Diagnosis and Management of Headaches Dr. Richard H. Leu Via Christi Family Medicine Residency 1 Objectives • Discuss the diagnosis and management of the following headache types: • Tension – type headache • Migraine headache • Menstrual related migraine • Cluster headache 2 Headache Spectrum • Tension ͲͲͲͲͲͲͲ Migraine • How many types of headaches do you have? 3 Tension –Type Headache • Most common headache in adults • Approximately 40% of adults will treat a tensionͲtype headache in any given year • Uncommon in children or older adults 4 Diagnosis and Management of Headaches Richard Leu, MD Family Medicine Winter Symposium December 5, 2014 1
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Diagnosis and Managementof Headaches
Dr. Richard H. LeuVia Christi Family Medicine Residency
1
Objectives
• Discuss the diagnosis and managementof the following headache types:
• Tension – type headache• Migraine headache• Menstrual related migraine• Cluster headache
2
Headache Spectrum
• TensionMigraine
• How many types ofheadaches do youhave?
3
Tension –TypeHeadache
• Most commonheadache in adults
• Approximately 40%of adults will treat atension typeheadache in anygiven year
• Uncommon inchildren or olderadults
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Characteristics ofTension – Type Headache
• Bilateral• Mild to moderate pain• No aura• Minimal disability• Minimal impact ofexercise
• Occasional light/soundsensitivity
• Scalp or cervicaltenderness
5
Migraineurs
• 41% report bilateral pain• 50% report non pulsatingpain
• 75% describe neck pain• 84% identify stress as atrigger
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Pathophysiology ofTension – Type headache
• Heightenedsensitivity of nervecells in the brain
• The “muscular”component is merelya secondaryphenomenon
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Pathophysiology ofTension – type headache
• Many experts feel that episodic tension –type headache may merely reflect amilder or less developed version ofmigraine.
• Tension HA Migraine HA
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Diagnosis ofTension – Type headache
• Diagnosis is definedby the absence offeatures typical ofmigraine or clusterheadache.
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Precipitating Factors ofTension – type headache
• STRESS
• Hunger
• Sleep disruption
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Treatment ofTension – type headache
• Regulate sleep /meals
• Adequate hydration• Exercise 30minutes/day
• Limit alcohol,caffeine and artificialsweeteners
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Treatment ofTension – type headache
• Stress management
• Biofeedback
• Massage therapy
• Physical therapy(Integrative ManualTherapy)
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Acute Treatment ofTension – type headache
• Acetaminophen
• Aspirin products
• Non – steroidal anti – inflammatories
• Limit use to 2 3 days / week to avoid reboundheadache
• Headache occurs more than 2 days per week• Use of acute medications more than 2 daysper week
• Headache attacks that are disabling despitetreatment
• Prolonged aura, complex aura or migraineinduced stroke
• Patient desires to reduce frequency
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Principles of Prevention
• Reduce frequency of attacks by more than50%
• Start low ; Go slow• Often requires lower dosages• May take 2 3 months to see benefit• Maintain for 6 12 months once 50% reductionachieved, then taper
• Reduces cortical spreading depression (CSD)
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Evidence based Recommendations forPreventive Treatment
Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Migraine Prevention(probably ineffective)
• Montelukast (Singulair)
• Nabumetone (Relafen)
• Oxcarbazepine (Trileptal)
• Telmisartan (Micardis)
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Migraine Prevention
• In one study, 3 mg of melatonin taken 30minutes before bedtime for threemonths decreased the number ofmigraines by almost 2/3 and reducedseverity by half.
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Side –effects of Melatonin
• The side – effects noted in this studyincluded :
• Excessive sleepiness• Hair loss• Increased sexual libido
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Botox• Approved by FDA fortreatment of chronicmigraines in adults
• Children age > 10with chronicheadaches have hadexcellent results
• Cost is a drawback –must code as chronicmigraine (346.70)
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Principles of AbortiveTherapy
• Use the mosteffective therapy atthe onset of themigraine
• Must always havemedication withyou!
