HCNE - BOSTON Massachussetts General Hospital
November 4, 2004
Treatment of Headache
ALAN M. RAPOPORT, M.D.Founder and Director
The New England Center for Headache
Stamford, Connecticut
Clinical Professor of Neurology
Columbia University College of Physicians & Surgeons
New York, N.Y.
Headache Therapeutic Options
• Nonpharmacologic approaches• Acute (abortive, symptomatic) therapy• Preventive therapy• Adjunctive therapies (Vitamins, Minerals,
Supplements, Herbs): – Vitamin B-2 (400 mg per day)– Magnesium (400 mg per day)– Feverfew– Petasites – Coenzyme Q 10 (300 mg per day)
• Physical Techniques
Rapoport AM,Rapoport AM, Sheftell FD & Tepper SJ 2004Sheftell FD & Tepper SJ 2004
Nonpharmacologic Therapies for Headache
• Avoidance of triggers (e.g., dietary, weather, altitude, sleep and stress)
• Making lifestyle changes (e.g., eating regularly, going to sleep on schedule, and exercising on a regular basis)
• Behavioral therapies– Relaxation techniques– Biofeedback training– Stress management– Conflict resolution
Rapoport AM,Rapoport AM, Sheftell FD & Tepper SJ 2004Sheftell FD & Tepper SJ 2004
Goals of Acute Migraine Treatment
• Effective headache relief rapidly and consistently
without recurrence →→ Pain Free State
• Restore the patient’s ability to function
• Minimize the use of rescue and backup medications
• Optimize self-care and reduce resource utilization
• Minimize side effects
• Be cost-effective
35
71
84
84
87
0 25 50 75 100
% Migraineurs
Pain relief takes too long
Doesn’t relieve all pain
Doesn’t always work
Headache comes back
Too many side effects
Reasons for Dissatisfaction with Current Treatment (U.S. Data)
Lipton et al. Headache 1999;39:S20-S26
Classes of Medications for Acute Treatment of Migraine
• OTC simple analgesics • NSAIDs and COX 2 Inhibitors• Combination analgesics (Excedrin Migraine)• Fiorinal®, Fioricet®, Esgic®, Midrin®
• Anti-nausea medication• (Triptans)• Ergots (Ergotamine and DHE)• Opiates (Narcotics i.e Vicodin, Codeine)
What is the Syndrome of “Rebound Headache”?
• It is the increase in headache from the overuse of pain medications (now called MOH)
• Occurs only in patients with pre-existing chronic headache
• A self-sustaining rhythm of predictable and escalating medication use
• Headaches increase in frequency and intensity and become refractory to acute care and preventive treatments
• Medication withdrawal results in escalation of headache followed by improvement
Rapoport AM, Sheftell FS & Tepper SJ 2004
TRIPTANS: Routes of Delivery
Tablets• Sumatriptan• Zolmitriptan• Naratriptan• Rizatriptan• Almotriptan• Frovatriptan• Eletriptan
“Fast-melts”• Rizatriptan - MLT• Zolmitriptan - ZMT
Suppository• Sumatriptan (Europe)
Injection• Sumatriptan
Nasal Sprays• Sumatriptan
• Zolmitriptan
Sheftell FD, Rapoport AM, 2004Sheftell FD, Rapoport AM, 2004
Which is the best Triptan?
• Many patients appear to be satisfied with the triptan they are taking
• But is it the ideal triptan for them? It may be. We ask 5 Questions to be sure:
1. How quickly does it start to work?2. When has it reached maximum effect?3. What % of the headache is gone?4. Are there any side effects?5. Does the headache recur within 24 hrs?
So... which is the best triptan?
• The one that works best for YOU!
• The triptans are more similar than different.
