Transcript Headache - University of California, Irvine

Maryam Rahimi, M.D.
University of California Irvine
Objective
 Identify patient who need urgent evaluation and
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treatment
Review red flags
Primary headache
Secondary headache
Acute treatment
Prophylactic treatment
Menstrual headache
Effective communication with patients
 19 yr old college student with c/o headache, has
called the office asking for pain medication. In
high school, he used to take his mom’s headache
medications, what is your recommendation?
 1) have him take an Aspirin and call back if no
improvement
 2) have the nurse call and find out name of mom’s pain
med
 3) have the patient come in the next available appt, in 2-3
day
 4) obtain more information
 He has been up studying for exam all
night now he has neck stiffness, feels
tired and can not concentrate, he feels
warm, there is no AC at his dorm
Meningitis
 Triad of:
 Nuchal rigidity ( 88%),
 sudden high fever of 38 degree( 95%)
 altered mental status, confusion, lethargy(78%)
 Triad present in 44-46% of cases
 99% of cases have at least one of the 3
 Absence of the 3 excludes meningitis
45 year old presents with sudden
onset sever explosive headache,
worst headache of his life
Thunderclap headache
 Sever, sudden, explosive, unexpected
 Similar to clap of thunder
 Maybe associated with brief loss of
conscious
 May have Nausea, vomiting, meningismus
 Exacerbated by physical exertion
 What is the first step in evaluation of patient who
present with thunderclap headache?
 1) call neurology
 2) CT without contrast
 3) CT with contrast
 4) MRI
Computed Tomography
 CT without contrast
 To confirm or exclude bleeding
 Fast, easy, available and cost effective
 If negative CT  Lumbar puncture
 72 yr old female was brought in by her family,
reporting that she is acting depressed, has lost weight
due to not eating, can not sleep at night, looks tired
during the day, and complaining of headache.
 1- Treat depression with amitriptyline, it will also help
her headache
 2- Prescribe mirtazepine to help her sleep, it may
improve appetite
 3- complete history and exam, check blood test
including CBC, Sed rate, CRP
Temporal Arteritis
 Age 50 ( mean age onset 72)
 Temporal headache that can wax and wane
 Abrupt onset of visual disturbance
 Systemic symptoms of fever, fatigue, weight
loss, joint pain, jaw claudication, morning
stiffness
 Delay in treatment can cause permanent
loss of vision
Red flags
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Worst headache/ thunderclap
Focal neurological deficit( not typical aura)
Sudden onset, and rapid progression
Triggered by cough, exertion or sexual intercourse
Change of mental status or level of consciousness
Meningismus
New onset headache after age 50
Papilledema
New headache in patient with cancer, HIV, immunodeficiency
Tenderness over temporal artery
Systemic illness ( fever, rash, weight loss)
Illicit drug abuse( cocaine, methamphetamine ,…)
Carbon monoxide poisoning
 Among patient with headache, normal neurological
exam, and no hx of cancer, prevalence of tumor is very
low
 Among patient with known malignancy, who present
with headache, prevalence of brain metastasis as the
cause of headache is high
 ( Lung, breast, melanoma, kidney, GI)
 21 yr old female present to establish care, she
has no complaints, medication list includes
daily Ibuprofen for headache and ROS
positive for heavy menstrual cycle
 1- No further action, continue ibuprofen
 2- Add triptans
 3- Perform complete history, physical and check lab
including CBC
Primary headache
 The headache is the disease
 No abnormal brain lesion
 Treat the headache
 Goal is pain relief and prevention of
recurrence
Secondary headache
 The headache is only a symptom of another
underlying disease
 Treat the underlying disease
 Secondary headache will not improve unless
the underlying disease is treated
Secondary headaches
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Head and neck trauma
Cranial or cervical vascular disorder
Cranial tumor
Substance abuse
Withdrawal
Infection
Psychiatric disorders
Systemic disease ( anemia, hypoglycemia,
dehydration)
