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Medication Overuse Headache . Morris Maizels MD Blue Ridge Headache Center Asheville Hendersonville NC . Migraine Remembered . S evere U ni- L ateral 2 of 1st 4 T hrobbing A ctivity worsens ha N ausea S ensitive to light/sound 1 of last 2

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Medication overuse headache l.jpg

Medication Overuse Headache

Morris Maizels MD

Blue Ridge Headache Center

Asheville Hendersonville NC


Migraine remembered l.jpg
Migraine Remembered

S evere

U ni-

L ateral 2 of 1st 4

T hrobbing

A ctivity worsens ha

N ausea

S ensitive to light/sound 1 of last 2

Headache is episodic, and usually lasts 4-72 hours


Neurovascular theory of migraine l.jpg

Goadsby, 2000.

Neurovascular theory of Migraine


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1

3

2

Sensitization and migraine

1. Throbbing headache

1. Peripheral

Trigeminal Sensitization

2. Forehead Allodynia

3. Thalamic Sensitization

3. Extracephalic Allodynia

2. Central Trigeminal Sensitization

Adapted from Ambassadors program after Burstein et al., Brain 2000


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Migraine Triggers

  • hormones

  • emotions/stress

  • disrupted sleep

  • caffeine withdrawal

  • foods

  • change


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Symptomatic Medication Mild to Moderate Headaches

  • NSAID’s - high dose (+/- antiemetic)

  • ASA/acetaminophen/caffeine (Excedrin)*

  • ASA or acetaminophen/butalbital/caffeine (Fiorinal/Fioricet)*

  • Acetaminophen/isometheptene/dichlrophenazone (Midrin) - ii po at onset, then i qhr up to 5/day

  • Ergotamine tartrate/caffeine (Cafergot)*

    *** Limit use to 2 days/week ***


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Sumatriptan (Imitrex)

Rizatriptan (Maxalt)

Zolmitriptan (Zomig)

Naratriptan (Amerge)

Frovatriptan (Frova)

Almotriptan (Axert)

Eletriptan (Relpax)

DHE im/sq, iv, ns

Group by

parenteral

po rapid onset

po slow onset

rapid --> slow

high --> low efficacy

high --> low relapse

more --> less se’s

Triptans and DHE


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Triptan side effects/risks

  • Common: sedation, nausea, muscle ache, chest tightness (2 – 5%)

  • Contraindications

    • CAD, CVA, PVD

    • hemiplegic/basilar migraine

  • Risk of serious cardiac event with triptans is ~ 1:1,000,000


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General approach to acute Rx

  • Who gets triptans?

  • Which triptan?

  • How to use the triptan?


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Principles of acute therapy

  • Stratified care

  • Early use of medication for patients with episodic headache

  • Limit use of all acute meds to 2 days/week


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Stratified Care

  • Usual level of disability

  • Rapidity of onset

  • Associated nausea/vomiting

  • Tendency to relapse

  • Side effect tolerance


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An approach for triptan non-responders

  • Review diagnosis

    • migraine?

    • daily headache (drug rebound)?

  • Use early in attack, at sufficient dose

  • Try at least 3 triptans

  • Polypharmacy (NSAID/antiemetic)

  • ?Mg deficiency


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Alternatives for Refractory Headaches

  • Chlorpromazine (Thorazine) 12.5 mg iv;

    mr q 20 min x 3; total 50 mg

  • IV Depacon 100mg/kg over 5 min

  • IV DHE (q8h Raskin protocol)

  • IV Mg 2 gm/100 ml D5W may be added to any other regimen


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Drug Rebound Headache

  • h/o episodic migraine

  • more frequent/daily

  • refractory to usual Rx

  • narcotics for rescue

  • Fiorinal - “preventive”

  • escalating Rx use

  • trying to survive


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“The desire to take medication is, perhaps, the greatest feature which distinguishes man from the other animals.”

Sir William Osler


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Worst offenders: feature which distinguishes man from the other animals.”

Narcotics

Ergotamine

Caffeine-containing compounds:

Excedrin

Fiorinal/Fioricet

Cafergot

Lesser offenders:

aspirin

acetaminophen

NSAID’s

triptans

Innocent until proven guilty

DHE

What drugs cause drug rebound?


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“The Unrecognized Epidemic” feature which distinguishes man from the other animals.”

  • 1-2% of population is affected

  • (near) daily tension-type headache, with migrainous flares

  • present upon awakening

  • refractory to other abortive or prophylactic measures

  • headache worsens when medication is stopped


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Treatment of Drug Rebound feature which distinguishes man from the other animals.”

  • Patient education

  • Withdraw medication

  • Initiate prophylaxis

  • Provide rescue therapy


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Impact of continuing vs discontinuing symptomatic medication feature which distinguishes man from the other animals.”


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Prevention of drug rebound feature which distinguishes man from the other animals.”

All Rx’s state:

“Limit use to 2 days/week”

eg, Triptan A, B, or C x mg #9

i po at onset migraine–mr x 2 within 24 hr

Limit use to 2 days/week


Conclusion l.jpg
Conclusion feature which distinguishes man from the other animals.”

  • Episodic disabling = migraine

  • “Migraine-in-a-Minute” for triage

  • Stratify care

    • treat early

    • migraine-specific therapy

  • Refractory headache is usually due to:

    • drug rebound

    • co-morbidity

  • Incorporate behavioral assessment/Rx