Chronic Daily Headache Who is at risk and what can the provider do about it?

Patient Experience Chronic Daily Headache Who is at risk and what can the provider do about it? Karen Williams, MSN, RN, FNP-BC TNP 2017 56 year old male with a history of tension/migraine headaches since the 1980 s while on active duty- Tanker (heavy gear, awkward positioning in tanker), currently a contractor-working on tanks Headaches 6 days per week, 3 days mild, 3 days severe lasting 3-5 hours. Has to stay home 3 days per week Evaluated by neurology, failed multiple medications/pt made his neck hurt more Disclosures Objectives Off label use of medications The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of the Veterans Affairs, Department of Defense, or U.S. Government Discuss the burdens and risk factors associated with headaches Define Chronic Daily Headache (CDH) Review tension type headache and migraine Identify strategies to reduce the patients chance of developing CDH Identify treatments to treat CDH Case presentation 1

Epidemiology of Headaches Socioeconomic Primary headache disorder is estimated to affect 45(+) million individuals in the US 1 World-wide, the percentage of the adult population with an active headache disorder is 46% 2 42% suffer from tension-type 11% from migraine 3% from chronic daily headache Headache is the most common pain-related complaint among workers 3 Most common cause of absenteeism from work and school 1 One of the most common complaints in the ER, with over 3 million ER visits in 2000 3 Estimated $17 billion annually, for the cost of healthcare associated with migraines 4 Chronic Daily Headache Step 1- Classify the primary headache 15 or more headache days per month lasting 4 or more hours for > 3 months 5 Chronic migraine (CM) has features of migraine; at least 8 days per month, relieved by a triptan or ergot derivative 5 Chronic tension type headache ( CTTH)- bilateral pressure/pain lasting hours to days, mild to moderate intensity, not worsened by exertion 5 New daily persistent headache (NDPH) Hemicrania continua 2

Tension- Type Headache The most common primary headache Pain is bilateral, often described as pressing, band like or vise-like. In the forehead, temples or back of head and neck Intensity - Mild to moderate Can last from 30 minutes to 7 days Can be associated with photophobia or phonophobia but not both Tension (Continued) Often accompanied by fatigue, inadequate sleep Triggered by stress, fatigue or emotional bursts Usually not aggravated by physical activity Usually relieved with OTC analgesics, relaxation, reduction of stress Frequently coexists with migraine 5 3

Migraine Recurrent episodes of generally unilateral (may be bilateral), pulsating/throbbing pain Usually aggravated by physical activity and often relieved with sleep Pain is moderate to severe and debilitating Associated symptoms of nausea, vomiting, photophobia and phonophobia Time frame of 4 to 72 hours, if untreated Step 2 - Headache Evaluation and Diagnosis Helpful questions Accurate and through headache history Family Hx, Personal medical Hx, Hx of head trauma, Time frame of headache, age of onset, how frequent, duration, triggers, aggravating factors, co-morbid illnesses, impact on family and work/school Clinical description of the headache: Location, intensity, nature of the pain, preceding symptoms, aura or neurologic symptoms Do they have more than 1 type of headache? 4

Diagnosis of Migraine or TTH Helpful questions: How do headaches interfere with your life? How Frequently do you experience headaches of any type? Has there been a change in your headache pattern over the last 6 months? How often and how effectively do you use medications to treat headaches? 7 Headache Assessment Tools Headache Calendar- iheadache/migrainebuddy (free phone apps) Headache Impact test (6 questions) Helps patients communicate the severity of the headache pain to their provider The Migraine Disability Assessment Questionnaire (5 questions) Measures headache-related disability in: work/school, household and family/social Migraine Specific Quality of Life Questionnaire (MSQ) (14 questions) Role Function-Restrictive Role Function- Preventive Emotional Function Step 3 - Physical Exam Trigger points Neurological exam: Cranial nerves, Strength, Coordination, DTR s (rule-out papilledema, diploplia, facial weakness, gait disturbances, nuchal rigidity) ROM of neck/palpation of the TMJ and occipital nerves (looking for tenderness or edema, trigger points in paraspinal, shoulder areas)- Blood Pressure: diastolic over 120 mmhg are associated with an increase in headaches Consider CBC, CMP, Thyroid function testing, Vit D level (Looking for treatable cause) 8 Rule out a systemic illness or other organic cause With permission from Sean Riehl Real Bodywork 5