 Facial or cranial disorders( eyes, ears, sinuses, teeth,
mouth, trigeminal neuralgia)
History
 Quality, characteristics
 Duration
 Associated symptoms
 Previous history of similar headache
 Family history
 Medication use
Primary headaches
 Tension
 Migraine
 Cluster
Cluster Headache
 Excruciating pain
 Unilateral
 Conjunctival injection
 Lacrimation
 Episodic
 Last 15 min to 3 hours
 Recur at the same time of the day
 More often at night
 More common in men
Triggers for cluster headache
 Hypoxia
 Sleep apnea
 Vasodilators ( NTG, alcohol, carbon
dioxide)
Treatment of cluster headache
 Oxygen 7L per minute for 15 minutes
face mask
 Sumatriptan 6 mg subcutaneously
Tension headache
 Most common type of headache
 Tightness, pressure , dull ache
 Band like
 Bilateral
 From forehead to the occiput
 Can radiate to neck
 Usually does not limit daily activities
 Absence of red flags
Evaluation of Tension headache
 History
 Exam ( vitals, neurological exam, including the cranial
nerves, cerebellar function, , visual field, fundoscopic
exam, motor and sensory exam, cervical neck exam,
temporal exam)
 In the absence of red flags in history and physical no
neurological imaging is needed
 25 yr old patient present with c/o headache,
band like sensation that increases when he
is stressed at work, 1 or 2 x month. H& P
does not reveal any red flag sign or
symptoms. What is the next step?
 1- Treat tension headache with NSAIDs
 2- Life style modification to prevent headache
 3- Patient education to prevent rebound headache
 4- all of the above
Tension headaches can be due to tightened
muscles in the back of the neck and scalp
 Inadequate rest.
 Poor posture.
 Emotional or mental stress, including
depression.
 Anxiety.
 Fatigue.
 Hunger.
 Overexertion.
 Relaxation therapies / hypnosis / biofeedback
 Dietary monitoring for triggers and elimination of
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caffeine
Improving sleep habits
Daily exercise
Cognitive-behavioral therapy – This is talk therapy
with a trained counselor, designed to identify stressors
and develop coping strategies to minimize their effect
on behavior.
Counseling and treatment for depression and/or
anxiety
Treatment of tension headache
 OTC analgesics including
 Acetaminophen ( 325-1000 mg)
 NSAIDs Ibuprofen 200- 800 mg, naproxen 220-500 mg
 Sedating antihistamine , diphenhydramine
 Anti emetic ( metchlopramide 10 mg tablet)
 Sever tension headache in the office: Ketorolac 30-60
mg IM
 35 yr old patient with previous hx of
tension headache, used to get
headache 1-2 x month, now having
more frequent headache, has been
taking OTC pain meds 3 days a week
with resolution of pain. ( no red flags)
 1- No further action , continue OTC pain meds
 2- Needs to have MRI since headache frequency has
increased
 3- Consider preventive/ prophylactic medication
Rebound headache
 Using pain medication
more than twice per week
increases the risk of rebound headache
Preventive medication for tension
headache
 When pain medications are used more than twice a
week
 When treatment is not effective in reducing headache
 When treatment is causing other side effects
 Patient preference
Prevention of tension headache
 Eliminate the cause ( life style modification, stress
reduction, improve sleep hygiene)
 Amitriptyline is the most common prophylactic
medication used for tension headache
 10- 75 mg tablet 1-2 hr before bed time, tricyclic
antidepressant, with anticholinergic side effects
 Selective serotonin reuptake inhibitor (SSRIs)
 Fluoxetine ( Prozac) 20 mg tablet in the morning
 May take up to two months before benefits are seen
 26 yr old who had been taking ibuprofen for
headache 6 x week, comes in asking for help
to treat his rebound headache
 1- Gradually reduce dosage of ibuprofen
 2- Stop ibuprofen and give him an opiate for pain
control
 3- Stop ibuprofen and inform him that it will take up
to 2 weeks before rebound headache are resolved
Sign and symptoms of withdrawal
from pain medications
 Nervousness
 Restless
 Headache
 Nausea and vomiting
 Insomnia
 Diarrhea
 Tremor
POUND
 Pulsatile quality, with the headache described as
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“pounding” or “throbbing.”
