nausea See Ergotamine by mouth Sublingual (under the tongue) Ergomar Hydrocortisone Solu-Cortef Anti-inflammatory and steroid medication Chest pain, tingling, nausea See Ergotamine by mouth Effective date: August, 2007 Page 5

6 Drug Notes Side Effects Contraindications Isometheptene Mucate 65 mg / Dichloralphenazone 100 mg/ Acetaminophen 325 mg Midrin CIV Type of sedative and combination drug use to treat migraine and tension headache Drowsiness, dizziness Ischemic heart disease *, severe renal disease *, ischemic cerebrovascular disease* Ketorolac IM (inject into the muscle) Toradol Lidocaine 4% Solution * Magnesium Sulfate Opiates Hydromorphone Dilaudid Morphine NSAID (non-steroidal anti-inflammatory) Local anesthetic Electrolyte replenisher and anticonvulsant for treatment of acute (sudden) migraine. Affects muscle constriction and nerve transmission. Type of drug that depresses the central nervous system and used to relieve pain Drowsiness, nausea, dyspepsia * Burning or numbness in nose or pharynx * Flushing, hypotension*, burning sensation in the face and neck Sedation, confusion, risk of habituation Active peptic ulcer disease *, renal insufficiency * Heart block *, severe renal impairment * Meperidine HCL Demerol NSAIDs Ibuprofen Advil Motrin Nuprin Non-steroidal antiinflammatory drug Gastrointestinal * Active peptic ulcer disease *, renal insufficiency * Ketoprofen Orudis K Actron Naproxen Sodium Anaprox Aleve Prochlorperazine IV Compazine Valproate Sodium Depacon Antiemetic (stops nausea or vomiting) Type of antiepileptic medication Gastrointestinal * Gastrointestinal * Drowsiness, extrapyramidal symptoms * Nausea, vomiting, tremor, dizziness See Ibuprofen See Ibuprofen Hypotension * Liver disease, pregnancy Effective date: August, 2007 Page 6

7 Drug Notes Side Effects Contraindications 5-HT Agonists (Triptans) Almotriptan Axert Eletriptan Relpax Frovatriptan Frova Naratriptan Amerge Rizatriptan Maxalt Mazalt MLT Sumatriptan Imitrex by mouth Nasal spray Subcutaneous (inject into the skin) Zolmitriptan Zomig Zomig-ZMT by mouth Medications specific to the treatment of migraine and cluster headaches Tingling, nausea, dry mouth, drowsiness, chest tightness (26% of time) Dizziness, drowsiness, nausea, dry mouth, paresthesia *, chest/abdominal tightness, vomiting, dysphagia * Chest tightness, flushing, dizziness, tingling, fatigue Chest/throat tightness, tingling, flushing, dizziness, nausea Chest/throat tightness, dizziness, tingling Chest tightness, tingling, flushing, dizziness, limb heaviness, nausea Chest/throat tightness Chest/throat tightness Chest/throat tightness, tingling, flushing, dizziness, nausea Not to be used within 72 hours of treatment with the following potent CYP3A4 inhibitors: ketocomazole, itracomazole, mefazodome, troleandomycin, clarithromycin, ritomavir, nelfinavir Hypertension*, vasospastic angina*, peripheral vascular disease*, pregnancy, ischemic cerebrovascular disease*, use of other 5-HT agonists* or ergotamines* if used within 24 hours Ischemic heart disease*, uncontrolled hypertension*, vasospastic angina*, peripheral vascular disease*, pregnancy, ischemic cerebrovascular disease*, use of 5-HT agonists* or ergotamines* if used within 24 hours, use of MAO inhibitors* within 2 weeks Nasal spray Effective date: August, 2007 Page 7

8 Drug Notes Side Effects Contraindications Antiepileptics Divalproex Sodium (valponate sodium) Depakote Depakote-ER (time release) Anti epileptic and anticonvulsant drugs Nausea, tremor, weight gain, alopecia*, increased LFTs* Avoid in patients with liver disease, pregnancy Gabapentin Neurontin Dizziness, somnolence*, peripheral edema*, fatigue, ataxia*, nervousness, tremor, weight gain Topiramate Topamax Beta-Blockers Atenolol Tenormin Metoprolol Lopressor Heart medication Somnolence*, nervousness, fatigue, dizziness, confusion, anorexia*, ataxia*, acute-angle closure of glaucoma*, nausea, metabolic acidosis*, paresthesias*, kidney stones Fatigue, bronchospasm*, bradycardia*, hypotension*, CHF*, depression, impotence*, decreased libido*, sleep disturbance Reduced renal* or hepatic* functions Sinus bradycardia*, 1 st degree heart block*, acute CHF* Nadolol Corgard Propranolol Inderal Timolol Blocadren Ca+ Channel Blockers Verapamil Calan Veselan Muscle relaxants Tizanidine Zanaflex Tricyclics Amitiptyline Elavil Heart medication Muscle relaxants Constipation, dizziness, edema*, hypotension*, nausea Dry mouth, drowsiness, asthesia*, dizziness, mild hypotension* Atrial fibrillation*, CHF*, sick sinus syndrome*, hypotension*, 2 nd, 3 rd degree heart block* Doxepin Sinequan Nortiptyline Aventyl Pamelor Effective date: August, 2007 Page 8