Red Flags SNOOP4 Systemic symptoms or disease (fever, weight loss, jaw claudication) Neurologic signs or symptoms (motor weakness, memory loss, papillary abnormality, sensory loss) Onset sudden (if < 60 sec, called thunderclap headache) SNOOP4 (continued) Precipitated by Valsalva maneuver- worrisome for underlying vascular lesion Positional headache precipitated by laying down or standing up Papilledema- elevated intracranial pressure 8,9 Onset before age 5 or after age 50 Pattern change from prior headaches Diagnostics for Red Flags Step 4- Identify Exacerbating Factors Imaging studies: Ct of head, MRI Looking for structural abnormalities Blood chemistries and Blood counts Sed rate should be measured in adults that are 50 and older Lumbar puncture (after obtaining brain imaging): in suspected meningitis, subarachnoid hemorrhage, Pseudotumor cerebri, encephalitis or systemic illness (lupus, sarcoidosis, vasculitis) 7 Medication overuse Caffeine overuse Depression/anxiety/stress Increased BMI Suboptimal sleep- < 6 or > 8, Sleep apnea- untreated Low economic status Frequency of baseline headache- greater frequency leads to progression Nutrition/diet- skipping meals Tobacco use Prior head or neck trauma* Any use of barbiturates or opioids can increase chance of CDH, to include Butalbital (Fioricet) 9, 10 6

Step 5- Action Plan Migraine Treatments Preventative Acute treatments Lifestyle modifications Education- on going Realistic expectations Abortive Treatments for Migraine Symptom Interaction Abortives: First line: NSAIDS or Acetaminophen First line if moderate to severe: Tripitans Constrict dilated blood vessels, reduce neuropeptide release and inhibit impulse transmission centrally within the trigeminovascular system Ergotamine/Dihydroergotamine (DHE) Oxygen inhalation (100%) for cluster migraine11, 12 Sleep Cognitive Headache Irritability/ Mood 7

Preventative Treatments for CDH/Migraines Preventives (continued) Consider if 4 or more headaches per month, consider co-morbid conditions Propranolol* Topiramate* Divalproex* Antidepressants TCA s NSAIDS Tizanidine Calcium Channel Blockers- Cluster migraine 9,10 *FDA approved for migraine prevention Riboflavin (Vit B2) - Dosed at 100mg, 2 tabs twice per day Magnesium 400mg per day (dose in evening) 10 OnabotulinumtoxinA (Botox)* Cefaly* Acupuncture - more research showing this to be promising 13 Occipital Nerve Blocks 9,10 Biofeedback and Cognitive therapy 9,10 Effective Treatment for CDH Medication Overuse Effective treatment - based on the right preventative treatment Success at 50% less headaches or 50% decrease in intensity 9 Need time for medication or treatment to work Start low Right dosage Close follow-up 9 Starting a preventative medication while stopping the offending agent is helpful When weaning off the offending agent a transient increase in headache can occur lasting 2-10 days Consider short course of corticosteroids, NSAIDS, or dihydroergotamine (unless these were the offending agent) Occipital blocks 9,10 8

Headache Education Episodic Headache Characterize type Abortive therapy Maximum 6 doses/week Abortive Avoid narcotics & Benzos Chronic Daily Headache > 15 HA days per month Analgesic rebound Prophylaxis is key Prophylaxis Onset of action ~ 4 wks Headache calendar Sleep hygiene techniques Abstinence/limited alcohol use Proper nutrition/limited caffeine/proper water consumption Coping strategies/journaling/stress management Limited use of abortive medication/avoid overuse headaches Realistic expectations 9,10 NSAIDs GI side effects Ibuprofen Naproxen Sodium Acetaminophen Aspirin Triptans Contraindicated in patients with CAD Imitrex inj/oral/ns Zomig oral/ns Maxalt/Relpax/ Axert Amerge/Frova Combination Medications Risk of W/D Excedrin Alternatives Promethazine Metoclopramide Prochloroperazine Ondansetron Tizanidine Occipital block Acupuncture Anti-depressants AEDS Beta & Alpha May improve mood Neuropathic pain Improves sleep Blockers Gabapentin Propranololhelp w/ anxiety Tofranil/Nortriptylline/ Mood lability Amitryptilline Valproic acid Prazosin- help w/ Venlafaxine/Duloxetine Topirimate Nightmares and Paroxetine/Fluoxetine/ possibly ETOH abuse Mirtazapine Trazodone CAM Bio-feedback Vit B2/Magnesium Acupuncture BOTOX PT/Chiropractic Cefaly CES-Alpha-stim (Botox) Injection Paradigm: 31 Injection Sites Across 7 Muscle Areas Additional Modalities When medication is not working or not tolerated BOTOX* Prescribing Information, February 2014; 2. Blumenfeld, Headache. 2010 9

