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ChronicDailyHeadacheWhoisatriskandwhatcantheprovider

doaboutit?

KarenWilliams,MSN,RN,FNP-BCTNP2017

PatientExperience• 56yearoldmalewithahistoryoftension/migraineheadachessincethe

1980’swhileonactiveduty- Tanker(heavygear,awkwardpositioningintanker),currentlyacontractor-workingontanks

• Headaches6daysperweek,3daysmild,3daysseverelasting3-5hours.Hastostayhome3daysperweek

• Evaluatedbyneurology,failedmultiplemedications/PTmadehisneckhurtmore

Disclosures

• Offlabeluseofmedications

• TheviewsexpressedinthispresentationarethoseoftheauthoranddonotreflecttheofficialpolicyoftheDepartmentoftheVeteransAffairs,DepartmentofDefense,orU.S.Government

Objectives

• Discusstheburdensandriskfactorsassociatedwithheadaches

• DefineChronicDailyHeadache(CDH)

• Reviewtensiontypeheadacheandmigraine

• IdentifystrategiestoreducethepatientschanceofdevelopingCDH

• IdentifytreatmentstotreatCDH

• Casepresentation

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EpidemiologyofHeadaches

• Primaryheadachedisorderisestimatedtoaffect45(+)millionindividualsintheUS1

• World-wide,thepercentageoftheadultpopulationwithanactiveheadachedisorderis46%2

– 42%sufferfromtension-type– 11%frommigraine– 3%fromchronicdailyheadache

Socioeconomic

• Headacheisthemostcommonpain-relatedcomplaintamongworkers3

• Mostcommoncauseofabsenteeismfromworkandschool 1

• OneofthemostcommoncomplaintsintheER,withover3millionERvisitsin20003

• Estimated$17billionannually,forthecostofhealthcareassociatedwithmigraines4

ChronicDailyHeadache

• 15ormoreheadachedayspermonth

• lasting4ormorehours

• for>3months5

Step1- Classifytheprimaryheadache

• Chronicmigraine(CM)– hasfeaturesofmigraine;atleast8dayspermonth,relievedbyatriptanorergotderivative5

• Chronictensiontypeheadache(CTTH)- bilateralpressure/painlastinghourstodays,mildtomoderateintensity,notworsenedbyexertion5

• Newdailypersistentheadache(NDPH)

• Hemicraniacontinua

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Tension- TypeHeadache

• Themostcommonprimaryheadache

• Painisbilateral,oftendescribedaspressing,band–likeorvise-like.Intheforehead,templesorbackofheadandneck

• Intensity- Mildtomoderate

• Canlastfrom30minutesto7days

• Canbeassociatedwithphotophobiaorphonophobia butnotboth

Tension(Continued)

• Oftenaccompaniedbyfatigue,inadequatesleep

• Triggeredbystress,fatigueoremotionalbursts

• Usuallynotaggravatedbyphysicalactivity

• UsuallyrelievedwithOTCanalgesics,relaxation,reductionofstress

• Frequentlycoexistswithmigraine5

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Migraine

• Recurrentepisodesofgenerallyunilateral(maybebilateral),pulsating/throbbingpain

• Usuallyaggravatedbyphysicalactivityandoftenrelievedwithsleep

• Painismoderatetosevereanddebilitating

• Associatedsymptomsofnausea,vomiting,photophobiaandphonophobia

• Timeframeof4to72hours,ifuntreated

Step2- HeadacheEvaluationandDiagnosis

• Accurateandthroughheadachehistory

– FamilyHx,PersonalmedicalHx,Hx ofheadtrauma,Timeframeofheadache,ageofonset,howfrequent,duration,triggers,aggravatingfactors,co-morbidillnesses,impactonfamilyandwork/school

– Clinicaldescriptionoftheheadache:Location,intensity,natureofthepain,precedingsymptoms,auraorneurologicsymptoms

– Dotheyhavemorethan1typeofheadache?

Helpfulquestions

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DiagnosisofMigraineorTTH

• Helpfulquestions:– Howdoheadachesinterferewithyourlife?

– HowFrequentlydoyouexperienceheadachesofanytype?

– Hastherebeenachangeinyourheadachepatternoverthelast6months?

