Transcript Headache Diagnosis and Management An Overview

Managing Headache at
UW Health:
Making a Tough Job Easier
Nathan J. Rudin, M.D.
Associate Professor, Orthopedics and Rehabilitation
Medical Director, Pain Treatment and Research Center
UW Health
Headache: A Worldwide Problem
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Up to 25% of American
adults have a severe
headache each year
Up to 4% have daily or
near-daily headache
Lifetime prevalence:
90% or more
Significant suffering
and economic loss
Headache: A Local Problem
UW Em ergency Dept Headache Visits
1600
1400
1200
#o
f
its
Vis
1000
1467
1413
FY 2003
FY 2004
1220
800
600
400
200
0
FY 2002
• Average visit length: 3.5 hours
Barriers To Success
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Limited physician training
Limited access to care
Inappropriate or incomplete treatment
Underestimation of morbidity
Ambulatory Care Innovation Grant
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Funding from UW Medical Foundation
Goal:
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Improve pain care referral, triage and
utilization across UW Health
First step:
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Survey physicians, nurses, and midlevel providers
about their comfort with and use of pain
management
Staff Survey Results
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Key areas
Reduce emergency department utilization for nonemergency pain care
 Improve pain education for staff at all levels
 Improve communication of pain-related
information across UW Health
 Centralize pain referral and case triage
 Improve coordination of perioperative pain care
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Staff Survey Results
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Key areas
Reduce emergency department utilization for
non-emergency pain care
 Improve pain education for staff at all levels
 Improve communication of pain-related
information across UW Health
 Centralize pain referral and case triage
 Improve coordination of perioperative pain care
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Goals 2006 – 2007
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Familiarize primary care and emergency room
providers with basic headache management
Educate patients
Standardize treatment protocols
Standardize communication of headache care
plans
Incorporate care plans, protocols and
educational tools into EMR
Provider Toolkit
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Video on Headache Care Basics (DVD and
online)
Introductory article on headache
Headache diagnostic classification
Madison citywide headache treatment
guidelines
Headache treatment plan form
Headache Clinic consult request form
downloadable from uconnect and uwhealth.org
Headache Treatment Guidelines
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Developed by panel of specialists
Provides a framework for headache treatment,
particularly migraine
uconnect: Clinical Guidelines / Pain Management Resources
Headache Treatment Plan
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Outline patient’s individual treatment plan
One copy scanned into EMR
Copy 2 – give to patient
Standard Register #SR300078
When To Call The Headache Clinic?
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Refractory headache
608-263-9550
Unclear diagnosis
Intensive and/or interdisciplinary treatment
needed
Consult Form – Standard Register #SR300077
Patient Toolkit
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Video on Headache Basics (DVD and online)
Introductory letter
Headache Diary
Health Facts
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Migraine; Medication Overuse Headache; Diet and
Headache; Avoiding the ED
downloadable from uconnect and uwhealth.org
Headache Diary
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Patient fills this
out daily
Brings to clinic
visit
Lets you evaluate
headache pattern
and treatment
effects
Standard Register #SR300079
Basic Principles
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Rule out potentially dangerous (secondary)
headache
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Neoplasm, infection, hemorrhage, etc.
