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Headache Management

Headache Management. Fariborz Khorvash Associate Professor of Neurology. Why talk about headaches?. Headaches are a common problem They are sometimes difficult to treat Can usually be treated well by internists Headache management is often not optimal

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Headache Management

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  1. Headache Management Fariborz Khorvash Associate Professor of Neurology

  2. Why talk about headaches?

  3. Headaches are a common problem • They are sometimes difficult to treat • Can usually be treated well by internists • Headache management is often not optimal • Recent advances can translate into better treatment

  4. Problems in management • Chest pain approach • Does this patient have a brain tumor? • Episodic care • Underdiagnosis of migraine headache • Ineffective treatments are commonly used • Acetaminophen, Butalbital/ASA/Caffeine • Inappropriate use of analgesics

  5. Red Flag Signs: • Thunderclap headache • New onset headache • Headache with neurologic signs • Headaches in pregnancy • Headaches in elderly • Progressing headaches • Changes in frequenc or quality of headache

  6. Internal medicine residents • Prepared to manage migraines 48% • Prepared to manage MI, DKA, Asthma 95%

  7. Sinus Headache? • What is a sinus headache? • Many patients with migraines have sinus symptoms. • Rhinorrhea, congestion, ocular symptoms occur in up to 46% of patients with migraines

  8. Study of 2991 patients with sinus headaches • Self or physician diagnosed • 88% met IHI criteria for migraine • Patients reported • Sinus pressure – 84% • Sinus pain – 82% • Nasal congestion – 64% • Diagnosis of sinus headache should be reserved for those patients who meet diagnostic criteria for sinusitis. Schreiber, Archives of Int. Med. 2004; 164: 1769

  9. Brain Imaging: • New onset headache • Headache with neurologic sign • Headache with seizure • Headache with elevated ICP • Patient request • …….

  10. Headaches • Intracranial pathology • Contiguous structures • Migraine • Cluster • Tension type • Chronic daily/Rebound

  11. Intracranial pathology • Tumor • Subarachnoid hemorrhage • Meningitis • Pseudotumor cerebri

  12. Tumor 111 consecutive patients with primary or metastatic brain tumor • Classic early morning headache is uncommon • Primary symptom in only - 44% • Worse with bending over - 33% • Similar to TTH in 77%; migraine in 9% • Nausea and vomiting – 40% Forsyth, Neurology, 1993

  13. Imaging • Relatively solid recommendations • Not indicated in patients with migraines and normal exam • Indicated in patients with headache and abnormal exam

  14. Less solid recommendations • Headache worsened by valsalva, exertion, sex • Abrupt onset or awakens patient from sleep • Change in established pattern • New headache in patient >50 • Progressively worsening headache • Comorbidities: HIV, cancer, immune suppression

  15. Contiguous structures • Sinuses? • Eyes • Ears • TMJ • Teeth • Temporal artery • Cervical spine

  16. IHS criteria for migraine without aura • Duration 4-72 hours • Two of the following characteristics • Unilateral • Moderate – severe intensity • Pulsating • Aggravated by routine physical activity • Headache accompanied by one the following • Nausea or vomiting • Photophobia or phonophobia • 5 attacks • No other explanation

  17. Pathophysiology of migraine • Old theory: vasoconstriction triggers vasodilation • Current concepts • Originates as a neurologic event in the brain stem • Trigeminal nerve ganglion is stimulated • Vasodilation occurs • Serotonin release contributes

  18. Treatment of migraines • Acute • Preventive • Life style • Pharmacologic

  19. Principles of management • Establish a diagnosis • Treat early • Use adequate doses • Tailor treatment to the severity of attack • Use migraine specific therapies • Use preventive strategies • Form a therapeutic alliance with the patient • Empower the patient • Avoid narcotics

  20. Acute treatment • Mild - oral • ASA 975 mg • Naproxen 500-1250 mg • Ibuprofen 800-2400 mg • Cataflam • Ergotamine 2 mg + caffeine 200 mg • Brufen/caffeine/codeine • Mild with nausea • Add metaclopramide 10 mg

  21. Severe • Tryptans: oral, nasal, wafer, subQ • DHE 1mg subQ, IV, nasal spray • Alternatives • Ketorolac 60 mg IM • Adjuncts • Promethazine • Chlorpromazine (phenergan) • Narcotics

  22. Tryptans • Contraindications • CAD • CAD likely • Side effects • Chest and neck pressure • Dizziness • Warmth, numbness, tingling, tightness, flushing • Nausea and vomiting

  23. Though sumatriptan may not be the most effective of the tryptans, it is available generically and should be the first choice.

