Pearls and Pitfalls of Headache Management

1. Pearls and Pitfalls of Headache Management Georgann S. Dickey MS, ANP-C MMP-Neurology 49 Spring Street Scarborough, ME

2. Some Numbers • Among adults of all ages, migraine is 19 in top causes of disability and over 10% of population suffers from migraine (more than asthma and diabetes combined) • Migraine is the least publicly funded of all neurological illnesses relative to its economic impact • 18% of American women and 6% of men suffer with migraine • Most common during peak productive years 25-55 • 14 million or 4 % have chronic daily headache • Migraine tends to run in families: 40% chance a child will suffer with migraine if 1 parent has migraine and 90% if both parents Migraine Research Foundation, Cephalalgia Sept. 2007

3. Prevalence in U.S. Population

4. Two Major Questions: • Primary vs. Secondary Headache? • If Primary, can we classify the headache type and (hopefully) thereby offer the most appropriate therapy?

5. International Headache Society Classification 2012, 2nd edition • Primary Headache -Tension type headache -Migraine -Cluster -Other primary headaches • Secondary Headache attributed to: -Head and neck trauma -Cranial or cervical vascular disorder -Non-vascular intracranial disorder -A substance or its withdrawal -Infection -Disturbance of homeostasis -Psychiatric disorder -Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures Cranial Neuralgias and other Facial pain ihs-classification.org

6. Cranial and Cervical Pain-Sensitive Structures • Bone/Periostium • Skin • Muscle/Tendon/Ligament • Joints – Cervical, TMJ • Blood Vessels – Large Arteries, Venous Sinuses • Meninges • Cranial Nerves • Air Sinuses, Teeth, Ocular • Brain itself insensate – role of central sensitization

7. Cranial & Cervical Nerves • Trigeminal Nerve – anterior 2/3 of head, supratentorial meninges & blood vessels • C2 – posterior 1/3 of head, meninges & vessels of posterior fossa • IX, X – pharynx, +/- meninges – referred pain from vagal-innervated structures • Infarction/inflammation/compression of any nerve

9. DIAGNOSIS is in the HISTORY • Timeframe – overall syndrome and acute attacks • Stereotypy • Frequency of attacks • Location, radiation of pain • Quality of pain – dull, sharp, throbbing, pressure • Associated sx – N/V, photophobia, phonophobia, autonomic phenomena, altered cognition, visual changes, focal neurologic • Mitigating factors – Valsalva, bend over, recumbent • Recent fever, other illness, nasal discharge

10. WHY IS THE TIME COURSE IMPORTANT? • The time course is the primary clue to the PATHOPHYSIOLOGY of the disorder • Determine the time course of the onset, progression and improvement of each symptom independently

11. Headache History 2 - Triggers • Hormonal • Medications • Sleep – too much, too little • Stress – too much, too little • Cough, exercise, sexual activity • Food or lack thereof • Light, odor, noise • Weather changes • Caffeine, Alcohol, Illicit drugs

12. Headache History 3 – Biopsychosocial • General Medical History • History of head/neck trauma or CNS infection • History of affective problems • History of physical, emotional, sexual abuse • Emotional profile – current life stressors • Sleep habits • Effect on work and home life – missed days • Family History • Overall lifestyle – exercise, diet, tobacco

13. Headache History 4 – Prior Evaluations & Therapy • Previous diagnosis(es) • Imaging – if already done, yield on repeat low • Other studies – Bloods, LP, special • Prior medications – efficacy, side-effects • Current medications – question carefully about analgesic use/overuse (OTC’s), BCP, herbs, dietary supplements • Prior non-pharmacologic treatment(s)

14. Physical Examination • Vital Signs • Cardiovascular – carotid/cranial bruits, palpation • Range of motion – cervical spine, TMJ’s • Palpation – cervical/upper/cranial musculature, bones, sinuses • Signs of trauma • Good neurologic exam with emphasis on cranial nerves

15. Red Flags - ? Secondary Headache • Abnormal level of alertness, focal neurologic signs +/- sx • Underlying illness – Cancer, HIV, immunosuppressed • Fever, nuchal rigidity, rash • New headache in older patients • Paroxysmal onset • ? First/worst ever • Steadily progressive or refractory to usual treatments • Change in longstanding pattern or character • Certain triggers – positional, cough, strain • Persistent unilateral or focal pain

