12/20/2018 1 ECHO Ontario Chronic Pain Bootcamp – HEADACHE Saturday, December 8, 2018 Andrew J Smith, MDCM Staff Physician, Neurology, Pain and Addiction Medicine Centre for Addiction and Mental Health Disclosures • Presenter: Andrew Smith • Conflicts of Interest: None 2 Headache Learning Objectives At the end of this session, participants will be able: • Diagnose chronic headache type and identify medication overuse • Perform a screening physical and neurological examination for headache • Describe the best practice approaches to managing medication overuse and cervicogenic headache 3 Headache Diagnosis and Classification ICHD -3 (2018) A. Primary Headaches B. Secondary Headaches – rule out red flags C. Painful Cranial Neuropathies, Other Facial Pains and Other Headaches Does the patient have a primary of secondary headache? Good history and physical examination is usually sufficient to make Dx 4 5 Headache Red Flags 6
Transcript
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ECHO Ontario Chronic PainBootcamp – HEADACHE
Saturday, December 8, 2018
Andrew J Smith, MDCM
Staff Physician, Neurology, Pain and Addiction Medicine
Centre for Addiction and Mental Health
Disclosures
• Presenter: Andrew Smith
• Conflicts of Interest: None
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HeadacheLearning Objectives
At the end of this session, participants will be able:
• Diagnose chronic headache type and identify medication overuse
• Perform a screening physical and neurological examination for headache
• Describe the best practice approaches to managing medication overuse and cervicogenic headache
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Headache Diagnosis and ClassificationICHD -3 (2018)
A. Primary Headaches
B. Secondary Headaches – rule out red flags
C. Painful Cranial Neuropathies, Other Facial Pains and Other Headaches
Does the patient have a primary of secondary headache?
Good history and physical examination is usually sufficient to make Dx
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Headache Red Flags
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34 yo woman with a history of migraine, with new onset R arm weakness and L facial pain
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• 24 year old pregnant female
• Severe sudden onset headache.
• She is lying in a darkened room vomiting and is unable to move
• Papilledema on neuro exam
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Scenario A 32-year-old man came to ED because of abnormal sensation down the left side of his body. This had never happened before.
He described pins and needles that started in the face, then spread to his arm, and then to his leg, over a period of around 15 minutes.
A CT scan of the head had been requested by ED, which showed an area of hyperintensity adjacent to the right lateral ventricle. The patient was admitted for further investigations.
His only past medical history was migraine
Neurological examination was normal
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Not a Tumor, But…What’s That?Incidentalomas on MRI Scans of Migraineurs
•Subcortical White Matter Lesions: 6-40%
•Developmental venous anomalies: 5-10%
•Cerebral aneurysms 1-5% (vs 2.4% found incidentally at autopsy)
•Cavernous malformations 0.1 – 0.5%
•Chiari 1 malformations 0.1 – 0.5%
Imaging Begets Imaging
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Chance of finding a lesion?
US headache consortium meta-analysis of patient with migraine and normal exam:
•0.018% rate of significant pathology (for migraine)
•0.00% for TTH
AAN Quality Standard Subcommittee (2008)
1. Avoid testing if there will be no change in management
2. Avoid testing if chance of finding abnormality is not greater than in the general population
3. Use individual judgement for individual patients
4. Neuroimaging usually NOT WARRANTED with migraine and normal examination
AAN 2008. Cephalalgia 2005;25:30-35. Neurology 1994;44:1353-54
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Headache Diagnosis - History1. How many different headache types does the patient experience?
2. Time questionsa. Why consulting now? b. How recent in onset? c. How frequent, and what temporal pattern (especially distinguishing between episodic and daily
or unremitting) …ie days per week or per monthd. Duration?
