Essential Headache Management

Essential Headache ManagementTouro University Nevada

Alumni EventSeptember 14, 2019

2-2:30 PM

MICHAEL J. OLEK, DO

ASSOCIATE PROFESSOR OF NEUROLOGY

TOURO UNIVERSITY NEVADA

COLLEGE OF OSTEOPATHIC MEDICINE

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2Essential Headache Management

Objectives1. To recognize different headache types2. To understand the pathophysiology of headache3. To learn about traditional and new headache treatments4. To be aware of non-pharmacological treatments for

headache

Dr. Olek has nothing to disclose financially

The Scream, Edvard Munch: 1893Downloaded from Pinterest


Classifications of HeadachesPrevalence of Headache

Non-Sinister versus Sinister HeadachesHeadache-Associated ConditionsMigraine Etiology and Treatment

Status Migrainosus FDA approved devices for Headache

Cluster HeadacheMedication Overuse Headache (MOH)

Headache and pregnancy


International Headache Society(HIS) International Classification of Headache Disorders Third Edition (ICHD-3 alpha: 2018)

Part 1: The Primary Headaches1. Migraine

1.1 Migraine without aura*1.2 Migraine with aura*

1.2.3 Hemiplegic Migraine1.2.4 Retinal Migraine1.4.1 Status Migrainosus*

2. Tension-Type3. Trigeminal Autonomic Cephalgia (TAC)

3.1 Cluster HA*3.2 Paroxysmal Hemicrania

4. Other Primary Headache Disorders (Cough, Exercise, Sexual Activity, Thunderclap, etc.)

*To be discussed in detail



Part 2: The Secondary Headaches5. HA attributed to Trauma of Head/Neck6. HA attributed to Vascular Disorder7. HA attributed to Non-vascular Intracranial Disorder8. HA attributed to a Substance or its withdrawal

8.2 Medication Overuse Headache (MOH)*9. HA attributed to Infection10. HA attributed to Disorder of Homeostasis11. HA attributed to disorders of the cranium, neck, eyes, ears, nose,

sinuses, teeth, mouth or other facial structure12. HA attributed to Psychiatric Disorder

*To be discussed in detail



Part 3: Painful Cranial Neuropathies and Facial Pain13. Painful Cranial Neuropathies and Other Facial Pain

13.1 CN V13.2 CN IX, X13.3 CN VII13.4 Occipital Neuralgia13.6 Painful Optic Neuritis

14. Other HA Disorders


Headache (HA) Prevalence

½ to ¾ of adults have suffered with a HA within the past year 30% had a migraine in the past year 1-5% have had a HA at least 15 days or more each month Severe HA or Migraine reported in 1 out of 6 over a 3 month period Fifth leading cause of ER visits 1.3% of Outpatient visits

Lifetime prevalence in Women: 25% Lifetime prevalence in Men: 8% Peak age is 25-50 70% of patients have relatives with Headache Third highest cause nationwide of years lost to disability (YLD)


Headache Prevalence

12% found to have a severe disability related to migraine 14% of women experience HA with menses Women on OCP-Migraine frequency increases 10X Migraine frequency decreases 2/3 in women after menopause Migraine is most often seen by Primary Care Providers 15% of persons with migraine see a HA specialist 15% of persons with migraine see a Pain specialist

Most frequently prescribed medication: Opioids 23.1% of ER patients received opioids for headache and 58% of the time

they were used as first-line treatment 63.7% of persons with migraine used Over The Counter (OTC) medications


Headaches: Non-Sinister: Major Causes

Medication Overuse Headache (MOH) Post-Trauma Errors of Refraction Tempo-Mandibular Joint (TMJ) Dysfunction Sinus Related Hypertension Occipital Neuralgia


Headaches: Sinister Clinical Clues “Worst Headache of My Life” First Severe HA Subacute worsening over days Abnormal neurological examination Fever or unexplained systemic signs Vomiting that Precedes HA Pain induced by valsalva Pain that awakens from sleep Known systemic illness Age > 55 Pain localized to temporal artery


