Maryam Rahimi, M.D. University of California Irvine

Objective Identify patient who need urgent evaluation and treatment Review red flags Primary headache Secondary headache Acute treatment Prophylactic treatment Menstrual headache Effective communication with patients

19 yr old college student with c/o headache, has called the office asking for pain medication. In high school, he used to take his mom’s headache medications, what is your recommendation? 1) have him take an Aspirin and call back if no improvement 2) have the nurse call and find out name of mom’s pain med 3) have the patient come in the next available appt, in 2-3 day 4) obtain more information

He has been up studying for exam all night now he has neck stiffness, feels tired and can not concentrate, he feels warm, there is no AC at his dorm

Meningitis Triad of: Nuchal rigidity ( 88%), sudden high fever of 38 degree( 95%) altered mental status, confusion, lethargy(78%) Triad present in 44-46% of cases 99% of cases have at least one of the 3 Absence of the 3 excludes meningitis

45 year old presents with sudden onset sever explosive headache, worst headache of his life

Thunderclap headache Sever, sudden, explosive, unexpected Similar to clap of thunder Maybe associated with brief loss of conscious May have Nausea, vomiting, meningismus Exacerbated by physical exertion

What is the first step in evaluation of patient who present with thunderclap headache? 1) call neurology 2) CT without contrast 3) CT with contrast 4) MRI

Computed Tomography CT without contrast To confirm or exclude bleeding Fast, easy, available and cost effective If negative CT  Lumbar puncture

72 yr old female was brought in by her family, reporting that she is acting depressed, has lost weight due to not eating, can not sleep at night, looks tired during the day, and complaining of headache. 1- Treat depression with amitriptyline, it will also help her headache 2- Prescribe mirtazepine to help her sleep, it may improve appetite 3- complete history and exam, check blood test including CBC, Sed rate, CRP

Temporal Arteritis Age 50 ( mean age onset 72) Temporal headache that can wax and wane Abrupt onset of visual disturbance Systemic symptoms of fever, fatigue, weight loss, joint pain, jaw claudication, morning stiffness Delay in treatment can cause permanent loss of vision

Red flags Worst headache/ thunderclap Focal neurological deficit( not typical aura) Sudden onset, and rapid progression Triggered by cough, exertion or sexual intercourse Change of mental status or level of consciousness Meningismus New onset headache after age 50 Papilledema New headache in patient with cancer, HIV, immunodeficiency Tenderness over temporal artery Systemic illness ( fever, rash, weight loss) Illicit drug abuse( cocaine, methamphetamine,…) Carbon monoxide poisoning

Among patient with headache, normal neurological exam, and no hx of cancer, prevalence of tumor is very low Among patient with known malignancy, who present with headache, prevalence of brain metastasis as the cause of headache is high ( Lung, breast, melanoma, kidney, GI)

21 yr old female present to establish care, she has no complaints, medication list includes daily Ibuprofen for headache and ROS positive for heavy menstrual cycle 1- No further action, continue ibuprofen 2- Add triptans 3- Perform complete history, physical and check lab including CBC

Primary headache The headache is the disease No abnormal brain lesion Treat the headache Goal is pain relief and prevention of recurrence

Secondary headache The headache is only a symptom of another underlying disease Treat the underlying disease Secondary headache will not improve unless the underlying disease is treated

Secondary headaches Head and neck trauma Cranial or cervical vascular disorder Cranial tumor Substance abuse Withdrawal Infection Psychiatric disorders Systemic disease ( anemia, hypoglycemia, dehydration) Facial or cranial disorders( eyes, ears, sinuses, teeth, mouth, trigeminal neuralgia)

History Quality, characteristics Duration Associated symptoms Previous history of similar headache Family history Medication use

Primary headaches Tension Migraine Cluster

Cluster Headache Excruciating pain Unilateral Conjunctival injection Lacrimation Episodic Last 15 min to 3 hours Recur at the same time of the day More often at night More common in men

Triggers for cluster headache Hypoxia Sleep apnea Vasodilators ( NTG, alcohol, carbon dioxide)

Treatment of cluster headache Oxygen 7L per minute for 15 minutes face mask Sumatriptan 6 mg subcutaneously

Tension headache Most common type of headache Tightness, pressure, dull ache Band like Bilateral From forehead to the occiput Can radiate to neck Usually does not limit daily activities Absence of red flags

Evaluation of Tension headache History Exam ( vitals, neurological exam, including the cranial nerves, cerebellar function,, visual field, fundoscopic exam, motor and sensory exam, cervical neck exam, temporal exam) In the absence of red flags in history and physical no neurological imaging is needed

25 yr old patient present with c/o headache, band like sensation that increases when he is stressed at work, 1 or 2 x month. H& P does not reveal any red flag sign or symptoms. What is the next step? 1- Treat tension headache with NSAIDs 2- Life style modification to prevent headache 3- Patient education to prevent rebound headache 4- all of the above

Tension headaches can be due to tightened muscles in the back of the neck and scalp Inadequate rest. Poor posture. Emotional or mental stress, including depression. Anxiety. Fatigue. Hunger. Overexertion.

