Management of Primary Management of Primary Headache Disorders Headache Disorders
Jan 04, 2016
Management of Primary Management of Primary Headache DisordersHeadache Disorders
Primary Headache disordersPrimary Headache disorders
Include all the non-malignant recurrent headache Include all the non-malignant recurrent headache disorders not caused by structural causes or disorders not caused by structural causes or medical disease.medical disease.
Includes: migraines, tension headaches, cluster Includes: migraines, tension headaches, cluster headaches, hypnic headaches, paroxysmal headaches, hypnic headaches, paroxysmal hemicrania and many others.hemicrania and many others.
Have a high prevalence and incidenceHave a high prevalence and incidence
Basic Headache FundamentalsBasic Headache Fundamentals
Multifactoral ContributionsMultifactoral Contributions -genetic -genetic -environmental (stress, sleep)-environmental (stress, sleep) -chemical (caffeine, medication)-chemical (caffeine, medication) -organic (sinus disease, muscle strain)-organic (sinus disease, muscle strain) -physical (posture, ergonomics, eye -physical (posture, ergonomics, eye
strain)strain) -psychologic (secondary gain, anxiety, -psychologic (secondary gain, anxiety,
depression, hypochondriasis)depression, hypochondriasis)
MigrainesMigraines
CharacteristicsCharacteristics
EpisodicEpisodic
UnilateralUnilateral
Pounding, throbbingPounding, throbbing
Photophobia,Photophobia,
PhonophobiaPhonophobia
Nausea/ vomitingNausea/ vomiting
Need for sleepNeed for sleep
Visual or sensory auraVisual or sensory aura
Migraine-general conceptMigraine-general concept
Think of migraine as:Think of migraine as:
Neurologic disorder +/- headacheNeurologic disorder +/- headache
Also often include autonomic and Also often include autonomic and GI symptomsGI symptoms
Migraine EpidemiologyMigraine Epidemiology
In a given year, 15% to 18% of women In a given year, 15% to 18% of women and 6% of men have at least one migraine and 6% of men have at least one migraine attack.attack.
28% of men and 40% of women used 28% of men and 40% of women used prescription medications.prescription medications.
Important Migraine medical historyImportant Migraine medical history
TriggersTriggers
Character of painCharacter of pain
Associated symptomsAssociated symptoms
DurationDuration
FrequencyFrequency
Behavior during an Behavior during an attack (hibernation-attack (hibernation-like)like)
AurasAuras
TreatmentTreatment
PMHPMH
Previous medicationsPrevious medications
OTC medicationsOTC medications
Family hxFamily hx
CaffeineCaffeine
Sleep (quality and Sleep (quality and quantity)quantity)
Life-StressLife-Stress
ExerciseExercise
Important ROSImportant ROS
Eye symptoms: visual loss, visual Eye symptoms: visual loss, visual changes, double vision, photophobiachanges, double vision, photophobia
GI symptoms: N/V, cravings, anorexiaGI symptoms: N/V, cravings, anorexia
Other: vertigo, numbness and tingling, Other: vertigo, numbness and tingling, phonophobia, need for sleep phonophobia, need for sleep
Important questionsImportant questions
Everyday or intermittentEveryday or intermittentFrequency of headachesFrequency of headachesDuration of headacheDuration of headacheOnset (rapid, during sleep or with aura)Onset (rapid, during sleep or with aura)Presence of nausea?Presence of nausea?Medications used?Medications used?Other measures used?Other measures used?Family historyFamily historyWhat do you do when you get a headache?What do you do when you get a headache?How well do you sleep?How well do you sleep?
Diagnostic work-upDiagnostic work-up
If headaches are intermittent, frontal If headaches are intermittent, frontal with photophobia/phonophobia, +Fhx. with photophobia/phonophobia, +Fhx. None neededNone needed
Atypical features: male, age >30, no Atypical features: male, age >30, no family hx, abnormal exam: consider family hx, abnormal exam: consider imagingimaging
No lab w/u generally requiredNo lab w/u generally required
Diagnosis is by history and description Diagnosis is by history and description of headaches.of headaches.
