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?