Relaxation therapies / hypnosis / biofeedback Dietary monitoring for triggers and elimination of caffeine Improving sleep habits Daily exercise Cognitive-behavioral therapy – This is talk therapy with a trained counselor, designed to identify stressors and develop coping strategies to minimize their effect on behavior. Counseling and treatment for depression and/or anxiety

Treatment of tension headache OTC analgesics including Acetaminophen ( mg) NSAIDs Ibuprofen mg, naproxen mg Sedating antihistamine, diphenhydramine Anti emetic ( metchlopramide 10 mg tablet) Sever tension headache in the office: Ketorolac mg IM

35 yr old patient with previous hx of tension headache, used to get headache 1-2 x month, now having more frequent headache, has been taking OTC pain meds 3 days a week with resolution of pain. ( no red flags) 1- No further action, continue OTC pain meds 2- Needs to have MRI since headache frequency has increased 3- Consider preventive/ prophylactic medication

Rebound headache Using pain medication more than twice per week increases the risk of rebound headache

Preventive medication for tension headache When pain medications are used more than twice a week When treatment is not effective in reducing headache When treatment is causing other side effects Patient preference

Prevention of tension headache Eliminate the cause ( life style modification, stress reduction, improve sleep hygiene) Amitriptyline is the most common prophylactic medication used for tension headache mg tablet 1-2 hr before bed time, tricyclic antidepressant, with anticholinergic side effects

Selective serotonin reuptake inhibitor (SSRIs) Fluoxetine ( Prozac) 20 mg tablet in the morning May take up to two months before benefits are seen

26 yr old who had been taking ibuprofen for headache 6 x week, comes in asking for help to treat his rebound headache 1- Gradually reduce dosage of ibuprofen 2- Stop ibuprofen and give him an opiate for pain control 3- Stop ibuprofen and inform him that it will take up to 2 weeks before rebound headache are resolved

Sign and symptoms of withdrawal from pain medications Nervousness Restless Headache Nausea and vomiting Insomnia Diarrhea Tremor

POUND Pulsatile quality, with the headache described as “pounding” or “throbbing.” One-day duration, with episodes lasting four to 72 hours if untreated. Unilateral location. Nausea or vomiting. Disabling intensity, with patients having to alter their daily activities during episodes.

Migraine with Aura Aura is a focal neurological symptoms most are visual 1 out of 8 migraine patients will have aura Last 5-20 minutes ( less than 60 minutes) Followed or accompanied with headache

Migraine with aura blind spots or scotomas blindness in half of your visual field in one or both eyes (hemianopsia) seeing zigzag patterns (fortification) seeing flashing lights (scintilla) feeling prickling skin (paresthesia) weakness seeing things that aren't really there (hallucinations)

Hemiplegic migraine Temporary paralysis or numbness on one side off the body Dizziness Visual disturbance Memory impairment Language disturbance

25 year old female with hx of migraine with aura 1- She should be treated with oral contraceptive to prevent migraine 2- Taking oral contraceptives will increase her risk of stroke

Migraine with Aura is a risk factor for stroke Should not smoke Should not use oral contraceptive

Treatment of Migraine Patient education Motivate them to participate in prevention and treatment Select effective medication with lowest side effect Advise and educate against medication overuse

30 yr old patient with unilateral pounding headache, associated with nausea & photophobia, ( no red flags) she has not tried any medication, what is your recommendation 1- Over the counter Aspirin (what dosage) 2- Excedrin 3- Imitrex

Treatment option for migraine Aspirin mg Ibuprofen mg Naproxen mg Acetaminophen, Aspirin, Caffeine, 250mg-250mg- 65mg Indomethacin 50 mg suppository Consider addition of antiemetic Triptans Ergot

Antiemetic Phenergan 25 mg, Compazine 5 mg, Reglan 10 mg Dopamine agonist Can cause dystonia Can cause QT prolongation

Which one of the following medications are safe during pregnancy for treatment of migraine 1- Triptans 2- Acetaminophen 3- Codene 4-NSAIDS 5- choice 2 & 3

The triptans are class C, and should be avoided during pregnancy, as should ergots (class X rating).

Migraine in pregnancy Consider no pharmacological treatment Acetaminophen, NSAIDs, codeine or other narcotics Avoid NSAIDs during the late third trimester( bleeding and premature closure of the ductus arteriosus.) Avoid prescribing narcotics in the late third trimester. These could cause neonatal withdrawal symptoms.

