4/14/18 1 Headache Management Utilizing an Integrative Approach Karen Williams, DNPc, RN, FNP-BC TNP 2018 1 Patient with refractory headaches • 44yr old female with a history of refractory headaches for the last 2 years • Migraines since 1990’s- described as posterior pressure, treated with Advil. If untreated will cause photophobia/phonophobia & worse with exertion • 2 nd type started 2 years prior. Described as bi-frontal and right eye pressure increases to 4-6/10 and occasion to 8-9/10 w/photo/phonphobia • Would occur upon waking up in the morning, worsen with exertion and when dehydrated. Lasting up to 2 weeks and occurring monthly • Treated with zomig and advil- with about 1/3 resolved with this • Treated in past by a neurologist- MRI of Brain WNL 2 VITAL BEHAVIORS Diagnosis Correctly Treat Appropriately Communicate Effectively Headache Management 3 Objectives • Discuss the burdens and risk factors associated with headaches • Review tension type headache and migraine • Identify appropriate medication treatments and medication overuse headaches • Review alternative headache treatments • Case presentations 4 Disclosures • 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 5 Epidemiology of Headaches • Primary headache disorder is estimated to affect 45(+) million individuals in the US (Cleveland Clinic Health Information Center, 2008) • World-wide, the percentage of the adult population with an active headache disorder is 46% (Stover, 2007) – 42% suffer from tension-type – 11% from migraine – 3% from chronic daily headache 6
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4/14/18
1
Headache Management Utilizing an Integrative Approach
Karen Williams, DNPc, RN, FNP-BCTNP 2018
1
Patient with refractory headaches
• 44yr old female with a history of refractory headaches for the last 2 years
• Migraines since 1990’s- described as posterior pressure, treated with Advil. If untreated will cause photophobia/phonophobia & worse with exertion
• 2nd type started 2 years prior. Described as bi-frontal and right eye pressure increases to 4-6/10 and occasion to 8-9/10 w/photo/phonphobia
• Would occur upon waking up in the morning, worsen with exertion and when dehydrated. Lasting up to 2 weeks and occurring monthly
• Treated with zomig and advil- with about 1/3 resolved with this
• Treated in past by a neurologist- MRI of Brain WNL
2
VITAL BEHAVIORS
Diagnosis Correctly
Treat Appropriately
Communicate Effectively
Headache Management
3
Objectives
• Discuss the burdens and risk factors associated with headaches
• Review tension type headache and migraine
• Identify appropriate medication treatments and medication overuse headaches
• Review alternative headache treatments
• Case presentations
4
Disclosures
• 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
5
Epidemiology of Headaches
• Primary headache disorder is estimated to affect 45(+) million individuals in the US (Cleveland Clinic Health Information Center, 2008)
• World-wide, the percentage of the adult population with an active headache disorder is 46% (Stover, 2007)
– 42% suffer from tension-type– 11% from migraine– 3% from chronic daily headache
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Socioeconomic
• Headache is the most common pain-related complaint among workers(Stewart, 2003)
• One of the most common complaints in the ER, with over 3 million ER visits in 2000 (Stewart, 2003)
• Most common cause of absenteeism from work and school (Cleveland Clinic Health Information Center, 2008)
• Estimated $17 billion annually, for the cost of healthcare associated with migraines (Goldberg, 2005)
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Types of Headache Disorders
• Primary- not associated with any cause or pathology– Migraine, Tension, cluster migraine
• Secondary- associated with some underlying pathology– Traumatic, Drug/substance related, infection, malignancy, vascular(Headache Classification Subcommittee of the International Headache Society, 2013)
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VITAL BEHAVIORS
Diagnosis Correctly
Treat Appropriately
Communicate Effectively
Headache Management
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Step 1- Diagnosis the headache
• Migraine verses Tension Type
• Chronic Daily Headache
• Medication overuse
• Trauma related
• Disease related
• Others?
