Transcript Primary_Headaches_Treatment

Management of Primary
Headache Disorders
Primary Headache disorders
Include all the non-malignant recurrent headache
disorders not caused by structural causes or
medical disease.
Includes: migraines, tension headaches, cluster
headaches, hypnic headaches, paroxysmal
hemicrania and many others.
Have a high prevalence and incidence
Basic Headache Fundamentals
Multifactoral Contributions
-genetic
-environmental (stress, sleep)
-chemical (caffeine, medication)
-organic (sinus disease, muscle strain)
-physical (posture, ergonomics, eye
strain)
-psychologic (secondary gain, anxiety,
depression, hypochondriasis)
Migraines
Characteristics
Episodic
Unilateral
Pounding, throbbing
Photophobia,
Phonophobia
Nausea/ vomiting
Need for sleep
Visual or sensory aura
Migraine-general concept
Think of migraine as:
Neurologic disorder +/- headache
Also often include autonomic and
GI symptoms
Migraine Epidemiology
In a given year, 15% to 18% of women
and 6% of men have at least one migraine
attack.
28% of men and 40% of women used
prescription medications.
Important Migraine medical history
Triggers
Character of pain
Associated symptoms
Duration
Frequency
Behavior during an
attack (hibernationlike)
Auras
Treatment
PMH
Previous medications
OTC medications
Family hx
Caffeine
Sleep (quality and
quantity)
Life-Stress
Exercise
Important ROS
Eye symptoms: visual loss, visual
changes, double vision, photophobia
GI symptoms: N/V, cravings, anorexia
Other: vertigo, numbness and tingling,
phonophobia, need for sleep
Important questions
Everyday or intermittent
Frequency of headaches
Duration of headache
Onset (rapid, during sleep or with aura)
Presence of nausea?
Medications used?
Other measures used?
Family history
What do you do when you get a headache?
How well do you sleep?
Diagnostic work-up
If headaches are intermittent, frontal
with photophobia/phonophobia, +Fhx.
None needed
Atypical features: male, age >30, no
family hx, abnormal exam: consider
imaging
No lab w/u generally required
Diagnosis is by history and description
of headaches.
Therapy Principles
Medical and non-medical
Non-medical therapies include: sleep, ice
packs, behavioral modification,
biofeedback
Medical therapies include prescription,
nutritional and herbal therapies
Treatment-general principles
Comes in 2 forms:
Abortive: treat each headache
symptomatically with a prn medication
Preventative: prevent recurrent headaches
with a daily medication
Abortive therapy-important
concepts
Staged therapy approach: treat mild
headaches with “mild medicines” and
severe headaches with “strong
medicine”
The earlier you treat the migraine, the
more effective the response.
Entrenched or established migraines
are harder to abort.
Abortive therapies
-For mild headaches:
NSAIDs, ASA, acetaminophen, ibuprofen,
naproxen
-For moderate headaches:
Fioracet, Fiorinal, Midrin, percocet, T3
Abortive therapies-continued
For severe headaches:
Triptans: imitrex, maxalt, zomig, amerge,
relpax, trexemet and others
Ergotamines: Dihydroergotamine -45 (DHE)
Abortive therapies-considerations
Triptans are contraindicated with
ischemic heart disease and complicated
migraine (hemiplegic, confusional)
Route of treatment determines speed of
response and effectiveness:
Oral, injectable or nasal spray
Abortive therapies-considerations
Not to be used more than 2-3
days per week to avoid
medication overuse headache/
rebound headache
Abortive therapies- continued
Miscellaneous:
IV Magnesium, phenothiazine
antiemetics: compazine, phenergan,
reglan
Depakon, thorazine, prednisone,
decadron
Preventative therapies-concepts
Used where headache frequency
exceeds 15 days per month or 2-3 days
per week.
Try to treat co-existing conditions with
preventative therapies
Insomnia, depression, HTN, obesity
Preventative therapies-concepts
Preventative therapies may take 3-4
weeks to start working
Start at a low dose and gradually increase
Have patient keep a headache calendar to
monitor actual progress
Preventative agents
Beta-blockers: propranolol, metoprolol
-main side effects: exercise intolerance
Calcium channel blockers: Verapamil
Anti-depressants: TCAs: pamelor, elavil,
SSRIs
Preventative agents
Anti-epileptics
Valproic acid- approved as migraine
preventative (weight gain, PCOD,
teratogenic)
Topiramate- approved as migraine
preventative (weight loss,
language/memory problems
“Stupamax”, “Dopamax”
Antiepileptic preventatives
Neurontin- seems to work OK if
tolerated. Limited by sedation, BID-TID
dosing
Lamictal (lamotrigine) not used too often
due to Steven’s-Johnson rash- 3rd line
agent
Other preventative therapies
Oral magnesium- may have a role in
perimenstrual migraine
Hormonal therapies: supplemental
estrogen during menstrual phase
Botox injections
Leukotriene inhibitors (montelukast)
Lisinopril
Alternative therapies
Feverfew (Tanacetum parthenium)
Ribolfavin (vitamin B2)
Accupuncture
Migrelief (Feverfew, magnesium sulfate
and vitamin B2)
Chronic daily headache
Daily or almost daily occurrence of
headache
Episodic migraine sometimes transforms
into chronic daily headache
Commonly associated with medication
overuse
Medication overuse headache
rebound headache
Must first address medication overuse.
Use of short acting analgesics, vasoactive
medications including triptans more than 2
days per week can result in medication
overuse headaches in susceptible
individuals
MOH treatment
1. Educate: a handout is often helpful (from
Mayoclinic.com or Jefferson Headache
center
2. Decide on abrupt withdrawal or taper
MOH treatment
Consider prednisone 4-7 days, 40-60mg
DHE infusion
Add migraine preventative
Treat insomnia
Limit analgesic use to 2 days/week
Use anti-nausea or valium for break
through headaches or symptoms.
Indomethacin responsive
headaches
Paroxysmal hemicrania
Short duration (3min to 45 min) intense,
boring, focal (temporal, frontal, parietal). No
nausea, photophobia, phonophobia, 4-30/day
Also described as “ice pick headaches” or “jolts
and jabs”
Indomethacin 75 to 150mg/day
Other headache types
Cluster headache
Less common, seen more in men, headache
is typically intense, stereotyped, unilateral,
30min to 2 hours in duration, turns on/off like
a switch. Associated with autonomic
symptoms: runny nose, lacrimation, etc
Cluster headaches continues
Treatment-abortive
Includes triptans, oxygen, most oral
analgesics work too slow
Treatment-preventative:
Depakote, verapamil, steroids, lithium
Exertional headaches
Typically sudden onset, occipital
May have mild photophobia
May symptomatically resemble subarachnoid hemorrhage
Post-coital headaches- typically in young
men, may occur at or before orgasim.
Recurrence may occur over 2-3 weeks but
then typically resolves
Exertional headaches
Rule SAH if appropriate
May treat with pre-exertion medication
including indocin, NSAIDs
May consider preventative B-blockers
Usually resolve after some period of
weeks.
Questions?