Headaches: Sinister: Major Causes Vascular Thunderclap [Sub-Arachnoid Hemorrhage (SAH) or Aneurysm] Carotid or Vertebral Dissection Giant Cell Arteritis Acute Severe Hypertension Acute or Chronic Sub-Dural Hematoma (SDH)

Non-Vascular (Space-Occupying Lesions) Infective (Meningitis or Encephalitis) Homeostasis (Central Venous Sinus Thrombosis) Carbon Monoxide Poisoning Acute Glaucoma Idiopathic Intracranial Hypertension (Pseudo Tumor Cerebri)


Headache Pathophysiology NO Pain receptors in Brain Parenchyma Extra-Cranial Structures with Pain Receptors Sinuses Eyes Ears Teeth Skin Skull Muscles Exiting cranial nerves V, VII, IX, X TMJ Blood vessels


Headache Pathophysiology

NO Pain receptors in Brain Parenchyma Intra-Cranial Structures with Pain Receptors Arteries in the Circle of Willis Proximal Dural Arteries Dural Venous Sinuses and Veins Meninges (Pia, Arachnoid, Dura)


Headache Associated Medical Conditions to Remember

Mitral Valve Prolapse (MVP) Patent Foramen Ovale (PFO) Hypertension (HTN) Stroke (CVA) Epilepsy Atopic allergies Asthma Irritable Bowel Syndrome (IBS) Depression BiPolar Disease Anxiety Panic Attacks

Headache Comorbidity and Coexisting ConditionsTherapeutic Opportunities and Limitations

Disorder with Migraine Consider Avoid/Caution

Depression TCA, SSRI (Selective Serotonin Reuptake Inhibitors), SNRI (Serotonin and Norepinephrine Reuptake Inhibitors)

Beta-blockers

Anxiety TCA, SNRI, Beta-Blockers

Bi-Polar Valproate, Topiramate TCA, SSRI,SNRI

Sleep Disturbance TCA (Tri-Cyclic Antidepressant)

Stroke ASA

Hypertension Beta-Blockers, Calcium Channel Antagonists such as Verapamil or Diltiazem

Ergot or Triptans if uncontrolled

Obesity Topiramate, SNRI TCA, Valproate, Gabapentin

Epilepsy Topiramate, Valproic Acid, Gabapentin TCA, SSRI, SNRI

Raynauds Calcium Channel Antagonists Beta-Blockers, Ergots

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Rare complications of Migraine

Prevalence of Migrainous Infarct: 0.5 to 1.5% of all ischemic strokes Relative Risk for Ischemic Stroke with Migraine 1.73 Usually occurs in younger women (<45 years of age) with a history of

migraine with aura Women on OCP with Migraine with aura: Relative Risk of 7 Patients that have migraine with aura and smoke: Relative Risk of 9


Migraine Headaches

Characteristics Phases Pathophysiology Acute Treatment Prophylactic Treatment


Characteristics of a Migraine

Attacks last from 4-72 Hours Patient history and physical exam best for diagnosis Often occur in the AM Unilateral location in 50% Pain can be throbbing, pounding, pulsating, aching, ice-pick Associated nausea, photophobia, blurred vision, phonophobia, dizziness May be associated with menses

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Downloaded from migrainebuddy.com

Four Phases of a Migraine

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Visual Aura Phase in Migraine: Affects 15-20% of patients Can develop over 5-15 minutes and last up to 1 hour

All images downloaded from Pinterest

Four Phases of a Migraine

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Migraine Attack Phase: May last hours to days Unilateral pain in 56-68% 90% have coexisting nausea

Post Drome Migraine Phase: Drowsiness Depression Difficulty with concentration Cognitive changes Memory loss

Four Phases of Migraine

22Migraine Pathophysiology Sequence

Hargreaves RJ et al. Can J Neurol Sci. 1999;26(suppl 3):S12-S19


Headache Pathophysiology: CNS Activation (Red Areas)

Pain Perception: Anterior Cingulate Cortex

Migraine Generators:Raphe NucleiLocus CoeruleusPeriaqueductal Gray

Weiler C, et al. Nat Med 1995;1:658-660


Migraine: International Class. of Headache Disorders, Third EditionA. At least five attacks fulfilling criteria B–D B. Headache attacks lasting 4–72 hours (when untreated or unsuccessfully

treated)C. Headache has at least two of the following four characteristics:

1. unilateral location 2. pulsating quality 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of routine physical activity (e.g.

walking or climbing stairs)D. During headache at least one of the following:

1. nausea and/or vomiting 2. photophobia and phonophobia

E. Not better accounted for by another ICHD-3 diagnosis

Cephalalgia 2018, Vol. 38(1) 1–211


Headache: General Treatment Strategies for Any Headache Type

Avoid Triggers (I use migraine trigger handout with HA calendar)https://uhs.berkeley.edu/sites/default/files/HeadachesMigraines.pdf Maintain regular sleep schedule (I use sleep hygiene handout)https://www.thoracic.org/patients/patient-resources/resources/healthy-sleep-in-adults.pdf Limit caffeine intake (coffee, tea, chocolate) Limit nitrates/nitrites/MSG Reduce Stress (I use meditation handout)https://www.health.harvard.edu/PDFs/Stress_Relief_Guide.pdf Adequate Water Intake

https://uhs.berkeley.edu/sites/default/files/HeadachesMigraines.pdf

https://www.thoracic.org/patients/patient-resources/resources/healthy-sleep-in-adults.pdf

https://www.health.harvard.edu/PDFs/Stress_Relief_Guide.pdf


Common Migraine Triggers Stress Emotions Sex Glaring lights Altered Sleep Menses Physical exertion Alcohol TOB Excessive or withdrawal from

caffeine

Physical exertion Odors (perfume, exhaust

fumes, paint, solvents) Allergens Drugs (OCP, Nitroglycerin,

Excessive OTC analgesic use, theophylline, cimetidine, cocaine)

Foods (tyramine, nitrates, chocolate, aspartame, MSG)


Headache: General Treatment Strategies

Ice and/or Heat Massage Regular Exercise Cognitive Behavioral Therapy (CBT) Weight Reduction Meditation Stress reduction Psychotherapy


Headache: Migraine Treatment Strategies

Abortive Treatments Preventative Treatments


Headache: Migraine Treatment Strategies Abortive Treatments OTC medications Non-Triptans and Other Prescription medications Triptans Parenterals Anti-emetics (IV Metoclopramide 20 mg every 30 minutes up to 4

doses/Prochlorperazine PO, PR, IV, IM) Rescue Therapies Opioids (Meperidine 75 mg IM or 1.5 mg/Kg IV) Corticosteroids (Dexamethasone IV 6-24 mg single dose) Neuroleptics

Electronic Devices


Treatment of Acute Migraines: Over The Counter

Excedrin Migraine (Acetominophen 250 mg/ASA 250 mg/Caffeine 65 mg) Bayer Migraine (Acetominophen 250 mg/ASA 250 mg/Caffeine 65 mg) Tylenol Migraine (Acetominophen 250 mg/ASA 250 mg/Caffeine 65 mg) Advil Migraine (Liquid Ibuprofen 200 mg/Potassium 20 mg) Motrin Migraine (Liquid Ibuprofen 200 mg) Anacin Max Strength (ASA 500 mg/Caffeine 32 mg) Migralex (ASA 500 mg/Magnesium oxide 75 mg)


Treatment of Acute Migraines: Non-Triptans and Other Prescription Medications

Cafergot Migrainol Midrin Fioricet/Fiorinal, Esgic NSAIDS-Cambia (Diclofenac 50 mg) COX-2 Inhibitors (Celebrex, Vioxx, Bextra) Codeine/Hydrocodone Stadol Nasal Spray


Treatment of Acute Migraines: Triptans

Imitrex (Oral, Intranasal, SQ-Autoinjector) Zomig (Oral, ODT) Maxalt (Oral, ODT) Amerge (Oral) Axert (Oral) Frova (Oral) Relpax (Oral)


Treatment of Acute Migraines: Parenteral

Magnesium sulfate: 1 gram IV Sumatriptan: 4-6 mg SQ Ketorolac: 60 mg IV Dexamethasone: 8 mg IV Metoclopramide: 10 mg IV Dihydroergotamine: 1 mg IV Valproate sodium: 500 mg IV Droperidol: 2.5-5 mg IV