One-day duration, with episodes lasting four to 72
hours if untreated.
Unilateral location.
Nausea or vomiting.
Disabling intensity, with patients having to alter their
daily activities during episodes.
Migraine with Aura
 Aura is a focal neurological symptoms most are visual
 1 out of 8 migraine patients will have aura
 Last 5-20 minutes ( less than 60 minutes)
 Followed or accompanied with headache
Migraine with aura
 blind spots or scotomas
 blindness in half of your visual field in one or both
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eyes (hemianopsia)
seeing zigzag patterns (fortification)
seeing flashing lights (scintilla)
feeling prickling skin (paresthesia)
weakness
seeing things that aren't really there (hallucinations)
Hemiplegic migraine
 Temporary paralysis or numbness on one side off the
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body
Dizziness
Visual disturbance
Memory impairment
Language disturbance
 25 year old female with hx of migraine with
aura
 1- She should be treated with oral
contraceptive to prevent migraine
 2- Taking oral contraceptives will increase
her risk of stroke
Migraine with Aura is a risk
factor for stroke
 Should not smoke
 Should not use oral contraceptive
Treatment of Migraine
 Patient education
 Motivate them to participate in prevention and
treatment
 Select effective medication with lowest side effect
 Advise and educate against medication overuse
 30 yr old patient with unilateral pounding
headache, associated with nausea & photophobia,
( no red flags) she has not tried any medication,
what is your recommendation
 1- Over the counter Aspirin (what dosage)
 2- Excedrin
 3- Imitrex
Treatment option for migraine
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Aspirin 800-1000 mg
Ibuprofen 400-1200 mg
Naproxen 750-1250 mg
Acetaminophen, Aspirin, Caffeine, 250mg-250mg65mg
Indomethacin 50 mg suppository
Consider addition of antiemetic
Triptans
Ergot
Antiemetic
 Phenergan 25 mg , Compazine 5 mg, Reglan 10 mg
 Dopamine agonist
 Can cause dystonia
 Can cause QT prolongation
 Which one of the following medications are
safe during pregnancy for treatment of
migraine
 1- Triptans
 2- Acetaminophen
 3- Codene
 4-NSAIDS
 5- choice 2 & 3
 The triptans are class C, and should be
avoided during pregnancy,
as should ergots (class X rating).
Migraine in pregnancy
 Consider no pharmacological treatment
 Acetaminophen, NSAIDs, codeine or other narcotics
 Avoid NSAIDs during the late third trimester(
bleeding and premature closure of the ductus
arteriosus.)
 Avoid prescribing narcotics in the late third trimester.
These could cause neonatal withdrawal symptoms.
Keep in mind Triptans are contraindicated
in patients
 Coronary artery disease
 Ischemic stroke
 Uncontrolled hypertension
 Hemiplegic or basilar migraine.
 Pregnancy
Triptans
Sumatriptan (Imitrex, Treximet)
Rizatriptan (Maxalt)
Zolmitriptan (Zomig)
Eletriptan (Relpax)
Naratriptan (Amerge)
Frovatriptan ( Frova)
Triptan side effects
 Injection site reaction
 Chest pressure heaviness
 Flushing, weakness, drowsiness
 Paresthesia
Sumatriptan / Imitrex
 Most option for route of delivery
 Subcutaneous, oral, nasal
 Subcutaneous 6 mg x one , can be repeated in one
hour if some response to the first injection
 Maximum dosage in 24 hr is 12 mg
 available in 4- and 6-mg single-dose prefilled syringe
cartridges
Sumatriptan nasal spray
 5 mg or 20 mg in single spray
 Can give 5 mg in each nostril ( 10 mg)
 If pain has not resolved or returns, can repeat a 2nd
dosage in two hours
 Maximum dosage is 40 mg in 24 hr
Sumatriptan tablet
 25- 50- 100 mg tablet
 Take one at the onset of the headache or aura
 Can repeat in 2 hours
 Maximum dosage is 200 mg in 24 hours
Treximet
 Sumatriptan 85 mg + naproxen 500 mg
 More effective than either agent as monotherapy
Rizatrptan ( Maxalt)
 Fastest onset of action
 5 mg – 10 mg tablet
 Disintegrating
 Maximum dosage 30 mg in 24 hr