• Try to limit acutetreatments to 3x perweek
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Common Abortive Medications
• NSAIDs• Aspirin• Combination analgesics with caffeine• Triptans• Antiemetics (often used in combinationwith NSAIDs or Triptans)
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Triptans
• Use with Naproxen500 mg at onset ofmigraine
• Use mostappropriate deliverymode
• Failure = noresponse to threedifferent triptans
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Triptans
• May use Triptanswith SSRIs (inform ptof symptoms ofserotonin syndrome)
• Treat the headache;not the aura
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Evidence based Recommendations forAcute Treatment of Migraine
• Triptans as initial treatmentfor moderate to severemigraine – Grade A
• Triptans as initial treatmentfor migraine of any severitywhen nonspecific treatmenthas failed – Grade C
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Evidence based Recommendations forAcute Treatment of Migraine
• DHE nasal spray formoderate to severemigraine Grade A
• DHE (IM,SC) for moderate tosevere migraine – Grade B
• DHE ( IV ) plus antiemetic (IV ) for severe migraine –Grade B
• Ergotamine (Ergomar) formoderate to severemigraine – Grade B
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Evidence based Recommendations forAcute Treatment of Migraine
• Metoclopramide (Reglan)IV / IM to control nausea –Grade C
• Metoclopramide (Reglan)IV as monotherapy formigraine pain relief – GradeB
• Prochlorperazine(Compazine) IV, IM, PR formigraine in appropriatesetting – Grade B
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Evidence based Recommendations forAcute Treatment of Migraine
• Acetaminophen notrecommended – Grade B
• NSAIDs and combinationanalgesics with caffeine asfirst line treatment formild moderate attacks –Grade A
• Corticosteroids(dexamethasone 16 mg IVor PO) for rescue therapyfor status migrainosus –Grade C
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Abortive Therapy
• WHO lists aspirin as an essential medicationfor treatment of migraine in adults
• FDA – approved dose for migraine is 1000 mgfor a one time administration in 24 hours;limit use to max of 3x/week to preventrebound headaches
• 1. ASA 1000 mg plus metoclopramide;prochlorperazine or promethazine at onset ofmigraine
• 2. limit use to once in 24 hours ; max of 3x perweek
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Difficult to Treat Migraines
• DHE (Migranal) nasalspray– One spray each nostril– May repeat in 15 mins.– Max: 4 sprays / attack6 sprays / 24 hrs8 sprays / week
– Use with an antiemetic
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Intractable Migraine• Inflammation !!!
Dexamethasone 8mg /16 mgIM, IV or oral as a singledose
Prednisone 50 mg daily x 3days
Methylprednisolone(Solumedrol) 80 mg IM
Ketorolac (Toradol) 60 mg IM
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Intractable Migraine
• 5 day Dexamethasone taper:
• Use 0.75 mg tablets
• Take two tablets twice daily x 2 days
• Take one tablet twice daily x 1 day
• Take one tablet daily x 2 days
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Steroids in Pregnancy
• Steroids should not beused in patients lessthan 10 weeks gestationdue to increased risk ofcleft palate
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Intractable Migraine(ER or Infusion Center)
• D.H.E. 45 1 mg IV ; dilute in 50ml of NS and run in over 30minutes; don’t use if pt. took atriptan within 24 hours; alwaysuse with an antiemetic ( mayrepeat in 1 hour x 2 doses; max of3 mg/attack and 6 mg / week)
• Magnesium sulfate 1 gram IV ;dilute in 50 ml of NS and run inover 30 minutes; may repeat in 812 hours
• Caffeine sodium benzoate 500mg IV; dilute in one liter of NSand run in over one hour
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Intractable Migraine(ER or Infusion Center)
• Valproic acid/Divalproex(Depacon) – 500 – 1000 mgIV; dilute 1:1 with NS andrun in over 15 minutes
• Antiemetics – IV
• Diphenhydramine(Benadryl) 25 – 50 mg IV
• Hydromorphone (Dilaudid)2 mg IV
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Infusion Center Protocol
• IV caffeine sodium benzoate 500 mg in one liter ofNS over one hour
• Prochlorperazine (Compazine) 10 mg IV• Diphenhydramine (Benadryl) 50 mg IV• Dexamethasone 8 or 16 mg IV upon completion ofcaffeine infusion and discharge to home
• Limit to 2 – 4 times per month• Use Dexamethasone only 1x/month
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Infusion Center Protocol
• Infuse one liter of NS over one hour• Magnesium sulfate – 1 gm diluted in 50 ml of NS andinfuse over 30 minutes
• Metoclopramide (Reglan) 10 mg IV• Hydromorphone (Dilaudid) 2 mg IV• Dexamethasone 8mg or 16 mg IV upon completionof infusion
• May use 2 4x /month• Use dexamethasone only 1x/month
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Inpatient Treatment