3. Character questionsa. Intensity of pain b. Nature and quality of pain c. Site and spread of pain d. Associated symptoms
For the patient presenting with headache for the first time or with a significant change in headache pattern, the headache history should include this information
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Headache Diagnosis - History
4. Cause and Co-Morbidity questionsa. Predisposing and/or trigger factors b. Aggravating and/or relieving factors c. Family history of similar headache d. Co-existing? Insomnia, depression, anxiety, HTN, asthma, h/o heart disease or stroke
5. Response questionsa. What does the patient do during the headache? b. How much is activity (function) limited or prevented? c. What medication has been and is used, and in what manner
6. State of health between attacksa. Completely well, or residual or persisting symptoms? b. Concerns, anxieties, fears about recurrent attacks, and/or their cause
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Headache: 8 Most Important Questions1. How many types of headaches?
2. How long does your headache last? seconds, minutes, days, hours (SUNCT—>Paroxysmal Hemicranial —> Cluster —> Migraine —> TTH —> MOH)
3. How frequent?
4. What is the intensity of the pain
5. What do you do during a headache attack
6. Where is the pain located?
7. Are there any associated sx
8. Do you take medications?
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Headache Diagnostic Approach: HISTORYOnset
• Stable h/a of long duration ALMOST ALWAYS BENIGN
• Migraines often begin in childhood, adolescence or early adulthood
• Recent-onset = MORE WORRISOME
• Worst-ever, increasing severity; change for the worst in existing h/a all raise possibility of intracranial lesion
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Headache Diagnostic Approach :HISTORYTime of Day and Precipitating Factors• Migraines can occur any time, but often in AM
• H/A of recent onset that disturbs sleep or is worse on awakening, may be cause by increased ICP
• TTH: present much of the day, often worsen as day goes on
• Obstructive sleep apnea h/a on awakening
• Medication overuse h/a h/a on awakening
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Headache Diagnostic Approach :HISTORYTime of Day and Precipitating Factors
• Migraine triggers• Bright light• Menstruation• Weather changes• Caffeine withdrawal• Fasting• Alcohol (esp beer and wine)• Sleeping more or less than usual• Stress and release from stress• Foods, food additives• Perfume• Smoke
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Headache Diagnosis – Physical Examination
Patients presenting to a healthcare provider for the first time with headache, or with a headache that differs from their usual headache, should have a physical examination that includes the following:
1) A screening neurological examination2) A neck examination3) A blood pressure measurement4) A focused neurological examination, if indicated; and 5) An examination for temporomandibular disorders, if indicated
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Examination Pearls
• VS: BP; T r/o infection• Habitus: young, obese women Pseudotumour (IIH)• Thickened, irreg temporal aa with reduced pulse GCA• Scalp tender in mig and TTH• Short neck or low hairline basilar invagination or Chiari
2. Cranial nerve examination: fundoscopy, examination of pupils for symmetry and reaction to light, eye movements, visual fields, facial movement for asymmetry or weakness
3. Assessment of all 4 limbs for unilateral weakness, reflex asymmetry, and evaluation of coordination in the upper limbs
4. Assessment of gait, including heel-toe walking (tandem gait)
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Migraine - Diagnostic Classification
1.1 Migraine without aura
1.2 Migraine with aura1.2.1 Migraine with typical aura
1.2.2 Migraine with brainstem aura
1.2.3 Hemiplegic migraine
1.2.4 Retinal migraine
1.3 Chronic migraine
Migraine is Like Ice Cream-Dr. Phillip Swanson, UW
Migraine - Diagnostic Classification
1.4 Complications of migraine1.4.1 Status migrainosus
1.4.2 Persistent aura without infarction
1.4.3 Migrainous infarction
1.4.4 Migraine aura-triggered seizure
1.5 Probable migraine
1.6 Episodic syndromes that may be associated with migraine1.6.1 Recurrent gastrointestinal disturbance
1.6.1.1 Cyclic vomiting syndrome
1.6.1.2 Abdominal migraine
1.6.2 Benign paroxysmal vertigo
1.6.3 Benign paroxysmal torticollis
Clinical DiagnosisMigraine without aura (migraine with aura if an aura is present) if they have at least two
of:
1. Nausea during the attack
2. Light sensitivity during the attack
3. Some of the attacks interfere with their activities
Episodic tension-type headache if headache attacks are not associated with nausea, and have at least two of the following:
1. bilateral headache
2. non-pulsating pain
3. mild to moderate intensity
4. headache is not worsened by activity. 24
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Clinical Diagnosis
• Chronic migraine if headaches meet migraine diagnostic criteria or are quickly aborted by migraine specific medications (triptans or ergots) on 8 days a month or more
• Chronic migraine with medication overuse if the patient uses ergots, triptans, opioids, or combination analgesics on 10 days a month or more; or uses plain acetaminophen or NSAIDs on 15 days a month or more.
