Managing Headache at UW Health: Making a Tough Job Easier

1. Managing Headache at UW Health:Making a Tough Job Easier Nathan J. Rudin, M.D. Associate Professor, Orthopedics and Rehabilitation Medical Director, Pain Treatment and Research Center UW Health

2. Headache: A Worldwide Problem • Up to 25% of American adults have a severe headache each year • Up to 4% have daily or near-daily headache • Lifetime prevalence: 90% or more • Significant suffering and economic loss

3. Headache: A Local Problem • Average visit length: 3.5 hours

4. Barriers To Success • Limited physician training • Limited access to care • Inappropriate or incomplete treatment • Underestimation of morbidity

5. Ambulatory Care Innovation Grant • Funding from UW Medical Foundation • Goal: • Improve pain care referral, triage and utilization across UW Health • First step: • Survey physicians, nurses, and midlevel providers about their comfort with and use of pain management

6. Staff Survey Results • Key areas • Reduce emergency department utilization for non-emergency pain care • Improve pain education for staff at all levels • Improve communication of pain-related information across UW Health • Centralize pain referral and case triage • Improve coordination of perioperative pain care

7. Staff Survey Results • Key areas • Reduce emergency department utilization for non-emergency pain care • Improve pain education for staff at all levels • Improve communication of pain-related information across UW Health • Centralize pain referral and case triage • Improve coordination of perioperative pain care

8. Goals 2006 – 2007 • Familiarize primary care and emergency room providers with basic headache management • Educate patients • Standardize treatment protocols • Standardize communication of headache care plans • Incorporate care plans, protocols and educational tools into EMR

9. Provider Toolkit • Video on Headache Care Basics (DVD and online) • Introductory article on headache • Headache diagnostic classification • Madison citywide headache treatment guidelines • Headache treatment plan form • Headache Clinic consult request form downloadable from uconnect and uwhealth.org

10. Headache Treatment Guidelines • Developed by panel of specialists • Provides a framework for headache treatment, particularly migraine uconnect: Clinical Guidelines / Pain Management Resources

11. Headache Treatment Plan • Outline patient’s individual treatment plan • One copy scanned into EMR • Copy 2 – give to patient Standard Register #SR300078

12. When To Call The Headache Clinic? • Refractory headache • Unclear diagnosis • Intensive and/or interdisciplinary treatment needed 608-263-9550 Consult Form – Standard Register #SR300077

13. Patient Toolkit • Video on Headache Basics (DVD and online) • Introductory letter • Headache Diary • Health Facts • Migraine; Medication Overuse Headache; Diet and Headache; Avoiding the ED downloadable from uconnect and uwhealth.org

14. Headache Diary • Patient fills this out daily • Brings to clinic visit • Lets you evaluate headache pattern and treatment effects Standard Register #SR300079

15. Basic Principles • Rule out potentially dangerous (secondary) headache • Neoplasm, infection, hemorrhage, etc. • Thorough history and physical • Diagnose headache type • Implement treatment • Monitor outcome

16. Secondary Headache Disorders • <2% of headaches in primary care offices • Head trauma • Vascular disease • Neoplasms • Substance abuse or withdrawal • Infection/Inflammation • Metabolic disorders • others

17. “Warning Signs” • first or worst HA (“thunderclap headache”) • progressive or new daily persistent HA • age >50 or <5 years • HA associated with fever, rash, stiff neck • HA associated with abnormal mental status or abnormal neuro exam

18. “Warning Signs” • HA associated with papilledema • new HA in patient with h/o malignancy, immunosuppression/HIV, pregnancy • awakening because of HA • HA with Valsalva or exertion

19. Primary Headache • Intrinsic dysfunction of the nervous system • Most patients presenting to PCP with headache have primary headache syndromes • Episodic headache: more common • Chronic headache: attacks occurring more frequently than 15 days/month for more than 6 months

20. Diagnostic Steps • Rule out secondary headache • Thorough history • Neurological and musculoskeletal examinations • Imaging, blood work and/or CSF analysis if “red flag(s)” found • Diagnose headache type • Identify comorbid illnesses

21. Headache History • Area of head involved • Pain quality • Pain severity • Other symptoms (nausea, vomiting, light sensitivity) • Triggers • Timing (including perimenstrual) • Pre-headache warning symptoms (“aura”) – for example, visual changes

22. Migraine Pathophysiology • Migraine is a brain disorder • Brain becomes hypersensitive and overly responsive to stimuli • The trigeminal nerve appears to be a key pathway

23. Migraine Cascade • Vasoactive substances inflame vascular and meningeal tissue, activate trigeminal axons • Perivascular release of vasoactive neuropeptides; spreading neurogenic inflammation

24. Migraine Cascade • Pain signals reach trigeminal nucleus caudalis and other pain systems • Dorsal raphe nucleus may modulate migraine pain • The inflammatory response spreads along the trigeminovascular system

25. Migraine • Episodic, progressive head pain • Pulsating, throbbing, stabbing • Attacks: 4-72 hours • Unilateral in 60% • Up to 75% may have neck pain

26. Migraine • 3 : 1 female : male • 6% of males, 18% of females, 4% of children • Family history + in 80-90% • Onset typically during adolescence or young adulthood • Onset after age 40 possible

27. Migraine Triggers • Hormonal fluctuations • Perimenstrual migraine very common • Weather changes • Diet, including missed meals • Stress

