WAPA Spring CME

Diagnosis and Management of Difficult Headache

Sylvia Lucas MD, PhD, FAHS Clinical Professor of Neurology & Neurosurgery

Adjunct Rehabilitation Medicine University of Washington Medical Center

Seattle Sports Concussion Clinic Harborview Medical Center

April 22, 2017

My head hurts….

• The most important clinical question in the evaluation of a patient presenting with headache is to establish a specific diagnosis: is this a primary or secondary headache disorder?

• Headache is the 4th most common reason to go to the ED (1.4-3.3 million visits per annum)

• More than 2/3 are for a primary headache diagnosis

ICHD Classification 2nd Edition – ICHD II

Primary HA

(presumably a genetic-based cause with environmental triggers)

1. Migraine

2. Tension-type

3. Cluster and its relatives (TACs)

4. Other primary headaches (exertional, coital, hypnic, etc.)

Secondary HA

(thought to be causative and in close

temporal relationship to cause)

5. Posttraumatic

6. Vascular disease

7. Abnormal ICP, Neoplasm, etc

8. Substances

9. CNS infection

10. Metabolic

11. Cervicogenic, Eyes, Sinuses

12. Psychiatric HA

13. Neuralgias

14. Other

International Classification of Headache Disorders, 2nd edition

ONE-YEAR PREVALENCE OF COMMON HEADACHE DISORDERS

0

13

25

38

50

Migraine Episodic Tension-Type Headache

Frequent Headache

18

41

5 6

40

3

%

(>15 attacks per month)

Female

Male

Lipton RB, Stewart WF. Neurology. 1993. Schwartz BS et al. JAMA. 1998. Scher AI et al. Headache. 1998.

AGE- AND GENDER-SPECIFIC PREVALENCE OF MIGRAINE

Lipton RB, Stewart WF. Neurology. 1993.

Mig

rain

e P

reva

len

ce (

%)

Secondary Headache Warnings

• “Worst or first”

• New headache pattern

• Change in headache pattern

• Progressive headache syndrome

• Onset with valsalva or intercourse

• Papilledema or abnormal neurological exam

• New headache over the age of 50

• History of cancer or HIV

Scanning the Headache Patient

• Not always mandatory

• Indications for scan

– “First or worst,” new or different, change in pattern

– Abnormal exam

– Under age 5 or over age 50

– History of trauma

• Which scan?

– MRI – preferred

– CT – in ED, especially if bleed possible

Neurology. 1994;44:1353-1354.

32 year old woman Headache since age 12 Severe pain Stabbing, jabbing Knife through her eye Nausea and vomiting Scalp hurts Light hurts Sound hurts Movement hurts Stays in bed Lasts 24-36 hours Can’t work Misses 2 days of work per month

What kind of headache is this?

Differentiating Migraine and Tension-Type Headaches

Migraine • Usually lasts 4-72 hours

• Moderate to severe

• Often unilateral (60%), aura in a minority of patients

• Exacerbated by routine activity

• Nausea and/or vomiting, photophobia and phonophobia

Tension type • Low impact

• Usually bilateral, mild to moderate headache

• Photo- or phonophobia sometimes present

• No nausea or vomiting

Dowson AJ et al. Curr Med Res Opin. 2002;18:414-439.

Migraine is a Syndrome

• Pain Pathways – Referred pain

• Genetics

• Associated symptoms – Autonomic, mood changes, cognition

• Aura

• Internal and external triggers

Headache is a Referred Pain

Bartsch & Goadsby Current Pain and Headache Reports 2003;7:371-376

Activation of the TNC May Result in Referred Pain that Could be Perceived Anywhere along the Trigeminocervical Network

International Headache Genetics Consortium is a multinational research collaboration studying genetic causes of headache (IHGC Coordinator Risto

Kajanne, PhD University of Helsinki)

• As of 2016 there are 59,000 cases and 314,000 controls of genome datasets

• The genes are split approximately 50-50 between genes controlling neuronal function and genes controlling vascular function

Phases of a Migraine Headache

Adapted from Cady RK. Clin Cornerstone. 1999;1(6):21-32.

Premonitory/ Prodrome

Aura Mild Moderate to Severe HA Postdrome

Pre-HA Post-HA Headache

Time

Inte

nsi

ty

Migraine With Aura

• Pain preceded or accompanied by: • Visual phenomena such as

– Fortification spectrum – Scotoma – Photopsia

• Sensory phenomena – Paresthesia – Numbness

• Language dysfunction – Typically word finding difficulty

• Motor dysfunction Migraine with Aura may consist of aura symptoms without pain

Cephalalgia, 2013; 33(9) 629–808

STRATEGIES FOR MIGRAINE TREATMENT

Preemptive

treatment

Migraine trigger time-limited and

predictable

Preventive

treatment

Decrease in migraine frequency

warranted

Acute

treatment

To stop pain and prevent progression

Silberstein SD. Cephalalgia. 1997.

