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Headache Management. Fariborz Khorvash Associate Professor of Neurology. Why talk about headaches?. Headaches are a common problem They are sometimes difficult to treat Can usually be treated well by internists Headache management is often not optimal
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Headache Management Fariborz Khorvash Associate Professor of Neurology
Headaches are a common problem • They are sometimes difficult to treat • Can usually be treated well by internists • Headache management is often not optimal • Recent advances can translate into better treatment
Problems in management • Chest pain approach • Does this patient have a brain tumor? • Episodic care • Underdiagnosis of migraine headache • Ineffective treatments are commonly used • Acetaminophen, Butalbital/ASA/Caffeine • Inappropriate use of analgesics
Red Flag Signs: • Thunderclap headache • New onset headache • Headache with neurologic signs • Headaches in pregnancy • Headaches in elderly • Progressing headaches • Changes in frequenc or quality of headache
Internal medicine residents • Prepared to manage migraines 48% • Prepared to manage MI, DKA, Asthma 95%
Sinus Headache? • What is a sinus headache? • Many patients with migraines have sinus symptoms. • Rhinorrhea, congestion, ocular symptoms occur in up to 46% of patients with migraines
Study of 2991 patients with sinus headaches • Self or physician diagnosed • 88% met IHI criteria for migraine • Patients reported • Sinus pressure – 84% • Sinus pain – 82% • Nasal congestion – 64% • Diagnosis of sinus headache should be reserved for those patients who meet diagnostic criteria for sinusitis. Schreiber, Archives of Int. Med. 2004; 164: 1769
Brain Imaging: • New onset headache • Headache with neurologic sign • Headache with seizure • Headache with elevated ICP • Patient request • …….
Headaches • Intracranial pathology • Contiguous structures • Migraine • Cluster • Tension type • Chronic daily/Rebound
Intracranial pathology • Tumor • Subarachnoid hemorrhage • Meningitis • Pseudotumor cerebri
Tumor 111 consecutive patients with primary or metastatic brain tumor • Classic early morning headache is uncommon • Primary symptom in only - 44% • Worse with bending over - 33% • Similar to TTH in 77%; migraine in 9% • Nausea and vomiting – 40% Forsyth, Neurology, 1993
Imaging • Relatively solid recommendations • Not indicated in patients with migraines and normal exam • Indicated in patients with headache and abnormal exam
Less solid recommendations • Headache worsened by valsalva, exertion, sex • Abrupt onset or awakens patient from sleep • Change in established pattern • New headache in patient >50 • Progressively worsening headache • Comorbidities: HIV, cancer, immune suppression
Contiguous structures • Sinuses? • Eyes • Ears • TMJ • Teeth • Temporal artery • Cervical spine
IHS criteria for migraine without aura • Duration 4-72 hours • Two of the following characteristics • Unilateral • Moderate – severe intensity • Pulsating • Aggravated by routine physical activity • Headache accompanied by one the following • Nausea or vomiting • Photophobia or phonophobia • 5 attacks • No other explanation
Pathophysiology of migraine • Old theory: vasoconstriction triggers vasodilation • Current concepts • Originates as a neurologic event in the brain stem • Trigeminal nerve ganglion is stimulated • Vasodilation occurs • Serotonin release contributes
Treatment of migraines • Acute • Preventive • Life style • Pharmacologic
Principles of management • Establish a diagnosis • Treat early • Use adequate doses • Tailor treatment to the severity of attack • Use migraine specific therapies • Use preventive strategies • Form a therapeutic alliance with the patient • Empower the patient • Avoid narcotics
Acute treatment • Mild - oral • ASA 975 mg • Naproxen 500-1250 mg • Ibuprofen 800-2400 mg • Cataflam • Ergotamine 2 mg + caffeine 200 mg • Brufen/caffeine/codeine • Mild with nausea • Add metaclopramide 10 mg
Severe • Tryptans: oral, nasal, wafer, subQ • DHE 1mg subQ, IV, nasal spray • Alternatives • Ketorolac 60 mg IM • Adjuncts • Promethazine • Chlorpromazine (phenergan) • Narcotics
Tryptans • Contraindications • CAD • CAD likely • Side effects • Chest and neck pressure • Dizziness • Warmth, numbness, tingling, tightness, flushing • Nausea and vomiting
Though sumatriptan may not be the most effective of the tryptans, it is available generically and should be the first choice.
