Headache: A Practical Summary for Primary Care Providers

1. Headache:A Practical Summary for Primary Care Providers Annette goodman, do Redington neurology

2. Objectives • Be able to identify common types of primary headache syndromes seen in primary care: • Medication overuse headache • Migraine • Cluster Headache • Muscle Tension Headache • Avoid triggers contributing to medication overuse headache • Differentiate between treatment options for migraines, both acutely and as a preventative • Be aware of emerging therapies for migraines

3. Prevalence • ½ - ¾ of adults have suffered from a headache within the past year. • 30% have had a migraine in the past year. • 1.7-4% have had a headache at least 15 days or more each month. • Severe headache / migraine reported in 1out of 6 Americans over a 3 month period. • 9.7% males, 20.7% females • Fifth leading cause of ER visits • Third leading cause among females age 18-44 • 1.3% of outpatient visits • Third highest cause nationwide of years lost to disability [YLD]. Headache. 2018 Apr;58(4):496-505. doi: 10.1111/head.13281. Epub 2018 Mar 12. World Health Organization fact sheet, 2016

4. Today’s Scope: • Medication Overuse Headache • Migraine • Tension-type Headache • Cluster Headache

5. Introduction • NO pain receptors in the parenchyma [the brain tissue itself] • Pain receptors ARE present in: • Blood vessels • Meninges • Scalp • Skull

6. Medication Overuse Headache

7. Medication Overuse Headache • Also known as Rebound Headache • Defined as: • Headache present on >15 days/month. • Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache. • Headache has developed or markedly worsened during medication overuse. TherAdv Drug Saf. 2014 Apr; 5(2): 87–99.

8. Medication Overuse Headache • Can be precipitated by many agents: • NSAIDs • Acetaminophen • Aspirin • Caffeine • Triptans • Opioids • Butalbital • Ergotamines

10. Pathophysiology • Etiology is uncertain given multiple medication triggers • Present in patients predisposed to headache • Consideration given to chronic low serotonin, elevated CGRP and central sensitization TherAdv Drug Saf. 2014 Apr; 5(2): 87–99.

11. Medication Overuse Headache • Goal: withdrawal of offending agent • Baseline headache pattern can therefore be established • Achieved by one of three methods: • Abrupt withdrawal • Gradual wean • Steroid taper – data does not prove superiority • After successful wean, relapse is 20-40% • Limit future abortive use to no more than twice weekly in susceptible patients

13. Migraine

14. Introduction • Prevalence: • Women 25% (lifetime) • Men 8% (lifetime) • 28 million persons have migraine each year in the U.S. • Highest from 25-50 years of age • Genetics • About 70% of migraineurs have a positive family history in a first-degree relative • Unknown mode of transmission

15. Strange (Scary) Facts • Increased prevalence of: • MVP • PFO • HTN • Stroke • Epilepsy • Atopic allergies • Asthma • IBS • Depression • Bipolar disease • Anxiety disorders • Panic attacks

16. Migraine The International Classification of Headache Disorders, 3rd edition • A. At least five attacks fulfilling criteria B–D • B. Headache attacks lasting 4–72 hours (when untreated or unsuccessfully treated) • C. Headache has at least two of the following four characteristics: • 1. unilateral location • 2. pulsating quality • 3. moderate or severe pain intensity • 4. aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs) • D. During headache at least one of the following: • 1. nausea and/or vomiting • 2. photophobia and phonophobia • E. Not better accounted for by another ICHD-3 diagnosis. Cephalalgia 2018, Vol. 38(1) 1–211