Transcutaneous Supraorbital Neurostimulation/ Cefaly FDA approved for prevention of migraine (March 2014) Varying results- need to use it daily for 20 min Currently not covered by Insurance Cost $349.00, pack of 3 electrodes $25.00 (good for 20 treatments each) Cranial Electrotherapy Stimulation Alpha-stim AID FDA approved for treatment of Anxiety, Depression, Insomnia No need to monitor labs/minimal side effects/no dependency Cost savings in reduction of other meds/treatments Acupuncture Auriculotherapy/Auricular Acupuncture Qi, or energy, travels along 12 main pathways or meridians within the body Health is influenced by the quality, quantity and balance of our Qi Qi is profoundly disturbed by traumatic stress Cochrane systemic review 2016 Acupuncture should be considered for migraine patients for prevention, particularly if having adverse effects from medications Acupuncture effect size was statically significantly larger in real acupuncture verses sham acupuncture for chronic headaches Acupuncture should be considered for treating episodic or chronic tension headaches 17 With permission from Terry Oleson, Ph.D www.auriculotherapy.org 10

Mobile Apps Mobile APPS Breath2Relax http://t2health.dcoe.mil/products/mobileapps Virtual Hope Box Mindfulness Coach http://t2health.dcoe.mil/sites/default/files/t2 -TSWF-AIM-Client-Handout-Aug2016-web.pdf Checklist for providers to recommend specific apps or websites Peppermint oil Peppermint oil Well tolerated- used for aromatherapy, topical use, enema Helpful for: Tension headache Irritable Bowel Non-ulcer dyspepsia Nausea Relaxes smooth muscle/relieves colonic spasms with barium enemas When ingested side effects- allergic reactions, heartburn, perianal burning, blurred vision, nausea/vomiting May inhibit cytochrome P450 1A2 system Contraindicated - Hiatal hernia, severe GERD, gallbladder d/o, caution with pregnancy and breast feeding. (Has been used to trigger menstruation) Should not be used near the face of infants due to potential to cause bronchspasms 14,15 11

Lavender Thought to act on the limbic system, when inhaled, especially on the amygdala and hippocampus- Safety concerns- short term safe, need long term studies, some concern for gynecomastia when applied to skin. Some GI upset when ingested Do not ingest during pregnancy or breastfeeding Helpful for- Anxiety Depression Insomnia No potential for drug abuse 16 No one cares how much you know, until they know how much you care Theodore Roosevelt Empathetic Listening Case Presentation 12

Background 56 yr old male with a history of tension /migraines since 1980 s Chronic Daily Headache Veteran with 21 years active duty Started while working at a Tanker, heavy gear, awkward positioning in the tanks Described as starting as a pressure that builds over 15 min- in the cervical occipital area radiating forward, stabbing pain through the eyes throbbing/aching associated with photophobia/phonophobia, occasional nausea, worse with exertion. 3 /wk rated as 3-5/10 lasting 3-4 hours, 3/wk rated as 7-8/10 lasting 4-5 hours Has to leave work about 3 days per week Background (continued) Unsure what triggers the headaches Treated with Excedrin migraine/ cyclobenzaprine, Laying in a dark, quiet room with ice to his head, eyes and neck Preventative: Gabapentin and Venlafaxine for back pain ( does not feel these help with the headaches) Past treatments: Nortriptyline, Topamax, Depakote, Robaxin, Naprosyn, Midrin. PT made his neck hurt CT of head WNL, MRI of c/spine and L/spine- DDD and spinal canal stenosis of C/spine- declined surgery or injections for cervical spine Social History Retired from Army after 21 yrs as E7 (Sergeant First Class) MOS Tanker, deployed during Gulf War Divorced, 14 yr old son children/some college No tobacco / No ETOH/ 1 cup of caffeine- coffee/diet balanced/walking & household duties/hobbies- activities with his son Spiritual affiliation-christian Current stressors: my divorce, keep my son happy, finances 13