• Chronic tension-type headache if headaches meet episodic tension-type headache diagnostic criteria (above), except mild nausea may be present.
Patients with headache on 15 or more days per month for more than 3 months and with a normal neurological examination
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Case - CB
• C.B. is a 45-year-old female who presented to you, her new primary care physician recently to establish care. She has been quite healthy except for recurrent sinus headaches.
• These headaches began approximately 15 years ago and, at least initially, nearly always responded to antibiotics. She had an agreement with her previous healthcare provider that when her sinuses acted up, he would call in a prescription for a course of antibiotics. After taking the antibiotics for 2-3 days, her headaches would almost always go away.
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Case - CB
• The headaches were located over the forehead and cheeks.
• She rarely noted fevers or chills, but would often have clear nasal discharge and nasal congestion.
• Her stomach was also upset, which she attributed to post nasal drainage.
• The episodes would occur 8-9 times per year and, at times, were so bad that she would have to miss work because of the pain.
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Case - CB
• Because of her frequent episodes, she had been referred to an ENT physician. He ordered a CT scan of her sinuses which showed mild inflammation of the lining of the sinuses as well as a deviated septum.
• C.B. underwent two separate surgeries to correct the septal deviation and to improve the drainage from the sinus passages.
• The headaches improved after the first surgery, but then gradually returned to their previous pattern.
• C.B. saw numerous other healthcare providers over the years for these sinus headaches and even tried such therapies as acupuncture, chiropractic, cranial sacral therapy, and a TMJ splint.
• She presented to you, her new primary care physician frustrated and resigned to suffer from these recurrent headaches
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Migraine – Definition and Epidemiology
• A chronic neurological disorder characterized by attacks of moderate or severe headache and reversible neurological and systemic symptoms
• WHO: Migraine = 3rd most prevalent medical condition
• 1-year prevalence: 12% (18% women/ 6% men)
• Migraine affects ~ 10% of school aged children
• Most prevalent from 25 – 55 yrs old, then drops off
• But can occur earlier and later
• Infantile colic = earliest manifestation of migraine
• Disabling to inidividuals, families and societies ($20B/year in US; 113 M work-days)
• Postdromal phase• Occurs in about 80% of px – usally lasts less than 12h (but can last >24h in
~12%)• Most common sx: fatigue, impaired concentration, photophobia, irritability,
nasuea• Low threshold for recurrent, brief head pain with Valsalva or head
movement
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Case• 34 yo woman working as investment banker• Dx with episodic migraine without aura at 12 yo around menarche• Usually experiences 1 attack per month• Effectively treated with 50mg oral sumatriptan – pain aborts within 20
minutes• ~6-8 hours before her attacks yawning, extreme fatigue, difficulty
concentrating, photophobia, very difficult focusing on all the trading screens (consistently)
• Dull head discomfort or retro-orbital eye discomfort would sometimes build at this time, but would only use triptan once sx were moderate
• Patient attributes these symptoms to migraine triggers (eg when more busy at work, would be more tired; looking at bright screens would trigger an attack)
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Aura• Aura = focal, reversible cerebral symptoms assoc with a migraine attack• Occur in ~ 1/3 of patients with migraines
• Usu last 20-30 minutes (but can last an hour)…usu precede headache
• Visual sx most common (90%)• Positive: flickering lights, spots, lines• Negative: scotomas, visual field loss
• Other: Paresthesias (tingling, numbness)
• Expressive dysphasias are least common• Aura sx usually gradual onset and increase over minutes• Can experience mig aura without h/a• Pos sx, slow spread of symptoms and staggered onsets help differentiate migraine aura from
