Primary Headache disorders October 28, 2016

No Disclosures Translates to not a professional speaker so keep that in mind

Primary Headache Disorders Migraine Tension Cluster Miscellaneous Headache is the problem, not a symptom of something else Most headache talks are on primary headache disorders since that is what you will likely see. Even in the headache clinic secondary headaches are rare

Migraine versus Tension Headache Migraine is a headache with associated symptoms Tension Headache is a headache without associated symptoms Basic definition clinically migraine versus tension headache

Associated Migraine Symptoms Spots before eyes Stiff neck Blindness or partial blindness Nasal blockage and/or drainage Blurry Vision/Double vision Nausea and/or vomiting Fatigue Dizziness Light sensitivity Numbness Noise Sensitivity Speech problems Odor Sensitivity Difficulty concentrating Muffled hearing, ringing in the ears

Migraine with aura An aura is neurological symptoms which precede a headache An aura may be visual such as flashing lights, kaleidoscope An aura may be physical such as numbness typically in marching fashion, fingers, hand, arms, face An aura is within 60 minutes prior to headache Around 25% migraines with aura

Stages of Migraines Prodrome Aura Headache Postdrome

Migraine triggers Diet: tyramine, alcohol, skipping meals, other Hormones Sleep alterations Emotional factors Environmental: weather, odors, florescent lights, sound Medications: Estrogen, NTG, ranitidine, many Citric acid, gluten intolerance, hormones premenstrual, during menstruation, after menstruation, some patients have one good week a month. Ovulation

Tension Headache Bilateral Mild to moderate Without associated symptoms Not aggravated by routine activities such as walking or climbing steps Triggers: stress, mental tension and neck movement Treatment: acetaminophen, NSAID’s, tricyclic antidepressants, venlafaxine, tizanidine

Episodic cluster headache Very localized pain, 1 finger, for 15-180 minutes, 1-8 attacks per day Can last 2-3 months and remission 2 months-20 years Ipsilateral lacrimation, rhinorrhea, congestion, eyelid edema, sweating, miosis and/or ptosis Acute treatment Bridge therapy Prophylactic treatment Most patients prefer injections, fastest. Oxygen. Nasal sprays. Tablets. Preventative verapamil year round. Topiramate, Lithium. Bridge, ONB, prednisone.

Chronic migraine 15 headache days a month or more Obesity, sleep disorder, mood disorder, stress, abuse, medication overuse Most common overuse medications, caffeine products, butabitol, opioids Behavior modifications Cycle breakers Prophylactic medications History of sexual abuse common

Miscellaneous headaches Idiopathic stabbing headache (ice pick headache) Benign exertional headache Headache associated with sexual activity Paroxysmal hemicrania New daily persistent headache

Laboratory ESR and CRP to rule out temporal arteritis age 60 or above Thyroid profile

imaging Worse headache of life, rule out aneurysm Headache associated with fever and stiff neck Headache associated with severe nausea and vomiting New onset of headache after age 50 Headache with abnormal neurological findings Patient with cancer or immunodeficiency Change in headache pattern

Treatment of Migraines Abortive medications Rescue medications Prophylactic Medications Non pharmacologic treatments

Abortive medications NSAID’S Midrin (isometheptene, APAP, dichloralphenazone, two onset of headache and may repeat one every hour up to 5/24 hours Triptans Migranal Muscle relaxants Gabapentin

Guidelines for abortive medications Goal two days a week for all Caffeine containing products, opioids and butalbital products worst offenders for overuse headaches Triptan, 4, 6, 9, 12 Refills up to 3 Injection or nasal spray if waking up with migraine or add metoclopramide

Rescue medications NSAID’s Anti-emetics, prochlorperazine, promethazine Benadryl Steroids Narcotics when pregnant or when other medications contraindicated IM ketorolac and promethazine IV treatments

Guidelines for rescue Plan Goal to keep people out of the ER Not for routine use unless combined with abortive medications Goal to treat with all abortive/rescue medications two days a week on average Start early Over 72 hours, intractable headaches

Prophylactic medications Tricyclic Antidepressants Anticonvulsants Beta Blockers Verapamil Cyproheptadine Venlafaxine Supplements

Tricyclic antidepressants Amitriptyline 10 mg evening, increase by one tablet every 4-7 days until headaches improve or SE (sedation, dry mouth, weight gain) Nortriptyline 10 mg evening, increase the same , less side effects than amitriptyline Imipramine 25 mg supper time, increase the same (neutral sedation, dry mouth and some weight gain) Protriptyline 5 mg morning for 4 days than morning and noon (stimulating, less weight gain)

Anticonvulsants Divalproex ER 250 mg bedtime for 1week than 500 mg (weight gain, tremor, hair loss) Topiramate 25 mg bedtime for 1 week, than 2 at bedtime for 2 weeks, than call (paresthesia’s most common, weight loss, sedation, altered taste, cognitive issues, mood, risk of kidney stones and rare acute second angle glaucoma) Zonisamide 25 mg at bedtime for 2 weeks than 2 at bedtime (vague abdominal complaints, mood, monitor for itching for patients with sulfa antibiotic allergy) Gabapentin 100 mg or 300 mg one at bedtime for 3 days, one twice a day for 3 days, than one three times a day for 1 week, may add a second tablet every 3 days (sedation, dizzy)

Beta Blocker Propranolol 60 mg at bedtime, call in 3 weeks. May start at 10 mg twice a day and increase every 2 weeks Nadolol 20 mg at bedtime, call in 3 weeks Metoprolol or atenolol Common side effects, fatigue, vivid dreams

verapamil 120 mg at bedtime for 3 weeks than call 40 mg three times a day Constipation common side effect Used when neurological symptoms are more disabling than headaches Prophylaxis for cluster headaches

Supplements Magnesium Riboflavin Feverfew Coenzyme Q10 Melatonin Not Butterbur

Guideline for prophylactic medications Minimal 6 week to 3 month trial Not a cure Reduce frequency and severity Consider 4-8 headache days a month and certainly 8 or more days a month Fluctuate dose certain time of year or time of month

Botox Only FDA treatment for chronic migraine, greater than 15 headache days a month and greater than 4 hours a day Reduces the frequency of headaches, not a cure Typically takes a couple of weeks to be effective and may wear off before next injection in 3 months Neck pain unique with migraine patients Coverage issues

Challenging patients Chronic pain patients Anxious patients Depressed patients Students Patient not the main contact Poor lifestyle

Hormonal Menarche Menstrual Birth control pills Pregnancy Breast Feeding Menopausal

Non Pharmacological treatments Physical therapy Chiropractor/osteopath Acupuncture Massage therapy Lifestyle changes Biofeedback Craniosacral

Lifestyle changes Regular sleep Regular meals Regular exercise Good hydration Coping with headache triggers Smoking cessation

Conclusion Treat early but don’t over treat Goal treat two or less headaches a week or eight or less headaches a month Headache is the problem, not a symptom of something else Combination of medications, lifestyle changes, and non pharmacological treatments