Headache CME Dave Martin MPAS, PAC Idaho State University Assistant Clinical Professor

Objectives Review alarm symptom & signs for serious HA’s Discuss patient evaluation and treatment Discuss more common headache syndromes Recall headache syndromes that are truly emergent and how evaluate for them

Headaches Your next patient today has a headache They are lying in a dark room laying on the exam table with an emesis basin What are you thinking and what are your emotions? Headaches account for 9th most common reason to consult a physician Headaches account for 1-4% of ER visits

Intracranial Lesion Concern & HA Alarms Morning HA or awakens pt Worst HA of pt’s life Thunderclap HA – max in 1 minute Abrupt onset Worse with posture change or exertion or straining Nausea New onset HA or change from usual or progressive Onset of HA <5yo or >50yo New HA with history cancer or immunosuppression Hx of medication or ETOH

Intracranial Lesion Concern & HA Alarms Papilledema Aura >1hr Focal neurological sx’s or deficits on exam Vague neuropsychiatric sx’s Personality change Trouble thinking or remembering Fever Nuchal rigidity Syncope or seizure Altered consciousness

Alarm Clock Headache Hypnic Headache REALLY Alarm Clock Headache Hypnic Headache REALLY!! I just wanted info on HA alarms – internet Usually involves pts >65yo Cause unknown = related to REM sleep? Awakened at night by HA Intense dull or throbbing Unilat or bilat Usually occurs 0100-0300 Lasts 30-60 minutes Tx: lithium

Headache Differential Migraine Meningitis/encephalitis Cluster Temporal arteritis Tension Tumor Trauma Psychological Sinus Drugs/toxins Musculoskeletal Viral illness Stroke Vascular

Evaluation History and PE to include what? Lab for temporal arteritis, infection, metabolic causes CBC ESR & CRP CMP Imaging for intracranial bleed or lesion CT MRI With or without contrast Angiography imaging – CTA/MRA LP for infection and SAH Angiography for vascular lesions

Imaging Recommendations = Who? First/worst HA Subacute HA with increasing frequency/severity Progressive or new daily persistent HA Chronic daily HA HA always on same side HA not responding to tx

Imaging Recommendations = Who? New HA >50yo Hx of cancer or HIV Fever, stiff neck, N&V Aura and focal neuro sx’/signs in non-migraine HA Papilledema, cognitive impairment or personality changes Seizures

Tension HA Very common at 20.8% of population Episodic or chronic Pt’s don’t typically present for care Pain classically mild to moderate Pressure/tightness Steady Neck/occipital Bilateral Tx: OTC Rx NSAIDs Muscle relaxants don’t typically help

Migraine HA Neurovascular syndrome Trigeminovascular reflex – altered central neuronal processing Neurochemical activation, irritation, inflammation Sensory sensitivity Vascular constriction then dilation – OLD theory 30 million in US with at least one migraine per year Female:Male 3:1 Inherited  70% plus with positive FH

Migraine HA Signs and symptoms Pain moderate to severe Lasting hours to days Commonly improved by sleep Unilateral (classic) or bilateral Frontotemporal area Aching/squeezing/throbbing N&V Photophobia

Migraine HA Signs and symptoms Phonophobia/hyperacusis/sonophobia Osmophobia/hyperosmia Reduced concentration Physical activity aggravates Commonly people like to lie in a dark quiet room Frequency quite variable Symptoms or intensity may vary

Migraine HA Defined as w/o aura Chronic episodic HA typically lasting 4-72 hours Five episodes required for diagnosis Presence of episodic severe HA is 93% predictive of a migraine diagnosis Criteria 2 pain qualities Unilateral Throbbing/pulsating Worse with movement – routine physical activity Moderate to severe pain 1 associated sx Nausea and/or vomiting Photophobia or phonophobia

Migraine HA Defined with aura At least two attacks for diagnosis Aura consisting of at least one of: Fully reversible visual sx’s Positive and/or negative features Fully reversible sensory sx’s Fully reversible dysphasic speech

Migraine HA Defined with aura At least two of: Homonymous visual sx’s Unilateral sensory sx’s At least one aura sx develops gradually over >5min and/or different aura sx’s occur in succession over >5min Sx’s last ≥5min but ≤60min Migraine occurring during or within 60 min of aura Migraine aura w/o HA can occur – visual most common

Hemiplegic Migraine Neuro deficit with HA Clears as HA improves Sensory Motor – hemiparesis or hemiplegia Speech – aphasia/dysphagia Altered LOC possible Clears as HA improves Controversy using Triptans “contraindicated” but probably safe

Basilar Migraine HA with N&V and photosensitivity and hyperacusis Two or more of following fully reversible auras Vertigo Hypacusia and/or tinnitus Ataxia Visual field loss or diplopia Bilateral paresthesias Dysarthria Altered LOC – obtundation, amnesia, syncope Common

