Faculty Disclosure Karen L. Bremer, MD Dr. Bremer has listed no financial interest/arrangement that would be considered a conflict of interest. HEADACHE UPDATE Karen L. Bremer, MD November 10, 2017 karen.bremer@creighton.edu 1
Objectives Learn techniques on diagnosis of headaches. Become familiar with medications used for headache treatment. Common Causes of Headache Primary headache Migraine Tension-type Chronic Daily Ice-pick Exertional Cluster Secondary headache Systemic infection Head injury Vascular Subarachnoid hemorrhage Neoplasm 2
Headache History Where is your headache (pain) located? Does the pain spread to anywhere else? How and when did it start? Headache History What is the pain like? Is it throbbing, stabbing, shooting, pressure, aching? When you have a headache, do you have sensitivity to light or sound? Are you nauseated? Do you have fever or chills? When did you start having headaches? 3
Headache History How often do you have headaches? How long do your headaches usually last? What makes your headache better? What have you tried for your headaches? Does movement make your headache worse? What makes your headaches worse? Headache History What triggers your headaches? How severe is your pain, on a scale from 0-10? (what have you tried before, who have you consulted for this problem previously?) 4
Headache Examination Head and neck Pupils, funduscopic exam, eye movements Palpate the area of pain Cranial nerves Carotid auscultation (for bruits) Neurological exam Strength, reflexes, coordination, sensation International Headache Society (IHS) Criteria for primary Headaches Migraine without aura (Common) 5 attacks duration: 4-72 hours At least 2: unilateral, pulsating, moderate or severe, aggravation by activity At least 1: Nausea and/or vomiting Photophobia and phonophobia Sx not suggestive of secondary headache. 5
International Headache Society (IHS) Criteria for primary Headaches Migraine with aura At least 2 attacks 3 of the following: a fully reversible aura symptom develops gradually over 4 minutes lasts no longer than 60 minutes headache follows with a free interval of <60 min Sx not suggestive of secondary headache. Migraine Aura vs. TIA AURA TIA Positive visual symptoms gradual onset/evolution sequential progression repetitive attacks of identical nature flurry of attacks mid-life duration: 20 minutes headache follows 50% Visual loss abrupt simultaneous duration <15 minutes headache uncommon 6
IHS Cluster headaches At least 5 attacks severe, unilateral orbital, supraorbital, and/or temporal pain lasting 15-180 minutes. Associated with at least one ipsilateral sign: Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, meiosis, ptosis, eyelid edema Frequency: 1 every-other-day to 8 per day No suggestion of organic headache. May be precipitated by alcohol 7
Diagnosis testing: neuroimaging In patients with recurrent migraine, neither CT nor MRI is warranted except in cases where: recent substantial change in headache pattern history of seizures focal neurological symptoms or signs Role of CT or MRI in patients with non-migraine headache is unclear. Yield of pathology 0.4-2.4% AAN practice handbook pages 169-171, 1993 LUMBAR PUNCTURE INDICATED FOR: the first unusually severe headache thunderclap headache with negative CT head subacute progressive headache headache associated with fever, confusion, meningismus, or seizures high or low CSF pressure suspected (even if papilledema is absent) 8
Treatment options: Acute pain First-line agents Triptans Sumatriptan, rizatriptan, almotriptan, naratriptan, Zolmatriptan, elatriptan, Frovatriptan Dihydroergotamine (DHE) Combination analgesics (ASA/caffeine/acetaminophen, and others) NSAIDS Naproxen, Ibuprofen Triptans Serotonin 5HT 1b/1d receptor agonists Indicated for use in migraine headache. Use limited to about 6-9 per month. Expensive (except for generic forms) Indicated for migraine but may have benefit for other headache types Each triptan has unique forms, administration options, onset of action, and T ½. Contraindicated in patients with uncontrolled hypertension, heart disease, stroke. 9
Triptans Generic available Sumatriptan: 25, 50, 100 mg PO and 6 mg SQ Rizatriptan 5, 10 mg PO + MLT. Naratriptan 1, 2.5 mg PO Zolmitriptan 2.5, 5 mg PO + ZMT + Nasal. Branded only Eletriptan (Relpax) 20, 40 mg Almotriptan (Axert) 6.25,12.5 mg Frovatriptan (Frova) 1, 2 mg Ergotamines Historically useful in migraine headache. Less selective receptor action. More side-effects (nausea) Same contra-indications as for triptans. DHE (dihydroergotamine) still used SQ and IM and IN (intra-nasal) for migraine. Ergotamine Tartrate recently made available, but isn t available. (You can get a prescription, but good luck trying to fill it.) 10