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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
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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(Headache Classification Subcommittee of the International Headache Society, 2013)
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Case #1
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18 year old Male High School Student
• History of occasional annoying headaches for the last year• The last month have increased to almost daily lasting about an hour at a
time• Described as a band around the head, sometimes accompanied with
phonophobia• Denies any nausea/vomiting and not worsened by routine physical
activities• Relieved by Tylenol or OTC NSAIDS• Triggers: Stress and inadequate sleep• Family history was noncontributory• Neurologic exam was normal
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Migraine
• World wide prevalence of 11% and is the 2nd most common primary headache (Stovner, et al., 2007)
• Affecting women 3 times more than men, with a comparison of 17% female vs 6% male (Lipton & Bigal, 2007)
• Occurs from childhood to adulthood with the peak prevalence occurring in mid-adulthood (Lipton & Bigal, 2007)
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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(Headache Classification Subcommittee of the International Headache Society, 2013)
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Case #2
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38 year old Pediatrician
• 38 yr old female with reoccurring headaches since high school: left more often than right temporal or occasional bi temporal pressure
• Nausea occasional vomiting lasting 24 hours• Headaches could interfere with her activities including awakening her
from sleep• Frequency was 1-4 times per month, now weekly• OTC’s of little help• Triggers: Stress and heat, not triggered by menses, foods or alcohol• No recent contraceptive use• Family history was noncontributory• Neurologic exam was normal
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Step 2 - Headache Evaluation and Diagnosis
• Accurate and detailed 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?
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Helpful questions
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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? (Martin, 2004)
• Female presents to the ER: complains of a severe occipital headache and vomiting
• Describes it as the “Worst headache of her life”, stated that is started suddenly after a stressful day at work
• She had a similar headache 2 days prior but it only lasted a few seconds, then resolved
• No prior history of a similar headache• No prior head trauma, fever, vision changes, photophobia• Medical history: 2 normal pregnancies, only taking oral contraceptive for
15 years, no use of illicit drugs, tobacco or alcohol• Family history was noncontributory
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39 yr old DesignerPhysical Exam
Obese female, mild distress due to painPulse- 78, B/P 160/80, Resp-20, AfebrileHead is normal with no tenderness, ENT exam WNL, pupils are small at 2mm
but reactive to light with EOM intact, no photophobia or nystagmus. Fundi and optic discs WNL.
No neck mass but does have nuchal rigidityChest/heart exam WNL, lungs clear with normal respiratory effort. Abdomen
soft and nontenderNeuro exam reveal fully alert, orientated and mildly anxious. Cranial nerves
intact, with motor strength symmetrical, DTR’s symmetric and brisk without clonus. Cerebellar function and sensory systems are normal
CBC, CMP, U/A are WNLNoncontrast Cerebral CT : hyperdensity in the subarachnoid space
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Step 4- Identify Common Triggers of Migraine
• Hormonal-– menstruation, ovulation, oral contraceptives with estrogen
• 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(Koulivand, Ghadiri & Gorji, 2013)
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Empathetic Listening
• No one cares how much you know, untilthey know how much you care” – Theodore Roosevelt
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Case Presentation
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Headache Syndrome
Migraines + new onset headaches for 2 years
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Background
• 44yr old female with a history of refractory headaches for the last 2 years
• Migraines since 1990’s- described as posterior pressure, treated with Advil. If untreated will cause photophobia/phonophobia & worse with exertion
• 2nd type started 2 years prior. Described as bi-frontal and right eye pressure increases to 4-6/10 and occasion to 8-9/10 w/photo/phonphobia
• Would occur upon waking up in the morning, worsen with exertion and when dehydrated. Lasting up to 2 weeks and occurring monthly
• Treated with zomig and advil- with about 1/3 resolved with this
• Treated in past by a neurologist- MRI of Brain WNL
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Social & Medical History
• 44 yr old female/Married/Home-maker/ Graduated High School- some college
• No Tobacco/ Occasional ETOH/Occasional caffeine/Diet balanced/Elliptical 3 x’s per week
• Enjoys travel, reading and volunteering
• Migraines, Right shoulder arthritis, Cervical DDD, low back pain
• Hx of fall while skiing 2006 with tailbone fx, right shoulder injury and concussion
• Allergic to Sulfa
• Surgical- none
• Family hx- Migraines- Mother & Father
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Significant Exam Findings
• Normal Neurologic exam
• Bil occipital tenderness
• Pulling sensation to right of C4 to C7 with rotation of head to left
• MRI of c/spine- DDD with disc protrusion
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Treatment
• Topiramate titration/maintain zolmitriptan• Botox• Headaches improved at f/u but still with multiple headaches • Consult to neurosurgeon- stable- consult to PT • Occipital blocks & auricular acupuncture at f/u with dramatic reduction in
headaches• B/P elevated and switched Topiramate to Propranolol 80 LA• 2nd & 3rd rounds of Botox• Maintained on Propranolol 80LA• Continued control of headaches to one per month and occasional occipital
headache• Overjoyed at having this treated!