17. Migraine • Migraine without aura [common migraine] • Migraine with aura [classic migraine]

18. Migraine • 1. Migraine • 1.1 Migraine without aura • 1.2 Migraine with aura • 1.2.1 Migraine with typical aura • 1.2.1.1 Typical aura with headache • 1.2.1.2 Typical aura without headache • 1.2.2 Migraine with brainstem aura • 1.2.3 Hemiplegic migraine • 1.2.3.1 Familial hemiplegic migraine (FHM) • 1.2.3.1.1 Familial hemiplegic migraine type 1 (FHM1) • 1.2.3.1.2 Familial hemiplegic migraine type 2 (FHM2) • 1.2.3.1.3 Familial hemiplegic migraine type 3 (FHM3) • 1.2.3.1.4 Familial hemiplegic migraine, other loci • 1.2.3.2 Sporadic hemiplegic migraine (SHM) • 1.2.4 Retinal migraine • 1.3 Chronic migraine • 1.4 Complications of migraine • 1.4.1 Status migrainosus • 1.4.2 Persistent aura without infarction • 1.4.3 Migrainous infarction • 1.4.4 Migraine aura-triggered seizure • 1.5 Probable migraine • 1.5.1 Probable migraine without aura • 1.5.2 Probable migraine with aura • 1.6 Episodic syndromes that may be associated with migraine • 1.6.1 Recurrent gastrointestinal disturbance • 1.6.1.1 Cyclical vomiting syndrome • 1.6.1.2 Abdominal migraine • 1.6.2 Benign paroxysmal vertigo • 1.6.3 Benign paroxysmal torticollis Cephalalgia 2018, Vol. 38(1) 1–211

19. Pathophysiology • The neurovascular theory:

20. Pathophysiology • The neurovascular theory:

21. Time Is Critical in Preventing Migraine From Becoming Full-blown Harvard Research Suggests: A Sequence of Events Leads to Central Sensitization Within minutes of a migraine being triggered, the peripheral neurons that innervate meningeal blood vessels become sensitized If migraine is left untreated, those peripheral pain neurons activate and sensitize central neurons, leading to central sensitization Central sensitization signifies full-blown migraine, when central neurons are continually firing and the attack becomes more difficult to treat Burstein R et al. Ann Neurol. 2000;47:614-624. Burstein R et al. Brain. 2000;123:1703-1709.

22. STAGES OF MIGRAINE Phases of a Migraine Attack Pre-HA Headache Post-HA Intensity Moderate to Severe HA Premonitory/ Prodrome Aura Mild Postdrome Time Adapted from Cady RK. Clin Cornerstone. 1999;1(6):21-32.

23. Prodrome • Mood Changes • Irritability, depression, sleepy, apathy • Neurologic symptoms • Yawning, photo/phonophobia, vision changes • Constitutional symptoms • Fatigue, pallor, fluid retention, myalgia • Alimentary symptoms • Hunger, anorexia, nausea, diarrhea

24. Aura • 15% of patients • Episode of focal neurologic changes • Develop over 5 to 15 minutes & last up to 60 minutes • Visual, weakness, numbness, confusion

25. Headache • Headache lasts hours to days • Migraine head pain unilateral in 56 – 68% of patients • 90% of patients have coexisting nausea • Constitutional symptoms common

26. Postdrome • Depression • Drowsiness • Cognitive changes • Memory loss • Difficulty with concentration

27. Treatment philosophy • If the pain can be stopped early, the cascade of pain responses can be controlled • Headache needs to be caught before central sensitization occurs • Patients may receive the greatest benefit from their migraine medication if they: • Practice early intervention • Use a fast-acting migraine medication

28. General Treatment • Avoid triggers! • Maintain regular sleep schedule • Maintain regular meal schedule • Low tyramine • Limit caffeine • Avoid nitrates/nitrites/MSG • Limit chocolate • Reduce stress • Adequate water intake

29. Treatment Options Two Treatment Approaches • Acute therapy • Work quickly to relieve migraine pain and other symptoms • Are taken only at migraine onset • Preventative therapy • Prevent or reduce the number of migraine attacks • Are taken on a daily basis

30. Migraine Abortives • NSAIDs • Triptans • Acetaminophen/Butalbital/Caffeine • OTC migraine preparations “Excedrin Migraine” • DHE

31. Acute Treatment • NSAIDS • Inhibit prostaglandin formation, thus reducing inflammation • Naproxen • Ibuprofen • ASA • COX2 inhibitors

32. Acute Treatment • Triptans • Selective 5-HT1B/1D agonists • Block actions of 5-HT such as dilation of cranial arteries/AV anastomoses, neurogenic dural plasma extravasation • Use early! • More effective in mild/moderate pain • Caution about rebound