Combination analgesics Many over-the-counter and prescription preparations available. Butalbital/APAP/caffeine ASA/APAP/caffeine Effective for mild-moderate migraine. Inexpensive. Patients will not volunteer that they are taking these, so need to ask specifically. Risk of overuse. Recommend limiting use to less than 10 doses per month. If using 1/week or more, recommend adding on a preventive. NSAIDs Over-the-counter and Rx available, multiple brands and generics. Ketorolac very effective but usually administered (IM) in ED. Diclofenac 50 mg powder FDA approved for migraine OTC and Rx (naproxen/ibuprofen) effective for mildmoderate migraine and used in combination with triptans for moderate to severe migraines. 11
Adjunctive agents Anti-nausea medications Promethazine 12.5-25 mg PO or PR Ondansetron 4 mg PO Metoclopramide 5 mg PO, 5-20 mg IV Anti-cholinergics (promote sleep and decrease side-effects of Rx) Diphenhydramine 25-50 mg PO Benztropine 1-2 mg PO Anti-anxiety medications Diazepam 2-5 mg PO Narcotic analgesics (high risk of overuse) avoid Treatment Options: prevention First-line agents Amitriptyline Propranolol Valproic acid/divalproex Topiramate Verapamil Candesartan Chronic migraine Onobotulinumtoxin A Misc Sphenocath Herbal therapies Magnesium oxide Riboflavin (vitamin B2) CoEnzyme Q10 Butterbur Feverfew CAM Acupuncture Massage Dry-needling Essential oils 12
Preventive Therapies Decrease frequency and severity of migraines. Aim for 50% reduction (it s no cure). Start with very small dose and increase slowly. Common side-effects dependent on agent chosen. Trials should last at least 3 months at therapeutic dose before switching to another agent. Preventive agents Tricyclic antidepressants Amitriptyline Nortriptyline Common side effects: Weight gain Drowsiness Dry mouth Urinary retention/constipation Suicidal thoughts (teen-agers) Useful for patients who have difficulty sleeping, have fibromyalgia or other somatic pain symptoms. 13
Preventive agents Beta Blockers Use centrally acting agents. Propranolol and atenolol are preferred. Low dose Can make patients light-headed, depressed. Useful for patients with hypertension. Calcium Channel Blockers Verapamil used less than other agents listed here. Useful for patients with hypertension. Angiotensin Receptor Blockers Candesartan found recently to be effective for migraine prevention. Preventive agents Anti-seizure medications Valproate Not for use in women who may get pregnant. Can cause weight gain, tremors, hair loss, liver enzyme elevations, decreased platelets. Decreases frequency/severity of migraine Topiramate Not for use in women who may get pregnant. Can cause weight loss, tingling in the feet and hands, kidney stones. Decreases frequency/severity of migraine 14
Preventive agents Botox Indicated for treatment of chronic migraine headache (CM). CM = headaches more than 15 days per month lasting >4 hours per day More than 8 of these must be migraine headaches (moderate-severe, unilateral, throbbing, associated with nausea or photo/phonophobia). Expensive (@$2000 per treatment). Covered by insurance. Prior-authorization recommended. Benefits: when effective, decreases frequency and/or severity of migraine 50%. Risks: Expensive and may not work Pain at injection sites Ptosis Nausea Dry mouth Botox injection sites 15
What s New? CGRP antagonists Monoclonal antibodies Monthly or every-3-month intervals. 3 will be SQ, self-administered One will be IV, administered in an infusion center. For migraine prevention Gepants CGRP receptor blockers Initial trials with telcagepant associated with liver toxicity Newer gepants still in clinical trials (olcegepant). Vagal nerve stimulator (hand-held). Vagal nerve stimulator 16
Marijuana for migraines? No. Cannabis may help with the nausea and vomiting associated with migraine. It also is effective for spasticity (in MS) and tense muscles are a symptom of migraine, so maybe this pain would be improved with MJ. Smoking marijuana may also result in a calm feeling that can relieve some associated anxiety. Some of my patients indicate smoking marijuana will trigger a migraine. The source below noted that pupil dilation from MJ may cause increased light sensitivity or trigger a migraine from the increased light perception. www.medicalmarijuanablog.com/benefits/migraine-072.html The AAN has a position statement on MJ but does not include headache or migraine. SO: Get a clear history. There s no test to confirm a diagnosis of migraine headache. Do a good exam and history taking to evaluate for secondary causes of headaches. Lots of migraine and headache treatments are available and can be tailored to an individual patient. Get the patient to invest in their care. They should keep a record of headaches to review at the next visit. 17