28. Migraine Subtypes • Migraine with aura (20%) • Neurologic event precedes migraine (usually by 30-60 minutes) • Visual, auditory, olfactory disturbances • Migraine without aura • No aura or other warning symptoms • Chronic migraine

29. Chronic Migraine • Starts as episodic migraine • Attacks occur at increasing frequency • Eventually 15+ attacks/month • Frequent association with medication overuse • Psych comorbidity common

30. Medication Overuse Headache • Persistent, recurring headache in the setting of regular analgesic use • Continues until medication is stopped • Often responsible for “transformation” of episodic into chronic headache Ingredients: Succinic acid, fumaric acid, dextrose and bioflavonoids

31. Overuse Headache: Features • Short-acting analgesic use more than 2-3 times/week • Headaches become predictable, more frequent, even continuous • Medications no longer prevent headaches

32. Common Culprits • Analgesics, especially short- or intermediate-acting • Opioids • NSAIDs including acetaminophen • Combination analgesics • Caffeine • Triptans • Hormones: OCPs, others

33. Tension-Type Headache • Episodic or chronic; possible migraine variant • Episodic form affects up to 38% of US adults annually • Less disability and morbidity than migraine, so less seen by MDs

34. Tension-Type Headache • “Bandlike” • Bilateral: frontal, temporoparietal • Referred (myofascial) pain from neck to head • Neck structures may contribute to pain (“cervicogenic headache”)

35. Cluster Headache • Rare disorder • M:F 3:1; genetic predisposition • Cycles/clusters lasting weeks to months • Repetitive headaches during a cluster • 1-3 hours apiece; always unilateral • Focal facial and eye pain, lacrimation, rhinorrhea • Often occur when sleeping or napping

36. Cluster Headache • “CH face”: leonine face, furrowed and thickened skin with prominent folds, a broad chin, vertical forehead creases, and nasal telangiectasias. • Typically tall and rugged-looking

37. Chronic Daily Headache • Chronic migraine • Chronic tension-type headache • New daily, persistent headache • Generally poor prognosis • Hemicrania continua • Unilateral, persistent • Some migraine features; head trauma in 20%

38. Treatment: Define Goals • Patient’s goals • Pain relief; medication; ? improved function • Your goals • Pain relief or reduction; improved function; appropriate medication use • Bring goals into congruence

39. Treatment Plan • Preventive therapy • Abortive therapy • Pre-emptive therapy • Short-term to prevent anticipated headache • Urgent (“rescue”) therapy • Minimize or eliminate where possible

40. Non-Drug Treatment • Learn appropriate prevention and treatment • Avoid headache triggers: foods, drugs, activities • Avoid frequent abortive treatment • Stop smoking • Normalize sleeping and eating • Exercise • Relaxation and biofeedback • Psychotherapy

41. Rehabilitation • Treat postural dysfunction and myofascial pain • Relaxation training • Physical therapy • Reduce spasm • Improve posture • Reduce triggers/perpetuating factors

42. Eliminate Overuse Headache • Taper and stop offending agents • Severe headache invariably results • Supportive treatment: hydration, antiemetics, anti-withdrawal agents if needed • Initiate preventive therapy as taper begins • Initiate nondrug therapies • Add abortive therapy once withdrawal headache passes

43. Migraine: Preventive Treatment • Tricyclic antidepressants – first-line • Amitripyline, doxepin if sleep is disturbed • Beta-blockers – first-line • Atenolol, nadolol • Ca++ channel blockers – less effective • Verapamil most commonly used

44. Migraine: Preventive Treatment • Anticonvulsants – second-line; valuable • Valproate and topiramate are quite effective • Gabapentin – best tolerated, ? effect • Lamotrigine, levetiracetam – no good data as yet • Pregabalin – may help (anecdotal) • Psychotropic effects may be useful

45. Migraine: Preventive Treatment • Ergots: Rarely used for prevention • Side effects may be problematic • Methysergide: fibrosis (use 6 months max) • MAOIs: Can be very effective • Tyramine-free diet a must • Numerous drug interactions

46. Migraine: Abortive Treatment • Simple and combined analgesics • APAP, NSAIDs, others • Mixed analgesics (barbiturate plus simple analgesics) – avoid wherever possible • Ergot derivatives • Triptans • Opioids

47. Triptans • Serotonin 5-HT1 agonists • Reduce neurogenic inflammation • Most effective if used at onset of headache or aura, though may be helpful at other phases • Used specifically for migraine • For nonresponders, try ergots (also act on NE, DA, other receptors)

48. Triptans • Generally well tolerated • Contraindications: • Uncontrolled hypertension • CAD, PVD, cerebrovascular disease • Pregnancy • MAOIs • High-dose SSRIs, tramadol (rare interaction) • Ergotamine or other triptan use within 24 hrs

49. Triptans • Short-acting • Sumatriptan, almotriptan, rizatriptan, zolmitriptan, eletriptan • Longer half-lives • Naratriptan, frovatriptan • Successive trials may be needed to determine the best triptan for a given patient

50. DHE • Nasal spray • Administer each nostril, may repeat in 15 minutes • Works best if taken early • Longer half-life than sumatriptan, though not as reliable for some patients • Injection • 1 mg can be given SQ or IM • Max dose: 3 mg/24 hours