Migraine OTC Tx Percentage of Responders at 2 hr (% Placebo) Medication and Dose Mild or No Pain Ibuprofen, 400 mg 42 (28) 49 (32) Acetaminophen, 1,000 mg 58 (39) 77 (46) Acetaminophen, 500 mg, plus aspirin, 500 mg, plus caffeine, 130 mg 59 (33) 79 (52) Aspirin, effervescent, 1,000 mg 55 (37) Not assessed

Maximum Daily Dose (mg) Migraine Triptans Drug (Brand Name) Formulation Doses* (mg) Maximum Daily Dose (mg) Almotriptan (Axert) Tablet 6.25, 12.5 25 Eletriptan (Relpax) 20, 40 80 Frovatriptan (Frova) 2.5 5 Naratriptan (Amerge) 1, 2.5 Rizatriptan (Maxalt) Orally disintegrating preparation (Maxalt MLT) 5,10 5, 10 30 30 Sumatriptan (Imitrex) Tablet with 500 mg naproxen sodium (Treximet) Nasal spray Subcutaneous injection 25, 50, 100 85 5, 20 4, 6 200 170 40 12 Zolmitriptan (Zomig) Orally disintegrating preparation (Zomig ZMT) 2.5, 5 2.5, 5 5 10 10 10

Migraine ER Tx Evidence-based guidelines recommend the first-line use of DHE, subcutaneous sumatriptan, dopamine antagonists (metoclopramide, prochlorperazine, and chlorpromazine), and ketorolac, which have response rates of up to 70% Narcotic analgesics, recommended as rescue drugs, are still widely used first line.

Migraine ER Tx Migraine pain persists or recurs in over half of patients within 24 hours of discharge from the emergency Not treatment dependent Intravenous dexamethasone (10 to 24 mg) has a modest effect (the number needed to treat is nine) on preventing recurrence Not effective for acute treatment of migraine pain

Migraine Tx Parenteral medication options for persistent or recurrence: Imitrex - Sumatriptan, 4 or 6 mg SC DHE, 0.5 to 1 mg by SC, IM, IV (DHE and triptans should not be used within 24 hours of each other). Reglan - Metoclopramide 10 IV Zofran - Ondansetron 4 to 8 mg IV Compazine - Prochlorperazine, 5 to 10 mg IV Thorazine – Chlorpromazine, 25 mg IV, 25 to 50 mg IM Toradol - Ketorolac, 30 mg IV, 30 to 60 mg IM Inapsine - Droperidol (2.5 mg IM or IV) Parenteral narcotics, which may be combined with promethazine Depakote - Valproate sodium, 500 to 1,000 mg IV Decadron - Dexamethasone, 10 mg IM or IV

Migraine Tx Magnesium 1 gm IV – some sources Adjunct Tx IV fluids Rest in quite dark room Antiemetics Hydroxyzine Metoclopramide Prochlorperazine Promethazine Caffeine Trigger point injections neck/trapezius can be very effective

Migraine Prophylaxis Prophylaxis  most efficacious listed first Start low and titrate over 8-12 weeks Beta blockers Metoprolol, propranolol, timolol Others – atenolol, nadolol Antidepressants Amitriptyline Others – nortriptyline, protriptyline, venlafaxine Anticonvulsants Divalproex/valproic acid, topiramate Others – gabapentin Menstrual migraine may respond to estrogen

Case #1 38 yo female presents with migraine HA Maxalt didn’t help after 2 doses What questions do you want to ask What physical exam are you going to do What are you going to give pt for tx What will you give if the first med doesn’t work

Cluster HA Uncommon: US 0.4% in men & 0.08% in women Clusters = QOD to several per day & remission times Severe – unilat – orbital/temporal Lasts 15 min to 3 hours Ipsilateral Conjunctival injection and lacrimation 80% Nasal congestion and coryza 75% Miosis Ptosis Hyperhidrosis face N&V, photophobia, hyperacusis – 50%

Cluster HA Evaluation: MRI with pituitary views – r/o mimics Treatment 100% O2 with NRB 7-15L for 15-20 minutes  70-80% Imitrex injection 6mg SQ – 75% DHE 1mg IV works faster than subQ Lidocaine 4% nasal drops – modestly effective Zomig or Imitrex nasal spray – less effective Prednisone as transitional med for prophylaxis

Temporal Arteritis >50yo with female>male 3:1 Giant cell arteritis Polymyalgia rheumatica Jaw claudication Throbbing severe HA – usually unilat Constitutional sx’s Visual changes possible – on to blindness Scalp tender over temporal artery – diminished pulse Brushing hair or laying on pillow = tender

Temporal Arteritis 3 of 5 criteria for dx Dx lab and bx 1) >50yo 2) new onset HA 3) temporal artery tenderness 4) ESR >50 5) abnormal temporal artery bx Dx lab and bx Elevation ESR & CRP Both elevated specificity 97% Tx steroids 40-80mg QD Avoid blindness – start tx as soon as suspicion