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Medication Route Dose (mg)Metoclopramide (Reglan) PO, IM, IV 5-20Prochlorperazine (Compazine) PO 5-10

PR 25IV 5-10

Droperidol (Inapsine) IM, IV 0.625-2.5Chlorpromazine (Thorazine, Largactil) PO 25-100

PR 50-100IV 10-50

Haloperidol (Haldol) IM 5IV 2-5

Olazepine (Zyprexa) PO 2.5-20

Treatment of Acute Migraines: Neuroleptics

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Extrapyramidal, tardive dystonias Hyperprolactinemia Anticholinergic Weight gain, metabolic syndrome Sedation Hypotension (chlorpromazine) QTc prolongation (droperidol,

haloperidol, chlorpromazine) Lowered seizure threshold

The Side Effects of Neuroleptics


Treatment of Migraines: When to Use Prophylaxis

> 2 migraines/month Attacks lasting several days per week Severity/Frequency that critically impacts patient’s daily life Abortive therapies are contraindicated, ineffective, overused or not tolerated Uncommon Migraine Type Hemiplegic Basilar Prolonged Aura


Treatment of Migraines: Classes of Prophylactics

4 Classes of Medications Anti-Epileptic Medications (Topiramate, Valproate, et al) Anti-Hypertensives (Beta-Blockers, Calcium channel blockers) Anti-Depressants (Amitriptyline, Nortriptyline, Venlafaxine) Calcitonin Gene-Related Peptide (CGRP) MAB (Monoclonal Antibodies)

Other Oral Medications Electronic Devices Subcutaneous Medications: BOTOX



4 Classes of Medications Class I: Anti-Hypertensives (Beta-Blockers, Calcium channel blockers) Propranolol (Inderal) 120-400 mg/day * Timolol (Blocadren) 20-40 mg/day * Naldolol (Corgard) 40-160 mg/day Metoprolol (Lopressor) 50-200 mg/day Atenolol (Tenormin) 25-100 mg/day Verapamil 240-620 mg/day Flunarazine 5-10 mg daily

* FDA Approved

These medications are contra-indicated in patients with CHF, Heart Block, Hypotension and Sick Sinus Syndrome



4 Classes of Medications Class II: Anti-Epileptics Topiramate (Topamax) 25-100 mg/day either QD or BID * AE: Weight loss, neuralgia, kidney stones

Valproic Acid (Depakote) 500-3000 mg/day * AE: Nausea, Sedation, Hair loss, Low PLT, Hepatic dysfunction,

Weight gain, Cognitive problems Need to follow CBC and LFT’s

* FDA Approved



4 Classes of Medications Class III: Anti-Depressants Tri-Cyclic Antidepressants (Amitriptyline, Nortriptyline) SSRI’s (Celexa, Lexapro, Prozac, Paxil, Zoloft, Viibryd) SNRI’s (Venlafaxine 150 mg daily, Duloxetine 60 mg daily, Effexor,

Cymbalta, Savella, Pristiq, Fetzima, Irenka, Khdezla) MAOI’s (Selegeline, Phenelzine, Isocarboxazid, Tranylcypromine) Avoid foods with tyramine and all alcohol to avoid blood pressure

crisisNone are FDA approved for migraine



4 Classes of MedicationsClass IV CGRP Antagonists* Erenumab (Aimovig): Dose 70 mg or 140 mg SQ monthly Binds to CGRP receptor

Fremanezumab (Ajovy): Dose 225 mg SQ monthly or 675 mg quarterly Blocks the ability of CGRP to bind to the CGRP receptor

Galcanezumab (Emgality): Dose 240 mg SQ initially then 120 mg monthly Blocks the ability of CGRP to bind to the CGRP receptor

* ALL FDA Approved


Treatment of Migraines: Other Prophylactics

Other Preventative Medications for Migraines: Cyproheptadine: 4 mg every 8 hours then 4-20 mg/day given q8hr

Serotonin antagonist (5-HT1a and 5-HT2 receptors) Adverse events: Dry mouth and lightheadedness