Therapy PrinciplesTherapy PrinciplesMedical and non-medicalMedical and non-medical
Non-medical therapies include: sleep, ice Non-medical therapies include: sleep, ice packs, behavioral modification, packs, behavioral modification, biofeedbackbiofeedback
Medical therapies include prescription, Medical therapies include prescription, nutritional and herbal therapiesnutritional and herbal therapies
Treatment-general principlesTreatment-general principles
Comes in 2 forms:Comes in 2 forms:
Abortive: treat each headache Abortive: treat each headache symptomatically with a prn medicationsymptomatically with a prn medication
Preventative: prevent recurrent headaches Preventative: prevent recurrent headaches with a daily medicationwith a daily medication
Abortive therapy-important Abortive therapy-important conceptsconcepts
Staged therapy approach: treat mild Staged therapy approach: treat mild headaches with “mild medicines” and headaches with “mild medicines” and severe headaches with “strong severe headaches with “strong medicine”medicine”
The earlier you treat the migraine, the The earlier you treat the migraine, the more effective the response. more effective the response. Entrenched or established migraines Entrenched or established migraines are harder to abort.are harder to abort.
Abortive therapiesAbortive therapies
-For mild headaches:-For mild headaches:NSAIDs, ASA, acetaminophen, ibuprofen, NSAIDs, ASA, acetaminophen, ibuprofen,
naproxennaproxen
-For moderate headaches:-For moderate headaches:Fioracet, Fiorinal, Midrin, percocet, T3Fioracet, Fiorinal, Midrin, percocet, T3
Abortive therapies-continuedAbortive therapies-continued
For severe headaches:For severe headaches:
Triptans:Triptans: imitrex, maxalt, zomig, amerge, imitrex, maxalt, zomig, amerge,
relpax, trexemet and othersrelpax, trexemet and others
Ergotamines: Dihydroergotamine -45 (DHE)Ergotamines: Dihydroergotamine -45 (DHE)
Abortive therapies-considerationsAbortive therapies-considerations
Triptans are contraindicated with Triptans are contraindicated with ischemic heart disease and complicated ischemic heart disease and complicated migraine (hemiplegic, confusional)migraine (hemiplegic, confusional)
Route of treatment determines speed of Route of treatment determines speed of response and effectiveness:response and effectiveness:
Oral, injectable or nasal sprayOral, injectable or nasal spray
Abortive therapies-considerationsAbortive therapies-considerations
Not to be used more than 2-3 Not to be used more than 2-3 days per week to avoid days per week to avoid medication overuse headache/ medication overuse headache/ rebound headacherebound headache
Abortive therapies- continuedAbortive therapies- continued
Miscellaneous:Miscellaneous:
IV Magnesium, phenothiazineIV Magnesium, phenothiazine
antiemetics: compazine, phenergan, antiemetics: compazine, phenergan,
reglanreglan
Depakon, thorazine, prednisone, Depakon, thorazine, prednisone, decadrondecadron
Preventative therapies-conceptsPreventative therapies-concepts
Used where headache frequency Used where headache frequency exceeds 15 days per month or 2-3 days exceeds 15 days per month or 2-3 days per week.per week.
Try to treat co-existing conditions with Try to treat co-existing conditions with preventative therapiespreventative therapies
Insomnia, depression, HTN, obesity Insomnia, depression, HTN, obesity
Preventative therapies-conceptsPreventative therapies-concepts
Preventative therapies may take 3-4 Preventative therapies may take 3-4 weeks to start workingweeks to start working
Start at a low dose and gradually increaseStart at a low dose and gradually increase
Have patient keep a headache calendar to Have patient keep a headache calendar to monitor actual progressmonitor actual progress
Preventative agentsPreventative agents
Beta-blockers: propranolol, metoprololBeta-blockers: propranolol, metoprolol
-main side effects: exercise intolerance-main side effects: exercise intolerance
Calcium channel blockers: VerapamilCalcium channel blockers: Verapamil
Anti-depressants: TCAs: pamelor, Anti-depressants: TCAs: pamelor, elavil,elavil,
SSRIsSSRIs
Preventative agentsPreventative agents
Anti-epilepticsAnti-epilepticsValproic acid- approved as migraine Valproic acid- approved as migraine
preventative (weight gain, PCOD, preventative (weight gain, PCOD, teratogenic)teratogenic)
Topiramate- approved as migraine Topiramate- approved as migraine preventative (weight loss, preventative (weight loss, language/memory problems language/memory problems “Stupamax”, “Dopamax”“Stupamax”, “Dopamax”
Antiepileptic preventativesAntiepileptic preventatives
Neurontin- seems to work OK if Neurontin- seems to work OK if tolerated. Limited by sedation, BID-TID tolerated. Limited by sedation, BID-TID dosingdosing
Lamictal (lamotrigine) not used too often Lamictal (lamotrigine) not used too often due to Steven’s-Johnson rash- 3due to Steven’s-Johnson rash- 3rdrd line line agentagent
Other preventative therapiesOther preventative therapies
Oral magnesium- may have a role in Oral magnesium- may have a role in perimenstrual migraineperimenstrual migraine
Hormonal therapies: supplemental Hormonal therapies: supplemental estrogen during menstrual phaseestrogen during menstrual phase
Botox injectionsBotox injections
Leukotriene inhibitors (montelukast)Leukotriene inhibitors (montelukast)
LisinoprilLisinopril
Alternative therapiesAlternative therapies
Feverfew (Feverfew (Tanacetum partheniumTanacetum parthenium))
Ribolfavin (vitamin B2)Ribolfavin (vitamin B2)
AccupunctureAccupuncture
Migrelief (Feverfew, magnesium sulfate Migrelief (Feverfew, magnesium sulfate and vitamin B2)and vitamin B2)
Chronic daily headacheChronic daily headache
Daily or almost daily occurrence of Daily or almost daily occurrence of headacheheadache
Episodic migraine sometimes transforms Episodic migraine sometimes transforms into chronic daily headacheinto chronic daily headache
Commonly associated with medication Commonly associated with medication overuseoveruse
Medication overuse headacheMedication overuse headacherebound headacherebound headache
Must first address medication overuse.Must first address medication overuse.