Case #2 64 yo female presents with unilateral throbbing HA Pt reports muscle pain and stiffness in shoulder, hips and back muscles for a number of weeks Stiffness in am They feel weak but PE w/o weakness Pt has been feeling: malaise, poor appetite Reports temps to 100 What do you expect on PE What tests would help What is the tx

Headaches Your next pt today is complaining of a “sinus HA” They have a long hx of sinus infections They are requesting and abx because this is what clears up their sinus HAs

Sinus HA How many have heard the pt say “I have a sinus headache and I need antibiotics” Pt typically has a hx of recurrent sinus HA’s By hx antibiotics typically start to clear the sinus problem within a day or two Why is that?

Sinus HA Recurrent sinus HA 2nd to infection essentially NOT Think of migraine with complaint of episodic “sinus” HA Migraine can have sinus like sx’s Sinus pain and pressure -- 82% & 84% Nasal congestion -- 63% Rhinorrhea -- 40% Watery eyes -- 38% Itchy nose -- 27% Big majority of pt’s with “sinus HA” do NOT have real sinus disease on CT ~ 88%

Sinus HA Descriptors for migraine Pulsing/throbbing 89% Worse with physical activity 85% Sinus pressure 84% Sinus pain 82% Nasal congestion 63% Photophobia 79% Nausea 73% Phonophobia 67% Sinusitis dx criteria: purulent discharge, nasal obstruction, facial pain/pressure/fullness American Academy of Otolaryngology-Head and Neck Surgery

Chronic Daily HA 15 or more HA’s per month 50% are rebound/medication overuse headaches (MOH) Chronic migraine (CM) Multiple other etiologies What are original HA’s like Cause: more than 2 acute med doses per week – any meds OTC’s Rx’s – narcotics – triptans

Chronic Daily HA MUST stop meds including OTC’s for MOH & CM Endure for a few weeks until back to baseline Start prophylactic drugs Will help accelerate improvement Will not work well if con’t pain meds May take 1-3 months to work VERY difficult to manage

Case #3 44 yo female presents with “severe” migraine for 3 days Headaches occur 4-5 days a week Imitrex isn’t helpful or minimally helpful OTC’s commonly used – Tylenol and ibuprofen Vicodin using 2-4 times daily when has the HA and not helping – given by PCP Commonly gets Demerol and Phenergan which provides relief for a couple days What is dx What is tx

Brain Tumors 70% report HA Similar to tension HA Usually bilat Neuro exam may be normal New onset or progressive HA Morning HA’s are worst – 20% HA with Seizure Confusion Focal neuro findings Prolonged N&V Mental changes Dx: imaging CT with contrast

Subarachnoid Hemorrhage Sudden onset severe/worst HA May be improving by time of presentation Onset with exertion N&V Focal neuro sx’s or findings on PE May be non focal Meningeal signs May have changes in consciousness to LOC to coma Dx: CT without contrast LP may help if CT neg and still suspect

Case #4 45 yo male JHS teacher presents with mild HA for 2 days and mild neck stiffness 2d ago while splitting wood passed out – uncertain time frame – woke with saw dust on clothing Unwitnessed No prodromal sx’s Ate lunch 2 hours previous Denies injury and no focal neuro sx’s No hx consistent with seizure Negative PMH SH: married with kids, mod ETOH use, denies drugs

Case #4 What is your differential What is your w/u What is your tx

Pseudotumor Cerebri Idiopathic intracranial hypertension Increased ICP CSF analysis nl 1:100,000 (normal wt) & 20:100,000 (obese) Common in women of child bearing age Idiopathic usually Occasionally drugs or systemic conditions Daily HA freq with nausea Worse with straining

Pseudotumor Cerebri May have visual changes Papilledema Abducens palsy common – lateral gaze – diplopia Papilledema May be present in asx pt Dx -- MRI with contrast normal Elevated CSF pressure on LP Tx with Diamox, steroids, wt loss and LP’s Lumboperitoneal or ventriculoperitoneal shunt for failure of conservative measures

Papilledema – mild, mod, severe

Case #5 50 yo male presents to a rural Idaho town with 1 day severe HA with N&V No CT capability No hx of HA like this Negative PMH and SH Further hx and PE all normal IV fluids and parenteral narcotics/antiemetics w/o help By the way pt has a hx of a brain tumor dx’d many years ago but forgot to mention anything about it Pt life flighted to referral hospital – 2 days later dx of meningitis

HA Info Sources http://www.icsi.org http://www.ihs-headache.org Copy and paste into browser Click on guidelines then search for headache http://www.ihs-headache.org Click on guidelines then down to classification guidelines Medscape Merck Manual 19th Edition AAFP American Academy of Otolaryngology-Head and Neck Surgery