33. Acute Treatment • Triptans: • Almotriptan (Axert) • Eletriptan (Relpax) • Frovatriptan (Frova) • Naratriptan (Amerge) • Rizatriptan (Maxalt) • Sumatriptan (Imitrex) • Zolmitriptan (Zomig)

34. Acute Treatment • Triptans side effects: • Chest pressure/heaviness • Jaw tightness • Dizziness • Somnolence • Fatigue • Nausea • Paresthesias

35. Acute Treatment • Triptans • Relative contraindication: • Complicated migraine • CAD, CVD, PVD • Smoker + oral contraception • Severe HTN

36. Acute Treatment • Ergotamine tartrate • Available for over 50 years • Vasoconstrictors • Oral, SL, IV, PR • Caution about rebound, dependence • Contraindicated: • CVD • CAD • PVD • Severe HTN • Sepsis • CKD • Hepatic disease • Pregnancy

37. Acute Treatment • OTC agents • Cautious of rebound! • Opioids and butalbital are NOT considered appropriate abortive agents except in cases of last resort. [US Headache Consortium]

38. Status Migrainosus • Migraine lasting greater than 72 hours in duration • Refractory to conventional treatment • Steroid burst – oral methylprednisolone, prednisone • “Headache cocktail”: • Ketorolac 60mg IM • Diphenhydramine 50mg IM • Prochlorperazine 10mg IM • Patient must have a driver

39. Prophylactic Treatment • Indicated in patients with: • >2 migraines per month • Attacks lasting for several days per week • Severity/frequency that critically impacts patient’s daily life • Abortive therapies are contraindicated, ineffective, overused, not tolerated • Uncommon migraine type (hemiplegic, basilar, prolonged aura, migrainous infarction)

40. Prophylactic Treatment • Start low and go slow! • Adequate trial with adequate dose • Consider comorbid conditions when choosing a medication • May add a second medication

41. Reduce Frequency • Seizure Medications • Topiramate, valproate, gabapentin, zonisamide • Blood Pressure Medications • Beta Blockers: propranalol, nadolol • Ca+ Channel Blockers: verapamil • Antidepressants • Tricyclics: amitriptyline, nortriptyline • Combos: venlafaxine

42. Botulinum Toxin • FDA approved for chronic migraine • Defined as headache present for 15 days per month or more • Administered every 12 weeks

43. Other treatment options • Magnesium glycinate 400mg bid • Riboflavin 400mg daily • Melatonin • CoQ10 • Butterbur/Feverfew/Skullcap • Acupuncture • Biofeedback/Yoga/Meditation

44. Other treatment options • Vagus Nerve Stimulation • Spring TMS • Transcranial magnetic stimulation • Cefaly • Tens-like unit

45. Emerging migraine therapy ClinPharmacol Drug Dev. 2017 Nov-Dec; 6(6): 534–547.

46. Tension-type Headache

47. Tension-Type Headache: Diagnostic Criteria At Least 10 Episodes Fulfilling the Criteria Below Description of Headache Associated Symptoms Headache lasting 30 minutes to 7 days AND Both of the following: Two of the following: Pressing/tightening quality(nonpulsating) Mild or moderate intensity (may inhibit, does not prohibitactivities) Bilateral location No aggravation by walking upstairs or similar routine physicalactivity No nausea or vomiting Photophobia and phonophobia are absent, or one but not the other is present AND Olesen J. Cephalalgia. 1988;8(Suppl 7):1-96.

48. Treatment • Acute • NSAIDs • Acetaminophen • Muscle relaxers ? • Chronic • TCA • Physical Therapy • OMT • Occipital Nerve Block

49. Cluster Headache

50. Cluster Headache: Diagnostic Criteria At Least 5 Attacks Fulfilling the Criteria Below Frequency of attacks: 1 every other day to 8 per day Description of Headache Associated Symptoms AND All of the Following: One of the Following Present on the Pain Side: Severe Unilateral orbital, supraorbital, and/or temporal location Lasts 15 to 180 minutes(untreated) Conjunctival injection Lacrimation Rhinorrhea Nasal congestion Forehead and facial sweating Miosis Ptosis Eyelid edema AND Olesen J. Cephalalgia. 1988;8(Suppl 7):1-96.