Headache Management Fariborz Khorvash Associate Professor of Neurology

l Why talk about headaches?

l l l 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 l Chest pain approach – l l l Episodic care Underdiagnosis of migraine headache Ineffective treatments are commonly used – l Does this patient have a brain tumor? Acetaminophen, Butalbital/ASA/Caffeine Inappropriate use of analgesics

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

Internal medicine residents l l Prepared to manage migraines 48% Prepared to manage MI, DKA, Asthma 95%

Sinus Headache? l l 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

l Study of 2991 patients with sinus headaches – – l Patients reported – – – l Self or physician diagnosed 88% met IHI criteria for migraine 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.

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

Headaches 1. 2. 3. 4. 5. 6. Intracranial pathology Contiguous structures Migraine Cluster Tension type Chronic daily/Rebound

Intracranial pathology l l Tumor Subarachnoid hemorrhage Meningitis Pseudotumor cerebri

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 l Relatively solid recommendations – – Not indicated in patients with migraines and normal exam Indicated in patients with headache and abnormal exam

Less solid recommendations l l l 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 l l l l Sinuses? Eyes Ears TMJ Teeth Temporal artery Cervical spine

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

Pathophysiology of migraine l l 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 l l Acute Preventive – – Life style Pharmacologic

Principles of management l l l l l 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 l Mild - oral – – – l 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

l Severe – – – Tryptans: oral, nasal, wafer, sub. Q DHE 1 mg sub. Q, IV, nasal spray Alternatives l – Adjuncts l l – Ketorolac 60 mg IM Promethazine Chlorpromazine (phenergan) Narcotics

Tryptans l Contraindications – – l CAD likely Side effects – – Chest and neck pressure Dizziness Warmth, numbness, tingling, tightness, flushing Nausea and vomiting

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

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

Preventive therapies l l l l 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

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

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

Nonpharmacologic management l Effective – – l Relaxation training Cognitive behavioral therapy Ineffective – – – Acupuncture Hypnosis Manipulation TENS Hyperbaric oxygen

Aspirin for migraine prevention? l Observations from the Physicians’ Health Study – 22, 071 doctors randomized to 325 mg of ASA or control l Treatment group: 6% experienced migraine after randomization Control group: 7. 4% experienced migraine Treatment effect: 20% Buring, JAMA, 1990

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

Clinical features l l l l 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 l l l Duration: 8 weeks Bouts per year: 1 Maximum attacks per day: 4 Attack duration: 15 -180 min Nocturnal: 73%

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

Treatment l Prophylactic – a small trial involving 30 patients – Verapamil 120 tid l 80% of patients responded – l 40% at the end of one week Attacks per day after one week Verapamil -. 6 – Placebo – 1. 6 – Leone, Neurology, 2000

l Other effective therapy – Prednisone l l – – – Bridge to verapamil Tapered over 3 week Lithium Sodium valproate Methysergide

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

Management of TT headaches l Acute headaches – l Minor analgesics Chronic tension type headaches – – Same diagnostic criteria Occur 15 days per month

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

l 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

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

Analgesic abuse or rebound headaches l l ¾ of patients with chronic daily headaches overuse analgesics Transformed migraines – Past history of discrete migraines

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

Management strategies l l l l 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 l l l 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 l l l l 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?