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Medication Overuse Headache

Medication Overuse Headache . Morris Maizels MD Blue Ridge Headache Center Asheville Hendersonville NC . Migraine Remembered . S evere U ni- L ateral 2 of 1st 4 T hrobbing A ctivity worsens ha N ausea S ensitive to light/sound 1 of last 2

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Medication Overuse Headache

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  1. Medication Overuse Headache Morris Maizels MD Blue Ridge Headache Center Asheville Hendersonville NC

  2. Migraine Remembered S evere U ni- L ateral 2 of 1st 4 T hrobbing A ctivity worsens ha N ausea S ensitive to light/sound 1 of last 2 Headache is episodic, and usually lasts 4-72 hours

  3. Goadsby, 2000. Neurovascular theory of Migraine

  4. 1 3 2 Sensitization and migraine 1. Throbbing headache 1. Peripheral Trigeminal Sensitization 2. Forehead Allodynia 3. Thalamic Sensitization 3. Extracephalic Allodynia 2. Central Trigeminal Sensitization Adapted from Ambassadors program after Burstein et al., Brain 2000

  5. Migraine Triggers • hormones • emotions/stress • disrupted sleep • caffeine withdrawal • foods • change

  6. Symptomatic Medication Mild to Moderate Headaches • NSAID’s - high dose (+/- antiemetic) • ASA/acetaminophen/caffeine (Excedrin)* • ASA or acetaminophen/butalbital/caffeine (Fiorinal/Fioricet)* • Acetaminophen/isometheptene/dichlrophenazone (Midrin) - ii po at onset, then i qhr up to 5/day • Ergotamine tartrate/caffeine (Cafergot)* *** Limit use to 2 days/week ***

  7. Sumatriptan (Imitrex) Rizatriptan (Maxalt) Zolmitriptan (Zomig) Naratriptan (Amerge) Frovatriptan (Frova) Almotriptan (Axert) Eletriptan (Relpax) DHE im/sq, iv, ns Group by parenteral po rapid onset po slow onset rapid --> slow high --> low efficacy high --> low relapse more --> less se’s Triptans and DHE

  8. Triptan side effects/risks • Common: sedation, nausea, muscle ache, chest tightness (2 – 5%) • Contraindications • CAD, CVA, PVD • hemiplegic/basilar migraine • Risk of serious cardiac event with triptans is ~ 1:1,000,000

  9. General approach to acute Rx • Who gets triptans? • Which triptan? • How to use the triptan?

  10. Principles of acute therapy • Stratified care • Early use of medication for patients with episodic headache • Limit use of all acute meds to 2 days/week

  11. Stratified Care • Usual level of disability • Rapidity of onset • Associated nausea/vomiting • Tendency to relapse • Side effect tolerance

  12. An approach for triptan non-responders • Review diagnosis • migraine? • daily headache (drug rebound)? • Use early in attack, at sufficient dose • Try at least 3 triptans • Polypharmacy (NSAID/antiemetic) • ?Mg deficiency

  13. Alternatives for Refractory Headaches • Chlorpromazine (Thorazine) 12.5 mg iv; mr q 20 min x 3; total 50 mg • IV Depacon 100mg/kg over 5 min • IV DHE (q8h Raskin protocol) • IV Mg 2 gm/100 ml D5W may be added to any other regimen

  14. Drug Rebound Headache • h/o episodic migraine • more frequent/daily • refractory to usual Rx • narcotics for rescue • Fiorinal - “preventive” • escalating Rx use • trying to survive

  15. “The desire to take medication is, perhaps, the greatest feature which distinguishes man from the other animals.” Sir William Osler

  16. Worst offenders: Narcotics Ergotamine Caffeine-containing compounds: Excedrin Fiorinal/Fioricet Cafergot Lesser offenders: aspirin acetaminophen NSAID’s triptans Innocent until proven guilty DHE What drugs cause drug rebound?

  17. “The Unrecognized Epidemic” • 1-2% of population is affected • (near) daily tension-type headache, with migrainous flares • present upon awakening • refractory to other abortive or prophylactic measures • headache worsens when medication is stopped

  18. Treatment of Drug Rebound • Patient education • Withdraw medication • Initiate prophylaxis • Provide rescue therapy

  19. Impact of continuing vs discontinuing symptomatic medication

  20. Prevention of drug rebound All Rx’s state: “Limit use to 2 days/week” eg, Triptan A, B, or C x mg #9 i po at onset migraine–mr x 2 within 24 hr Limit use to 2 days/week

  21. Conclusion • Episodic disabling = migraine • “Migraine-in-a-Minute” for triage • Stratify care • treat early • migraine-specific therapy • Refractory headache is usually due to: • drug rebound • co-morbidity • Incorporate behavioral assessment/Rx

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