Narcotics • Not more effective • Not specific for underlying pathophysiology • Sedating • Positive reinforcement? • Potential for abuse • Public health crisis
Preventive therapies • Amitriptyline 25-150 mg • Propranolol 80-240 mg • Divalproex sodium 500-1500 mg • Sodium valproate 800-1500 mg • Venlafaxine 75-150 mg • Fluoxetine 20-40 mg?????? • Dysport
All are 70% effective • Reduce frequency and severity of attacks • Response cannot be predicted • Dose adjustments necessary • Calcium channel blockers less effective • Decision process
Life style changes • Establish and maintain routines • Sleep • Meals • Exercise • Dietary triggers • Caffeine, chocolate, alcohol, aged cheeses, monosodium glutamate
Nonpharmacologic management • Effective • Relaxation training • Cognitive behavioral therapy • Ineffective • Acupuncture • Hypnosis • Manipulation • TENS • Hyperbaric oxygen
Aspirin for migraine prevention? • Observations from the Physicians’ Health Study • 22,071 doctors randomized to 325 mg of ASA or control • Treatment group: 6% experienced migraine after randomization • Control group: 7.4% experienced migraine • Treatment effect: 20% Buring, JAMA, 1990
Cluster headaches “A healthy robust man of middle age was suffering from troublesome pain which came on every day at the same hour at the same spot above the orbit of the left eye: after a short time the left eye began to redden, and to overflow with tears; then he felt as if his eye was slowly forced out of its orbit with so much pain, that he nearly went mad. After a few hours all these evils ceased, and nothing in the eye appeared at all changed.” Textbook 1745
Clinical features • Unilateral – 100% • Restlessness – 93% • Retroorbital – 92%, (temporal – 70%) • Lacrimation – 91% • Conjuctival injections – 77% • Nasal congestion/rhinorrhea – 75% • Ptosis/eyelid swelling – 74% • Phonophobia/phophobia – 50%
Periodicity • Duration: 8 weeks • Bouts per year: 1 • Maximum attacks per day: 4 • Attack duration: 15-180 min • Nocturnal: 73%
Treatment • Acute • Subcut tryptans • 74% effective within 15 min • Nasal may be effective • Zolmitriptan 10 mg po – 60% response within 30 min • Oxygen
Treatment • Prophylactic – a small trial involving 30 patients • Verapamil 120 tid • 80% of patients responded • 40% at the end of one week • Attacks per day after one week • Verapamil - .6 • Placebo – 1.6 Leone, Neurology, 2000
Other effective therapy • Prednisone • Bridge to verapamil • Tapered over 3 week • Lithium • Sodium valproate • Methysergide
Tension-type headaches • Duration 30 min – 7 days • Two of the following characteristics • Pressing or tightening ( not pulsatile) • Mild to moderate intensity (nonprohibitive) • Bilateral • No aggravations from walking stairs • Both of the following • No nausea or vomiting • Photophobia and phonophobia absent (or only one present) • 10 previous attacks
Management of TT headaches • Acute headaches • Minor analgesics • Chronic tension type headaches • Same diagnostic criteria • Occur 15 days per month
CTTH: An RCT • Amitriptyline vs stress management vs combination • 409 patients recruited from primary care practices and randomized to one of 4 treatment groups • Amitriptyline – 48 • Stress management – 38 • Amitriptyline and stress management – 45 • Placebo – 38 Holroyd, JAMA, 2001
Results: All three treatment groups effective • Mean headache index score • Days of at least moderate pain • Analgesic medication use • Headache disability Amitriptyline produced results more quickly. Combination treatment (AM+SM) produced greater than 50% reduction in HA severity in 2/3 of patients
Treatment goals for CTTH • Identify and eliminate triggers • Amitriptyline • Symptomatic treatment with NSAID • Avoid overuse • Stress management
Analgesic abuse or rebound headaches • ¾ of patients with chronic daily headaches overuse analgesics • Transformed migraines • Past history of discrete migraines
Analgesics implicated • Butalbital/aspirin/acetomenophen/caffeine • Codeine, propoxyphene, oxycodone, hydrocodone • Aspirin, acetomenophen • NSAID • Nasal decongestants and antihistamines • Ergotamine • Tryptans
Management strategies • Make a diagnosis • Establish and maintain a relationship • Inform the patients • Stop symptomatic treatment • Start prophylaxis – amitriptyline • Steroid taper (ranitidine 300 bid) • Recognize and treat the underlying headache disorder • Guard against overuse
Effectiveness of treatment • Most patients will stop symptomatic treatment • Steroids seem to reduce withdrawal symptoms • 60-70% of patients improve • Improvement occurs over 6 months • 30% of patients relapse
Conclusion • How do we diagnose migraine headaches? • How should we treat migraines? • What causes migraines? • Who needs a CT scan? • How do we recognize cluster headaches? • How do we diagnose tension type headaches? • Does anything work for chronic daily headaches?