Gabapentin: 1800 mg daily in divided doses Adverse events: Somnolence, weight gain, edema, lightheadedness

Cadesartan Angiotensin receptor blocker 16 mg daily Adverse events: lightheadedness


Treatment of Migraines: Prophylactics

A Closer Look at the Calcitonin Gene-Related Peptide (CGRP) Antagonists Pathways Pathophysiology Short and Potential Long Term Side Effects

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Benarroch EE. Neurology. 2011;77(3):281-287

CGRP Receptors Occur at All Sites Involved in Migraine Pathogenesis

Calcitonin Gene-Related Peptide (CGRP) Pathways

45Calcitonin Gene-Related Peptides (CGRP’s)

Actions of CGRP’s Vasodilation Mast cell degranulation/Dural Inflammation/Peripheral Sensitization Pain Transmission/Central Sensitization

CGRP are released into the jugular venous system during migraine which in turn evokes the migraine

Antibodies to CGRP or its receptor prevent Migraines by: Removing excess CGRP released from Trigeminal Nerve endings Receptor Antibodies Block the receptor from signaling transmission

Anti-CGRP monoclonal Antibodies are: Specific for Migraine > 75 % responder rate Rapid onset (< 1 week)/Consistent serum levels for 30 days Good patient adherence with well tolerated safety profile To date, No Neutralizing Antibodies have been detected

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Short-term effects of CGRP Injection site reactions Constipation Hyper-sensitivity reactions URI Nausea

Anti-CGRP monoclonal Antibodies

Potential Long-term effects since CGRP receptors are widespread Pituitary Gland dysfunction Cardio-vascular (Ischemia, HTN) GI (Ulcers, IBS, constipation/diarrhea) Skin (Erythema, Inflammation, Wound healing)


Treatment of Migraines: Other Prophylactics

Downloaded from Pinterest

Botox (Botulinum Toxin Type A) Reduces Sensory Input to CNS Reduces Input to Muscle Spindle

FDA-approved in 2010 for Chronic Migraine Chronic means > 15 HA/month Fail 2 Classes of Prophylactic Medications

Decreases Nocioceptor Pathways C and A delta fibers Substance P CGRP Glutamate release Mechano- and Chemo-receptors

Approx 30-40 injections each treatment Administered every 12 weeks Cost: Between $300-$600 per treatment

American Headache Society Guidelines for Preventative Therapies

Level A(> 1 Class I Trial)

Level B(1 Class I or 2 Class II)

Level C(1 Class II Trial)

Level U(Inadequate or conflicting data)

Ineffective

Anti-Epileptics (VPA, Topamax)

SSNRI/TCA(Effexor, Elavil)

ACE Inhibitors(Lisinopril)

Carbonic Anhydrase Inhibitors(Diamox)

NOT Effective:AED-Lamotrigine

Beta-Blockers(Metoprolol, Propranolol, Timolol)

Beta-Blockers(Atenolol, Naldolol)

Angiotensin Receptor Blockers(Candesartan)

Antithrombotics (Coumadin, Pictamide, Acenocoumarol)

Probably NOT Effective:TCA-Clomipramine

Triptans(Frovatriptan)

Triptans (Naratriptan, Zolmitriptan)

Alpha Agonists (Clonidine, Guanfacine)

SSRI(Prozac)

Possibly NOT Effective:Beta-Blocker-AcebutololAED-ClonazepamNSAID-NabumetoneAED-OxcarbazepineARB-Telmisartan

AED (Tegretol) AED (Gabapentin)

Beta-Blockers(Nebivolol, Pindolol)

TCA (Protriptyline)

Anti-Histamines(Cyproheptadine)

Beta-Blocker (Bisoprolol)

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49Status Migrainosus

Migraine > 72 Hours Refractory to conventional treatment May try: Steroid Burst: Oral Prednisone 60 mg x 1 day with rapid taper Oral Dexamethasone 4-8 mg x 1 day with rapid taper IV Methylprednisolone 100-200 mg IV Dexamethasone 4-16 mg

Headache Cocktail #1 Ketorolac 60 mg IM Diphenhydramine 50 mg IM Prochlorperazine 10 mg IM