– Howoftenandhoweffectivelydoyouusemedicationstotreatheadaches?7

HeadacheAssessmentTools

• HeadacheCalendar- iHeadache/Migrainebuddy (freephoneapps)

• HeadacheImpacttest(6questions)– Helpspatientscommunicatetheseverityoftheheadachepaintotheirprovider

• TheMigraineDisabilityAssessmentQuestionnaire(5questions)– Measuresheadache-relateddisabilityin:work/school,householdandfamily/social

• MigraineSpecificQualityofLifeQuestionnaire(MSQ)(14questions)– RoleFunction-Restrictive– RoleFunction- Preventive– EmotionalFunction

Step3- PhysicalExam

• Neurologicalexam:Cranialnerves,Strength,Coordination,DTR’s(rule-outpapilledema,diploplia,facialweakness,gaitdisturbances,nuchalrigidity)

• ROMofneck/PalpationoftheTMJandoccipitalnerves(lookingfortendernessoredema,triggerpointsinparaspinal,shoulderareas)-

• BloodPressure:diastolicover120mmHgareassociatedwithanincreaseinheadaches

• ConsiderCBC,CMP,Thyroidfunctiontesting,Vit Dlevel(Lookingfortreatablecause)8

•Rule out a systemic illness or other organic cause

Triggerpoints

WithpermissionfromSeanRiehl RealBodywork

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RedFlagsSNOOP4

• Systemicsymptomsordisease(fever,weightloss,jawclaudication)

• Neurologicsignsorsymptoms(motorweakness,memoryloss,papillaryabnormality,sensoryloss)

• Onsetsudden(if<60sec,calledthunderclapheadache)

• Onsetbeforeage5orafterage50

• Patternchangefrompriorheadaches

SNOOP4(continued)

• PrecipitatedbyValsalvamaneuver- worrisomeforunderlyingvascularlesion

• Positional– headacheprecipitatedbylayingdownorstandingup

• Papilledema- elevatedintracranialpressure8,9

DiagnosticsforRedFlags

• Imagingstudies:Ctofhead,MRI– Lookingforstructuralabnormalities

• BloodchemistriesandBloodcounts– Sed rateshouldbemeasuredinadultsthatare50andolder

• Lumbarpuncture(afterobtainingbrainimaging):insuspectedmeningitis,subarachnoidhemorrhage,Pseudotumor cerebri,encephalitisorsystemicillness(lupus,sarcoidosis,vasculitis)7

Step4- IdentifyExacerbatingFactors

• Medicationoveruse• Caffeineoveruse• Depression/anxiety/stress• IncreasedBMI• Suboptimalsleep- <6or>8,Sleepapnea- untreated• Loweconomicstatus• Frequencyofbaselineheadache- greaterfrequencyleadstoprogression• Nutrition/diet- skippingmeals• Tobaccouse• Priorheadornecktrauma*• AnyuseofbarbituratesoropioidscanincreasechanceofCDH,toinclude

Butalbital(Fioricet)9,10

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Step5- ActionPlan

• Preventative

• Acutetreatments

• Lifestylemodifications

• Education- ongoing

• Realisticexpectations

MigraineTreatments

AbortiveTreatmentsforMigraine

• Abortives:– Firstline:NSAIDSorAcetaminophen– Firstlineifmoderatetosevere:Tripitans

• Constrictdilatedbloodvessels,reduceneuropeptidereleaseandinhibitimpulsetransmissioncentrallywithinthetrigeminovascularsystem

– Ergotamine/Dihydroergotamine (DHE)– Oxygeninhalation(100%)forclustermigraine11,12

Sleep Headache

Irritability/MoodCognitive

SymptomInteraction

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PreventativeTreatmentsforCDH/Migraines

• Considerif4ormoreheadachespermonth,considerco-morbidconditions– Propranolol*– Topiramate*– Divalproex*– Antidepressants– TCA’s– NSAIDS– Tizanidine– CalciumChannelBlockers- Clustermigraine9,10

*FDAapprovedformigraineprevention

Preventives(continued)

• Riboflavin(Vit B2)- Dosedat100mg,2tabstwiceperday

• Magnesium400mgperday(doseinevening)10

• OnabotulinumtoxinA (Botox)*• Cefaly*

• Acupuncture- moreresearchshowingthistobepromising13

• OccipitalNerveBlocks9,10

• BiofeedbackandCognitivetherapy 9,10

EffectiveTreatmentforCDH

• Effectivetreatment- basedontherightpreventativetreatment

• Successat50%lessheadaches

or

• 50%decreaseinintensity9

• Needtimeformedicationortreatmenttowork

• Startlow

• Rightdosage

• Closefollow-up9

MedicationOveruse

• Startingapreventativemedicationwhilestoppingtheoffendingagentishelpful

• Whenweaningofftheoffendingagentatransientincreaseinheadachecanoccurlasting2-10days

