1 JUSTIN A. OSSMAN, MD CHATTANOOGA FAMILY MEDICINE UPDATE OH, MY ACHING HEAD! MANAGING HEADACHE IN THE OUTPATIENT SETTING 2 I HAVE NO DISCLOSURES OR CONFLICTS OF INTERESTS TO DECLARE OBJECTIVES International Headache Society (IHS) Classifications Common Headaches Medical and Alternative Therapies Role of Imaging IHS CLASSIFICATIONS PRIMARY HEADACHES Migraine Tension-Type Headache Cluster Headache and other Trigeminal Autonomic Cephalgias Other Primary Headache Disorders 3 4 IHS CLASSIFICATIONS SECONDARY HEADACHES Headache attributed to Trauma Vascular / Non-Vascular Substance or Withdrawal Infection Metabolic Disorder IHS CLASSIFICATIONS TERTIARY HEADACHES Cranial Neuralgias Central and Primary Facial Pain Other Headaches 5 6
CHARACTERISTICS Determine if with aura or without aura Lasts 4-72 hours Descriptive terms: Unilateral Pulsating / Throbbing quality Moderate to severe intensity A/w nausea and/or vomiting Photo- / Phonophobia Aggravated with exertional activity Neurovascular headache 5-HT Genetic component Vulnerability > Attack Initiation (Triggers) > Prodrome > with/without Aura > Headache > Resolution > Hangover 7 8 ACUTE Rest Analgesics Antiemetics Triptans Ergotamines Intranasal Lidocaine 4% ACUTE - ANALGESICS OTC Analgesics and NSAIDs NSAID combinations (Anacin, Excedrin) Barbiturate / NSAID combinations (Fioricet) Narcotics Tramadol 9 10 ACUTE - ANTIEMETICS Reglan Promethazine Ondansetron ACUTE - TRIPTANS Almotriptan (Axert): PO Eletriptan (Relpax): PO Frovatriptan (Frova): PO Naratriptan (Amerge): PO Sumatriptan (Imitrex / Treximet / Zecuity): PO, nasal spray, SC, transdermal Rizatriptan (Maxalt): PO, Dissolving wafer Zolmitriptan (Zomig): PO, Dissolving tablet, nasal spray 11 12
ACUTE - ERGOT ALKALOIDS Ergotamine (Ergomar): PO Dihydroergotamine (D.H.E. 45 / Migranal): Injectable, intranasal, inhaled (pending FDA approval) PROPHYLAXIS Tricyclic Antidepressants Anti-Epileptics ß-Blockers Ca2+-Channel Blockers NSAIDs Botulinum Toxin A CAM 13 14 CAM Acupuncture Biofeedback Botox Butterbur Behavioral Tx Feverfew Magnesium CHARACTERISTICS Lasts 30 minutes to 7 days 2 pain characteristics: Pressing or tightening quality Mild to Moderate intensity Bilateral No aggravation w/ routine activity Both: No N/V 1 of Photophobia or Photophobia Physical activity / Yoga Riboflavin (B2) CoQ10 Meditation TENS device TMS Dietary 15 16 Muscle tension Usually absent any signs of serious underlying condition Trigger control Analgesics +/ Adjuncts Trigger point injections Botulinum toxin A Biofeedback, etc. Physical Therapy Acupuncture 17 18
PROPHYLAXIS Amitriptyline Venlafaxine Mirtazapine Trigger Point Injections Behavioral Treatment Acupuncture Physical Tx / OMT TRIGGER POINT INJECTIONS OCCIPITAL NERVE INJECTION Image credits (clockwise from left): burnabyneurology.com, vanderbilthealth.com, intelligentpainsolutions.com 19 20 CHARACTERISTICS CLUSTER HEADACHE Unilateral in temporal or periorbital area Lasts approx. 15 180 minutes (Untreated) 1 episode QOD to 8 episodes/day Severe pain ( Suicide headache ) Associated Sx: 1 ipsilateral Sx in Eye, Nose, or Face Restlessness or Agitation CLUSTER HEADACHE Vascular dilation Trigeminal nerve stimulation Histamine release Circadian rhythm disturbances Genetics 21 22 ACUTE CLUSTER HEADACHE Supplemental Oxygen Triptans Intranasal Lidocaine 4% CHRONIC CLUSTER HEADACHE Verapamil Lithium Corticosteroids: PO, Trigger point Deep brain stimulation 23 24
PROPHYLAXIS CLUSTER HEADACHE Verapamil Corticosteroids Topiramate Melatonin Gabapentin CHARACTERISTICS MEDICATION OVERUSE HEADACHE (MOH) Nearly daily occurrence Diffuse or dull Usually bilateral Headaches worsen as Tx becomes less effective Typical offenders: OTC / Rx analgesics, Caffeine, Sedatives, Ergotamines 25 26 MEDICATION OVERUSE HEADACHE Increased excitability of neurons 5-HT mediated MEDICATION OVERUSE HEADACHE Stop offending agent Counsel patient HA may worsen Consider alternative methods of Tx 27 28 ACR APPROPRIATENESS CRITERIA 29 ROLE OF IMAGING CT brain: Acute Worst headache of my life Post-traumatic MRI brain: New or Chronic w/ or w/o new features and neurologic findings 2/2 sinusitis or mastoiditis Suspected temporal arteritis, meningitis / encephalitis IF ONLY IT WERE THIS SIMPLEÁ 30 NO BRAIN, NO HEADACHE. Anonymous
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