PostdromePostdromeProdromeProdrome Headache
Phases of The Migraine AttackWhen to Use Your Triptan
Associated Associated FeaturesFeatures
AuraAura
TimeTime
Inte
nsi
ty o
f S
ymp
tom
s o
r P
has
es
Early Intervention
Sheftell FD, Rapoport AM, 2004Sheftell FD, Rapoport AM, 2004
Indications for Preventive Strategies
• Frequency– Former: more than two attacks per month– Current: more than two attacks per week
• Disability/QOL related to headache• Unresponsive to acute therapies• Contraindications to acute therapies• Significant adverse events with acute therapies• Pharmacoeconomic considerations
Migraine Preventive Agents
Beta blockersBeta blockers• PropranololPropranolol**• NadololNadolol• AtenololAtenolol• TimololTimolol**• MetoprololMetoprolol
Ca channel blockersCa channel blockers• VerapamilVerapamil• AmlodipineAmlodipine• DiltiazemDiltiazem• NifedipineNifedipine• NimodipineNimodipine• NisoldipineNisoldipine
AntidepressantsAntidepressants• TricyclicsTricyclics
– AmitriptylineAmitriptyline– NortriptylineNortriptyline
• MAOIsMAOIs• SSRIsSSRIs
– FluoxetineFluoxetine– SertralineSertraline– ParoxetineParoxetine
AntiepilepticsAntiepileptics• Divalproex sodiumDivalproex sodium**• GabapentinGabapentin• Topiramate Topiramate **• CarbamazepineCarbamazepine• DilantinDilantin• LamotrigineLamotrigine• TiagabineTiagabine• ZonegranZonegran• LevetiracetamLevetiracetam• OxcabazepineOxcabazepineNSAIDsNSAIDs
• NaproxenNaproxen• MeclofenamateMeclofenamate• IbuprofenIbuprofen• KetoprofenKetoprofen• FlurbiprofenFlurbiprofen
• CelecoxibCelecoxib• RofecoxibRofecoxib• ValdexcoxibValdexcoxib
5-HT5-HT22 antagonists antagonists• CyproheptadineCyproheptadine• Methysergide*Methysergide*• MethylergonovineMethylergonovine‡‡
Alternative therapiesAlternative therapies• RiboflavinRiboflavin• MagnesiumMagnesium• ??CyanocobalaminCyanocobalamin• Feverfew, Co Q 10Feverfew, Co Q 10• PetasitesPetasites
Others Others • ACE inhibitorsACE inhibitors• ARBs-candesartanARBs-candesartan• QuetiapineQuetiapine• TizanidineTizanidine• ??OpiatesOpiates
FutureFuture AMPA/Kainate AntagAMPA/Kainate Antag NOS inhibitorsNOS inhibitors ?? LT antagonists LT antagonists Botulinum toxinBotulinum toxin NMDA antagonistsNMDA antagonists CGRP antagonists CGRP antagonists CSD antagonistsCSD antagonists Adenosine A1 AgonAdenosine A1 Agon Pure 5-HTPure 5-HT1B/1D1B/1D Agon Agon
•
Sheftell FD, Rapoport AM, 2004Sheftell FD, Rapoport AM, 2004•Approved indication for migraine in US; †Not available in the US; Approved indication for migraine in US; †Not available in the US; •‡ ‡ Methylergometrine in Europe; NOS = nitric oxide synthase; Methylergometrine in Europe; NOS = nitric oxide synthase; LT = leukotriene; CSD = cortically spreading depressionLT = leukotriene; CSD = cortically spreading depression
Menstrual Migraine - Therapy
• 1. NSAIDs, eg. Naproxen Na 550 mg tid
• 2. COX 2 inhibitor eg. rofecoxib 50 mg qd
• 3. Pulsed estrogens + combo
• 4. Corticosteroids (dexamethasone)
• 5. Short burst of Triptans (all may help)
• 6. Pulsed methylergonovine, beta blockers, ergotamine tartrate, DHE
Perimenstrual Pharmacologic Rx
Conclusion
• Get an accurate diagnosis from MD
• Don’t accept tension-type or sinus headaches as a diagnosis
• Don’t undertreat your migraine
• Don’t delay taking your medications
• Treat headache until pain-free
Thanks for your attention!