Headache Cocktail #2 Metoclopramide 10 mg PO Benadryl 25 mg PO Ibuprofen 600 mg PO

Headache Cocktail #3 DHE Nasal Spray 0.5 mg each nostril to max 4 mg/day Prochlorperazine 10 mg PO or 25 mg PR

IV Valproate DHE-DiHydroErgotamine: Most hospitals have specific

protocols for this medication


Emergency Room Treatment IV-NS 2-3 liter bolus or 80-100 cc/hr IV Diphenhydramine 12.5-25 mg IV Metoclopramide 10 mg IV Magnesium Sulfate 500-1000 mg IV Ketorolac 30 mg If no response: IV Sodium Valproate 500 mg OR IV Levetiracetam 500 mg OR IV Methylprednisolone 200 mg

IV Dihydroergotamine 0.5-1.0 mg if patient has not used a triptan within 24 hours and no other contraindications exist

Non-pharmacologic therapies for Headache tested in clinical trials

Behavioral Treatments Relaxation training Hypnotherapy Thermal Biofeedback training EMG Biofeedback Cognitive/Behavioral management

therapy New App called RELAXaHEAD

developed by NYU

Physical Treatments Accupuncture Heat TENS Occlusal adjustment OMM Yoga

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Over The Counter Treatments for Headaches

OTC Supplements Magnesium Glycinate 400 mg BID Riboflavin 400 mg daily Melatonin 3 mg nightly CoQ10 90-400 mg daily Butterbur 50-75 mg BID with meals Feverfew 18.75 mg daily Petadolex Topical Menthol 10% Other Neti Pot

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Lifestyle Modifications Diet Exercise Sleep Stress Management Stop Tobacco

FDA-Approved Devices to Treat Headaches

TENS Unit (Cefaly Device) FDA approved for Prevention of Migraines (with or without aura) AND FDA approved for Acute Migraine (with or without aura)

Vagus Nerve Stimulator (VNS) called gammaCore FDA approved for acute treatment of pain associated with episodic cluster HA FDA approved for prevention of cluster HA (No FDA approved medications) Also FDA approved for epilepsy and depression

Transcranial Magnetic Stimulation (TMS) called SpringTMS Approved in 2008 to treat depression Approved in 2014 to treat acute migraines Approved in 2017 or prevention of migraines Approved in 2018 for Obsessive Compulsive Disorder Approved in 2019 for children > 12 for migraine prevention 2019-Only device FDA approved for both acute and prophylactic treatment of

migraine in adults and children > 12 years old

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Cefaly Device 55 Transcutaneous electrical stimulation Acute-Works at

trigeminal nucleus caudalis

Chronic-Slow modulation of cortical areas

Daily 20 minute sessions for prophylaxis

60 minute session for acute treatment

Approximately $500 Although FDA

Approved, most insurances do not cover

Images from www.cefaly.us

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Images from www.gammacore.com

Prophyllaxis: 2 self-administered treatments consisting of three consecutive 2-minute stimulations should be applied daily

Acute TX-Three 2 minute stimulations applied consecutively and may repeat in 3 minutes and may treat up to 4 attacks or 8 treatments/day

$7,200 but hard to get covered by insurance

VNS Device: gammaCore

57Single-pulse Transcranial Magnetic Stimulation sTMS

Images from www.eneura.com

Presumed Mechanism of Action: Blocks Cortical Spreading Depression (CSD) Inhibits firing rate of VPM neurons

Acute Migraine Treatment 3 sequential pulses at onset of migraines and

wait 15 minutes and if needed 3 additional pulses and wait 15 minutes and if needed 3 more pulses

Preventative Migraine Treatment Treat with 4 pulses each morning and

evening given as 2 consecutive pulses then wait 15 minutes then 2 additional pulses and repeat this in the evening

Cluster Headache: ICHD-3 alpha Classification

A. At least 5 attacks fulfilling criteria B-DB. Severe or very severe “suicide headache” unilateral orbital, supraorbital and/or temporal pain lasting 15-180 min (when untreated)C. Either or both of the following:

