Transcript Document
HCNE - BOSTON Massachussetts General Hospital November 4, 2004 Treatment of Headache ALAN M. RAPOPORT, M.D. Founder and Director The New England Center for Headache Stamford, Connecticut Clinical Professor of Neurology Columbia University College of Physicians & Surgeons New York, N.Y. Headache Therapeutic Options • • • • Nonpharmacologic approaches Acute (abortive, symptomatic) therapy Preventive therapy Adjunctive therapies (Vitamins, Minerals, Supplements, Herbs): – – – – – Vitamin B-2 (400 mg per day) Magnesium (400 mg per day) Feverfew Petasites Coenzyme Q 10 (300 mg per day) • Physical Techniques Rapoport AM, Sheftell FD & Tepper SJ 2004 Nonpharmacologic Therapies for Headache • Avoidance of triggers (e.g., dietary, weather, altitude, sleep and stress) • Making lifestyle changes (e.g., eating regularly, going to sleep on schedule, and exercising on a regular basis) • Behavioral therapies – – – – Relaxation techniques Biofeedback training Stress management Conflict resolution Rapoport AM, Sheftell FD & Tepper SJ 2004 Goals of Acute Migraine Treatment • Effective headache relief rapidly and consistently without recurrence →→ Pain Free State • Restore the patient’s ability to function • Minimize the use of rescue and backup medications • Optimize self-care and reduce resource utilization • Minimize side effects • Be cost-effective Reasons for Dissatisfaction with Current Treatment (U.S. Data) Pain relief takes too long 87 Doesn’t relieve all pain 84 Doesn’t always work 84 Headache comes back 71 35 Too many side effects 0 25 50 75 100 % Migraineurs Lipton et al. Headache 1999;39:S20-S26 Classes of Medications for Acute Treatment of Migraine • • • • • • • • OTC simple analgesics NSAIDs and COX 2 Inhibitors Combination analgesics (Excedrin Migraine) Fiorinal®, Fioricet®, Esgic®, Midrin® Anti-nausea medication (Triptans) Ergots (Ergotamine and DHE) Opiates (Narcotics i.e Vicodin, Codeine) What is the Syndrome of “Rebound Headache”? • It is the increase in headache from the overuse of pain medications (now called MOH) • Occurs only in patients with pre-existing chronic headache • A self-sustaining rhythm of predictable and escalating medication use • Headaches increase in frequency and intensity and become refractory to acute care and preventive treatments • Medication withdrawal results in escalation of headache followed by improvement Rapoport AM, Sheftell FS & Tepper SJ 2004 TRIPTANS: Routes of Delivery Tablets • • • • • • • Sumatriptan Zolmitriptan Naratriptan Rizatriptan Almotriptan Frovatriptan Eletriptan Suppository • Sumatriptan (Europe) Injection • Sumatriptan Nasal Sprays • Sumatriptan • Zolmitriptan “Fast-melts” • • Rizatriptan - MLT Zolmitriptan - ZMT Sheftell FD, Rapoport AM, 2004 Which is the best Triptan? • Many patients appear to be satisfied with the triptan they are taking • But is it the ideal triptan for them? It may be. We ask 5 Questions to be sure: 1. How quickly does it start to work? 2. When has it reached maximum effect? 3. What % of the headache is gone? 4. Are there any side effects? 5. Does the headache recur within 24 hrs? So... which is the best triptan? • The one that works best for YOU! • The triptans are more similar than different. Intensity of Symptoms or Phases Phases of The Migraine Attack When to Use Your Triptan Associated Features Prodrome Aura Headache Early Intervention Time Postdrome Indications for Preventive Strategies • Frequency – Former: more than two attacks per month – Current: more than two attacks per week • • • • • Disability/QOL related to headache Unresponsive to acute therapies Contraindications to acute therapies Significant adverse events with acute therapies Pharmacoeconomic considerations Sheftell FD, Rapoport AM, 2004 Migraine Preventive Agents Beta blockers Ca channel blockers Antidepressants NSAIDs 5-HT2 antagonists • Propranolol* • Nadolol • Atenolol • Timolol* • Metoprolol • Naproxen • Meclofenamate • Ibuprofen • Ketoprofen • Flurbiprofen • Celecoxib • Rofecoxib • Valdexcoxib • Verapamil • Amlodipine • Diltiazem • Nifedipine • Nimodipine • Nisoldipine • Cyproheptadine • Methysergide* • Methylergonovine‡ Alternative therapies • Riboflavin • Magnesium • ?Cyanocobalamin • Feverfew, Co Q 10 • Petasites •Approved indication for migraine in US; †Not available in the US; •‡ Methylergometrine in Europe; NOS = nitric oxide synthase; LT = leukotriene; CSD = cortically spreading depression • Tricyclics – Amitriptyline – Nortriptyline • MAOIs • SSRIs – Fluoxetine – Sertraline – Paroxetine Others • ACE inhibitors • ARBs-candesartan • Quetiapine • Tizanidine • ?Opiates Sheftell FD, Rapoport AM, 2004 Antiepileptics • Divalproex sodium* • Gabapentin • Topiramate * • Carbamazepine • Dilantin • Lamotrigine • Tiagabine • Zonegran • Levetiracetam • Oxcabazepine Future AMPA/Kainate Antag NOS inhibitors ? LT antagonists Botulinum toxin NMDA antagonists CGRP antagonists CSD antagonists Adenosine A1 Agon Pure 5-HT1B/1D Agon Menstrual Migraine - Therapy Perimenstrual Pharmacologic Rx • 1. NSAIDs, eg. Naproxen Na 550 mg tid • 2. COX 2 inhibitor eg. rofecoxib 50 mg qd • 3. Pulsed estrogens + combo • 4. Corticosteroids (dexamethasone) • 5. Short burst of Triptans (all may help) • 6. Pulsed methylergonovine, beta blockers, ergotamine tartrate, DHE Conclusion • Get an accurate diagnosis from MD • Don’t accept tension-type or sinus headaches as a diagnosis • Don’t undertreat your migraine • Don’t delay taking your medications • Treat headache until pain-free Thanks for your attention!