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Headache Management. Tom Miller MD. 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 Recent advances can translate into better treatment.

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Headache management

Headache Management

Tom Miller MD



  • 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


Problems in management
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


Underdiagnosis and treatment of migraine
Underdiagnosis and Treatment of Migraine

  • Diagnosis established in only 48% of patients meeting IHS criteria for migraine

  • Prescription medications used in just 41%

  • Suggests that just 20% get specific treatment


Overlap in symptoms
Overlap in Symptoms

  • Prevalence of tension-type symptoms

    • Tightness in neck and shoulders 51%

    • Occipital/cervical pain 59%

    • Tender neck muscles 37%

    • Tension or stress 57%

    • Any of the above 87%

  • Prevalence of sinus symptoms

    • Facial or maxillary pain 39%

    • Nasal discharge 12%

    • Sensitive to weather changes 33%

    • Sinus problems 40%

    • Any of the above 72%


Internal medicine residents
Internal medicine residents

  • Prepared to manage migraines 48%

  • Prepared to manage MI, DKA, Asthma 95%


Sinus headache
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


  • 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


  • 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?


Headaches
Headaches

  • Intracranial pathology

  • Contiguous structures

  • Migraine

  • Cluster

  • Tension type

  • Chronic daily/Rebound


Intracranial pathology
Intracranial pathology

  • Tumor

  • Subarachnoid hemorrhage

  • Meningitis

  • Pseudotumor cerebri


Tumor
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


Imaging
Imaging

  • Relatively solid recommendations

    • Not indicated in patients with migraines and normal exam

    • Indicated in patients with headache and abnormal exam


Less solid recommendations
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


Contiguous structures
Contiguous structures

  • Sinuses?

  • Eyes

  • Ears

  • TMJ

  • Teeth

  • Temporal artery

  • Cervical spine


Ihs criteria for migraine without aura
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


Pathophysiology of migraine
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


Treatment of migraines
Treatment of migraines

  • Acute

  • Preventive

    • Life style

    • Pharmacologic


Principles of management
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


Acute treatment
Acute treatment

  • Mild - oral

    • ASA 975 mg

    • Naproxen 500-1250 mg

    • Ibuprofen 800-2400 mg

    • Midrin (isomethptene/dichloralphenazone/APAP)

    • Ergotamine 2 mg + caffeine 200 mg

    • Butalbital/apap/caffeine/codeine

  • Mild with nausea

    • Add metaclopramide 10 mg


  • Severe

    • Tryptans: oral, nasal, wafer, subQ

    • DHE 1mg subQ, IV, nasal spray

    • Alternatives

      • Ketorolac 60 mg IM

    • Adjuncts

      • Prochlorperazine (compazine) 10 mg IM/IV

      • Chlorpromazine (phenergan) 25 IV

    • Narcotics


Tryptans
Tryptans

  • Contraindications

    • CAD

    • CAD likely

  • Side effects

    • Chest and neck pressure

    • Dizziness

    • Warmth, numbness, tingling, tightness, flushing

    • Nausea and vomiting



Narcotics
Narcotics tryptans, it is available generically and should be the first choice.

  • Not more effective

  • Not specific for underlying pathophysiology

  • Sedating

  • Positive reinforcement?

  • Potential for abuse

  • Public health crisis


Preventive therapies
Preventive therapies tryptans, it is available generically and should be the first choice.

  • Amitriptyline 25-150 mg

  • Propranolol 80-240 mg

  • Timolol 20-30 mg

  • Divalproex sodium 500-1500 mg

  • Sodium valproate 800-1500 mg

  • Fluoxetine 20-40 mg


  • All are 70% effective tryptans, it is available generically and should be the first choice.

  • Reduce frequency and severity of attacks

  • Response cannot be predicted

  • Dose adjustments necessary

  • Calcium channel blockers less effective

  • Decision process


Life style changes
Life style changes tryptans, it is available generically and should be the first choice.

  • Establish and maintain routines

    • Sleep

    • Meals

    • Exercise

  • Dietary triggers

    • Caffeine, chocolate, alcohol, aged cheeses, monosodium glutamate


Nonpharmacologic management
Nonpharmacologic management tryptans, it is available generically and should be the first choice.

  • Effective

    • Relaxation training

    • Thermal biofeedback

    • Cognitive behavioral therapy

  • Ineffective

    • Acupuncture

    • Hypnosis

    • Manipulation

    • TENS

    • Hyperbaric oxygen

    • Occlusal adjustment


Aspirin for migraine prevention
Aspirin for migraine prevention? tryptans, it is available generically and should be the first choice.

  • 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


Cluster headaches
Cluster headaches tryptans, it is available generically and should be the first choice.

“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


Clinical features
Clinical features tryptans, it is available generically and should be the first choice.

  • Unilateral – 100%

  • Restlessness – 93%

  • Retroorbital – 92%, (temporal – 70%)

  • Lacrimation – 91%

  • Conjuctival injections – 77%

  • Nasal congestion/rhinorrhea – 75%

  • Ptosis/eyelid swelling – 74%

  • Phonophobia/phophobia – 50%


Periodicity
Periodicity tryptans, it is available generically and should be the first choice.

  • Duration: 8 weeks

  • Bouts per year: 1

  • Maximum attacks per day: 4

  • Attack duration: 15-180 min

  • Nocturnal: 73%


Treatment
Treatment tryptans, it is available generically and should be the first choice.

  • Acute

    • Subcut tryptans

      • 74% effective within 15 min

      • Nasal may be effective

      • Zolmitriptan 10 mg po – 60% response within 30 min

    • Oxygen


Treatment1
Treatment tryptans, it is available generically and should be the first choice.

  • 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


  • Other effective therapy tryptans, it is available generically and should be the first choice.

    • Prednisone

      • Bridge to verapamil

      • Tapered over 3 week

    • Lithium

    • Sodium valproate

    • Methysergide


Tension type headaches
Tension-type headaches tryptans, it is available generically and should be the first choice.

  • 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


Management of tt headaches
Management of TT headaches tryptans, it is available generically and should be the first choice.

  • Acute headaches

    • Minor analgesics

  • Chronic tension type headaches

    • Same diagnostic criteria

    • Occur 15 days per month


Ctth an rct
CTTH: An RCT tryptans, it is available generically and should be the first choice.

  • 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


  • Results: All three treatment groups effective tryptans, it is available generically and should be the first choice.

    • 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


Treatment goals for ctth
Treatment goals for CTTH tryptans, it is available generically and should be the first choice.

  • Identify and eliminate triggers

  • Amitriptyline

  • Symptomatic treatment with NSAID

  • Avoid overuse

  • Stress management


Analgesic abuse or rebound headaches
Analgesic abuse or rebound headaches tryptans, it is available generically and should be the first choice.

  • ¾ of patients with chronic daily headaches overuse analgesics

  • Transformed migraines

    • Past history of discrete migraines


Analgesics implicated
Analgesics implicated tryptans, it is available generically and should be the first choice.

  • Butalbital/aspirin/acetomenophen/caffeine

  • Codeine, propoxyphene, oxycodone, hydrocodone

  • Aspirin, acetomenophen

  • NSAID

  • Nasal decongestants and antihistamines

  • Ergotamine

  • Tryptans


Management strategies
Management strategies tryptans, it is available generically and should be the first choice.

  • 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


Effectiveness of treatment
Effectiveness of treatment tryptans, it is available generically and should be the first choice.

  • 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


Conclusion
Conclusion tryptans, it is available generically and should be the first choice.

  • 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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