cardiovascular sx
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Migraine – Headache Phase• Unilateral (60%), throbbing (50%), aggravated by
movement/activity (90%)
• Can change sides during and between attacks
• Mean time to peak: 1 hr
• Median duration: 24 hrs (range: 4-72h in adults; 2-48h in children)
• Can involve any part of the head, commonly posterior cervical and trap areas
• 75% of pts have neck pain along with migraine episode
1. Triggers of an attack initiate a cortical depolarizing neuroelectric and metabolic event; termed cortical spreading depression Posterior to anterior 3 mm/sec
2. This activates mechanisms of pain (unknown exactly how)
3. Trigeminovascular system releases neuropeptides: CGRP Neurokinin A Substance P VIP
Activates trigeminal nociceptors
Vasodilatation
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Migraine Pathophysiology
4. Headache occurs from activation of the gasserian ganglion
5. Central sensitization and cephalic allodynia secondary to activation of the trigeminal nucleus caudalis(also C1-C2 dorsal horns)
6. Extracephalic allodynia secondary to activation of central pain modulating centers and ipsilateralthalamus
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Treatment philosophy
• If the pain can be stopped early, the cascadeof pain responses can be controlled
• Headache needs to be caught before central sensitization occurs
• Patients may receive the greatest benefit from their migraine medication if they:• Practice early intervention
• Use a fast-acting migraine medication
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Comprehensive Migraine Management
• Pay attention to lifestyle and specific migraine triggers in order to reduce the frequency of attacks. Lifestyle factors to avoid include the following:• irregular or skipped meals• irregular or too little sleep• a stressful lifestyle• excessive caffeine consumption• lack of exercise• obesity
• Use acute pharmacologic therapy for individual attacks • Use prophylactic pharmacologic therapy, when indicated, to reduce attack
frequency • Use nonpharmacologic therapies • Evaluate and treat coexistent medical and psychiatric disorders
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Migraine Self-Management
• Encourage patients to participate actively in their treatment and to employ self-management principles:• Self-monitoring to identify factors influencing migraine
• Managing migraine triggers effectively
• Pacing activity to avoid triggering or exacerbating migraine
• Maintaining a lifestyle that does not worsen migraine
• Practising relaxation techniques
• Maintaining good sleep hygiene
• Developing stress management skills
• Using cognitive restructuring to avoid catastrophic or negative thinking
• Improving communication skills to talk effectively about pain with family and others
• Using acute and prophylactic medication appropriately 40
Treatment Options
Two Treatment Approaches
•Acute therapy • Work quickly to relieve migraine pain and other
symptoms
• Are taken only at migraine onset
•Preventative therapy• Prevent or reduce the number of migraine attacks
• Are taken on a daily basis
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Acute Treatment Principles• Back-up/rescue if initial treatment fails
• Two or more acute meds can be combined if necessary
• Sumatriptan + naproxen
• Antiemetic + NSAID +/- triptan
• Minimize adverse events and cost
• Limit to 3 days per week or less
• NO BUTALBITAL/OPIOIDS lead to medication overuse
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Acute Treatment - Triptans
• Reasonable first choice for patients with moderate to severe disability from migraines
• Limit use to 2-3 days per week
• Patients who fail one triptan often respond to another
• Do not use one triptan within 24 hours of another
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Acute Treatment - Triptans
Mechanism of action
• 5HT-1B/1D agonists
• Inhibit release of CGRP & substance P
• Inhibit activation of the trigeminal nerve
• Inhibit vasodilation in the meninges
Precautions
• Ischemic heart dz or stroke
• High risk for CAD
• Pregnancy
• Hemiplegic or basilar migraine
• Ergots
• Use w/ SSRIs?
