Transcript Slide 1

Dr. M. Togha
Professor of Neurology,
Tehran University of Medical Scienses
Failed an adequate trial of regulatory approved
and conventional treatments according to local
national guidelines
Adequate trial
Appropriate dose
Appropriate length of time
Consideration of medication overuse
Failed
No therapeutic or unsatisfactory effect
Intolerable side-effects
Contraindications to use
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Headaches cause significant interference
with function or quality of life, despite
modification of triggers, lifestyle factors,
and adequate trials of acute and preventive
medicines with established efficacy
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“Rebound" (meditation overuse headache) or
excessive medication overuse, toxicity,etc
Wrong diagnosis (wrong primary or undetected
secondary causes) or nondiagnosis
Medication selection not proper/dosages not
adequate
Psychological barriers
More aggressive treatment required:
hospitalization
Current or previous use of opioids
Requires interventional therapy
Beyond current physiological understanding
medication overuse headache
“Rebound" or excessive
medication overuse, toxicity,
etc
The overuse of simple analgesics (Aspirin,
acetaminophen, Ibuprofen, Indomethacin,
…., etc.), narcotics (Methadone,
Tramadole, Hydrocodones, codeine),
Ergot derivatives and triptans can lead to
this type of headache
Chronic daily headache> 15days/mth
Regular intake of drug for >3mths
May differ depending on drug being overused:
Triptans- daily migrainous headache
develops on using triptans for >/= 10days/mth
Analgesics- diffuse featureless headache
On using opiate or combination analgesics for > /= 10
days/month
On using simple analgesics for >/= 15 days /month
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Headache present on more than 15days/month
Pain is dull, presssing-tightening quality.
It has mild or moderate intensity.
bilateral location is common.
There is no aggravation by walking stairs.
Headache has developed or markedly
worsened during substance overuse.
Headache episodes either cease or return to
their previous pattern of frequency or intensity
within two months of stopping the overused
drug..
 Wrong
diagnosis (wrong
primary or undetected
secondary causes) or
 no diagnosis
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Chronic Hemicrania, (paroxysmal,
continoues)
Low CSF pressure Headache
Cervicogenic headache
Sphenoid sinusitis
Orofacial problems induced headache
Rhinological causes of headache
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A.Headache for >3 months fulfilling criteria B-D
B. All of the following characteristics
1.unilateral pain without side shift
2. daily and continuous, without pain-free periods
3. moderate intensity, with exacerbations of severe pain
C. At least one of the following autonomic features occurs
during exacerbations, ipsilateral to the pain:
1. conjunctival injection and/or lacrimation
2. nasal congestion and/orrhinorrhoea
3. ptosis and/or miosis
D. Complete response to therapeutic doses of indomethacin
E. Not attributed to another disorder
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A 40 y/o woman, with history of 3 months
headache
Pain in Lt periorbital area, Lt eye tearing
Lt nasal congestion
1-2 attacks a day, with mean duration of
30m.
Nearly fixed time of headaches
Severe
Accompanied by irritability
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Paroxysmal hemicrania?
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Cluster headache?
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Glaucoma?
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Sunct?
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A 39 y/o male with Severe headache for 1
months with progression
occipital headache suddenly after sitting up
for 10 mins. Last week： more severe,
extended to vertex
Quality：throbbing
No aura, no photophobia, no phonophobia
Nausea, vomiting present
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PMH: not significant
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Family history：not contributory
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P/E: T/P/R：36.3C, 80/min, 18/min, BP：
134/77 mmHg
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Normal systemic exam
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Normal Neurological examination
Subdural effusion
Diffuse dural
thickening
with enhencement
Fluxetin or Fluvoxamin for Migraine
Beta blocker for Cluster headache
Indometacin for SUNCT
 Dosages
are not adequate.
