Transcript The Dizzy Patient: an Update

Migraine and Chronic Daily
Headache
Laurence J. Kinsella, M.D., F.A.A.N.
You Make the Call: Case 1
 37-year-old man with lifelong migraine and
develops 6 weeks of unremitting headache (HA)
 Bitemporal, throbbing, 3-7/10, morning HA
 Relieved with acetaminophen/aspirin/caffeine
(Excedrin Migraine®)
 No visual disturbances, scotomata, nausea,
photophobia
 3 months of cyclosporin (Neoral®) for alopecia
universalis
Audience Question
What is the diagnosis?
1.
2.
3.
4.
Transformed migraine
Medication overuse headache
Cyclosporin induced headache
Chronic tension type headache
You Make the Call: Case 2
 55-year-old woman
 10/10 throbbing right periorbital HA awakens
her every night at 3 a.m.
 Gets relief after 45 minutes with combination
of icepack, T#3 x2,
acetaminophen/aspirin/caffeine x2,
acetaminophen/pseudoephedrine (Tylenol
Sinus®) x2
Audience Question
Diagnosis?
1.
2.
3.
4.
5.
Cluster headache
Thunderclap migraine
Raeder’s Paratrigeminal headache
Aneurysmal headache
Temporal arteritis
You Make the Call: Case 3
 75-year-old woman with right occipital/
burning 8/10 HA, radiating to vertex
 No nausea/photophobia/visual disturbances
 Present for 2 months, constant
 No relief with over-the-counter medications
 Exam is normal
Audience Question
Diagnosis?
1.
2.
3.
4.
Occipital Neuralgia
Cervicocephalgia
Temporal arteritis
Post herpetic neuralgia
History, History, History
P - Precipitating/palliative factors - diet,
exercise, caffeine, OTC drugs
Q - Quality of the pain - burning, aching,
stabbing, squeezing, pressure, throbbing
R - Radiation/location of pain
S - Severity - range of pain (least to the most)
on analog scale 1-10
T - Temporal factors - what time of day
International Headache
Classification
 Primary headaches - “benign” disorders
 Migraine (with and without aura)
 Tension type (episodic or chronic)
 Cluster, chronic paroxysmal hemicrania
 Other benign HA (cough, coital, cold, icepick, exertional HAs)
Headache Classification Subcommittee of the International Headache
Society (2004), Cephalalgia 24:1-150
International Headache
Classification (Cont.)
 Secondary headaches - symptomatic of organic
disease or medication overuse
 Posttraumatic
 Medication overuse HA
 Subarachnoid hemorrhage
 Temporal arteritis
 Meningitis
 High pressure/low pressure
Headache Classification Subcommittee of the International Headache
Society (2004), Cephalalgia 24:1-150
International Headache
Classification (Cont.)
 Cranial neuralgias, nerve trunk pain
 Headache or facial pain associated with disorders
of the cranium, neck, eyes, nose, sinuses, teeth,
mouth or other facial or cranial structures
Headache Classification Subcommittee of the International Headache
Society (2004), Cephalalgia 24:1-150
Chronic Daily Headache
 Not a diagnosis but a category of primary and
secondary headache types
 > 15 days/month for > 3 months
 > 4 hours/day
 4% prevalence; 5% of all women
 40-80% of patients referred to HA centers
Matthew NT et al. (1987), Headache 27:102-106; Colas R et al.
(2004), Neurology 62:338-342
Chronic Daily Headache
 Subtypes include:
 Transformed migraine/chronic migraine
 Chronic tension-type headache
 New daily persistent headache
 Hemicrania continua
 All may be complicated by:
 Medication overuse headache
Silberstein SD et al. (1996), Neurology 47:871-875
Transformed Migraine
(TM)
 > 15 days/month head pain
 Headache > 4 hours/day
 At least 1 of:
 Previous HA fulfills IHS criteria for migraine
 Increasing frequency > 3 months
 Medication overuse in 80% with TM
Silberstein SD et al. (1996), Neurology 47:871-875; Bigal ME et al.
