بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم Dr. M. Togha Professor of Neurology, Tehran University of Medical Scienses

2. Intractable headache Failed an adequate trial of regulatory approved and conventional treatments according to local national guidelines Adequate trial Appropriate dose Appropriate length of time Consideration of medication overuse Failed No therapeutic or unsatisfactory effect Intolerable side-effects Contraindications to use

3. Intractable headache • Headaches cause significant interference with function or quality of life, despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy

4. Possible Reasons for Intractability • “Rebound" (meditation overuse headache) or excessive medication overuse, toxicity,etc • Wrong diagnosis (wrong primary or undetected secondary causes) or nondiagnosis • Medication selection not proper/dosages not adequate • Psychological barriers • More aggressive treatment required: hospitalization • Current or previous use of opioids • Requires interventional therapy • Beyond current physiological understanding

5. medication overuse headache “Rebound" or excessive medication overuse, toxicity, etc

6. Medication overuse headache The overuse of simple analgesics (Aspirin, acetaminophen, Ibuprofen, Indomethacin, …., etc.), narcotics (Methadone, Tramadole, Hydrocodones, codeine), Ergot derivatives and triptans can lead to this type of headache

7. Medication overuse headacheclinical features Chronic daily headache> 15days/mth Regular intake of drug for >3mths May differ depending on drug being overused: Triptans- daily migrainous headache develops on using triptans for >/= 10days/mth Analgesics- diffuse featureless headache On using opiate or combination analgesics for > /= 10 days/month On using simple analgesics for >/= 15 days /month

8. Medication overuse headache • Headache present on more than 15days/month • Pain is dull, presssing-tightening quality. • It has mild or moderate intensity. • bilateral location is common. • There is no aggravation by walking stairs. • Headache has developed or markedly worsened during substance overuse. • Headache episodes either cease or return to their previous pattern of frequency or intensity within two months of stopping the overused drug..

9. Wrong diagnosis (wrong primary or undetected secondary causes) or • no diagnosis

10. Common misdiagnosis • Chronic Hemicrania, (paroxysmal, continoues) • Low CSF pressure Headache • Cervicogenic headache • Sphenoid sinusitis • Orofacial problems induced headache • Rhinological causes of headache

11. Hemicrania continua • A.Headache for >3 months fulfilling criteria B-D • B. All of the following characteristics • 1.unilateral pain without side shift • 2. daily and continuous, without pain-free periods • 3. moderate intensity, with exacerbations of severe pain • C. At least one of the following autonomic features occurs during exacerbations, ipsilateral to the pain: • 1. conjunctival injection and/or lacrimation • 2. nasal congestion and/orrhinorrhoea • 3. ptosis and/or miosis • D. Complete response to therapeutic doses of indomethacin • E. Not attributed to another disorder

12. Case 1 • A 40 y/o woman, with history of 3 months headache • Pain in Lt periorbital area, Lt eye tearing • Lt nasal congestion • 1-2 attacks a day, with mean duration of 30m. • Nearly fixed time of headaches • Severe • Accompanied by irritability

13. What is the diagnosis? • Paroxysmal hemicrania? • Cluster headache? • Glaucoma? • Sunct?

15. Case 2 • A 39 y/o male with Severe headache for 1 months with progression • occipital headache suddenly after sitting up for 10 mins. Last week： more severe, extended to vertex • Quality：throbbing • No aura, no photophobia, no phonophobia • Nausea, vomiting present

16. PMH: not significant • Family history：not contributory • P/E: T/P/R：36.3C, 80/min, 18/min, BP：134/77 mmHg • Normal systemic exam • Normal Neurological examination

17. Subdural effusion Diffuse dural thickening with enhencement

18. Medication selection is not proper.

19. Fluxetin or Fluvoxamin for Migraine Beta blocker for Cluster headache Indometacin for SUNCT

20. Dosages are not adequate.

21. Non adeuate dosage of Verapamil for Cluster Headache • Non adequate dosage of Propranolol for Migraine Headache • Non adequate dosage of Triptans to abort Migraine Headache

22. Period of time during which an appropriate dose of medicine is administered

23. typically for migraine prophylactic drugs, at least 2 months at optimal or maximum-tolerated dose, unless terminated early due to adverse effects At least 2 weeks, at full drug dose for chronic hemicrania At least 2-3 weeks, at optimal prophylactic drug for Cluster headache

24. Psychological barriers

25. Personality Disorders: the borderline personality disorder( stands above most) the narcissistic personality disorder • Depression • Underlying a family or social problem

26. More aggressive treatment is required: hospitalization, interventions

27. In some patients with Medication Overuse Headache • In some patients with Cluster Headache

28. Requires interventional therapy • Facet Joint Block for Cervicogenic Headache • Epidural Block for Cervicogenic Headache • GON block for chronic migraine or clustrer headache • Sphenopalatin ganglion block for Cluster headache

29. Current or previous use of opioids

30. Beyond current physiological understanding

31. A common case or refractory headache

32. Case 3 • A 43-year-old woman who describes frequent throbbing nauseating hemicranial headaches, lasting several hours in duration, associated with phonophobia and photophobia, but without focal neurological deficits, has been unresponsive to many prophylactic and abortive agents. • Thorough neurological examination, laboratory testing, and brain magnetic resonance imaging have been entirely normal. Diagnosis: Migraine without aura, refractory.

33. ICDH.Proposed Criteria for Definition of Refractory Migraine and Refractory Chronic Migraine

34. Common refractory cases are migrainers.

35. While the prognosis for the majority of patients with migraine is good, approximately 3-14% of episodic migraineurs will progress to chronic daily headache. It is necessary to overcome the headache before its chronification. Then, Central chemical and synaptic circuits changes, Could lead to intractability.

36. How intractability would be prevented? • Identify Medication Misuse and the Behavior That Underlies It.-Not everyone with severe headaches overuses medicines. • Approaching the Cluster B Personality Disorder Patient.-Of the problem patients, the borderline personality disorder patient stands above most. Patients with cluster B personality disorders, such as borderline and narcissistic

37. An adequate trial in this domain should consist of: (1) education on the nature of migraine and the factors that trigger it; (2)use of a diary to identify headache patterns and trigger factors; (3) advice on diet, sleep, exercise, stress management, and trigger avoidance.

38. How intractability would be prevented? (continue) • Trial a Wide Variety of "PRN" Medications That Will Not Cause MOH if Overused. • If the Patient Doesn't Sleep Well, Headaches Won't Be Controlled.-It is very important to induce a normal or near normal sleeping pattern. • Maintain Contact Whenever Possible With Referring and Other Interested Physicians During and at the End of Care.

39. Medicines to Use Acutely That Won't Cause MOH • Hydroxyzine (oral or parenteral) • Baclofen • Tizanidine • Neuroleptics {oral, p.r., parenteral) • Benzodiazepines (oral or parenteral) • Various muscle relaxants, including metaxalone and methocarbamol (which have a central effect)

40. Message of the speech The most common reasons for apparent intractability, diagnostic errors, and inappropriate use of normally effective medicines.