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Non adeuate dosage of Verapamil for Cluster
Headache
Non adequate dosage of Propranolol for
Migraine Headache
Non adequate dosage of Triptans to abort
Migraine Headache
typically for migraine prophylactic drugs, at
least 2 months at optimal or maximumtolerated dose, unless terminated early due
to adverse effects
At least 2 weeks, at full drug dose for
chronic hemicrania
At least 2-3 weeks, at optimal prophylactic
drug for Cluster headache
 Psychological
barriers
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Personality Disorders:
the borderline personality disorder( stands
above most)
the narcissistic personality disorder
Depression
Underlying a family or social problem
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More aggressive treatment is required:
hospitalization, interventions
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In some patients with Medication Overuse
Headache
In some patients with Cluster Headache
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Facet Joint Block for Cervicogenic Headache
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Epidural Block for Cervicogenic Headache
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GON block for chronic migraine or clustrer
headache
Sphenopalatin ganglion block for Cluster
headache
 Current
or previous use of opioids
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Beyond current physiological understanding
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A common case or refractory headache
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A 43-year-old woman who describes frequent
throbbing nauseating hemicranial headaches,
lasting several hours in duration, associated with
phonophobia and photophobia, but without focal
neurological deficits, has been unresponsive to
many prophylactic and abortive agents.
Thorough neurological examination, laboratory
testing, and brain magnetic resonance imaging
have been entirely normal.
Diagnosis: Migraine without aura, refractory.
Criteria
Definition
Primary
diagnosis
Refractory
A. ICHD-2 migraine or chronic migraine
B. Headaches cause significant interference with function or quality of
life despite modification of triggers, lifestyle factors, and adequate
trials of acute and preventive medicines with established efficacy.
1. Failed adequate trials of preventive medicines, alone or in
combination, from at least 2 of 4 drug classes:
a. Beta-blockers
b. Anticonvulsants
c. Tricyclics
d. Calcium channel blockers
2. Failed adequate trials of abortive medicines from the following
classes, unless contraindicated:
a. Both a triptan and DHE intranasal or injectable formulation
b. Either nonsteroidal anti-inflammatory drugs or combination
analgesics
Adequate
trial
Period of time during which an appropriate dose of medicine is
administered, typically at least 2 months at optimal or maximumtolerated dose, unless terminated early due to adverse effects
Modifiers
1. With or without medication overuse, as defined by ICHD-2
2. With significant disability, as defined by MIDAS ≥11
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Common refractory cases are migrainers.
While the prognosis for the majority of patients
with migraine is good, approximately 3-14%
of episodic migraineurs will progress to
chronic daily headache.
It is necessary to overcome the headache
before its chronification. Then, Central
chemical and synaptic circuits changes,
Could lead to intractability.
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Identify Medication Misuse and the Behavior
That Underlies It.-Not everyone with severe
headaches overuses medicines.
Approaching the Cluster B Personality
Disorder Patient.-Of the problem patients,
the borderline personality disorder patient
stands above most. Patients with cluster B
personality disorders, such as borderline and
narcissistic
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An adequate trial in this domain should
consist of: (1) education on the nature of
migraine and the factors that trigger it; (2)use
of a diary to identify headache patterns and
trigger factors; (3) advice on diet, sleep,
exercise, stress management, and trigger
avoidance.
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Trial a Wide Variety of "PRN" Medications That
Will Not Cause MOH if Overused.
If the Patient Doesn't Sleep Well, Headaches
Won't Be Controlled.-It is very important to
induce a normal or near normal sleeping
pattern.
Maintain Contact Whenever Possible With
Referring and Other Interested Physicians
During and at the End of Care.
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Hydroxyzine (oral or parenteral)
Baclofen
Tizanidine
Neuroleptics {oral, p.r., parenteral)
Benzodiazepines (oral or parenteral)
Various muscle relaxants, including
metaxalone and methocarbamol (which have
a central effect)
The most common reasons for apparent
intractability, diagnostic errors, and
inappropriate use of normally effective
medicines.