(2002), Cephalalgia 22:432-438
Migraine Without Aura Common Migraine
Mnemonic: SULTANS
 Headache has at least 2 of the following characteristics:
 S = severe
 UL = unilateral
 T = throbbing
 A = activity worsens HA
And at least 1 of the following during headache:
 N = nausea or vomiting
 S = sensitivity to light/sound
Headache Classification Subcommittee of the International Headache
Society (2004), Cephalalgia 24:1-150
Diagnostic Criteria for
Migraine With Aura (Classic Migraine)
 At least 2 attacks
 Aura must exhibit at least 3 of the following
characteristics:
 Fully reversible
 Gradual onset
 Lasts less than 60 minutes
 Followed by headache within 60 minutes
 HA may begin before or simultaneously with the aura
 Normal neurologic exam and no evidence of organic
disease that could cause headaches
Headache Classification Subcommittee of the International Headache
Society (2004), Cephalalgia 24:1-150
Migraine: Abortive Therapy
Individual Attacks at Home
 Aspirin/APAP/caffeine (Excedrin®)
 Sumatriptan (Imitrex), zolmitriptan (Zomig®),
rizatriptan (Maxalt®)
 Isometheptene/dichlo/apap (Midrin®)
 Ergot tart/caffeine (Cafergot®)
 Butalbital
 NSAID
 Do not exceed 2-3 days treatment in 1 week 
rebound
Silberstein SD (2000), Neurology 55(6):754-762
ED management of
migraine is ineffective
 57 patients in ED
 95% met migraine
criteria (SULTANS)
by questionnaire
 Only 32% given a dx
of migraine
 59% “cephalgia”, “HA
NOS”
 65% txed with
“migraine cocktail”benadryl, reglan,
toradol
 24% opioids
 Only 7% given specific
Tx- triptan, DHE
 60% had HA 24 hrs
later
Headache 2003;43:1026-31.
Migraine: Abortive Therapy
Emergency Room
 Dihydroergotamine mesylate (DHE 45) .5-1 mg q 8 hrs
 Metoclopramide (reglan) 10 mg IV
 Dexamethasone (Decadron) 16-24mg IV x1
 Reduces recurrent HA at 72 hours
 Sumatriptan (SC Imitrex®) 4-6 mg SQ, 5 mg Nasal
 Ketorolac injection (Toradol®) 15mg IV/IM
Cochrane Review: Steroids and Migraine. BMJ 2008 Jun 14; 336:1359
Silberstein SD (2000), Neurology 55(6):754-762
ED Management of Migraine
 Prochlorperazine (Compazine®) 10 mg IV vs.
metoclopramide* (Reglan®) 20 mg IV
 Both given with 25mg IV diphenhydramine (Benadryl®)
 Randomized, controlled trial; 77 patients
 Mean VAS change of 5.5 vs 5.2
 Similar at 2 and 24 hours later
 Compazine assoc with non-statistical increase in side
effects
A randomized controlled trial of prochlorperazine
versus metoclopramide for treatment of acute migraine.
Ann Emerg Med. 2008; 52(4):399-406
Triptans
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Major advance in migraine therapy
5-HT1B/1D agonists
Vasoconstriction
All act by suppressing nausea, confusion,
autonomic dysfunction and pain associated
with migraine attack
 Differ only in pharmacokinetics
Johnston MM, Rapoport AM. Triptans for the management
of migraine. Drugs. 2010 Aug 20;70(12):1505-18
Triptans List
 Sumatriptan 25-100 mg po/6 mg sq/5 mg nasal
at HA onset, rpt 1 hr sq, 2 hr po/nasal
 Zolmitriptan 2.5-5 mg
 Rizatriptan 10 mg SL
 Eletriptan (Relpax®), frovatriptan (Frova®),
almotriptan (Axert®), others
Johnston MM, Rapoport AM. Triptans for the management of
migraine. Drugs. 2010 Aug 20;70(12):1505-18
Migraine Prophylaxis
First Line (Pregnancy Class)
 -blockers (C): propranolol LA (Inderal-LA) FDA 60 mg
qd, timolol 20 mg qd FDA
 Anticonvulsants: topiramate FDA (Topamax®) (was C,
now D- 3/28/11 due to cleft palate) 25-100 mg bid
 Lower toxicity than divalproex (Depakote®),
no weight gain
 Tricyclics antidepressants (D): nortriptyline (Pamelor®)
10-60 mg
 NSAID: naproxen sodium (Anaprox DS®) (C) (menstrual
migraine - 550 mg bid x 10 days)
Silberstein SD (2000), Neurology 55(6):754-762
Migraine Prophylaxis
Other Options
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Divalproex (Depakote®) (D) FDA
Gabapentin (Neurontin®) (C)
Baclofen (Lioresal®) (C)
“MigreLief”1,2
$20 /60 pills
 Riboflavin (Vitamin B2) 400 mg/day (A)
 Magnesium oxide 360 mg/day (B)
 Feverfew 100 mg/day
 Petadolex 1 tid (Butterbur extract) (A)
1Pfaffenrath
V, Wessely P, Meyer C, et al. Magnesium in the Prophylaxis of Migraine A Double-Blind, Placebo-Controlled Study. Cephalalgia 1996;16:436-40.