Thorough history and physical
Diagnose headache type
Implement treatment
Monitor outcome
Secondary Headache Disorders
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<2% of headaches in primary care offices
Head trauma
Vascular disease
Neoplasms
Substance abuse or withdrawal
Infection/Inflammation
Metabolic disorders
others
“Warning Signs”
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first or worst HA (“thunderclap headache”)
progressive or new daily persistent HA
age >50 or <5 years
HA associated with fever, rash, stiff neck
HA associated with abnormal mental status or
abnormal neuro exam
“Warning Signs”
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HA associated with papilledema
new HA in patient with h/o malignancy,
immunosuppression/HIV, pregnancy
awakening because of HA
HA with Valsalva or exertion
Primary Headache
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Intrinsic dysfunction of the nervous system
Most patients presenting to PCP with headache
have primary headache syndromes
Episodic headache: more common
Chronic headache: attacks occurring more
frequently than 15 days/month for more than 6
months
Diagnostic Steps
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Rule out secondary headache
 Thorough
history
 Neurological and musculoskeletal
examinations
 Imaging, blood work and/or CSF analysis if
“red flag(s)” found
Diagnose headache type
 Identify comorbid illnesses
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Headache History
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Area of head involved
Pain quality
Pain severity
Other symptoms (nausea, vomiting, light sensitivity)
Triggers
Timing (including perimenstrual)
Pre-headache warning symptoms (“aura”) – for
example, visual changes
Migraine Pathophysiology
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Migraine is a brain
disorder
Brain becomes
hypersensitive and
overly responsive
to stimuli
The trigeminal
nerve appears to be
a key pathway
Migraine Cascade
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Vasoactive substances
inflame vascular and
meningeal tissue,
activate trigeminal
axons
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Perivascular release
of vasoactive
neuropeptides;
spreading neurogenic
inflammation
Migraine Cascade
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The inflammatory
response spreads along
the trigeminovascular
system
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Pain signals reach
trigeminal nucleus
caudalis and other
pain systems
Dorsal raphe nucleus
may modulate
migraine pain
Migraine
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Episodic, progressive head pain
Pulsating, throbbing, stabbing
Attacks: 4-72 hours
Unilateral in 60%
Up to 75% may have neck pain
Migraine
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3 : 1 female : male
6% of males, 18% of females, 4% of children
Family history + in 80-90%
Onset typically during adolescence or young
adulthood
Onset after age 40 possible
Migraine Triggers
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Hormonal fluctuations
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Perimenstrual migraine very common
Weather changes
Diet, including missed meals
Stress
Migraine Subtypes
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Migraine with aura (20%)
Neurologic event precedes migraine
(usually by 30-60 minutes)
 Visual, auditory, olfactory
disturbances
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Migraine without aura
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No aura or other warning symptoms
Chronic migraine
Chronic Migraine
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Starts as episodic migraine
Attacks occur at increasing frequency
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Eventually 15+ attacks/month
Frequent association with medication overuse
Psych comorbidity common
Medication Overuse Headache
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Persistent, recurring headache
in the setting of regular
analgesic use
Continues until medication is
stopped
Often responsible for
“transformation” of episodic
into chronic headache
Ingredients: Succinic acid, fumaric acid,
dextrose and bioflavonoids
Overuse Headache: Features
Short-acting analgesic use more than 2-3
times/week
 Headaches become predictable, more
frequent, even continuous
 Medications no longer prevent headaches
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Common Culprits
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Analgesics, especially short- or
intermediate-acting
Opioids
 NSAIDs including acetaminophen
 Combination analgesics
 Caffeine
 Triptans
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Hormones: OCPs, others
Tension-Type Headache
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Episodic or chronic; possible
migraine variant
Episodic form affects up to 38%
of US adults annually
Less disability and morbidity
than migraine, so less seen by
MDs
Tension-Type Headache
“Bandlike”
 Bilateral: frontal, temporoparietal
 Referred (myofascial) pain from neck to
head
 Neck structures may contribute to pain
(“cervicogenic headache”)
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Cluster Headache
Rare disorder
 M:F 3:1; genetic predisposition
 Cycles/clusters lasting weeks to months
 Repetitive headaches during a cluster
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1-3 hours apiece; always unilateral
 Focal facial and eye pain, lacrimation,
rhinorrhea
 Often occur when sleeping or napping
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Cluster Headache
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“CH face”: leonine face,
furrowed and thickened skin with
prominent folds, a broad chin,
vertical forehead creases, and
nasal telangiectasias.