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Acute Treatment - Triptans
Fast onset/short duration
• Sumatriptan
• Rizatriptan
• Zomitriptan
• Almotriptan
• Eletriptan
• Treximet (Suma + Naproxen)
Slow onset/long duration
• Naratriptan
• Frovatriptan
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NSAIDs
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Antiemetics
• Prevent and treat nausea
• Improve GI motility
• Enhance absorption of other anti-migraine medications
• Limited RCT to support their use in migraine
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Status Migranosus: ER Options
• Migraine lasting greater than 72 hours in durationRefractory to conventional treatment
• Sumatriptan 4-6 sc
• Antiemetics + DHE iv
• Neuroleptics
• Ketorolac 30-60mg im helpful for cutaneous allodynia if not complicated by opioid use
• MgSO4 1-2g iv limited evidence but better for Mig with aura
• VPA 300-500mg iv
• Corticosteroids
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Migraine Acute Treatment: Adequate?
Lipton et al. Cephalalgia 29: 751-9, 2009
If NO to 1 or more of these questions, consider changing acute migraine medication
• Do you have significant relief within two hours of taking the medication?
• Is the medication well tolerated?
• Do you take only one dose?
• Can you return to your normal activities within two hours of taking the medication?
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Migraine: Why Treatment Fails
• Wrong diagnosis
• Wrong medication or sub-therapeutic dose
• Premature discontinuation
• Raising dose too quickly
• Failure to recognize full spectrum of symptoms of exacerbating factors
• Eg…GI symptoms tablets less effective (zolmatriptan nasal; sumatriptan injectible)
• Failure to recognize comorbidites (NB MOOD DISORDERS)
• MOU (nb caffeine)
• Unrecognized triggers
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Indications for a Preventive Agent• Migraine-related disability > 3d/month
• Headaches > 8 days/month (risk of overuse)
• Migraines cause profound disability or prolonged aura (hemiplegic migraine, migraine with brainstem aura)
• Acute treatments are contraindicated, ineffective, or overused• > 10 days per month: Triptans,
Ergotamines, Opioids, Combination• > 15 days per month:
acetaminophen, NSAIDs
• Patient preference
Goal: Reduce migraine attack frequency and HA related disabilityEFFECTIVE TREATMENT = REDUCE ATTACK FREQUENCY BY 50% or MOREUse MIDAS or HIT-6 – Standard measurements of HA disability
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Pharmacological Prophylaxis for Migraine
• Educate patients on the need to take the medication daily and according to the prescribed frequency and dosage
• Realistic expectations of prophylaxis:-Headache attacks will likely not be abolished completely-A reduction in headache frequency of 50% = success-~4-8 wk for substantial benefit to occur
• If the prophylactic drug provides substantial benefit in the first 2 mo of therapy, this benefit might increase further over several additional months of therapy
• Evaluate the effectiveness of therapy using patient diaries that record headache frequency, drug use, and disability levels
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Pharmacological Prophylaxis for Migraine
• For most prophylactic drugs, start low and go slow (eg topiramate 15mg q 2-4 weeks
• Increase the dose until the drug proves effective, until dose- limiting side effects occur, or until a target dose is reached
• Provide an adequate drug trial. Unless side effects mandate discontinuation, continue the prophylactic drug for at least 6-8 wk after dose titration is completed
• Because migraine attack tendency fluctuates over time, consider gradual discontinuation of the drug for many patients after 6 to 12 mo of successful prophylactic therapy, but preventive medications can be continued for much longer in patients who have experienced substantial migraine-related disability
Scottish Intercollegiate Guidelines Network. Diagnosis and management of head-ache in adults. A national clinical guideline. Publication no. 107. Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network; 2008. Available from: www.sign.ac.uk/ guidelines/fulltext/107/index.html.