2Schoenen J, Lenaerts M, Bastings E. High-dose Riboflavin as a Prophylactic Treatment
of Migraine: Results of an Open Pilot Study. Cephalalgia 1994;l14:328-9
Transformed Migraine/Status
Migrainosus
 Unremitting headache > 72 hours
fulfilling criteria for migraine
 80% associated with medication overuse
Transformed Migraine/Status
Migrainosus
Treatment
 Withdraw all medication
 Raskin protocol: DHE IV 0.5 mg/metoclopramide
(Reglan®) 10 mg IV q 8 hours for 3 days1
 Dexamethasone (Decadron-LA®) 10-24 mg IV x1
 Dexamethasone (Decadron®) 2 mg bid for 3-5 days
 Prednisone (Deltasone®) 60 mg daily for 3-5 days
BMJ 2008 Jun 14; 336:1359
Am Fam Physician. 2011;83(3):271-280.
1Raskin NH (1986), Neurology 36(7):995-997
*FDA boxed warning 2/26/09 – Long-term or high-dose use of metoclopramide has been linked
to tardive dyskinesia.
Complicated Migraine
 Persistent neurologic residue of a migraine
attack
 Migraine with dramatic focal neurologic features
(include ophthalmoplegic, hemiplegic, basilar
migraine)
Chronic Daily Headache
 Subtypes include:
 Transformed migraine/chronic migraine
 Chronic tension-type headache
 New daily persistent headache
 Hemicrania continua
 All may be complicated by:
 Medication overuse headache
Silberstein SD et al. (1996), Neurology 47:871-875
Chronic Tension Type HA
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Head pain > 15 d/mo for at least 6 months
Last hours, or may be continuous
Pressing, tightening quality
Mild-to-moderate intensity
Bilateral, often occipital/posterior
May have mild nausea, photophobia
Do not fulfill migraine criteria
Consider other causes: ICP (Intracranial Pressure),
SDH (Subdural Hematoma), CO poisoning
Tension-Type Headache (TTH)
 Considered the most common HA type
(ICHD)
 30-78% prevalence
 Squeezing, band-like or global headache
 Environmental stressors
 May or may not limit function
Headache Classification Subcommittee of the International Headache
Society (2004), Cephalalgia 24:1-150
TTH
 Frequent overlap with other HA subtypes
 Migraine
 Medication overuse
 Ask about over-the-counter medication
especially those with caffeine
(Excedrin/Anacin/APC)
 How many cups/pots of coffee/tea daily?
 How many 2-liter bottles of soda?
Chronic Daily Headache
 Subtypes include
 Transformed Migraine/Chronic Migraine
 Chronic Tension Type Headache
 New Daily Persistent Headache
 Hemicrania continua
 All may be complicated by:
 Medication Overuse Headache
Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily
headaches: field trial of revised HIS criteria. Neurology 1996;47:871-875
New Daily Persistent HA
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> 3 mo, daily within 3 days of onset
82% recall exact day of HA onset
Bilateral, pressing quality
Mild-moderate
Nausea, photophobia
MRI, MRV to exclude venous thrombosis
LP with opening pressure to exclude intracranial
hypotension
Li, D & Rozen, TD (2002). "The clinical characteristics of new
daily persistent headache."
Cephalalgia 22 (1), 66-69.
Cerebral Venous Thrombosis
 54 yo M with new onset
headaches, syncope with
exertion
 Sudden onset bi-occipital
HA 8/10 aching without
relief, worsened supine
 Exam normal, except loss
of venous pulsations.
 MRI normal, MRV abnl.
 IV Venogram shows
stenotic left lateral sinus.
Chronic Daily Headache
 Subtypes include
 Transformed Migraine/Chronic Migraine
 Chronic Tension Type Headache
 New Daily Persistent Headache
 Hemicrania continua
 All may be complicated by
 Medication Overuse Headache
Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily
headaches: field trial of revised HIS criteria. Neurology 1996;47:871-875
Hemicrania Continua
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Cluster variant
Unilateral pain without side-shift
Daily and continuous
Moderate to severe
At least 1 of:
 Conjunctival injection or lacrimation
 Nasal congestion or rhinorrhea
 Ptosis or miosis
 Complete response to indomethacin
Cluster Headache
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
Uncommon (69/100,000)
Men:women 6:1
Headaches begin 20-50 years of age (mean 30)
High incidence of smoking, Peptic Ulcer Disease
(PUD)
 Familial cases unusual
Cluster Headache (Cont.)