Typically tall and rugged-looking
Chronic Daily Headache
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Chronic migraine
Chronic tension-type headache
New daily, persistent headache
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Generally poor prognosis
Hemicrania continua
Unilateral, persistent
 Some migraine features; head trauma in 20%
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Treatment: Define Goals
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Patient’s goals
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Your goals
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Pain relief; medication; ? improved
function
Pain relief or reduction; improved
function; appropriate medication use
Bring goals into congruence
Treatment Plan
Preventive therapy
 Abortive therapy
 Pre-emptive therapy
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 Short-term
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to prevent anticipated headache
Urgent (“rescue”) therapy
 Minimize
or eliminate where possible
Non-Drug Treatment
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Learn appropriate prevention and treatment
Avoid headache triggers: foods, drugs, activities
 Avoid frequent abortive treatment
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Stop smoking
Normalize sleeping and eating
Exercise
Relaxation and biofeedback
Psychotherapy
Rehabilitation
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Treat postural dysfunction and myofascial pain
Relaxation training
Physical therapy
Reduce spasm
 Improve posture
 Reduce triggers/perpetuating factors
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Eliminate Overuse Headache
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Taper and stop offending agents
Severe headache invariably results
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Supportive treatment: hydration, antiemetics, antiwithdrawal agents if needed
Initiate preventive therapy as taper begins
Initiate nondrug therapies
Add abortive therapy once withdrawal
headache passes
Migraine: Preventive Treatment
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Tricyclic antidepressants – first-line
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Beta-blockers – first-line
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Amitripyline, doxepin if sleep is disturbed
Atenolol, nadolol
Ca++ channel blockers – less effective
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Verapamil most commonly used
Migraine: Preventive Treatment
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Anticonvulsants – second-line; valuable
Valproate and topiramate are quite effective
 Gabapentin – best tolerated, ? effect
 Lamotrigine, levetiracetam – no good data as yet
 Pregabalin – may help (anecdotal)
 Psychotropic effects may be useful
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Migraine: Preventive Treatment
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Ergots: Rarely used for prevention
Side effects may be problematic
 Methysergide: fibrosis (use 6 months max)
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MAOIs: Can be very effective
Tyramine-free diet a must
 Numerous drug interactions
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Migraine: Abortive Treatment
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Simple and combined analgesics
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APAP, NSAIDs, others
Mixed analgesics (barbiturate plus simple
analgesics) – avoid wherever possible
Ergot derivatives
Triptans
Opioids
Triptans
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Serotonin 5-HT1 agonists
Reduce neurogenic inflammation
Most effective if used at onset of headache or
aura, though may be helpful at other phases
Used specifically for migraine
For nonresponders, try ergots (also act on NE,
DA, other receptors)
Triptans
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Generally well tolerated
Contraindications:
Uncontrolled hypertension
 CAD, PVD, cerebrovascular disease
 Pregnancy
 MAOIs
 High-dose SSRIs, tramadol (rare interaction)
 Ergotamine or other triptan use within 24 hrs
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Triptans
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Short-acting
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Longer half-lives
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Sumatriptan, almotriptan, rizatriptan, zolmitriptan,
eletriptan
Naratriptan, frovatriptan
Successive trials may be needed to determine
the best triptan for a given patient
DHE
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Nasal spray
Administer each nostril, may repeat in 15 minutes
 Works best if taken early
 Longer half-life than sumatriptan, though not as
reliable for some patients
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Injection
1 mg can be given SQ or IM
 Max dose: 3 mg/24 hours
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Other Agents
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Antiemetics/Neuroleptics: often combined
with abortive agents
Prochlorperazine, hydroxyzine, promethazine,
metoclopramide
 Chlorpromazine and other neuroleptics may be
effective alone
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Drugs To Avoid
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Butorphanol nasal spray
Very addictive and often poorly tolerated
 Not suitable for chronic or frequent use
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Meperidine
Neurotoxic metabolite, weak analgesic
 There are almost always better choices
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Overuse of any short-acting analgesic (opioids,
triptans, et al.)
Treating Cluster Headache
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Acute:
Oxygen inhalation 100% FM, or 7L NC
 Triptans/ergots
 Indomethacin
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Chronic/Preventive:
Verapamil, lithium
 Valproate, topiramate
 Prednisone burst
 Melatonin
 Ergots
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Paroxysmal Hemicranias
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Chronic and episodic
varieties
Uniquely sensitive to
indomethacin!
Opioids
“Headaches can sometimes get so bad that
doctors prescribe morphine or methadone.
Another way to look at this is that headaches
sometimes get so good that doctors
prescribe morphine or methadone.”
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The Onion’s Headache Relief Tips, 2002
Opioids and Chronic Intractable
Headache
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Saper et al., Neurology 2004; 62:1687-94
160 patients with intractable headache on
scheduled opioids
 Outcome variable: Reduction in headache
frequency x severity (Severe Headache Index)
 74% failed to improve or were discharged for
clinical reasons
 26% improved over 50%
 Problem drug behavior occurred in half of patients
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Cervicogenic Headache
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Differentiate from migraine or other
syndromes
Analgesics may be tried as for migraine
Reserve triptans/ergots for refractory cases
Rebound often a significant issue
Therapy directed at neck may help
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Facet blocks, trigger point injections, nerve blocks,
TENS, physical therapy
Other References
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uConnect: Clinical Guidelines: Pain
Management Guidelines
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Adult and Pediatric Migraine Guidelines
Health Facts For You: search under Pain or
Headache
Kaniecki R. Headache assessment and
management. JAMA 289(11): 1430-1433,
2003.
Thank
You!