Use of short acting analgesics, vasoactiveUse of short acting analgesics, vasoactive
medications including triptans more than 2medications including triptans more than 2
days per week can result in medicationdays per week can result in medication
overuse headaches in susceptibleoveruse headaches in susceptible
individualsindividuals
MOH treatmentMOH treatment
1.1. Educate: a handout is often helpful (from Educate: a handout is often helpful (from Mayoclinic.com or Jefferson Headache Mayoclinic.com or Jefferson Headache centercenter
2.2. Decide on abrupt withdrawal or taperDecide on abrupt withdrawal or taper
MOH treatmentMOH treatment
Consider prednisone 4-7 days, 40-60mgConsider prednisone 4-7 days, 40-60mg
DHE infusionDHE infusion
Add migraine preventativeAdd migraine preventative
Treat insomniaTreat insomnia
Limit analgesic use to 2 days/weekLimit analgesic use to 2 days/week
Use anti-nausea or valium for break Use anti-nausea or valium for break through headaches or symptoms.through headaches or symptoms.
Indomethacin responsive Indomethacin responsive headachesheadaches
Paroxysmal hemicraniaParoxysmal hemicrania
Short duration (3min to 45 min) intense,Short duration (3min to 45 min) intense,
boring, focal (temporal, frontal, parietal). Noboring, focal (temporal, frontal, parietal). No
nausea, photophobia, phonophobia, 4-30/daynausea, photophobia, phonophobia, 4-30/day
Also described as “ice pick headaches” or “jolts Also described as “ice pick headaches” or “jolts and jabs”and jabs”
Indomethacin 75 to 150mg/dayIndomethacin 75 to 150mg/day
Other headache typesOther headache types
Cluster headacheCluster headache
Less common, seen more in men, headacheLess common, seen more in men, headache
is typically intense, stereotyped, unilateral, is typically intense, stereotyped, unilateral,
30min to 2 hours in duration, turns on/off like30min to 2 hours in duration, turns on/off like
a switch. Associated with autonomic a switch. Associated with autonomic
symptoms: runny nose, lacrimation, etcsymptoms: runny nose, lacrimation, etc
Cluster headaches continuesCluster headaches continues
Treatment-abortiveTreatment-abortive
Includes triptans, oxygen, most oral Includes triptans, oxygen, most oral analgesics work too slowanalgesics work too slow
Treatment-preventative:Treatment-preventative:
Depakote, verapamil, steroids, lithiumDepakote, verapamil, steroids, lithium
Exertional headachesExertional headaches
Typically sudden onset, occipitalTypically sudden onset, occipital
May have mild photophobiaMay have mild photophobia
May symptomatically resemble sub-May symptomatically resemble sub-arachnoid hemorrhagearachnoid hemorrhage
Post-coital headaches- typically in young Post-coital headaches- typically in young men, may occur at or before orgasim. men, may occur at or before orgasim. Recurrence may occur over 2-3 weeks but Recurrence may occur over 2-3 weeks but then typically resolvesthen typically resolves
Exertional headachesExertional headachesRule SAH if appropriateRule SAH if appropriate
May treat with pre-exertion medication May treat with pre-exertion medication including indocin, NSAIDsincluding indocin, NSAIDs
May consider preventative B-blockersMay consider preventative B-blockers
Usually resolve after some period of Usually resolve after some period of weeks.weeks.
Questions?Questions?