• Considershortcourseofcorticosteroids,NSAIDS,ordihydroergotamine(unlesstheseweretheoffendingagent)

• Occipitalblocks9,10

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Headache

EpisodicHeadache•Characterizetype•Abortivetherapy

•Maximum6doses/week

ChronicDailyHeadache•>15HAdayspermonth•Analgesicrebound•Prophylaxisiskey

Abortive ProphylaxisOnsetofaction~4wks

Avoidnarcotics&Benzos

NSAIDs•GIsideeffects

IbuprofenNaproxenSodiumAcetaminophenAspirin

Triptans•ContraindicatedinpatientswithCAD

Imitrex inj/oral/NSZomig oral/NSMaxalt/Relpax/AxertAmerge/Frova

CombinationMedications•RiskofW/D

Excedrin

Beta&AlphaBlockersPropranolol-helpw/anxietyPrazosin- helpw/NightmaresandpossiblyETOHabuse

Anti-depressants•Mayimprovemood•Improvessleep

Tofranil/Nortriptylline/AmitryptillineVenlafaxine/DuloxetineParoxetine/Fluoxetine/MirtazapineTrazodone

AEDS•NeuropathicpainGabapentin•MoodlabilityValproic acidTopirimate

AlternativesPromethazineMetoclopramideProchloroperazineOndansetronTizanidineOccipitalblockAcupuncture

CAMBio-feedbackVit B2/MagnesiumAcupunctureBOTOXPT/ChiropracticCefalyCES-Alpha-stim

Education

• Headachecalendar• Sleephygienetechniques• Abstinence/limitedalcoholuse• Propernutrition/limitedcaffeine/properwaterconsumption• Copingstrategies/Journaling/Stressmanagement• Limiteduseofabortivemedication/avoidoveruseheadaches

• Realisticexpectations9,10

AdditionalModalities

Whenmedicationisnotworkingornottolerated

(Botox)InjectionParadigm:31InjectionSitesAcross7MuscleAreas

BOTOX*PrescribingInformation,February2014;2.Blumenfeld,Headache.2010

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TranscutaneousSupraorbitalNeurostimulation/Cefaly

• FDAapprovedforpreventionofmigraine(March2014)• Varyingresults- needtouseitdailyfor20min• CurrentlynotcoveredbyInsurance

– Cost$349.00,packof3electrodes$25.00(goodfor20treatmentseach)

CranialElectrotherapyStimulationAlpha-stimAID

• FDAapprovedfortreatmentofAnxiety,Depression,Insomnia

• Noneedtomonitorlabs/minimalsideeffects/nodependency

• Costsavingsinreductionofothermeds/treatments

Acupuncture

Qi,orenergy,travelsalong12mainpathwaysormeridianswithinthebody

Healthisinfluencedbythequality,quantityandbalanceofourQi

Qiisprofoundlydisturbedbytraumaticstress

• Cochranesystemicreview2016– Acupunctureshouldbe

consideredformigrainepatientsforprevention,particularlyifhavingadverseeffectsfrommedications

– Acupunctureeffectsizewasstaticallysignificantlylargerinrealacupunctureversesshamacupunctureforchronicheadaches

– Acupunctureshouldbeconsideredfortreatingepisodicorchronictensionheadaches17

Auriculotherapy/AuricularAcupuncture

WithpermissionfromTerryOleson,Ph.Dwww.auriculotherapy.org

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MobileApps

• Breath2Relax

• VirtualHopeBox

• MindfulnessCoach

MobileAPPS

• http://t2health.dcoe.mil/products/mobile-apps

• http://t2health.dcoe.mil/sites/default/files/T2-TSWF-AIM-Client-Handout-Aug2016-web.pdf– Checklistforproviderstorecommendspecificappsorwebsites

Peppermintoil

• Welltolerated- usedforaromatherapy,topicaluse,enema• Helpfulfor:

– Tensionheadache– IrritableBowel– Non-ulcerdyspepsia– Nausea– Relaxessmoothmuscle/relievescolonicspasmswithbariumenemas

Peppermintoil

• Wheningestedsideeffects- allergicreactions,heartburn,perianalburning,blurredvision,nausea/vomiting