Establish diagnosis Set realistic goals

Educate patients Individualize care

Acute Migraine Medications

• Nonspecific – Simple Analgesics – NSAIDS – Combination analgesics – Opioids – Corticosteroids

• Adjunctive therapies – Antiemetics/dopamine antagonists

• Specific – Ergotamine/Dihydroergotamine – Triptans

Migraine-Specific Treatment Choices • Sumatriptan (Imitrex)

– Tablet (25, 50,100mg) – Injection (6mg, 4 mg stat dose) – Single Dose Vial 6mg/0.5cc – Nasal Spray (5, 20mg) – Needleless injection (Sumavel

Dose Pro 6mg) – Intranasal (Onzetra Sail 22mg)

• sumatriptan 85 mg and naproxen sodium 500 mg (Treximet)

• zolmitriptan (Zomig)

– Tablet (2.5, 5mg) – ZMT (2.5, 5mg) – Nasal Spray 5.0 mg

• Naratriptan (Amerge) – Tablet (1, 2.5mg)

• Rizatriptan (Maxalt) – Tablet (5, 10mg) – ODT (5, 10mg)

• Almotriptan (Axert) – Tablet (6.25,12.5mg)

• Frovatriptan (Frova) (Relpax) – Tablet 2.5mg

• Eletriptan – Tablet (20,40mg)

• DHE-45 (dihydroergotamine

mesylate) 4mg/cc injectable

• Migranal Nasal Spray 4mg/cc

Management Issues at First Visit

• Initial therapy – Match treatment needs to attack profile, associated

symptoms and level of disability (stratify the care)

– Explain recurrence

• Back-up therapy – If initial treatment fails

• Rescue therapy

• Education – Treat early and optimally, lifestyle changes, avoid triggers

Escalation of Migraine Pain Optimal Delivery

Time

Intensity Fast

Slow

Rescue therapy

• Patient has already used oral and usual medication

• Injectable treatment used most often

– Severe pain and later in the headache

– Gastroparesis, nausea or vomiting

• Both patient and physician desire rapid relief

– Need resources for sicker patients

– Need the room

Outpatient Treatment Protocols A combination approach

• Treatment with injectable anti-nausea medication – Dopamine antagonist if sedation is not an issue

– Ondansetron if sedation is to be avoided

• Treatment with a migraine specific therapy – Subcutaneous sumatriptan

– DHE-45®

• Treatment with injectable NSAID (especially if allodynia is present) – Ketorolac IM

Jakubowski M, Levy D, Goor-Areh I. et al. Headache 2005;45:850-861.

Neuroleptics (D2 receptor antagonists)

• Phenothiazines – Prochlorperazine, chlorpromazine, promethazine

• Butyrophenones – Droperidol, haloperidol

• Metoclopromide

• Anti-adrenergic, anticholinergic, antiseritonergic, antihistaminic effects – Sedation, drowsiness, EPS

– Prevent EPS (dystonia and akasthesia) by premedicating with an anticholinergic

Conclusions for Treatment Protocols • Based on weighted averages of percentage pain relief for medications

studied in at least 2 randomized single agent trials:

– Recommend combination of:

• Droperidol or proclorperazine IV (77-82% pain relief)

• Sumatriptan 6 mg SQ or DHE IV (67-78% pain relief)

• Ketorolac 30 mg IV or dexamethasone 6 mg IV (69-78% pain relief)

• Based on weighted averages of percentage pain free for medications studied in at least two randomized trials with drugs used as single agents:

– Recommend combination of:

• Proclorperazine IV or chlorpromazine IV (53% pain free)

• Meperidine IM, sumatriptan SQ or magnesium IV (30-36% pain free)

• IV is the preferred route of administration and recurrence many be decreased by the addition of dexamethasone

CHRONIC DAILY HEADACHE

Headache occurring on 15 or more days per month for more than 3 months ( which has the features of migraine headache on at least 8 days per month)

Cephalalgia, 2013; 33(9) 629–808

What is the CDH Phenotype?

Frequent

Daily

Continuous

Source: Scher/Stewart/Lipton, 2001, 2003

Differential Diagnosis of Chronic Daily

Headache

Adapted from Bigal ME, Lipton RB. J Headache Pain. 2007;8:263-272.