16. Testing - Serum • CBC, diff, plts, ESR/CRP • Electrolytes, LFT’s • Hormonal • Drug Screen • Lyme • HIV • Autoimmune • Pregnancy

17. What Might Standard Imaging (CT, MRI) Demonstrate or Miss ? Usually Apparent Space-occupying intraparenchymal Hydrocephalus Skull, soft tissue Sinus disease Congenital structural Acute blood Might Miss Meningitic process SAH Vascular problems –small or large vessel Aneurysm/AVM Dissection Vasculitis Cranial Nerve Pathology

18. Should I Obtain a CT or an MRI ? CT Advantages • Cost, availability • Speed • Cooperation, movement • Bone, acute Blood • Hardware, Pacemakers • Habitus MRI Advantages • Far greater detail • No beam artifact – posterior fossa • Better view vessels • Patient worry factors

19. Should I Order the Scan With or Without Contrast (Gadolinium)? • Contrast generally stays in vessels unless there is a breakdown in the blood-brain barrier • Generally, any intraparenchymal tumor large enough to cause headache will be visible without contrast • May or may not enhance meninges with inflammatory, infectious, or neoplastic processes • Often good for evaluating extra-axial structures – nerves, sinuses, bone, etc. • Adds significantly to cost • Potential morbidity

20. Vascular Imaging • Lesions: Aneurysm AVM Dissection Vasculitis Venous Sinus Thrombosis • MRA • MRV • Arteriography • Ultrasonography

21. Lumbar Puncture • Infection • Neoplastic • Inflammatory • For RBC’s if suspicion of SAH and imaging negative • Pressure measurement – proper positioning!

22. Don’t perform neuroimaging studies in patients with stable headache that meet criteria for Migraine • Don’t perform CT imaging for headache when MRI is available, except in emergency settings • Don’t recommend surgical deactivation of migraine trigger points outside of a clinical trial • Don’t prescribe opioid or butabital containing medications as first line treatment for recurrent headache disorders • Don’t recommend prolonged or frequent use of OTC pain medications for headache Choosing Wisely 5 Things Migraine and Headache Patients and Health Care Providers Should Know American Headache Society 2014

23. Tension – Type Headache • Poorly – defined and understood. Most common headache type. May have some migrainous features. ? Part of a continuum rather than separate entity. • May be episodic or chronic. • May co-exist with clearly migrainous headache • Short or long duration • Usually, but not always, bilateral. Frontal, temporal, occipital, over maxillary region • Mild to moderate – usually not disabling • Pain often described as tightness or pressure • Usually no migrainous accompaniments • May or may not have significant pericranial/cervical muscular tenderness • May or may not respond to triptans • Overall treatment options similar to migraine but often does not respond well to pharmacotherapy, especially if chronic/frequent

24. Migraine - Diagnosis • Commonly misdiagnosed – “sinus”, stress,“cluster”, etc. • Many subtypes – with/without aura, aura without migraine, “basilar”, hemiplegic, abdominal, etc. • Criteria (migraine without aura) - ICHD A. At least 5 attacks fulfilling criteria B-D B. 4 – 72 hours duration C. 2 of the following characteristics: 1. Unilateral location 2. Pulsating quality 3. Moderate or severe intensity 4. Aggravation by physical activity D. During headache at least one of the following: 1. Nausea and/or vomiting 2. Photophobia and phonophobia E. Not attributed to another disorder • These are not absolute, and many patients who do not fulfill them all probably have migraine

25. Migraine – Key Clinical Features • Genetic and environmental influences • Can clearly be triggered or exacerbated by sequelae of secondary headache causes • 3:1 female: male ratio in adults - role of hormones • Usual onset before 30 but any decade possible • May be divided into prodrome, aura, headache, postdrome with possibility of significant overlap • Aura - visual, motor, sensory, cognitive/emotive, brainstem autonomic. Usually progressive over minutes but may be paroxysmal. Duration variable but usually short. DDx of aura = ischemia vs. epileptiform

