1. Medication Overuse Headache Morris Maizels MD Blue Ridge Headache Center Asheville Hendersonville NC

3. Migraine Remembered S evere U ni- L ateral2 of 1st 4 T hrobbing A ctivity worsens ha N ausea S ensitive to light/sound1 of last 2 Headache is episodic, and usually lasts 4-72 hours

5. Neurovascular theory of Migraine Goadsby, 2000.

6. Adapted from Ambassadors program after Burstein et al., Brain 2000 1. Peripheral Trigeminal Sensitization 2. Central Trigeminal Sensitization 2. Forehead Allodynia 3. Thalamic Sensitization 3. Extracephalic Allodynia 1 3 2 Sensitization and migraine 1. Throbbing headache

7. Migraine Triggers  hormones  emotions/stress  disrupted sleep  caffeine withdrawal  foods  change

9. Headache Medications  Acute non-triptannon-triptan triptantriptan  Prophylactic FDA-approvedFDA-approved non-FDA-approvednon-FDA-approved “natural supplements”“natural supplements”

10. Symptomatic Medication Mild to Moderate Headaches  NSAID’s - high dose (+/- antiemetic)  ASA/acetaminophen/caffeine (Excedrin)*  ASA or acetaminophen/butalbital/caffeine (Fiorinal/Fioricet)*  Acetaminophen/isometheptene/dichlrophenazone (Midrin) - ii po at onset, then i qhr up to 5/day  Ergotamine tartrate/caffeine (Cafergot)* *** Limit use to 2 days/week ***

11. Triptans and DHE  Sumatriptan (Imitrex)  Rizatriptan (Maxalt)  Zolmitriptan (Zomig)  Naratriptan (Amerge)  Frovatriptan (Frova)  Almotriptan (Axert)  Eletriptan (Relpax)  DHE im/sq, iv, ns Group by  parenteral  po rapid onset  po slow onset rapid --> slow  high --> low efficacy  high --> low relapse  more --> less se’s

12. Triptans and DHE  Sumatriptan (Imitrex) po, sq, ns  Rizatriptan (Maxalt)  Zolmitriptan (Zomig)  Naratriptan (Amerge)  Frovatriptan (Frova)  Almotriptan (Axert)  Eletriptan (Relpax)  DHE im/sq, iv, ns

13. Triptans Group by onset of action  parenteral  po - rapid onset  po - slow onset rapid --> slow  high --> low efficacy  high --> low relapse  more --> less se’s

14. Triptan side effects/risks  Common: sedation, nausea, muscle ache, chest tightness (2 – 5%)  Contraindications CAD, CVA, PVDCAD, CVA, PVD hemiplegic/basilar migrainehemiplegic/basilar migraine  Risk of serious cardiac event with triptans is ~ 1:1,000,000

15. General approach to acute Rx  Who gets triptans?  Which triptan?  How to use the triptan?

16. Principles of acute therapy  Stratified care  Early use of medication for patients with episodic headache  Limit use of all acute meds to 2 days/week

17. Stratified Care  Usual level of disability  Rapidity of onset  Associated nausea/vomiting  Tendency to relapse  Side effect tolerance

18. Therapeutic Phases of Migraine

19. An approach for triptan non-responders  Review diagnosis migraine?migraine? daily headache (drug rebound)?daily headache (drug rebound)?  Use early in attack, at sufficient dose  Try at least 3 triptans  Polypharmacy (NSAID/antiemetic)  ?Mg deficiency

20. Alternatives to Narcotics in the Emergency Room IM antiemetic 10 mg + NSAID 60 mg +/- DHE 1mg +/- glucocorticoid IV antihistamine 25 mg + antiemetic10 mg + DHE 1mg +/- NSAID 30 mg +/- glucocorticoid

21. Alternatives for Refractory Headaches  Chlorpromazine (Thorazine) 12.5 mg iv; mr q 20 min x 3; total 50 mg  IV Depacon 100mg/kg over 5 min  IV DHE (q8h Raskin protocol)  IV Mg 2 gm/100 ml D5W may be added to any other regimen

22. Drug Rebound Headache  h/o episodic migraine  more frequent/daily  refractory to usual Rx  narcotics for rescue  Fiorinal - “preventive”  escalating Rx use  trying to survive

23. “The desire to take medication is, perhaps, the greatest feature which distinguishes man from the other animals.” Sir William Osler

24. What drugs cause drug rebound? Worst offenders:  Narcotics  Ergotamine  Caffeine-containing compounds: ExcedrinExcedrin Fiorinal/FioricetFiorinal/Fioricet CafergotCafergot Lesser offenders:  aspirin  acetaminophen  NSAID’s  triptans Innocent until proven guilty  DHE

25. “The Unrecognized Epidemic” 1-2% of population is affected1-2% of population is affected (near) daily tension-type headache, with migrainous flares(near) daily tension-type headache, with migrainous flares present upon awakeningpresent upon awakening refractory to other abortive or prophylactic measuresrefractory to other abortive or prophylactic measures headache worsens when medication is stoppedheadache worsens when medication is stopped

26. Treatment of Drug Rebound  Patient education  Withdraw medication  Initiate prophylaxis  Provide rescue therapy

27. Impact of continuing vs discontinuing symptomatic medication

28. Treatment strategies for DRH  Combined prophylaxis (TCA + BB + AC) + NSAID+ NSAID + Tizanidine+ Tizanidine  Daily naratriptan  DHE im/sq  IV rescue regimens (esp. IV DHE)  Steroid burst

29. Prevention of drug rebound All Rx’s state: “Limit use to 2 days/week” eg, Triptan A, B, or C x mg #9 i po at onset migraine–mr x 2 within 24 hr i po at onset migraine–mr x 2 within 24 hr Limit use to 2 days/week Limit use to 2 days/week All Rx’s state: “Limit use to 2 days/week” eg, Triptan A, B, or C x mg #9 i po at onset migraine–mr x 2 within 24 hr i po at onset migraine–mr x 2 within 24 hr Limit use to 2 days/week Limit use to 2 days/week

30. Medication Overuse is not the same as Drug Rebound!  Medication overuse - the ongoing use of symptomatic medications >/= 3 days/week  Drug rebound headache implies medication overusemedication overuse secondary headaches excludedsecondary headaches excluded headache may first worsen, but then improves with withdrawal of symptomatic medicationsheadache may first worsen, but then improves with withdrawal of symptomatic medications

31. Conclusion  Episodic disabling = migraine  “Migraine-in-a-Minute” for triage  Stratify care treat earlytreat early migraine-specific therapymigraine-specific therapy  Refractory headache is usually due to: drug rebounddrug rebound co-morbidityco-morbidity  Incorporate behavioral assessment/Rx