 Abrupt onset of pain, builds in 2-15 minutes
 Pain is excruciating, severe (deep, constant,
stabbing, explosive or pulsatile)
 Location: in and around 1 eye
 Unilateral, usually same side
 Patient up and pacing due to pain
Cluster Headache (Cont.)
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
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
Duration: 30 minutes - 2 hours
75% of attacks between 9 p.m.-10 a.m.1
Awakens from sleep
1-2 clusters per year, 4-8 weeks or longer
1Russell
D (1981), Cephalalgia 1:209-216
Cluster Headache
Associated Symptoms and Signs
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Lacrimation
Blocked nostril
Rhinorrhea
Conjunctival injection
Temporary ipsilateral Horner’s (2/3)
Sweating of forehead
Pallor or flushing
Nausea
Bradycardia
Other Cluster Variants
 Chronic paroxysmal hemicrania
 Multiple short, severe HA occurring daily
 Short episodes of cluster 1-2 minutes
 Average 14 daily
 SUNCT (Short-Lasting, Unilateral, Neuralgiform
headaches with Conjunctival injection and Tearing)
 30-100 attacks daily
 Usually < 30 seconds
 Responds to indomethacin
Cluster Headache:
Treatment
 Stop smoking
 Prophylactic treatment of chronic cluster
 Indomethacin (Indocin®) 75 mg SR, 25-100 mg tid
 Avoid over age 60
 Lithium carbonate 300-900 mg daily
 Methysergide (Sansert®) 2-8 mg daily
 Propranolol, Nifedipine (Procardia®), verapamil
(Calan®)
Silberstein SD (2000), Neurology 55(6):754-762
Cluster Headache:
Treatment (Cont.)
 Abortive therapy
 Rectal ergot for nocturnal attacks
 100% oxygen
 Sumatriptan injection
 Prednisone or dexamethasone:
burst and taper
Silberstein SD (2000), Neurology 55(6):754-762
Chronic Daily Headache
 Subtypes include
 Transformed Migraine/Chronic Migraine
 Chronic Tension Type Headache
 New Daily Persistent Headache
 Hemicrania continua
 All may be complicated by:
 Medication Overuse Headache
Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily
headaches: field trial of revised HIS criteria. Neurology 1996;47:871-875.
Medication Overuse
Headache
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Prevalence 1-2%
Morning headaches
Chronic daily headache > 15 days/month
Simple analgesics > 15 days/month
Ergots, triptans, opioids, combo NSAIDS > 10
days per month
 Most have baseline migraine HA
Dodick DW (2006), N Engl J Med 354(2):158-165; Zwart JA
(2003), Neurology 61:160-164
Medication Overuse
Headache
Treatment
 Stop all OTC analgesics, caffeine consumption
 Wean butalbital, opioids, benzodiazepines
 Ketorolac PO 60 mg x1, 10 mg q 6 hours x 3
days
 Tizanidine (Zanaflex®) 2-8 mg tid1
 May require hospitalization
 Raskin protocol: DHE 0.5-1 mg IV q 8 hours/
metoclopramide 10 mg for 3 days
1Saper
JR et al. (2002), Headache 42(6):470-482
Steroids ineffective for MOH
Neurology 2007
 Randomized controlled trial of 100 patients
 51 rcvd prednisone 60 mg taper, 49 placebo
 No change in mean HA (MH) severity or frequency
©
Boe, M. G. et al. Neurology 2007;69:26-31
“Sinus Headaches”?
 Over-diagnosed and over-treated
 Not a recognized form of HA by the IHS except in setting
of acute bacterial sinusitis
 74% fulfill IHS migraine criteria
 45-50% of asymptomatic adults have evidence of sinus
mucosal thickening or edema
 Utility of routine CT sinuses not established
Gupta M, Silberstein SD. Expert Opin Pharmacotherapy
2005;6:715-722.
Mehle ME, Kremer PS. Sinus CT scan findings in “sinus
headache “ migraneurs. Headache 2008;48:67.
How often is “Sinus”
Headache Really Migraine?
