Transcript Headache 8-08 (Email Version)

Headache
By Dr. Andrew Gutwein
We all get ‘em!
So why do patients come to the doctor?
• Severity
• Worried about brain tumor
Headache History
Be mute!
Its all pattern recognition.
Headache Physical
Not your internists general physical exam! It’s not about the
lungs, heart, and abdomen!
• examine the head
• look at and feel the scalp
• can they tell a coherent story
• look at the fundi
• can they walk on a narrow
base
• listen to the orbits with the
stethoscope
• check the reflexes and the
plantar response
• check the visual fields
• focus on the neurologic
systems
• is their language normal
Diagnostic Testing
• Only to prove a specific diagnosis (such as
MRI for suspected MS or CT scan with
contrast for suspected tumor)
• 99% of headache patients do not need
imaging or blood tests of any kind.
• Consider the non-contrast CT if it is going to
be the only way the patient will stop worrying
(cost effective)
Differential Diagnosis
>95% of all headaches seen in the internists office fall into these
three categories:
• Migraine
• Tension Type
• CDH (Chronic Daily Headache)
Migraine Overview
• 18% of women and 6% of men are migraneurs
• Described as pulsating or pounding and unilateral but
can be bilateral
• Frequently associated with neck pain – don’t be fooled!
Cause
neurologic, not vascular vasoconstriction and
vasodilation. It is the spreading depression/ depolarization
of neurons across the cortex that results in a release of
neurotransmitters which causes normal vascular pulsation
to be felt as nociception.
Migraine History
3 Keys to the history:
• photophobia/ phonophobia
• nausea/ vomiting
• disability (the patient must stop what they are doing and
frequently they need to lie down in a quiet room)
Timeline: Lasts 4 hours to 3 days
Any hemicranial HA, any pulsating headache, and any
neurologic phenomenon lasting over 20 minutes may also help
clue you in on this diagnosis. 10% of migraine patients have
aura and 50% of the time the aura is not followed by HA. When
this happens it is called the dissociated migraine.
Migraine Cycle
Migraneur life cycle:
• infantile colic
• childhood abdominal pain
• menstrual accompaniment
• motion sickness
• red wine headache
• benign sex headache
• ice cream headache
• worsening of headache
with life stressors
• cerebrovascular disease
• transient global amnesia
• Depression, bipolar disorder,
generalized anxiety
disorder and social phobia
are all more common in
the migraneur.
Migraine - Mild
Treatment of mild to moderate Migraine:
2/3 of patients with migraine headache have mild migraine and
never come to complain to you about the headache.
They self treat with: massage, relaxation techniques, avoiding
light, going to bed, acetaminophen, low dose NSAIDs, or
combination products like Excedrin Migraine which has
aspirin, acetaminophen and caffeine in it.
These medications work well for many people but be wary of
using any of these (especially ones with caffeine) too frequently
for too long.
Migraine - Triptans
Acute treatment of the moderate to severe Migraine:
Triptans
• expensive (about $20-25 per dose for PO) but safe.
• Use as early in the headache as possible and beat the
headache until it is gone or it will come back.
• When taken early pain free 50% at 2 hours, 85% at 4 hours.
• If you wait until the headache is moderate to severe you get
only about half that response.
• If the headache continues for 1 hour after taking the triptan
take another dose.
Migraine - Triptans
• One can even prevent the HA when taken during the
prodrome but do not take during an aura as it does not
work.
• Avoid in pregnant patient - pregnancy category C
• Chest pain side effect that can occur is not myocardial (<1 in a
million)
• Triptans can be used in a patient on an SSRI (serotonin
syndrome is very rare)
• Triptans are not contraindicated in women on oral
contraceptives with migraine with aura but you should
advise smoking cessation as all these things add up to
increased relative risk of CVA.
Migraine - Triptans
All triptans are available PO but only a few have other routes.
• Injectable (expensive) – sumatriptan
• Intranasal (nasty aftertaste) – sumatriptan, zolmitriptan,
rizatriptan
• Sublingual – zolmitriptan, rizatriptan
Of the PO frovatriptan and naratriptan are slower to act - this may
be good in the patient that has a slow growing headache
and patients who get a rebound headache after using the
more rapid acting triptans.