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Summary
• Step 1- Diagnosis the headache or headaches- 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 triggers and exacerbating factors
• Step 5- Action Plan- Acute , preventative, lifestyle modifications, education is a key component (Realistic Expectations)
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VITAL BEHAVIORS
Diagnosis Correctly
Treat Appropriately
Communicate Effectively
Headache Management
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Headache table
Migraine Tension-Type SAHLocation Unilateral Bilateral OccipitalIntensity Moderate to Severe Mild to Moderate Severe/”Worst HA
of life”Duration 4 to 72 hours 30 mins to 7 days Sudden/rapid onset
Female: Male ratio 3 : 1 1.3 : 1 No preference, seen
often after
head/neck trauma
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References
1. Becker, W. J. (2015). Acute migraine treatment in adults. Headache: The Journal of Head and Face Pain, 55(6), 778-793.
2. Briggs, P. (2016). Inhaled peppermint oil for postop nausea in patients undergoing cardiac surgery. Nursing, 46(7), 61-67.
3. 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.
4. Deen, M., Correnti, E., Kamm, K., Kelderman, T., Papetti, L., Rubio-Beltrán, E., … On behalf of the European Headache Federation School of Advanced Studies (EHF-SAS). (2017). Blocking CGRP in migraine patients – a review of pros and cons. The Journal of Headache and Pain, 18(1), 96.
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5. De Luca GC, Bartleson JD. When and how to investigate the patient with headache. Semin Neurol. 2010; 30:131-144.
6. Goldberg LD. The cost of migraine and its treatment. AM J ManagCare 2005:11(2 suppl): 562-567.
7. Hay, D. L., & Walker, C. S. (2017). CGRP and its receptors. Headache: The Journal of Head and Face Pain, 57(4), 625-636.
8. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders:3rd
edition (beta version). Cephalagia 2013; 33(9): 629-808.9. Kligler, B., & Chaudhary, S. (2007). Peppermint oil. American Family
Physician, 75(7), 1027-1030.
References(continued)
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References(continued)
10. Koulivand, P. H., Ghadiri, M. K., & Gorji, A. (2013). Lavender and the nervous system. Evidence-Based Complementary & Alternative Medicine (eCAM), 2013, 1-10.
11. Lipton RB, Bigal ME, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007; 68:343-349.
12. Marmura, M. J., Silberstein, S. D., & Schwedt, T. J. (2015). The acute treatment of migraine in adults: The american headache society evidence assessment of migraine pharmacotherapies. Headache: The Journal of Head and Face Pain, 55(1), 3-20.
13. 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.
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References (continued)
14. Murinova, N., & Krashin, D. (2015). Chronic daily headache. Physical Medicine and Rehabilitation Clinics of North America, 26(2), 375-389.
15. 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.
16. 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.
17. Stewart WF, et al. Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce. JAMA 2003; 290 2443-2454.
18. Stovner LJ, et al. The Global Burden of headache: A Documentation of Headache Prevalence and Disability Worldwide. Cephalgia 2007; 27:193-210.
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References(continued)
19. Pringsheim, T., Davenport, W. J., Marmura, M. J., Schwedt, T. J., & Silberstein, S. (2016). How to apply the AHS evidence assessment of the acute treatment of migraine in adults to your patient with migraine. Headache: The Journal of Head and Face Pain, 56(7), 1194-1200.
20. The Cleveland Clinic Health Foundation. Overview of headache in adults. Cleveland Clinic Health Information Center website. Accessed Feb 12 2008.