• IV antiemetic followedby D.H.E. 45 0.5 1 mgIV
• Repeat every 8 hours x3 days
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Outpt. Modification ofInpatient Protocol
• IV/IM antiemetic• DHE 45 – 0.5 mg IV diluted
in 50 ml of NS and infuseover 30 minutes; start 20minutes after antiemetic;don’t start if pt took atriptan in previous 24 hours
• Give twice daily (8 hoursapart) for three consecutivedays if needed
• May use up protocol up to2x per month (at least oneweek apart)
• Often will give 5 daydexamethasone taper withfirst protocol for the month
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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MRI/MRAIndications
• New onset headache < age 5 or > age 50• Exacerbation of headache with physicalactivity
• A change in patient’s headache pattern• Patients with a past history of cancer orimmunosuppression
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Menstrual – Related Migraine
• Pure menstrual migraineis uncommon
• 60% of migraineurs haveattacks related to menses
• MRM – attack occurs 2days before and up to 2days after the menses
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Treatment of Acute Attacks of MRM
• Behavioral management– avoid triggers
• NSAIDs• DHE – nasal spray, IM, SC• Triptans• Acetaminophen/ASA/Caffeine
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Intractable Acute Attacks of MRM
• Analgesics
• Corticosteroids
• Any of previousinfusion centerprotocols
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Preventive Treatment for MRMLevel A
Level A: established as effective
Should be offered to patients requiringprophylaxis
Frovatriptan (Frova) – 2.5 mg bid for 5 daysperimenstrually (loading dose was used)
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Preventive Treatment for MRMLevel B
• Level B: probably effective• Should be considered for patients requiringprophylaxis
• Naratriptan (Amerge) – 1 mg bid for 5 daysperimenstrually (no loading dose)
• Zolmitriptan (Zomig) – 2.5 mg bid or tid for 5days perimenstrually (no loading dose)
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Preventive Treatment for MRMLevel C
• Level C: possibly effective
• May be considered for patients requiringprophylaxis
• Estrogen – 1.5 mg estradiol in gel (EstroGel)daily x 7 days perimenstrually
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Preventive Treatment for MRM(expert opinion)
• Start Naproxen 500 mgbid with food two tothree days before onsetof menses and continuethrough the menses
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Preventive Treatment forMRM
• Melatonin levels have been shown to bedecreased during menses in women withmenstrual migraine
• Melatonin may be helpful in the prevention ofmenstrual related migraine
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Hormonal Treatment in MRM
Menstrual migraines aretriggered by drops inestrogen
Don’t be overly concernedabout using a low – dose(20 mcg of ethinyl estradiol)OC in women with migraineif they are under 35 yrs;have normal BP ; don’tsmoke and do not have anaura
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Hormonal Treatment of MRM• Use a 20 mcg ethinyl
estradiol mono – phasicOCP for 3 4 monthsconsecutively; then off for 1week using syntheticconjugated estrogen A(Cenestin) 0.9 mg daily asan estrogen supplementduring the week off theactive pills
• Repeat cycle
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Hormonal Treatment of MRM
• Levonorgestrel/ethinyl estradiol (LoSeasonique) withsynthetic conjugated estrogen A (Cenestin) 0.9 mgdaily during the 13th week (week off between 12week cycles of LoSeasonique)
• May use extended regimes using ethinylestradiol/norelgestromin (OrthoEvra patch) or ethinylestradiol/etonogestrel (NuvaRing)
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Diagnosis and Management of Headaches Richard Leu, MD
Family Medicine Winter Symposium December 5, 2014
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Cluster Headache
• Attacks frequently occurat night
• One to severalheadaches / day
• Short duration (30 – 45minutes); rarely lastover 4 hours
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Cluster Headache
• Describes headachepattern
• Clusters can last days tomonths
• Remission (often foryears)
• Seasonal (spring or fall)
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Cluster Headache
• Men/Women = 5:1• Onset 20 – 40 yrs of age• Always one – sided(behind eye)
• Excruciating pain (hotpoker in eye)
• Patient paces
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Cluster Headache• May have flushing offace, tearing, nasalcongestion or runnynose
• Pupil may contract
• Eyelid may be swollenor droop
• “Lower half syndrome”– cheek and mouthaffected instead of eye ,temple and forehead
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Diagnosis and Management of Headaches Richard Leu, MD