1. How to Manage Recurrent Headache Allan Gordon MD, FRCP(C) Neurologist and Director Wasser Pain Management Centre John and Josie Watson Pain Education and Research Centre www.mtsinai.on.ca/wasser wasser@mtsinai.on.ca

2. Objectives To discuss Chronic Headache Program at the Wasser Pain Management Centre To discuss the Canadian Headache Society guideline for headache prophylaxis To describe the management of chronic migraine

3. Disclosures Allergan Purdue Pharma Merck AstraZeneca Pfizer Eli Lilly Boehringer Mount Sinai Hospital Foundation CIHR

5. RECURRENT HEADACHE | | Episodic Migraine Chronic Migraine \ / 15 days per month 8 migraines

6. Stephanie 28 F lawyer Married no children (yet). On Yaz Onset of headaches at 14 (2 years after menarche) Now 1 per week except for week of menses when there may be 2 or 3 days in a row with a headache (6-7 per month). 8/10severity No aura except slight nausea Then pain usually right temple and forehead (70%), or left temple (30%) Throbbing pain, severe, dark room Takes Advil, lies down, wakes up in 4 hours and feels better 50% of HA do not respond to this treatment and spends time off Physical Exam is normal

7. What is the diagnosis? A Migraine with aura B Tension type headache C Episodic Migraine without aura D Cervicogenic headache E Glioblastoma F Chronic migraine

8. Examples of oral acute therapy Acetaminophen ASA Ibuprofen Sumatriptan Rizatriptam Eletriptan Metclopromide Codeine and oxycodone (not usually recommended

9. Examples of prophylactic therapy used Topirimate Propranolol Lamotrigine Onabotulinum toxin A Valproic Acid “natural” medications

10. Canadian Guidelines Migraine Prophylactic Guideline Summary for Primary Care Physicians Tamara Pringsheim, W. Jeptha Davenport, Gordon Mackie, Irene Worthington, Michel Aubé, Suzanne N. Christie, Jonathan Gladstone, Werner J. Becker1 on behalf of the Canadian Headache Society Prophylactic Guidelines Development Group Can J Neurol Sci. 2012; 39: Suppl. 2 - S41-S44

11. Objective To assist the physician in choosing an appropriate prophylactic medication for an individual with intermittent migraine headaches (headache on ≤ 14 days a month). Episodic migraine 17% of women /5% of men

12. Who should receive prophylaxis? i. Migraine prophylactic therapy should be considered in patients whose migraine attacks have a significant impact on their lives despite appropriate use of acute medications and trigger management / lifestyle modification strategies.

13. ii. Migraine prophylactic therapy should be considered when the frequency of migraine attacks is such that reliance on acute medications alone puts patients at risk for medication overuse (rebound) headache. Medication overuse is defined as use of opioids, combination analgesics, or triptans on ten days a month or more, or use of simple analgesics (acetaminophen,ASA, NSAIDs) on 15 days a month or more,

14. iii. Migraine prophylaxis should be considered for patients with greater than three moderate or severe headache days a month when acute medications are not reliably effective, and for patients with greater than eight headache days a month even when acute medications are optimally effective because of the risk of medication overuse headache.

16. Botulinum toxin type A (Onabotulinum toxin Although there is good evidence for efficacy in chronic migraine, onabotulinumtoxinA is not recommended for prophylaxis of episodic migraine in patients with less than 15 headache days per month. “We found high quality evidence that botulinum toxin type A is no better than placebo for the prophylaxis of migraine in such patients”.

17. Non pharmacologic treatments Biofeedback Acupuncture Hypnosis Injections CBT Mindfulness Psychotherapy Physical therapy Massage Chiropractic therapy

18. Dana 40 F Not working Every day a headache, more than 15 days a month Throbbing, nauseated photophobia, one or both sides Partial response to rizatriptan, zolmitriptan, ASA acetaminophen, naproxen (taken almost every day) Failed gabapentin antiepileptics, beta blockers, tricyclics, riboflavin, nerve blocks Widespread joint and muscle pain Irritable bowel Vulvar pain

19. Chronic Migraine (see Silberstein et al 2013) Chronic Migraine is a distinct and severe neurological disorder characterized by patients who have a history of migraine and suffer from headaches on 15 days or more per month for at least three months, with at least 8 headache days being migraine and/or are treated and relieved by triptan/ergot Report lower health related quality of life, use a greater amount of direct and indirect medical/healthcare resources and incur greater loss of productivity than patients suffering from episodic migraine (<15 headache days per month) Afflict 1.7% of global female population (.5% of men) More overlap conditions

20. Treatment of CM generally involves preventative medications, take on a daily basis whether or not headache is present and acute treatments, taken when attacks occur to relieve pain and restore function Identifying and eliminating exacerbating factors including the overuse of acute medications is the conventional treatment

21. Health Canada has approved BOTOX® (onabotulinumtoxinA) manufactured by Allergan, Inc. as a prophylactic (preventive) treatment for headaches in adult patients with Chronic Migraine who suffer from headaches 15 days or more per month, lasting four hours a day or longer.

27. Compared with placebo-treated patients, topiramate 100 mg/day appears to contribute to reductions in migraine- related limitations on daily activities and emotional distress beginning as early as week 4 and continuing up to week 16 after treatment. Physician's Global Impression of Change results are very similar with Subject's Global Impression of Change, indicating concordance between the physician's and the subject's assessment of improvement.

29. Onabotulinumtoxin A for treatment of chronic migraine: PREEMPT 24 hour pooled subgroup analysis of patients who had acute headache medication overuse at baseline Silberstein et al (2013) Journal of Neurological Sciences (in press)

30. The frequent intake of analgesics or other acute headache medications may lead to the development of a secondary headache disorder – MOH (medication overuse headache) Increasing headache frequency may lead to increased uptake of acute headache medications In MOH withdrawal of drug therapy may improve headache symptoms Most MOH patients in tertiary headache centres overuse acute medications (73% Mathew 1996) Suggested to try terminating acute Rx does not always work and hard to do

31. PREEMPT (Phase III Research Evaluating Migraine Prophylaxis Therapy) Showed that onabotulinumtoxinA treatment is safe, tolerable and effective as long-term (up to 56 weeks) headache prophylaxis in adults with CM Silberstein 2013 showed that the number and severity of headache days in the CM plus MO group but no decrease in use of acute medications