  24. Narcotics • Not more effective • Not specific for underlying pathophysiology • Sedating • Positive reinforcement? • Potential for abuse • Public health crisis

  25. Preventive therapies • Amitriptyline 25-150 mg • Propranolol 80-240 mg • Divalproex sodium 500-1500 mg • Sodium valproate 800-1500 mg • Venlafaxine 75-150 mg • Fluoxetine 20-40 mg?????? • Dysport

  26. All are 70% effective • Reduce frequency and severity of attacks • Response cannot be predicted • Dose adjustments necessary • Calcium channel blockers less effective • Decision process

  27. Life style changes • Establish and maintain routines • Sleep • Meals • Exercise • Dietary triggers • Caffeine, chocolate, alcohol, aged cheeses, monosodium glutamate

  28. Nonpharmacologic management • Effective • Relaxation training • Cognitive behavioral therapy • Ineffective • Acupuncture • Hypnosis • Manipulation • TENS • Hyperbaric oxygen

  29. Aspirin for migraine prevention? • Observations from the Physicians’ Health Study • 22,071 doctors randomized to 325 mg of ASA or control • Treatment group: 6% experienced migraine after randomization • Control group: 7.4% experienced migraine • Treatment effect: 20% Buring, JAMA, 1990

  30. Cluster headaches “A healthy robust man of middle age was suffering from troublesome pain which came on every day at the same hour at the same spot above the orbit of the left eye: after a short time the left eye began to redden, and to overflow with tears; then he felt as if his eye was slowly forced out of its orbit with so much pain, that he nearly went mad. After a few hours all these evils ceased, and nothing in the eye appeared at all changed.” Textbook 1745

  31. Clinical features • Unilateral – 100% • Restlessness – 93% • Retroorbital – 92%, (temporal – 70%) • Lacrimation – 91% • Conjuctival injections – 77% • Nasal congestion/rhinorrhea – 75% • Ptosis/eyelid swelling – 74% • Phonophobia/phophobia – 50%

  32. Periodicity • Duration: 8 weeks • Bouts per year: 1 • Maximum attacks per day: 4 • Attack duration: 15-180 min • Nocturnal: 73%

  33. Treatment • Acute • Subcut tryptans • 74% effective within 15 min • Nasal may be effective • Zolmitriptan 10 mg po – 60% response within 30 min • Oxygen

  34. Treatment • Prophylactic – a small trial involving 30 patients • Verapamil 120 tid • 80% of patients responded • 40% at the end of one week • Attacks per day after one week • Verapamil - .6 • Placebo – 1.6 Leone, Neurology, 2000

  35. Other effective therapy • Prednisone • Bridge to verapamil • Tapered over 3 week • Lithium • Sodium valproate • Methysergide

  36. Tension-type headaches • Duration 30 min – 7 days • Two of the following characteristics • Pressing or tightening ( not pulsatile) • Mild to moderate intensity (nonprohibitive) • Bilateral • No aggravations from walking stairs • Both of the following • No nausea or vomiting • Photophobia and phonophobia absent (or only one present) • 10 previous attacks

  37. Management of TT headaches • Acute headaches • Minor analgesics • Chronic tension type headaches • Same diagnostic criteria • Occur 15 days per month

  38. CTTH: An RCT • Amitriptyline vs stress management vs combination • 409 patients recruited from primary care practices and randomized to one of 4 treatment groups • Amitriptyline – 48 • Stress management – 38 • Amitriptyline and stress management – 45 • Placebo – 38 Holroyd, JAMA, 2001

  39. Results: All three treatment groups effective • Mean headache index score • Days of at least moderate pain • Analgesic medication use • Headache disability Amitriptyline produced results more quickly. Combination treatment (AM+SM) produced greater than 50% reduction in HA severity in 2/3 of patients

  40. Treatment goals for CTTH • Identify and eliminate triggers • Amitriptyline • Symptomatic treatment with NSAID • Avoid overuse • Stress management

  41. Analgesic abuse or rebound headaches • ¾ of patients with chronic daily headaches overuse analgesics • Transformed migraines • Past history of discrete migraines

  42. Analgesics implicated • Butalbital/aspirin/acetomenophen/caffeine • Codeine, propoxyphene, oxycodone, hydrocodone • Aspirin, acetomenophen • NSAID • Nasal decongestants and antihistamines • Ergotamine • Tryptans

  43. Management strategies • Make a diagnosis • Establish and maintain a relationship • Inform the patients • Stop symptomatic treatment • Start prophylaxis – amitriptyline • Steroid taper (ranitidine 300 bid) • Recognize and treat the underlying headache disorder • Guard against overuse

  44. Effectiveness of treatment • Most patients will stop symptomatic treatment • Steroids seem to reduce withdrawal symptoms • 60-70% of patients improve • Improvement occurs over 6 months • 30% of patients relapse

  45. Conclusion • How do we diagnose migraine headaches? • How should we treat migraines? • What causes migraines? • Who needs a CT scan? • How do we recognize cluster headaches? • How do we diagnose tension type headaches? • Does anything work for chronic daily headaches?

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