• MayinhibitcytochromeP4501A2system

• Contraindicated- Hiatalhernia,severeGERD,gallbladderd/o,cautionwithpregnancyandbreastfeeding.(Hasbeenusedtotriggermenstruation)

• Shouldnotbeusednearthefaceofinfantsduetopotentialtocausebronchspasms 14,15

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Lavender

• Thoughttoactonthelimbicsystem,wheninhaled,especiallyontheamygdalaandhippocampus-

• Safetyconcerns- shorttermsafe,needlongtermstudies,someconcernforgynecomastiawhenappliedtoskin.SomeGIupsetwheningested

• Donotingestduringpregnancyorbreastfeeding

• Helpfulfor-– Anxiety– Depression– Insomnia

• Nopotentialfordrugabuse16

EmpatheticListening

• Noonecareshowmuchyouknow,untiltheyknowhowmuchyoucare”– TheodoreRoosevelt

CasePresentation

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ChronicDailyHeadache

Veteranwith21yearsactiveduty

Background

• 56yr oldmalewithahistoryoftension/migrainessince1980’s

• StartedwhileworkingataTanker,heavygear,awkwardpositioninginthetanks

• Describedasstartingasapressurethatbuildsover15min- inthecervicaloccipitalarearadiatingforward,stabbingpainthroughtheeyesthrobbing/achingassociatedwithphotophobia/phonophobia,occasionalnausea,worsewithexertion.

• 3/wk ratedas3-5/10lasting3-4hours,3/wk ratedas7-8/10lasting4-5hours

• Hastoleaveworkabout3daysperweek

Background(continued)

• Unsurewhattriggerstheheadaches

• TreatedwithExcedrinmigraine/cyclobenzaprine,Layinginadark,quietroomwithicetohishead,eyesandneck

• Preventative:GabapentinandVenlafaxineforbackpain(doesnotfeelthesehelpwiththeheadaches)

• Pasttreatments:Nortriptyline,Topamax,Depakote,Robaxin,Naprosyn,Midrin.PTmadehisneckhurt

• CTofheadWNL,MRIofc/spineandL/spine- DDDandspinalcanalstenosisofC/spine- declinedsurgeryorinjectionsforcervicalspine

SocialHistory

• RetiredfromArmyafter21yrs asE7(SergeantFirstClass)MOSTanker,deployedduringGulfWar

• Divorced,14yr oldsonchildren/Somecollege

• Notobacco/NoETOH/1cupofcaffeine- coffee/Dietbalanced/Walking&householdduties/hobbies- activitieswithhisson

• Spiritualaffiliation-Christian

• Currentstressors:“mydivorce”,keepmysonhappy,finances

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MedicalHistory

• Migraine,cervicalradiculopathy,lowbackpain,OSA,Anxiety/depression,Allergicrhinitis,HTN,Colitis(duetoNSAIDS)

• NKDA

• Surgical- Rightshoulderreconstruction,Rfoot

• FamilyHx-Non-contributory

SignificantExamFindings

• NeurologicexamWNL

• Bilateraloccipitaltenderness,reproducesheadachewithpalpation,musclespasmsofcervicalandtrapeziusmuscles

• Teethwithsignsofbruxism

Treatment• Education onfindings,treatmentconsiderationstoincludeAcupuncture,

Botox,Occipitalblocks

• Selfhelpstrategiestoinclude,icetothebackofthehead,Breathingandneckexercises,Magnesium400mg.StopdailyuseofExcedrin

• EncouragedtocontinuewithMentalhealth

• Startedwithacupunctureandalpha-stim(failedcefaly)

Outcomes

• At2nd visit3weekslater,hestoppedExcedrin- headachesreducedto2-3mild/week,intheposteriorarea

• 1monthlaterusingalpha-stimtoreduceeachheadache,TEN’sunitforshoulderandbackpain,goingtoacupuncturistweeklyandworkingwithmentalhealthonthenightmares

• 3monthslater- Headachesremainmildatabout3perweek,continuestoavoidExcedrin,usingpeppermintoil,mindfulnessforrelaxation

• Theenvironmentoftheheadacheclinicallowedhimtorelax,hewasnowawareofhistriggersandworkingonrelaxingmore

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Summary

• Step1- Classifytheprimaryheadache- TensionandMigrainearethemostcommonprimaryheadaches