1. ≥1 of the following ipsilateral symptoms or signs: a) conjunctival injection and/or lacrimation; b) nasal congestion and/or rhinorrhoea; c) eyelid oedema; d) forehead and facial sweating; e) miosis and/or ptosis2. a sense of restlessness or agitation

D. Frequency from 1/2 d to 8/d for > half the time when activeE. Not better accounted for by another ICHD-3 diagnosis

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Cluster Headache: Characteristics

More common in men in a 2.5 to 1 ratio Onset 20 to 40 years of age Affects 0.4% of the population Usually occurs the same time of year with no headache between clusters Primarily nocturnal attacks (50%) and wake the patient from sleep Alcohol triggers the headaches Usually unilateral with ipsilateral autonomic features Patient usually agitated during attacks Relieved with activity, medication, oxygen

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Cluster Headache: Treatment 60

Level A (Based on Level I evidence) Oxygen-100% at 12-15 L/min by face mask for 15-20 minutes* Sumatriptan 6mg SQ or 20 mg NS* Zolmitriptan 5mg NS* Non-invasive VNS for episodic Cluster Headache Sub-occipital steroid injections (12.46 mg of betamethasone

dipropionate plus 5.26 mg of betamethasone disodium phosphate plus 0.5 mL of 2% lidocaine)*

Deep Brain Stimulation (DBS) for Chronic Cluster HA Level B (Based on Level II evidence or extrapolated Level I evidence) Sphenopalatine Ganglion (SPG) trans-oral stimulation in Chronic

Cluster Headache Steroids: 50-80 mg/day tapered over 10-12 days Ergotamine 3-4 mg orally in divided doses for up to 3 weeks

* Used for Acute

Treatment


Level C (Level III evidence or extrapolated Level I or II evidence) Lidocaine NS or 1 mL of 10% solution applied for 5 minutes Octreotide (Sandostatin) 100 mcg SQ* DHE 45 1 mg IM, SQ or IV at first sign of HA and may repeat x 2-3x* Lithium 900 mg daily for chronic cluster headache Verapamil 360 mg daily for prophylaxis or chronic cluster HA Warfarin to INR 0.9-1.5 for prophylaxis Melatonin 10 mg daily for prophylaxis Valproic acid 600-2000 mg daily for prophylaxis Topamax 25 mg daily x 7 then increase to 400 mg/day for prophylaxis

* Used for Acute Treatment


Level U (Unclassified-Inconsistent or Inconclusive studies) Frovatriptan 5 mg daily for prophylaxis Melatonin 10 mg PO at Bedtime for prophylaxis Capsaicin cream intra-nasaly 3-4/day for prophylaxis Prednisone 20 mg QOD for prophylaxis Tizanidine 2-4 mg every 6-8 hours up to 24 mg/day in divided doses

for prophylaxis Medications Tried for Cluster HA which do NOT work or NOT

recommended Opioids OTC medications Nimodipine Clonidine

63Review of Levels of Evidence in Therapeutic Studies


8.2 Medication-Overuse Headache Classification8.2.1 Ergotamine-overuse headache8.2.2 Triptan-overuse headache8.2.3 Non-opioid analgesic-overuse headache8.2.4 Opioid-overuse headache8.2.5 Combination-analgesic-overuse headache8.2.6 Medication-overuse headache attributed to multiple drug classes

not individually overused8.2.7 Medication-overuse headache attributed to unspecified or

unverified overuse of multiple drug classes8.2.8 Medication-overuse headache attributed to other medication

Classifications of Medication Overuse Headaches: ICHD-3 alpha


Medication-overuse Headache: Diagnostic CriteriaA. Headache occurring on 15 days/month in a patient with a pre-existing headache disorderB. Regular overuse for >3 months of one or more drugs that can be taken for acute and/or

symptomatic treatment of headacheC. Not better accounted for by another ICHD-3 diagnosis

• Regular intake on 10 days/month for >3 months:• 8.2.1 Ergotamine-overuse headache• 8.2.2 Triptan-overuse headache• 8.2.4 Opioid-overuse headache• 8.2.5 Combination-analgesic-overuse headache

• Regular intake on 15 days/month for >3 months• 8.2.3 Non-opioid analgesic-overuse headache (Paracetamol