Migraine with or w/o
Aura (IHS 1.1, 1.2)
80
Migrainous (IHS 1.7)
8
Recurrent episodes (at least 6 in the past 6 months)
8
No fever or purulent discharge
No history of abnormal sinus radiographs
Episodic Tensiontype (IHS 2.1)
Other
4
0
20
40
60
Subject (%)
Schreiber CP, et al. Arch Intern Med. 2004;164:1769-1772
80
100
Treatment of Transformed Migraine
and Medication Overuse Headache
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Education, close followup for 8-12 weeks
Lifestyle changes: caffeine, smoking, sleep
Behavioral therapy
Abrupt withdrawal of analgesics except:
 Barbiturates: wean over 1 month
 Opioids: clonidine withdrawal
Dodick DW (2006), N Engl J Med 354(2):158-165
Bridging Medications for
Outpatient Treatment
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Tizanidine 2-6 mg po TID
Baclofen 10-20mg TID
Hydroxyzine 25-50mg PO, IM
NSAIDS (Naproxen 500 mg, Ketorolac 10-30 po)
Dihydroergotamine 0.5-1 mg nasal, IM, subq
Antiemetics: metoclopramide 10-20 mg
Intravenous Therapies for
Intractable Headaches
 IV DHE 1 mg (FDA)/
Reglan 10 mg q8 x 3
days
 IV DHE 3mg/L NS over
24 hrsx3
 IV decadron 12-24 mg IV
x1
 IV Magnesium 1 gm x 1
 IV depacon 250 mg q
12 hr
 IV Keppra 500 mg q
12 hr
 Propafol, others
Saper J. Intravenous management of intractable headache.
American Academy of Neurology Course. 2010
Emerging Therapies
• Calcitonin gene-related
peptide (CGRP) antagonists
 Olcegepant (Phase II)
 Telcagepant (withdrawn due
to increased LFTs)
• Combinations
• Sumatriptan and naproxen
(Treximet®) - (FDA)
• Anticonvulsants
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Pregabalin
Zonisamide
Levetiracetam
Lacosamide
Carabersat
lamotrigine
Arulmozhi DK et al. (2009), Vascul Pharmacol 43(3):176-187; Rapoport
AM, Bigal ME (2005), Neurol Sci 26(suppl 2):S111-S120; Available at:
www.clinicaltrials.gov
Physical Examination
 Blood pressure
 Funduscopy: papilledema in idiopathic
Intracranial hypertension, tumor; subhyaloid
hemorrhage in SAH
 Temporal artery tenderness: temporal arteritis
 Neck stiffness, Kernig’s/Brudzinski’s, orbital
tenderness: meningitis
SAH = subarachnoid hemorrhage
Worrisome HA Red Flags
“SNOOPS”
 Systemic symptoms: fever, weight loss
 Neurologic symptoms or signs: confusion,
depressed alertness or consciousness
 Onset: sudden, abrupt, split-second
 Older: new HA > 50 years old - temporal arteritis
 Previous HA history: change in usual HA pattern
- change in frequency, character, severity
 Secondary risk factors: HIV, cancer
Headaches to be Considered
for Emergency Referral
 Abrupt onset of “the worst HA of my life”
 Change in an established HA pattern
 Headache plus:
 Stiff neck
 Fever
 Confusion, alteration of consciousness
 Focal neurologic signs
 Inability to walk
Headaches to be Considered
for Emergency Referral (Cont.)
 Any patient over 50 years old with new
onset of headaches
 Get a sedimentation rate (ESR)
 Headaches that last more than 72 hours
Summary
 Chronic daily headache is common
 Transformed migraine, tension type and
cluster variants
 Medication overuse HA is seen in all
subtypes
 History is critical
 SULTANS and SNOOPS
Questions from the
Audience?
References
1. Dodick DW. Chronic Daily headache. NEJM 2006;354:158-165.
2. Headache Classification Subcommittee of the International Headache
Society (2004), Cephalalgia 24:1-150
3. Edlow JA. Diagnosis of subarachnoid hemorrhage in the emergency
department. Emerg Med Clin North Am 2003;21:73-87.
4. Silberstein SD. Practice parameter: evidence-based guidelines for
migraine headache (an evidence-based review): report of the Quality
Standards Subcommittee of the American Academy of Neurology.
Neurology. 2000 Sep 26;55(6):754-62.
5. Freitag FG. Acute treatment of migraine and the role of triptans. Curr
Neurol Neursci Rep 2001;1:125-132.
6. Silberstein SD, Liu D. Drug overuse and rebound headache. Curr Pain
Headache Rep 2002;6:240-247.
7. Snow V, et al. pharmacologic management of acute attacks of
migraine and prevention of migraine headache.Ann Intern Med
2002;137:840-849.
8. Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and neardaily headaches: field trial of revised HIS criteria. Neurology
1996;47:871-875