26. Chronic Daily Headache –“Transformational Migraine” • Mostly female • Intermittent migraine by age 20-30 years • Slowly increased frequency over time • Progression to constant background headache with variable frequency of migrainous exacerbations • Marked reduction in quality of life • High incidence of co morbidity: sleep disturbance; depression/anxiety; family history of headache; history of abuse; fibromyalgia or chronic neck/upper back muscular pain. • Analgesic overuse very common

27. Multi-faceted approach • Education about disorder (handouts, website resources) • Self-management strategies (exercise, regular food/fluids, trigger avoidance) • Acute care therapies • Preventive pharmacotherapy • Non-medication treatments • Treatment of co morbid disorders such as anxiety and depression • Positive message and realistic expectations

28. Lifestyle management • Nutrition, sleep, fluids • Reasonable avoidance of triggers • Exercise • Headache calendar/log • Tobacco cessation • Limit caffeine to 12-16 oz per day • Limit alcohol to 2 drinks per day or less • Weight loss

29. Key points if too many headaches • At risk for disability • At risk for decrements in quality of life • At risk for analgesic overuse • Worthy of targeted treatment ? YES!

30. When to Choose Migraine/ Headache Prophylaxis • Headache frequency (> 2 days per week), but no set criteria • Degree and frequency of migraine-related disability • Amount of prescription and OTC medications used • Presence of concomitant disorders (e.g., depression) • Willingness and ability to comply with daily medication prescribed • Success or failure of non-drug prophylactic therapies • Special circumstances • Preference

31. The Need for Prevention • Currently underused, headache population underserved. 25% of migraine sufferers could benefit but only 3-13% receive it. • Factor may be patient unawareness • Lack of familiarity with process by health care providers • Benefits: reduce frequency, duration and severity of individual headache events, improved responsiveness to acute treatments Headache 2014; 54: 364-369

32. Treatment selection • FDA approved should be considered first • Medication and dosage selection dictated by specific features of the individual • Whether FDA approved or not, discuss and document rationale for use and selection • Collaborate with patient, be creative, artful in approach and guide patient from misinformation • MUST TREAT COMORBID DISORDERS (sleep, obesity, anxiety, depression)

33. Treatment Selection Level A: >2 Class I trials Level B: 1 Class I or 2 Class 2 trials • Divalproex sodium (Depakote) • Topiramate (Topamax) • Metoprolol (Lopressor) • Propranolol (Inderal) • Timolol • Amitriptyline (Elavil) • Venlafaxine (Effexor) • Atenolol • Nadolol Level C: 1 Class II trial Lisinopril Candesartan Clonidine Carbamazepine (Tegretol) Cyproheptadine (Periactin) Frovatriptan, naratriptan and zolmitriptan have Class I studies for short term prevention of menstrually associated migraine American Headache Society/AAN guideline: Neurology 2012;78: 1337-1345

34. NSADS &Complementary Treatments • Butterbur (Level A) • Vitamin B2/Riboflavin (Level B) • Magnesium (Level B) • Feverfew / MIG-99 (Level B) • NSAIDS (Level B) • Coenzyme Q10 (Level C) • Combo soy isoflavones, dong quai and black cohosh (1 class II study +) • Percutaneous estradiol (1 class II study +) • Alpha Lipoic Acid • Vitamin E • Ginko Biloba with coenzyme Q10 and B2 Headache. 2013; 53(3)459-473

35. Successful treatment • Start with low dose and increase slowly (every week) • Use an adequate trial of 2-3 months • Avoid medication interactions or contraindications • Monitor with calendar or diary: encourages active participation and helpful to identify pattern, triggers • Monitor for medication overuse • Consider comorbid conditions • Consider combination medication in refractory patients • Taper when headaches are controlled.

36. Abortive Medications for Migraine • NSAIDs • Acetaminophen • Opioids • Barbiturate – containing compounds (Fioricet) • Midrin • Ergotamine drugs including DHE – 45 • Triptans use early in H/A, repeat dose prn, try all seven if necessary • Multiple routes: Oral, intranasal, rectal, IM, IV • Adjuvant drugs for nausea/vomiting • Analgesic overuse - “rebound” headache

37. Non-pharmacologic Therapies Physical Treatments Acupuncture Transcutaneous electrical nerve stimulation (TENS) Occlusal adjustment Cervical manipulation Electrical stimulation of occipital nerve Yoga Cranial sacral therapy • Behavioral Treatments • Relaxation training • Hypnotherapy • Thermal biofeedback training • Electromyographic biofeedback therapy • Cognitive / behavioral management therapy

