1. Management of Primary Headache Disorders

2. Primary Headache disorders Include all the non-malignant recurrent headache disorders not caused by structural causes or medical disease. Includes: migraines, tension headaches, cluster headaches, hypnic headaches, paroxysmal hemicrania and many others. Have a high prevalence and incidence

3. Basic Headache Fundamentals Multifactoral Contributions -genetic -genetic -environmental (stress, sleep) -environmental (stress, sleep) -chemical (caffeine, medication) -chemical (caffeine, medication) -organic (sinus disease, muscle strain) -organic (sinus disease, muscle strain) -physical (posture, ergonomics, eye strain) -physical (posture, ergonomics, eye strain) -psychologic (secondary gain, anxiety, depression, hypochondriasis) -psychologic (secondary gain, anxiety, depression, hypochondriasis)

4. Migraines CharacteristicsEpisodicUnilateral Pounding, throbbing Photophobia,Phonophobia Nausea/ vomiting Need for sleep Visual or sensory aura

5. Migraine-general concept Think of migraine as: Think of migraine as: Neurologic disorder +/- headache Also often include autonomic and GI symptoms

6. Migraine Epidemiology In a given year, 15% to 18% of women and 6% of men have at least one migraine attack. 28% of men and 40% of women used prescription medications.

7. Important Migraine medical history Triggers Character of pain Associated symptoms DurationFrequency Behavior during an attack (hibernation- like) AurasTreatmentPMH Previous medications OTC medications Family hx Caffeine Sleep (quality and quantity) Life-StressExercise

8. Important ROS Eye symptoms: visual loss, visual changes, double vision, photophobia GI symptoms: N/V, cravings, anorexia Other: vertigo, numbness and tingling, phonophobia, need for sleep

9. Important questions Everyday or intermittent Frequency of headaches Duration of headache Onset (rapid, during sleep or with aura) Presence of nausea? Medications used? Other measures used? Family history What do you do when you get a headache? How well do you sleep?

10. Diagnostic work-up If headaches are intermittent, frontal with photophobia/phonophobia, +Fhx. None needed Atypical features: male, age >30, no family hx, abnormal exam: consider imaging No lab w/u generally required Diagnosis is by history and description of headaches.

11. Therapy Principles Medical and non-medical Non-medical therapies include: sleep, ice packs, behavioral modification, biofeedback Medical therapies include prescription, nutritional and herbal therapies

12. Treatment-general principles Comes in 2 forms: Abortive: treat each headache symptomatically with a prn medication Preventative: prevent recurrent headaches with a daily medication

13. Abortive therapy-important concepts Staged therapy approach: treat mild headaches with “mild medicines” and severe headaches with “strong medicine” The earlier you treat the migraine, the more effective the response. Entrenched or established migraines are harder to abort.

14. Abortive therapies -For mild headaches: NSAIDs, ASA, acetaminophen, ibuprofen, naproxen -For moderate headaches: Fioracet, Fiorinal, Midrin, percocet, T3

15. Abortive therapies-continued For severe headaches: Triptans: imitrex, maxalt, zomig, amerge, relpax, trexemet and others Ergotamines: Dihydroergotamine -45 (DHE)

16. Abortive therapies-considerations Triptans are contraindicated with ischemic heart disease and complicated migraine (hemiplegic, confusional) Route of treatment determines speed of response and effectiveness: Oral, injectable or nasal spray

17. Abortive therapies-considerations Not to be used more than 2-3 days per week to avoid medication overuse headache/ rebound headache Not to be used more than 2-3 days per week to avoid medication overuse headache/ rebound headache

18. Abortive therapies- continued Miscellaneous: IV Magnesium, phenothiazine antiemetics: compazine, phenergan, reglan Depakon, thorazine, prednisone, decadron

19. Preventative therapies-concepts Used where headache frequency exceeds 15 days per month or 2-3 days per week. Try to treat co-existing conditions with preventative therapies Insomnia, depression, HTN, obesity

20. Preventative therapies-concepts Preventative therapies may take 3-4 weeks to start working Start at a low dose and gradually increase Have patient keep a headache calendar to monitor actual progress

21. Preventative agents Beta-blockers: propranolol, metoprolol -main side effects: exercise intolerance Calcium channel blockers: Verapamil Anti-depressants: TCAs: pamelor, elavil, SSRIs

22. Preventative agents Anti-epileptics Valproic acid- approved as migraine preventative (weight gain, PCOD, teratogenic) Topiramate- approved as migraine preventative (weight loss, language/memory problems “Stupamax”, “Dopamax”

23. Antiepileptic preventatives Neurontin- seems to work OK if tolerated. Limited by sedation, BID-TID dosing Lamictal (lamotrigine) not used too often due to Steven’s-Johnson rash- 3 rd line agent

24. Other preventative therapies Oral magnesium- may have a role in perimenstrual migraine Hormonal therapies: supplemental estrogen during menstrual phase Botox injections Leukotriene inhibitors (montelukast) Lisinopril

25. Alternative therapies Feverfew (Tanacetum parthenium) Ribolfavin (vitamin B2) Accupuncture Migrelief (Feverfew, magnesium sulfate and vitamin B2)

26. Chronic daily headache Daily or almost daily occurrence of headache Episodic migraine sometimes transforms into chronic daily headache Commonly associated with medication overuse

27. Medication overuse headache rebound headache Must first address medication overuse. Use of short acting analgesics, vasoactive medications including triptans more than 2 days per week can result in medication overuse headaches in susceptible individuals

28. MOH treatment 1.Educate: a handout is often helpful (from Mayoclinic.com or Jefferson Headache center 2.Decide on abrupt withdrawal or taper

29. MOH treatment Consider prednisone 4-7 days, 40-60mg DHE infusion Add migraine preventative Treat insomnia Limit analgesic use to 2 days/week Use anti-nausea or valium for break through headaches or symptoms.

30. Indomethacin responsive headaches Paroxysmal hemicrania Short duration (3min to 45 min) intense, boring, focal (temporal, frontal, parietal). No nausea, photophobia, phonophobia, 4-30/day Also described as “ice pick headaches” or “jolts and jabs” Indomethacin 75 to 150mg/day

31. Other headache types Cluster headache Less common, seen more in men, headache is typically intense, stereotyped, unilateral, 30min to 2 hours in duration, turns on/off like a switch. Associated with autonomic symptoms: runny nose, lacrimation, etc

32. Cluster headaches continues Treatment-abortive Includes triptans, oxygen, most oral analgesics work too slow Treatment-preventative: Depakote, verapamil, steroids, lithium

33. Exertional headaches Typically sudden onset, occipital May have mild photophobia May symptomatically resemble sub- arachnoid hemorrhage Post-coital headaches- typically in young men, may occur at or before orgasim. Recurrence may occur over 2-3 weeks but then typically resolves

34. Exertional headaches Rule SAH if appropriate May treat with pre-exertion medication including indocin, NSAIDs May consider preventative B-blockers Usually resolve after some period of weeks.

35. Questions?