Eletriptan and almotriptan are the other triptans.
Migraine - Triptans
• If the patient does not respond to one triptan, they will still
have an 80% chance of responding to another.
• They can take 10mg of metoclopramide, wait 10 minutes, and
then take the oral medication if there is severe nausea or
vomiting. Otherwise use the sublingual route.
• Triptans are to be used no more than twice a week on average.
• Triptans are contraindicated in patients with CAD,CVA,
PAD, and uncontrolled HTN.
Migraine Other Treatments
Other acute treatment options:
• Ergotamines – not used almost at all because of toxicity
• Steroids PO for 2-3 days (prednisone 20mg, no taper
needed)
• Fioricet or Fiorinal and other medications that have
caffeine or narcotics are ok for migraine headaches,
but on a limited basis
Migraine Prophylaxis
Who needs prophylaxis against migraines headaches?
• If the patient is having headaches more frequently than twice
a week they likely need prophylaxis.
• If the patient is having headaches less than twice a week but
it interferes significantly you can still consider
prophylaxis.
Migraine Prophylaxis
Chronic prophylaxis against moderate to severe Migraine:
1. Tricyclic Antidepressants
2. Beta-blockers
3. Anti-seizure Medications
Candesartan/Lisinopril – some evidence
CCB – weak evidence
Migraine Prophylaxis
TCAs: amitriptyline, imipramine, nortriptyline, desipramine
• They work well but can have anticholinergic side effects
• Listed them in order of most to least anticholinergic side
effects
• The first three should be taken before bed as they can be
sedating and desipramine should be taken in the morning
• Start at 10-25mg depending on whether they are elderly and
titrate up if needed to max 150mg
• Check EKG for QT before starting
• TCAs are a good first/second line choice for men and women.
Migraine Prophylaxis
Beta Blockers: propranolol or nadolol
• Use non-selective as they cross the blood brain barrier and
can work on the brain.
• Propranolol or nadolol are excellent but side effects can
include impotence, fatigue, and depression.
• Start low and titrate up.
• These are a good first/second line in women.
Migraine Prophylaxis
Anti-seizure medications: valproic acid, topiramate
• Valproic acid 250-500mg BID with food works very well but
side effects include hair loss and weight gain and it is
contraindicated in pregnancy.
• Topiramate 25mg BID titrated to 100mg BID as needed is
now starting to be used for this indication as well.
Topiramate can cause mental slowing and paresthesias.
• These are good first/second line choices for men.
Tension Type Overview
• This type of headache is frequently described as neck
discomfort, or band like pain around the head but
can be only front, back or top of the head.
Cause:
• This is not caused by actual muscle tension (found on
testing) but is really psychogenic headache. Any
muscle tension is usually a secondary
phenomenon.
Tension Type Treatment
• The real cause is stress. Find out what kind of
stress is going on in their life and see if
you can find a way to help them alleviate
the stress.
• The answer is not the pills. Patients can use
acetaminophen or NSAIDs PRN but the
real answer is stress reduction. They
can do this any way then want.
Chronic Daily Headache (CDH)
Cause:
Taking medications for their headache!
People think the pills help the headache - the pills cause the
headache.
These are people that may have started out with tension
type or migraine headaches but now have almost daily
headaches, frequently the whole day long. This is really
rebound headache. CDH can be caused by any analgesic
taken too frequently. It is worse in drugs with caffeine
added (Fioricet, Excedrin) .
Chronic Daily Headache Treatment
• You should withdraw all meds (except barbiturates, opioids
and benzodiazepines which need tapering).
• You can use clonidine to avoid opioid withdrawal,
phenobarbital to avoid butalbital (found in Fioricet/
Fiorinal) withdrawal.
• If you have to, NSAIDs and antiemetics or even triptans can be
used while withdrawing everything else.
• 8 of 10 respond eventually
• Last ditch treatment is one month of steroids: 20-100mg
prednisone x2 weeks then taper for 2 weeks
Fin