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Other treatment options
• Magnesium glycinate 400mg bid
• Riboflavin 400mg daily
• Melatonin
• CoQ10
• Feverfew
• Acupuncture
• Biofeedback/Yoga/Meditation
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Emerging migraine therapy
Primary Sponsoring Company INN or Code Name
Molecular Format Target
Most Advanced
Phase Indications
Alder Biopharmaceuticals
ALD403/eptinezumab
Humanized IgG1
CGRP Phase 3Migraine prevention
Eli Lilly and Company
LY2951742/galcanezumab
Humanized IgG4
CGRP Phase 3
Migraine and cluster headache prevention
Teva Pharmaceuticals
TEV‐48125/frestanezumab
Humanized IgG2
CGRP Phase 3Migraine prevention
Amgen/Novartis
AMG334/erenumab
Human IgG2CGRP
receptorPhase 3
Migraine prevention
Clin Pharmacol Drug Dev. 2017 Nov-Dec; 6(6): 534–547. 56
Other treatment options
• Vagus Nerve Stimulation
• Spring TMS• Transcranial magnetic stimulation
• Cefaly• Tens-like unit
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Case Presentation
Anaka is a 28-year-old woman who was diagnosed with migraine with
aura 6 months ago. She has, on average, 1 migraine attack per
week, for which she takes triptan, an NSAID and an anti-emetic.
Because Anaka has migraine about 4 times per month, she is unlikely
to develop medication overuse headache. You are therefore happy
with her current treatment plan.
However, during an attack, she is unable to work or continue her
normal daily activities. She also worries a lot about when the next
attack is going to happen and their frequency causes her to take
a lot of time off work.
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Question
You note from Anaka's records that other than the
medication mentioned above she is not taking any
other forms of medication. You want to confirm that she
is not a taking combined hormonal contraceptive for
contraception purposes. Why is this?
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Question
Anaka asks if there is anything that can be done to reduce the frequency of her migraine attacks.
a) How would you assess the effectiveness of the propranolol?
b) When would you review the need to continue this prophylaxis?
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Question
Anaka asks if there is anything else she can do or take, such as a natural remedy, which could help reduce her migraine intensity. How would you address this?
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Question
Anaka tells you that her mum also takes treatment to prevent migraines, but that she takes amitriptyline.
Anaka says amitriptyline works for her mum and asks why she has not been offered it.
• Transitional• Daily use for 2-4 week to manage and attenuate severity of w/d
• Use other non-overused meds e.g. NSAIDs, DHE, Corticosteroids
• Consider nerve blocks
• Prevention
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Botulinum Toxin for Chronic Migraine
• Efficacy• Botulinum Toxin superior to placebo in 2 large, double blind, randomized,
controlled trials• Botulinum Toxin similar to topiramate and amitriptyline in small, shorter
duration studies• Botulinum toxin = placebo for episodic migraine
• Side effects = muscle weakness, injection site pain, and “spread of toxin effect”
• Mechanism of Action; Blocks release of Substance P and CGRPInhibits peripheral signals to CNS and blocks central sensitization
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Tension-type headache
A. At least 10 episodes occurring on <1 day per month on average (<12 days per year) and fulfilling criteria B-D
B. Headache lasting from 30 minutes to 7 days
C. Headache has at least two of the following characteristics:1. bilateral location
2. pressing/tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity such as walking or climbing stairs
D. Both of the following:1. no nausea or vomiting (anorexia may occur)
2. no more than one of photophobia or phonophobia
E.Not attributed to another disorder
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Tension-type headache• Infrequent < 1/month
• Episodic < 15 days/month
• Chronic >= 15 days/month
With/Without pericranial tenderness
Pathophysiology: NOT related to muscle tension; process akin to peripheral/central sensitization fibromyalgia
Rx: Dietary journal (nb caffeine, aspartame)
CBT, relaxation, structured exercise
For Frequent consider TCA +/- tizanadine, topiramate, mirtazapine
CHRONIC TTH >= 15 headache days per month of which 8 are primarily TTH
NB MOU
Doesn’t cause awakening usually
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Acute Treatment (Episodic TTH)
• First line: OTC analgesics (APAP, NSAIDs)
• High risk of rebound headaches
• Limit acute treatment to 2-3 days per week
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Case – RT• RT is a 38-year-old female who visited
you for evaluation of frequent headaches. She began experiencing headaches at age 20, which she described as intermittent, moderately severe, throbbing headaches that lasted one to two days and were associated with nausea and light sensitivity.
• The headaches would usually begin one day prior to the onset of menstrual bleeding. She was able to treat them with over-the-counter (OTC) analgesics such as the combination of aspirin, acetaminophen and caffeine.