39. Nerve Blocks and Stimulation • Local anesthetic blockage • Specific nerve blocks Greater and lesser occipital nerves Auriculotemporal nerve Supraorbital and supratrochlear nerves Infraorbital nerve Sphenopalatine nerve • Facet injections and root blocks • Occipital nerve and upper cervical root stimulation

40. Chronic Daily Headache - Treatment • Lifestyle - exercise • Psychiatric as needed • Biofeedback • Botox—FDA approved for chronic migraine • Detox from analgesic use. Slow taper, over weeks to months, with realization that improvement may lag discontinuation • Preventive meds – try antidepressants as first line • Judicious use of analgesics (preferably triptans) as acute abortive therapy • Regular office follow-up, especially if tapering. Use of calendar to document exact analgesic doses. • Avoid temptation to use chronic opioid therapy

42. Resources • National Headache Foundation: www. headaches.org or toll free at (888) NHF-5552 • American Headache Society: www.achenet.org • Migraine Awareness Group: www.migraines.org • Cephalalgia (Journal) • Headache (Journal)

44. My colleagues input • Repeat imaging in chronic headache rarely useful, wastes resources • Do not miss impact of musculoskeletal problems • Lack of mental health biggest barrier to success • Distraction underutilized—hobbies or some purpose in life • Relaxation and yoga can truly be helpful • Attention to sleep and treatment of insomnia • Abuse history needs to be reviewed; Psychosocial has big impact • Look for sleep apnea, sinus/allergies, vision problems, mood, medications as cause of HA • Do not give up too quickly on a drug as a failure—use highest tolerated dose for 2-3 months • Ask carefully about OTC use and r/o drug rebound HA with a 2-4 week drug free period before sending to specialist • Manage patient expectations, there is no promise of complete remission

45. Newer Treatments • Cefaly: TENS headband that stimulates branches of the trigeminal nerve. Once a day for 20 minutes used as preventive • Topamax now FDA approved in Headache in those ages 12-17 • In the pipeline: calcitonin gene-related peptide antagonists are effective to treat migraine attacks (does not cause vasoconstriction, making it safer for those who cannot use triptans) Telcagepant

46. Case Study 1: AW • 22 yr. old female referred by optometrist because of papilledema on routine eye exam • Headaches since age 17 • Mild at onset with quick worsening, associated with nausea, dizziness, mild photophobia, neck pain, left eye blurry. • Uses Exedrin Migraine 1 pill q 6 hrs, reduces from 10-2 and upon awakening is gone. • 4-5X a week, but now 2-3 X a week, triggered by stress, menses • FH of migraine • On OCP, Loratadine

47. AW • BMI 42.2, B/P 140/70, P 76 • Neuro exam normal except for fundoscopic exam • What is the differential? • What testing do you want completed? • What treatments ?

48. Idiopathic Intracranial Hypertension • Typically young overweight females • Headache, transient visual loss, tinnitus, etc. • Exam: papilledema; o/w nl (rarely, CN VI paresis) • W/U: MRI, MRV LP to exclude other causes • Treatment: Weight loss, acetazolamide, topamax, shunting. Careful follow-up of funduscopic exam and visual fields

49. AW Test results • Opening pressure with LP 39 (norm is 20 or <) • Started on Topamax as preventive for migraine and will help with pseudotumor cerebri • Brain MRI with possible partially empty sella • Visual field testing • Additional counseling? • Monitor response to treatment and will need recurrent eye exams Surgical treatments can include optic nerve fenestration and VP shunt

50. Case Study II: NC • 41 year old female describes 2 different types of headache • Severe HA with nausea, photophobia, phonophobia, dizziness, decreased concentration, rare vomiting, blurred vision, 1-3 times per week for several weeks at a time 10/10 • Daily headache with bitemporal pain, irritability 3-6/10 • Family history of migraine both parents • Uses Ambien for sleep, on Wellbutrin, Xanax, Proair HFA, Flovent, Maxalt, Fioricet, Hydrocodone, Tylenol • Exam is normal, BMI 21.9, B/P 114/72