Headache Master School Japan-Osaka 2016 (HMSJ-Osaka2016) October 23, 2016 II. Management of Refractory Headaches Case presentation 1: A case of intractable daily-persistent headache Keio University School of Medicine Mamoru Shibata
52-year-old woman Case Presentation Chief complaint: 3-year history of headache Headache characteristics initially occasional (2 3 times per month) became daily 3 months prior to the presentation moderate to severe pressing, squeezing mainly holocephalic (most severe intensity in the temples) nausea and vomiting only during headache worsening no exacerbation by physical activity amelioration with diclofenac suppository and oral loxoprofen Medical history: Allergic rhinitis Physical examination: increased tenderness in the temples Neurological examination: normal
The patient s typical headache diary immediately after the presentation Daily headache Moderate to severe intensity Variable durations Modifications by acute medications Few accompanying symptoms (nausea, vomiting, photophobia etc.)
Cranial MRI (FLAIR) R L R L R L Blood test CSF test No abnormalities
2. 3 Chronic tension-type headache A. Headache occurring on 15 days per month on average for >3 months ( 180 days per year), fulfilling criteria B-D B. Lasting hours to days, or unremitting C. At least two of the following four characteristics: 1. bilateral location 2. pressing or tightening (non-pulsating) quality 3. mild or moderate intensity 4. not aggravated by routine physical activity such as walking or climbing stairs D. Both of the following: 1. no more than one of photophobia, phonophobia or mild nausea 2. neither moderate or severe nausea nor vomiting E. Not better accounted for by another ICHD-3 diagnosis. 2. 3. 1 Chronic tension-type headache associated with pericranial tenderness A. Headache fulfilling criteria for 2.3 Chronic tension-type headache B. Increased pericranial tenderness on manual palpation.
HA onset First visit Withdrawal Headache Nausea Vomiting Tizanidine 3 mg Prophylactic 10 mg 20 mg 30 mg 20 mg Orthopedics Gabapentin 1200 mg 1800 mg Pregabalin 50 mg 100 mg 150 mg Abortive Diclofenac supp. Loxoprofen Eletriptan
8.2 Medication-overuse headache (MOH) A. Headache occurring on 15 days per month in a patient with a pre-existing headache disorder B. Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache C. Not better accounted for by another ICHD-3 diagnosis 8.2.3.3 Other non-steroidal anti-inflammatory drug (NSAID)-overuse headache A. Headache fulfilling criteria for 8.2 Medication-overuse headache B. Regular intake of one or more NSAIDs other than acetylsalicylic acid 15 days per month for >3 months
HA onset First visit Withdrawal Headache Throbbing headache! Nausea Vomiting * * * Photophobia Tizanidine 3 mg Prophylactic Amitriptyline 10 mg 20 mg 30 mg 20 mg 1200 mg 1800 mg 50 mg 100 mg 150 mg Abortive Diclofenac supp. Loxoprofen
Lumbar spine MRI R L R L
HA onset First visit Withdrawal Headache Nausea Vomiting * * * Photophobia * * Tizanidine 3 mg Prophylactic Amitriptyline 10 mg 20 mg 30 mg 20 mg Orthopedics Gabapentin 1200 mg 1800 mg Pregabalin 50 mg 100 mg 150 mg Abortive Diclofenac supp. Loxoprofen Effective! Eletriptan
1.3 Chronic migraine A. Headache (tension-type-like and/or migraine-like) on 15 days per month for >3 months and fulfilling criteria B and C B. Occurring in a patient who has had at least five attacks fulfilling criteria B-D for 1.1 Migraine without aura and/or criteria B and C for 1.2 Migraine with aura C. On 8 days per month for >3 months, fulfilling any of the following: 1. criteria C and D for 1.1 Migraine without aura 2. criteria B and C for 1.2 Migraine with aura 3. believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative D. Not better accounted for by another ICHD-3 diagnosis.
1.1 Migraine without aura A. At least five attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hr (untreated or unsuccessfully treated) C. Headache has at least two of the following four characteristics: 1. unilateral location 2. pulsating quality 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs) D. During headache at least one of the following: 1. nausea and/or vomiting 2. photophobia and phonophobia E. Not better accounted for by another ICHD-3 diagnosis.
Baseline After withdrawal 2 weeks 12 weeks 16 weeks Very severe symptoms prevented her from filling in the headache diary form.
Summary Overuse of acute headache medications may suppress migrainous features, such as nausea and photophobia. Withdrawal of acute headache medications may disclose the essential nature of headache. It may be worthwhile to examine the efficacy of triptans in undiagnosed headaches. Proper management of accompanying symptoms may be important to gain treatment satisfaction from patients. Gabapentin and pregabalin may somehow attenuate the severity of migraine symptoms.
Efficacy of gabapentin and pregabalin for migraine
Mathew NT, et al. Efficacy of gabapentin in prophylaxis of migraine. Headache 2001;41:119-128. 145 episodic migraine patients, double-blind, placebo-controlled study Gabapentin dose: starting at 300 mg/day, titrated up to 2400mg/day % of patients with at least 50% reduction
Pizzolato R, et al. Efficacy and tolerability of pregabalin as preventive treatment for episodic migraine: a 3-month follow-up study. J Headache Pain 2011;12:521-525. 47 episodic migraine patients Pregabalin dose: starting at 75 mg/day, titrated up to 300 mg/day
Calandre EP, et al. Pregabalin in the treatment of chronic migraine: An open-label study. Clin Neuropharm 2010;33:35-39. 30 chronic migraine patients Pregabalin dose: starting at 75 mg/day, finally between 125 and 450 mg/day
Clinical questions What is the diagnosis of her headache? Are there any additional examinations required for the diagnostic purpose? What is the best way to manage her headache?