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Evidence Based Guideline of Treatment of Chronic Headache

Limitations. Headache syndromes : Clinically diagnosed diseasesInhomogeneity Level I evidences are insufficient and limitedTreatment of acute migrainePrevention of migrainePrevention of tension headache. Chronic Headache. Very commonMigraineTension headacheCluster headacheOther rare headach

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Evidence Based Guideline of Treatment of Chronic Headache

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    1. Evidence Based Guideline of Treatment of Chronic Headache Asan Medical Center Sun U. Kwon

    2. Limitations Headache syndromes : Clinically diagnosed diseases Inhomogeneity Level I evidences are insufficient and limited Treatment of acute migraine Prevention of migraine Prevention of tension headache

    3. Chronic Headache Very common Migraine Tension headache Cluster headache Other rare headache syndromes Diagnosis is based on exclusion ? dilemma Secondary headache

    4. Contents Evaluation Migraine Acute treatment Prevention Treatment during pregnancy Tension headache prevention

    5. Evaluation of Headache Using IHS Criteria Indications for Neuroimaging Focal neurological finding (Gr B) Headache starting after exertion or valsalva’s maneuver Acute onset of severe headache Headaches awakens patient at night Change in well-established headache pattern New-onset headache in patient who has HIV or cancer (Gr C)

    6. Treatment of Migraine

    7. Treatment of Acute Attacks Analgesics and NSAIDs Ergot Derivatives Triptans Opiates

    8. NSAIDs First-line or initial choice for all migraine attacks Followings have evidence for migraine 900mg aspirin, 1000mg acetaminophen(?), 500-1000mg naproxen, 400-800mg ibuprofen Combination with antiemetic drugs or drugs for improving gastric motility Overuse of these drugs should be avoided

    9. Ergot Derivatives Ergotamine and dihydroergotamine (DHE) Low cost and long experience DHE : good evidence for the efficacy Erogtamine or café-ergot : inconsistent evidence with frequent adverse events Disadvantages Sustained generalized vasoconstrictor High risk of overuse and rebound Complicated pharmacokinetics

    10. Triptans Choice for moderate to severe migraine attacks Advantages over ergotamine Selective pharmacology: selective 5-HT1b/1d agonists Established efficacy based on well-designed controlled trials Well established safety profile Moderate side effects Disadvantages High cost Restrictions on their use in the presence of cardiovascular diseases

    11. U.S. Headache Consortium Recommendations First-line : NSAIDs or acetaminophen+aspirin+caffeine Use migraine specific agents in severe migraine or poor responder to NSAIDs Triptans, DHE, ergotamine Educate patients with migraine about their condition and its treatment Guard against medication-overuse headache

    12. AAFP/ACP-ASIM Recommendations First-line : NSAIDs Fail to respond to NSAIDs DHE nasal spray Triptans Educates patients with migraine about their condition and its treatment

    13. Pharmacokinetics of Triptans

    14. Fast Relief (Controlled Trials)

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