(Acetaminophen), Acetylsalicylic acid, NSAIDS)


Headache Types

Medication Overuse Headache Analgesic use > 2-3 days/week Headache present > 15 days/month Regular overuse > 3 months of one or more medication

that can be taken for acute and/or symptomatic treatment of HA

Headache has developed or markedly worsened during medication overuse

Primarily occurs in patients with a primary HA disorder such as migraine, cluster or tension-type HA

TX: Discontinuation of overused medication and a combination of pharmacological, non-pharmacological, behavioral and physical therapy interventions

Downloaded from www.doctormigraine.com


Medication Overuse Headache: Treatment Goal is to withdrawal from meds to establish baseline HA pattern This can be achieved by: Abrupt withdrawal (OTC analgesics, Triptans) Tapered withdrawal (BZD, Opioids, Barbiturates) Butalbital: Phenobarb taper for SZ prophylaxis with 30 mg

for every 100 butalbital and taper 30 mg every 2-3 days Opioid: Clonidine Patch 10.-0.2/24 hours x 1-2 weeks and

bridge with long-acting NSAID (Naproxen) daily


Medication Overuse Headache: TreatmentPossible In-patient or Outpatient Regimens Steroids (Prednisone 100 mg x 5 days) Ketorolac PO 60 mg x 1 then 10 mg q6h x 3 days Tizanidine 2-8 mg TID DHE 0.5-1 mg IV q8h with Reglan 10 mg x 3 days May bridge with Tizanidine/NSAIDs May bridge with IVMP 100-200 every 12 hours for 2-3 days

Relapse rate is 20-40% Limit future abortive medications to 2/week

Migraine Management in Pregnant Patients

Epidemiology In one retrospective study 30% of pregnant patients have

primary headachesMigraine without aura-64% Tension Headache-26%

Evaluate for pre-eclampsia > 20 weeks gestation If HA sudden or severe or worst HA of my life: Send to ER Migraine does NOT affect any outcome measure of pregnancy


First Trimester Hormonal changes

Lack of sleep

Low blood glucose

Hunger

Dehydration

Nasal congestion

Caffeine/sugar withdrawal

Stress


Second Trimester Occurrence is less

Avoid strong smells and exhaust fumes

Third Trimester Similar to First Trimester

Poor posture

Muscle tension from excess weight

Pre-eclampsia (Regular BP checks)

Migraine Management in Pregnant Patients Non-pharmacologic therapies preferred:

Cold compresses -Rest/Stress reduction/Psycho therapy

Warm bath -TMJ adjustment

Massage -Certain Herbal Treatments

Cefaly (TENS) Unit -Acupuncture

Hyperbaric oxygen -OMM

Short-term treatment

Acetaminophen, metoclopramide, small doses of caffeine, NSAIDs, IV Fluids, IV anti-emetic

If no effect may try Butalbital-acetaminophen-caffeine (Fioricet) 1-2 tabs q4h not to exceed 6/24h

Discontinue NSAIDs before week 32

No ASA in the third trimester

Prednisone (category B) may help shorten active migraine

Triptans (category C) used when benefits outweigh risks


Severe Headaches-Most Opioid analgesics are safe-Pregnancy Category B Codeine

Oxycodeine

Meperidone

Prophylactic treatment for frequent or disabling attacks

Beta-blockers relatively safe (pregnancy category C) except atenolol (Preg Category D)

Avoid Barbiturates and Benzodiazepines

Avoid ergotamine or DHE

Can try magnesium or riboflavin or fluoxetine

Avoid Butterbur in pregnancy (Association with Budd-Chiari syndrome)

Avoid feverfew and Co-Q 10

74Many Resources Online for Patients and Practitioners

https://americanmigrainefoundation.org/ https://americanheadachesociety.org/

http://www.achenet.org/

https://medlineplus.gov/headache.html

https://www.acponline.org/practice-resources/patient-education/online-resources/migraine

https://www.aan.com/

https://headaches.org/ http://www.migraines.org/

https://migraineresearchfoundation.org/

https://www.webmd.com/migraines-headaches/migraines-headaches-finding-help

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Essential Headache Management

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