Medical History Significant Exam Findings Migraine, cervical radiculopathy, low back pain, OSA, Anxiety/depression, Allergic rhinitis, HTN, Colitis (due to NSAIDS) NKDA Surgical- Right shoulder reconstruction, R foot Neurologic exam WNL Bilateral occipital tenderness, reproduces headache with palpation, muscle spasms of cervical and trapezius muscles Teeth with signs of bruxism Family Hx-Non-contributory Treatment Education on findings, treatment considerations to include Acupuncture, Botox, Occipital blocks Self help strategies to include, ice to the back of the head, Breathing and neck exercises, Magnesium 400mg. Stop daily use of Excedrin Encouraged to continue with Mental health Started with acupuncture and alpha-stim (failed cefaly) Outcomes At 2 nd visit 3 weeks later, he stopped Excedrin- headaches reduced to 2-3 mild/week, in the posterior area 1 month later using alpha-stim to reduce each headache, TEN s unit for shoulder and back pain, going to acupuncturist weekly and working with mental health on the nightmares 3 months later- Headaches remain mild at about 3 per week, continues to avoid Excedrin, using peppermint oil, mindfulness for relaxation The environment of the headache clinic allowed him to relax, he was now aware of his triggers and working on relaxing more 14

Summary Step 1- Classify the primary headache- Tension and Migraine are the most common primary headaches Step 2- Accurate and through headache history Step 3- Physical exam/ rule out systemic illness Step 4- Identifying exacerbating factors Step 5- Action Plan- Acute, preventative, lifestyle modifications, education is a key component (Realistic Expectations) Headache table Migraine Tension-Type CDH Location Unilateral Bilateral Varies Intensity Moderate to Severe Mild to Moderate Mild to severe Duration 4 to 72 hours 30 mins to 7 days Minutes to hours. 15 or more headache days per month for 3 months or more Quality Pulsating Pressure/Tightening Varies depending the type of primary headache Associated Symptoms Nausea, vomiting, photophobia, phonophobia Photophobia or phonophobia ( but not both) Look for medication over use, exacerbating factors Female: Male ratio 3 : 1 1.3 : 1 No preference References 1. The Cleveland Clinic Health Foundation. Overview of headache in adults. Cleveland Clinic Health Information Center website. Accessed Feb 12 2008. 2. Stovner LJ, et al. The Global Burden of headache: A Documentation of Headache Prevalence and Disability Worldwide. Cephalgia 2007; 27:193-210. 3. Stewart WF, et al. Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce. JAMA 2003; 290 2443-2454. 4. Goldberg LD. The cost of migraine and its treatment. AM J Manag Care 2005:11(2 suppl): 562-567. 5. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders:3 rd edition (beta version). Cephalagia 2013; 33(9): 629-808. 6. Lipton RB, Bigal ME, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007; 68:343-349. 15

References (continued) 7. Martin V, Elkind A. Diagnosis and classification of primary headache disorders. In: Standards of Care for Headache Diagnosis and Treatment. Chicago Ill: National headache Foundation 2004; 4-18. 8. De Luca GC, Bartleson JD. When and how to investigate the patient with headache. Semin Neurol. 2010; 30:131-144. 9. Sheeler, R. D., Garza, I., Vargas, B. B., & O'Neil, A. E. (2016). Chronic daily headache: Ten steps for primary care providers to regain control. Headache: The Journal of Head and Face Pain, 56(10), 1675-1684. 10.Murinova, N., & Krashin, D. (2015). Chronic daily headache. Physical Medicine and Rehabilitation Clinics of North America, 26(2), 375-389. doi:10.1016/j.pmr.2015.01.001 11.Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; 55-754. References (continued) 12. Becker, W. J. (2015). Acute migraine treatment in adults. Headache: The Journal of Head and Face Pain, 55(6), 778-793. doi:10.1111/head.12550 13. Coeytaux R, Befus D. Role of Acupuncture in the Treatment or Prevention of Migraine, Tension-Type headache, or Chronic Headache Disorders. Headache: The Journal of Head and Face Pain 2016, 56: 1238-1240. 14. Briggs, P. (2016). Inhaled peppermint oil for postop nausea in patients undergoing cardiac surgery. Nursing, 46(7), 61-67. 15. Kligler, B., & Chaudhary, S. (2007). Peppermint oil. American Family Physician, 75(7), 1027-1030. 16. Koulivand, P. H., Ghadiri, M. K., & Gorji, A. (2013). Lavender and the nervous system. Evidence-Based Complementary & Alternative Medicine (ecam), 2013, 1-10. 17. Coeytaux, R. R., & Befus, D. (2016). Role of acupuncture in the treatment or prevention of migraine, tension-type headache, or chronic headache disorders. Headache: The Journal of Head and Face Pain, 56(7), 1238-1240. doi:10.1111/head.12857. Karen Williams, MSN, RN, FNP-BC KDWHealthManagement@gmail.com 704-706-5519 16