Keep in mind Triptans are contraindicated in patients Coronary artery disease Ischemic stroke Uncontrolled hypertension Hemiplegic or basilar migraine. Pregnancy

Triptans Sumatriptan (Imitrex, Treximet) Rizatriptan (Maxalt) Zolmitriptan (Zomig) Eletriptan (Relpax) Naratriptan (Amerge) Frovatriptan ( Frova)

Triptan side effects Injection site reaction Chest pressure heaviness Flushing, weakness, drowsiness Paresthesia

Sumatriptan / Imitrex Most option for route of delivery Subcutaneous, oral, nasal Subcutaneous 6 mg x one, can be repeated in one hour if some response to the first injection Maximum dosage in 24 hr is 12 mg available in 4- and 6-mg single-dose prefilled syringe cartridges

Sumatriptan nasal spray 5 mg or 20 mg in single spray Can give 5 mg in each nostril ( 10 mg) If pain has not resolved or returns, can repeat a 2 nd dosage in two hours Maximum dosage is 40 mg in 24 hr

Sumatriptan tablet mg tablet Take one at the onset of the headache or aura Can repeat in 2 hours Maximum dosage is 200 mg in 24 hours

Treximet Sumatriptan 85 mg + naproxen 500 mg More effective than either agent as monotherapy

Rizatrptan ( Maxalt) Fastest onset of action 5 mg – 10 mg tablet Disintegrating Maximum dosage 30 mg in 24 hr Dosage can be repeated in 2 hr if needed

Frovatriptan ( Frova) 2.5 mg tablet Can be used for prevention of menstrual migraine Start two days before the onset and continue for 5-7 days

Naratriptan Slowest onset of action Lowes side effects

Menstrual Migraine Migraine headache that occurs in close temporal relationship to the menstrual cycle Due to decline in estrogen level Natural cyclic decline of estrogen Withdrawal of estrogen containing medication( placebo pills in BCP)

Menstrual migraine More sever Last longer Less responsive to treatment

Acute treatment of Menstrual migraine Similar to migraine NSAIDS, mefenamic acid 500 mg tablet Anti emetics ( metchlopramide) Triptans

Prophylactic treatment of menstrual migraine Naproxen 550 mg bid 7 days before start of menstruation & continue for days Frovatriptan 2.5 mg /day start 2 days before & continue for 5-6 days Avoid decline of estrogen

Patient with natural cycle, use estrogen patch 0.1 mg/ 24 hr, start at the onset of bleeding for 5-7 days Patient using combination estrogen/ progesterone pills ( day 1-21), add supplement estrogen 0.9 mg conjugated estrogen day Combination estrogen progesterone pills continually and avoid the placebo pill for 90 days

Migraine prophylaxis For patients with more than 4 acute attacks per month Headaches that last more than 12 hours Headaches that causes significant morbidity For patients who can not tolerate side effects of acute treatment Patents who can not take triptans

Beta blockers Propranolol mg / 24 hrs ( 20 mg bid) Metoprolol mg/ 24 hrs ( 50 mg bid) Timolol mg/ 24 hrs Start at a low dosage and titrate up Continue for 3 months before consider medication failure Inform patient and monitor for side effects ( hypotension, bradycardia, erectile dysfunction) 2012 guidelines American Academy of Neurology

Calcium channel blockers Verapamil mg a day Most common medication used for migraine prophylaxis Low side effect profile However tolerance can develop / dosage can be increased

Amitriptyline mg at bed time Tricyclic antidepressant Constipation, dry mouth, tachycardia, weight gain, somnolence, urinary retention, confusion

Anticonvulsants Valporate mg a day Side effects :Nausea, somnolence, tremor, dizziness, weight gain, hair loss) Topiramate mg bid Side effects: paresthesia,, weight loss, fatigue, diarrhea, memory or language problem Not to be used during pregnancy

Patient with hx of migraine headaches, reports no headache in the past 12 months, while taking prophylactic medication, what is next stop? 1- continue same meds 2- stop the prophylactic medication or if taking high dosage taper the medication

Migraine headaches can improve over time Migraine does improve after menopause Migraine does improve during pregnancy Migraine can increase in the perimenopausal period

Effective communication between patient and provider Limit the information to the most important, need to know items Avoid medical jargon Educate using multiple modalities Use the follow up appt for further education Review the written information with patient Ask patient to repeat the instruction

Follow up appointment Have patient leave the office with a follow up appt Ask if acute treatment is effective Ask about side effects Decide if prophylactic treatment is needed Find out if prophylactic Rx has reduce frequency of headache Adjust dosage of medications Ask is they tolerating prophylaxis Spend more time educating patient about triggers

Identify patient who need urgent evaluation and treatment ( infection, bleeding, temporal arteritis, acute stroke) Complete history & physical to look for red flags Distinguish between primary vs secondary headache For 2 nd headaches treat the cause Effective communication for prevention and treatment of primary headaches