 Dosage can be repeated in 2 hr if needed
Frovatriptan ( Frova)
 2.5 mg tablet
 Can be used for prevention of menstrual migraine
 Start two days before the onset and continue for 5-7
days
Naratriptan
 Slowest onset of action
 Lowes side effects
Menstrual Migraine
 Migraine headache that occurs in close temporal
relationship to the menstrual cycle
 Due to decline in estrogen level
 Natural cyclic decline of estrogen
 Withdrawal of estrogen containing medication(
placebo pills in BCP)
Menstrual migraine
 More sever
 Last longer
 Less responsive to treatment
Acute treatment of Menstrual
migraine
 Similar to migraine
 NSAIDS, mefenamic acid 500 mg tablet
 Anti emetics ( metchlopramide)
 Triptans
Prophylactic treatment of
menstrual migraine
 Naproxen 550 mg bid 7 days before start of
menstruation & continue for 10-13 days
 Frovatriptan 2.5 mg /day start 2 days before & continue
for 5-6 days
 Avoid decline of estrogen
 Patient with natural cycle, use estrogen patch 0.1 mg/
24 hr, start at the onset of bleeding for 5-7 days
 Patient using combination estrogen/ progesterone
pills ( day 1-21), add supplement estrogen
0.9 mg conjugated estrogen day 22-28
 Combination estrogen progesterone pills continually
and avoid the placebo pill for 90 days
Migraine prophylaxis
 For patients with more than 4 acute attacks per month
 Headaches that last more than 12 hours
 Headaches that causes significant morbidity
 For patients who can not tolerate side effects of acute
treatment
 Patents who can not take triptans
Beta blockers
 Propranolol 40-160 mg / 24 hrs ( 20 mg bid)
 Metoprolol 100-200 mg/ 24 hrs ( 50 mg bid)
 Timolol 20-30 mg/ 24 hrs
 Start at a low dosage and titrate up
 Continue for 3 months before consider medication
failure
 Inform patient and monitor for side effects
( hypotension, bradycardia, erectile dysfunction)
2012 guidelines American Academy of Neurology
Calcium channel blockers
 Verapamil 120-240 mg a day
 Most common medication used for migraine
prophylaxis
 Low side effect profile
 However tolerance can develop / dosage can be
increased
 Amitriptyline 10-75 mg at bed time
 Tricyclic antidepressant
 Constipation, dry mouth, tachycardia, weight gain,
somnolence, urinary retention, confusion
Anticonvulsants
 Valporate 500- 1500 mg a day
 Side effects :Nausea, somnolence, tremor, dizziness,
weight gain, hair loss)
 Topiramate 25- 100 mg bid
 Side effects: paresthesia, , weight loss, fatigue,
diarrhea, memory or language problem
 Not to be used during pregnancy
 Patient with hx of migraine headaches,
reports no headache in the past 12 months,
while taking prophylactic medication, what
is next stop?
 1- continue same meds
 2- stop the prophylactic medication or if taking high
dosage taper the medication
 Migraine headaches can improve over time
 Migraine does improve after menopause
 Migraine does improve during pregnancy
 Migraine can increase in the perimenopausal period
Effective communication between
patient and provider
 Limit the information to the most important, need to
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know items
Avoid medical jargon
Educate using multiple modalities
Use the follow up appt for further education
Review the written information with patient
Ask patient to repeat the instruction
Follow up appointment
 Have patient leave the office with a follow up appt
 Ask if acute treatment is effective
 Ask about side effects
 Decide if prophylactic treatment is needed
 Find out if prophylactic Rx has reduce frequency of
headache
 Adjust dosage of medications
 Ask is they tolerating prophylaxis
 Spend more time educating patient about triggers
 Identify patient who need urgent evaluation and
treatment ( infection, bleeding, temporal arteritis ,
acute stroke)
 Complete history & physical to look for red flags
 Distinguish between primary vs secondary headache
 For 2nd headaches treat the cause
 Effective communication for prevention and
treatment of primary headaches