Chronic Daily Headache ≥4 hours

Continuous unilateral pain with autonomic features and

an indomethacin response

Clear onset as a daily syndrome

Pain and associated symptom

profile (non-migrainous)

No

No

Yes

Yes

Yes Chronic Tension-Type Headache

New Daily Persistent Headache

Hemicrania Continua

Exclude secondary headache

Migraine or specific acute

medications ≥8 days/month

No

Yes Chronic Migraine

Hemicrania Continua

• HC is characterized by a continuous strictly unilateral headache that varies in intensity, waxing and waning in severity without complete resolution

• Exacerbations may be accompanied by ipsilateral cranial autonomic symptoms, with a complete and dramatic response to indomethacin (usually at least 150 mg per day)

New Daily Persistent Headache

• NDPH is a headache that is daily and unremitting from or almost from the moment of onset, typically in individuals without a prior headache history. NDPH may take either of two forms: a self-limiting form which resolves without therapy within several months, and a refractory form which is resistant to any treatment.

• 50 year old woman with episodic headache since age 12

• Over last 3 years, increasing frequency of headache

• Moderate headache daily, more severe headaches 10 X per month

• Daily headaches bi-temporal

• Intermittent severe headaches left retro-orbital, associated with photophobia, nausea and occasional vomiting

• Takes eletriptan – effective 75% of time, uses hydrocodone as rescue. Eletriptan 20 days/month, hydrocodone 10 days/month

Refractory Headache Case

• Preventives in past included amitriptyline, propranolol, divalproate sodium, and gabapentin. All transiently effective.

• PMHx - GERD, allergic rhinitis, mild hyperlipidemia, fibromyalgia, anxiety, depression, perimenopausal

• Current Medications: Topiramate 100 mg. BID, Eletriptan 40 mg 20/month, Hydrocodone 5 mg. 10/month, Sertraline 200 mg. qd, Pantoprazole (Protonix) qd, nasal steroid (Flonase) BID, Allegra D qd, Premarin qd

• Social history – Works as an attorney, some caffeine, minimal exercise

• MRI brain 4 years ago OK

Refractory Headache Case (continued)

Case Questions

• What is her diagnosis? • HA since age 12, daily bitemporal, unilateral severe with N/V, P/P,

triptans work mostly, stress, so-so response to preventives, hot flashes, lots of medications, repeat MRI?

• What is the differential diagnosis of her headache? • Chronic migraine without aura, history of episodic migraine without

aura, possible medication overuse headache • What is the role of medication in her headache?

• Possibly medication overuse headache • Sertraline, Allegra D, Premarin (equine estrogens)?

• What are appropriate acute therapies for this patient? • Migraine specific

• What are appropriate preventive therapies for this patient? • May be the ones she is already on, but you won’t know until

medication overuse headache is out of the picture

Prevent medication overuse headache-no acute therapy more than 2-3 days a week on average.

Medication-Overuse Headache Criteria ICHD-2, revised 2006

A. Headache > 15 days/month

B. Regular overuse for >3 months of > 1 acute/symptomatic treatment drugs: 1. Ergotamine, triptans, opioids or combination analgesic

medications on >10 days/month on a regular basis for > 3 months

2. Simple analgesics or any combination of ergotamine, triptans, analgesics or opioids on >15 days/month on a regular basis for > 3 months without overuse of any single class alone

C. Headache developed or markedly worsened during medication overuse

Syndrome of Medication Overuse Headache (MOH)

• Also may be known as rebound headache

• Occurs in patients with pre-existing migraine/pain

• Pattern of headaches and overuse of analgesics in predictable and escalating frequency

• Prevention: limit frequency and dose of meds to 2-3 times a week, on average

• Treatment: refractory to otherwise appropriate therapy – withdrawal therapy – restriction of monthly doses for acute treatment

Medications With Risk of MOH or Rebound HA

Adapted from Smith TR et al. Drugs. 2004;64:2503-2514.

High Moderate to Low

acetaminophen, aspirin,

caffeine

butalbital/caffeine-containing

combinations

short-acting opioids

nasal decongestants

benzodiazepines

ibuprofen

dihydroergotamine mesylate

long-acting NSAIDs

simple analgesics

long-acting opioids

triptans

naproxen

Preventive Therapies

Goals of Preventive Treatment

• Reduce attack frequency, severity, and duration

• Improve responsiveness to treatment of acute attacks

• Improve function and reduce disability

• Reduce use of acute medication and potential for rebound headache

• Prevent disease progression

Classification of Migraine Preventive Therapies Level A efficacy (> 2 class I trials)

• AEDs – Divalproex sodium – Sodium valproate – Topiramate

• Beta blockers – Metoprolol – Propranolol – Timolol

• Triptans (for menstrual-related migraine) – frovatriptan

Silberstein SD et al. Neurology 78;2012

Classification of Migraine Preventive Therapies Level B efficacy (1 class I or 2 class II trials)

• Antidepressants – amitriptyline – venlafaxine

• Beta blockers – atenolol – nadolol

• Triptans (MRM) – naratriptan – zolmitriptan

Classification of Migraine Preventive Therapies Level C efficacy (1 class II trials) possibly effective

