1. Primary Headache disorders
October 28, 2016

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

3. 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

4. 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

5. 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

6. 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

7. Stages of Migraines
Prodrome Aura Headache Postdrome

8. 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

9. 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

10. Episodic cluster headache
Very localized pain, 1 finger, for 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.

11. 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

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

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

14. 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

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

16. 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

17. 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

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

19. 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

20. Prophylactic medications
Tricyclic Antidepressants
Anticonvulsants
Beta Blockers
Verapamil
Cyproheptadine
Venlafaxine
Supplements

21. 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)

22. 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)

23. 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

24. 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

25. Supplements Magnesium Riboflavin Feverfew Coenzyme Q10 Melatonin
Not Butterbur

26. 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

27. 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

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

29. Hormonal Menarche Menstrual Birth control pills Pregnancy
Breast Feeding
Menopausal

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

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

32. 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