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Case – RT
• These headaches began to occur at other times during the month and increased in frequency over the next ten years. While the headaches still responded to the OTC combination, she gradually had to increase her use of the medication.
• At times, when she had an important family or work obligation, she would take the medication to ‘prevent’ a bad headache from occurring.
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Case – RT
• By her early thirties, RT occasionally missed work due to headaches. Though she previously was a very sound sleeper, her sleep pattern gradually became more disrupted.
• She would often wake in the early morning with a bad headache.
• She also began to notice that it was taking more medication to achieve the same level of pain relief.
• Her family noticed that she was becoming more irritable and even wondered if she could be depressed. This prompted her to make an appointment with you.
• She tells you that she just didn’t want to live like this anymore.
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Medication Overuse - Definition Headache present on >15 days/month
Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache
Headache has developed or markedly worsened during medication overuse.
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Medication Overuse - DefinitionMedication Class Overuse Threshold
ErgotsTriptansOpioidsButalbitalCombination forms (caff/acet/ASA,etc)
>= 10 days per month > 3 months
Others >= 15 days per month > 3 months
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Medication-overuse Headache
• Often variable and has a peculiar pattern with shifting from day to day, or within same day, from migraine-like to tension-type
• Important to diagnose as patients won’t respond to prophylactics while ongoing
• Degree of “overuse” is medication dependent
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Medication-overuse Headache
• Triptans (1 to 2 years), longer for • Ergots (3 years)• longest for analgesics (5 years)
Patients overusing ergots and analgesics typically have daily tension-type headache
Patients with triptan-induced headache are more likely to describe a daily migraine-like headache or an increase in migraine frequency
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Medication Overuse Headache -Management
When medication overuse headache is suspected, the patient should also be evaluated for the presence of the following:
• Psychiatric comorbidities (depression and anxiety); these may need to be considered in planning an overall treatment strategy
• Psychological and physical drug dependence
• Inappropriate or inadequate coping strategies (eg. Triggers, stress management, pacing, etc) SELF-MANAGEMENT SKILLS TRAINING
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Medication Overuse Headache -Management
1. Patient educationa) Acute medication overuse can increase headache (HA) frequency
b) When medication overuse is stopped, HA may worsen temporarily and patients may experience w/d sx
c) Many px will experience long-term reduction in HA frequency
d) Prophylactic medications may become more effective
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Medication Overuse Headache -Management
2. Make a roadmap for cessation of medication overuse
3. Start prophylactic medication• Onabotulinumtoxin A and Topiramate best evidence for efficacy
• Can use others if contraindication
4. Introduce alternative abortive treatment with limitations on use
5. Close follow-up and support
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Case KAA 32-year-old woman came to ED because of a severe headache. She stated that she had never had a headache like this before.
She described a left-sided headache of gradual onset that had lasted 12 hours and she had vomited once.
She had no past medical history and took no medications
The medical student is urging getting a CT scan and LP
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Cervicogenic Headache
• Definition• Referred head pain from upper cervical spine (occiput-C3) including joints,
discs, myofascial trigger points and spinal nerves.
• Usually unilateral
• Associated with reduced ROM of the neck
• Neck movements or deep palpation reproduces symptoms
Wang & Wang Curr Pain Headache Rep 2014
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Cervicogenic Headache
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Headache Clinical Pearls
• Inadequate acute treatment of episodic migraine is associated with an increased risk of new onset chronic migraine over the course of 1 year (Neurology 2015 Feb 17; 84(7):688-95)…GET ON TREATMENT AGGRESSIVE EPISODIC TREATMENT
• Neuroimaging IS NOT INDICATED in patients with recurrent headache with the clinical features of migraine, a normal neuro exam and no red flags
• Migraine is BY FAR the most common headache type in patients seeking help for headache from physicians
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Headache Clinical PearlsMigraine is historically underdiagnosed and undertreated even when pts consult with a physician
Bilateral headaches interfering with patients activities are usually migraine (and not TTH) and may require migraine-specific meds
NB Medication overuse
Opioids are not recommended
A large number of people who might benefit from prophylactic therapy do not receive it