• ACE inhibitors – lisinopril

• Angiotensin receptor blockers – candesartan

• Alpha-agonists – clonidine – guanfacine

• AED – carbamazepine

• Beta blockers – nebivolol – pindolol

• Antihistamines – cyproheptadiene

Classification of Migraine Preventive Therapies Level U efficacy (inadequate or conflicting data)

• Carbonic anhydrase inhibitor – acetazolamide

• Antithrombotics – coumadin

• Antidepressants – fluvoxamine – fuoxetine

• AEDs – gabapentin

• TCAs – protriptyline

• Beta blockers – bisoprolol

• Calcium channel blockers – nicardipine – nifedipine – nimodipine – verapamil

Classification of Migraine Preventive Therapies (NSAIDS and complementary treatments)

• Level A – petasites (butterburr)

• Level B – fenoprofen, ibuprofen, ketoprofen, naproxen – Magnesium, feverfew, riboflavin

• Level C (possibly effective) – flurbiprofen, mefenamic acid, Co-Q10, estrogen

• Level U (inadequate or conflicting data) – Aspirin, indomethacin, hyperbaric oxygen

Migraine Comorbidity May Assist With Selection

of Preventive Agent

Comorbidity – Anxiety

– Bipolar

– Depression

– Epilepsy

– Insomnia

– IBS

– Raynaud’s

Agent – SSRI/SNRI, AED

– AED, SSRI/SNRI

– TCA w/wo SSRI

– AED

– TCA or T4CA

- Caution re: type

– Calcium blocker

AED=antiepileptic (anticonvulsant) drug; MVP=mitral valve prolapse; SSRI=selective serotonin reuptake inhibitor; SNRI=serotonin norepinephrine reuptake inhibitor; TCA=tricyclic antidepressant

Lipton R, Silberstein S. Clinician. 2001;19:1-26.

Other Types of Primary Headache • Cluster headache

– Occurs in episodes, or “clusters”

– Brief, severe pain around 1 eye lasting 15 min to 3 hours

– Up to 8 times per day, often waking patient from sleep

– Pacing headache

• Tension-type headache – Bilateral pressure, vice-like pain of mild to moderate

intensity

– Rarely accompanied by associated symptoms

Silberstein SD et al. Wolff’s Headache and Other Head Pain 2001:6-26

Treatment of Cluster Headache

• Acute therapy – Oxygen 100% for 10-12 minutes at 8L/miin via tight-fitting

mask – Imitrex Injectable 4-6 mg SQ

• Short-term prevention – Triptan or ergot at bedtime

• Prevention for episodic or chronic – Two preventives with rapid induction

• AED e.g. valproic acid or topiramate • Calcium channel blocker e.g. verapamil ( can go up to 480 mg)

– Corticosteroids

4.4 Primary headache associated with sexual activity

• 4.4.1 Preorgasmic headache – A. Dull ache in the head and neck associated with

awareness of neck and/or jaw muscle contraction and fulfilling criteria B.

– B. Occurs during sexual activity and increases with sexual excitement.

– C. Not attributed to another disorder

• 4.4.2 Orgasmic headache – A. Sudden severe (explosive) headache fulfilling criteria B. – B. Occurs at orgasm. – C. Not attributed to another disorder

ICHD-II Cephalalgia 2004; 24 (Supplement 1).

Menstrual Migraine Frequency

0

5

10

15

20

25

30

35

34 29 24 19 14 9 4 2 7 12 17 22 27 32

Used with permission from Headache in Clinical Practice. Copyright © 1998, 2002 Martin Dunitz Ltd.

Day of cycle

No. of attacks

76

Migraine in women (n=55)

Day 1 = first day of bleeding

Menstrually Related Migraine (MRM) Occurs Days -2 to +3

• Approximately 60% of women who experience migraine relate the frequency of their attacks to the menstrual cycle

• Pure menstrual migraine occurs from days -2 to +3 of menstruation in at least 2 out of 3 menstrual cycles

• Menstrually-related migraine always occurs

• on days -2 to +3 in at least 2 out of 3 menstrual cycles, as well as other times of the cycle

• Thought to be an estrogen withdrawal phenomenon

Allais G, Benedetto C. Neurol Sci. 2004;25 (suppl 3):S229-S231.

Behavioral Therapy

• Explanation

• Education

• Self control

• Relaxation

• Biofeedback

• Cognitive therapy

• Imagery

• Breathing

Therapies in Development

Occipital nerve stimulation chronic headache

Supraorbital nerve stimulation – Cefaly device – acute migraine therapy

Transcutaneous vagal nerve stimulation acute cluster headache therapy

Sphenopalatine ganglion stimulation acute (preventive?) cluster headache therapy

Transcranial magnetic stimulation acute migraine therapy

Inhaled sumatriptan; inhaled DHE; CGRP monoclonal antibody antagonists; neuromodulation therapy:

Thank you!