• Step2- Accurateandthroughheadachehistory

• Step3- Physicalexam/ruleoutsystemicillness

• Step4- Identifyingexacerbatingfactors

• Step5- ActionPlan- Acute,preventative,lifestylemodifications,educationisakeycomponent(RealisticExpectations)

HeadachetableMigraine Tension-Type CDH

Location Unilateral Bilateral VariesIntensity ModeratetoSevere MildtoModerate Mild tosevere

Duration 4to72 hours 30mins to7days Minutestohours.15ormoreheadachedayspermonthfor3monthsormore

Quality Pulsating Pressure/Tightening Variesdependingthetypeofprimaryheadache

AssociatedSymptoms

Nausea,vomiting,photophobia,phonophobia

Photophobia orphonophobia(butnotboth)

Lookformedicationoveruse,exacerbatingfactors

Female:Maleratio 3:1 1.3:1 Nopreference

1. TheClevelandClinicHealthFoundation.Overviewofheadacheinadults.ClevelandClinicHealthInformationCenterwebsite.AccessedFeb122008.

2. Stovner LJ,etal.TheGlobalBurdenofheadache:ADocumentationofHeadachePrevalenceandDisabilityWorldwide.Cephalgia 2007;27:193-210.

3. StewartWF,etal.LostProductiveTimeandCostDuetoCommonPainConditionsintheUSWorkforce.JAMA2003;2902443-2454.

4. GoldbergLD.Thecostofmigraineanditstreatment.AMJManag Care2005:11(2suppl):562-567.

5. HeadacheClassificationSubcommitteeoftheInternationalHeadacheSociety.TheInternationalClassificationofHeadacheDisorders:3rd edition(betaversion).Cephalagia 2013;33(9):629-808.

6. LiptonRB,Bigal ME,etal.Migraineprevalence,diseaseburden,andtheneedforpreventivetherapy.Neurology2007;68:343-349.

References

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References(continued)

7. MartinV,Elkind A.Diagnosisandclassificationofprimaryheadachedisorders.In:StandardsofCareforHeadacheDiagnosisandTreatment.ChicagoIll:NationalheadacheFoundation2004;4-18.

8. DeLucaGC,Bartleson JD.Whenandhowtoinvestigatethepatientwithheadache.Semin Neurol.2010;30:131-144.

9. Sheeler,R.D.,Garza,I.,Vargas,B.B.,&O'Neil,A.E.(2016).Chronicdailyheadache:Tenstepsforprimarycareproviderstoregaincontrol.Headache:TheJournalofHeadandFacePain,56(10),1675-1684.

10.Murinova,N.,&Krashin,D.(2015).Chronicdailyheadache. PhysicalMedicineandRehabilitationClinicsofNorthAmerica,26(2),375-389.doi:10.1016/j.pmr.2015.01.001

11.SilbersteinSD.Practiceparameter:evidence-basedguidelinesformigraineheadache(anevidence-basedreview):reportoftheQualityStandardsSubcommitteeoftheAmericanAcademyofNeurology.Neurology2000;55-754.

References(continued)

12. Becker,W.J.(2015).Acutemigrainetreatmentinadults. Headache:TheJournalofHeadandFacePain,55(6),778-793.doi:10.1111/head.12550

13. CoeytauxR,Befus D.RoleofAcupunctureintheTreatmentorPreventionofMigraine,Tension-Typeheadache,orChronicHeadacheDisorders.Headache:TheJournalofHeadandFacePain2016,56:1238-1240.

14. Briggs,P.(2016).Inhaledpeppermintoilforpostopnauseainpatientsundergoingcardiacsurgery. Nursing,46(7),61-67.

15. Kligler,B.,&Chaudhary,S.(2007).Peppermintoil. AmericanFamilyPhysician,75(7),1027-1030.

16. Koulivand,P.H.,Ghadiri,M.K.,&Gorji,A.(2013).Lavenderandthenervoussystem. Evidence-BasedComplementary&AlternativeMedicine(eCAM),2013,1-10.

17. Coeytaux,R.R.,&Befus,D.(2016).Roleofacupunctureinthetreatmentorpreventionofmigraine,tension-typeheadache,orchronicheadachedisorders. Headache:TheJournalofHeadandFacePain,56(7),1238-1240.doi:10.1111/head.12857.

KarenWilliams,MSN,RN,FNP-BCKDWHealthManagement@gmail.com

704-706-5519