Headache Migraine, Tension, and Cluster: Brainstorm! JEFFREY R. UNGER, MD, ABFM, FACE, FAAFP
Speaker Disclosure • Dr. Unger has nothing to disclose regarding therapeutic interventions of migraine.
Learning Objectives By the end of this activity, the participant should be better able to: 1. Discuss the epidemiology and pathogenesis of migraine headaches. 2. Discuss ways by which migraine can be diagnosed by PCPs. 3. Discuss clues which may differentiate migraine from “secondary headache” disorders. 4. Outline preventative, acute, abortive and rescue interventions for migraine.
Migraine Is a Very Common Medical Disorder 1‐Year Prevalence Rates; Population‐Based Studies; IHS Criteria (or Modified)
Migraine has an estimated worldwide prevalence of ~10%
“Migraine is one of the four most disabling disorders known to mankind.” ‐ World Health Organization
http://www.who.int/mediacentre/factsheets/fs277/en/
Migraine Pain Intensity and Disability • Migraine Facts • 53% of migraineurs require bed rest during acute attack • 9% function normally • 39% report cognitive impairment • During acute attack > 75% of patients report having severe or very severe pain Lipton RB et al. Headache. 2001;41:638‐645
A typical migraine in an adult lasts 3‐5 days!
Migraine in the Primary Care Setting • 1/3 of patients in primary care waiting rooms have migraine • Half of migraineurs have not been diagnosed Sheftell FD, et al. Headache. 2002;42:58‐69. Couch JR, et al. Neurology. 2003;60(suppl 1):A320‐A321.
Prevalence of Headache in the General Population • Prevalence of any form of headache was 93% in men and 99% in women. • Among men, 8% had, at some point, experienced migraine, compared with 25% of women. Rasmussen BK. Epidemiology of headache in a general population‐ a prevalence study. J Clin Epidemiol. 1991: 44 (11):1147‐57
Migraine Prevalence, Age, and Gender • Migraine peaks between ages 25‐55 • F: M = 4‐1 • Migraine is a CHRONIC disease that can occur in patients age 3 months through their 80’s
• In children, migraines typically last 4 hours or less • Consider migraine in children with vertigo and cyclic vomiting
• Remember, in pediatric MIGRAINE, child is absolutely asymptomatic between • Uncontrolled migraine in younger patients attacks results in “kindling,” which can increase migraine frequency in the future Lipton RB, et al. Neurology. 2007;68(5):343‐349 Lewis DW. Headaches in children and adolescents. Curr Probl Pediatr Adolesc Health Care. 2007 Jul. 37(6):207‐46
Where Do Migraine Sufferers Seek Medical Care? • 67% PCP • 16% specialty (neurology/headache) • 17% other (peds, ob/gyn)
Adapted from Lipton RB, et al. Headache. 1998;38:87‐96.
Definition of Migraine A stable pattern of recurrent disabling headaches without evidence of underlying cause. Migraineurs have a genetic sensitivity toward severe, disabling headaches. Migraineurs are born with a very sensitive nervous system The goal of migraine management is to allow the migraineurs to learn to reduce their neurological sensitivity. Unger J. Migraine prophylaxis. The Pain Practitioner. 17 (1). 32‐36. 2007
Migraine Pathogenesis • Migraine has a genetic basis ◦ Migraineurs are born with a very sensitive nervous system. Environmental triggers can activate the trigeminal nerve, inducing a migraine event ◦ Migraine is NOT due to vasoconstriction or vasodilatation • Trigeminal activation induces all headache disorders including migraine • Migraine has 5 phases ◦ ◦ ◦ ◦ ◦
Prodrome Aura Headache phase Postdrome Recovery Unger J, Cady R, Farmer K. Migraine headaches, Part 1; The Female Patient. 2003. 28; 32‐39.
Phases of a Migraine Attack Duration of Attack 4 hrs‐5 days Pre‐Headache Phase Prodrome • Food cravings, yawning, irritable, fatigue, cold hands and feet, loss of cognition • Initiation of migraine generator • Recognized by 85% of all migraineurs • Can treat with NSAIDS if recognized Aura • Occurs in 15% of migraineurs • Flashes of light, wavy lines, loss of vision, tingling in tongue and arm • Paresthesias migraine DOWN arm, not up! • Best treatment: Aspirin
Headache Phase •
Associated with nausea, vomiting, light and sound sensitivity, cognitive defects, dizziness, disability.
•
Lasts 1‐3 days
Postdrome • Duration 24 hours • Pt. anxious. No pain, but feels the headache can reoccur at anytime. Fatigue, dizzy. Adapted from Cady RK. Headache. 2008;48(9):1415‐1416.
Prodrome (In 60‐70% of All Patients) • Mood changes • Food craving • Muscle pain • Sensory change • Cognitive changes • Cold hands • Anxiety/depression • Fatigue • Yawning Changes in neurologic function due to homeostatic disequilibrium at cortical and subcortical areas of the brain prior to onset of headache
Migraine: Spreading Cortical Depression and Aura
Photos courtesy of Migraine Headache Clinical Presentation. http://emedicine.medscape.com/article/1142556‐clinical
Neck Pain During Migraine Prevalence ◦ 75% of subjects
Descriptions ◦ 69% ‐ Tightness ◦ 17% ‐ Stiffness ◦ 5% ‐ Throbbing ◦ 5% ‐ Other 82% had previously been given a diagnosis of tension‐type headache Kaniecki R. Neurology. 2002;58(Suppl 6):S15‐S20.
Photo courtesy of Simon James
Migraine Pathogeneis Genetic predisposition Triggers evoke aberrant firing of neurons resulting in cortical spreading depression (CSD) CSD activates the release of neurokinins and CGRP causing vascular dilation and increased platelet adhesiveness. Neuronal flow into the nucleus caudalis can eventually cause nausea, vomiting, dizziness, and severe head pain
Hadjikhani N, Sanchez Del Rio M, Wu O, et al. Mechanisms of migraine aura revealed by functional MRI in human visual cortex. Proc Natl Acad Sci USA. 2001;98(8):4687‐4692 Video courtesy of American Headache Society. With Permission.
International Headache Society – Criteria for Migraine Migraine is an episodic headache lasting 4‐72 hrs with: Any 2 of the following characteristics: At least 1 of the following: • Unilateral location • Photophobia and phonophobia • Pulsating quality • Nausea and/or vomiting • Moderate or severe pain intensity • Worsened by movement
+
Headache Classification Committee of the IHS. Cephalalgia. 2004;24(suppl 1).
Diagnosis of Migraine (ID Migraine) During the last 3 months, did you have the following with your headaches? 1. You felt nauseated or sick to your stomach Yes ___
No ___
2. Light bothered you (a lot more than when you don’t have headaches) Yes ___
No ___
3. Your headaches limited your ability to work, study, or do what you needed to do? Yes ___
No ___
• 2/3 for migraine • Sensitivity: 0.81 • Specificity: 0.75 Lipton RB, et al. Neurology. 2003;61:375‐382.
Physical Exam Vital signs! Look for any focal neurological findings Listen to the head! Feel the scalp and neck muscles
Listen to the Head!
Headache Lab Tests • CBC • ESR (If new onset of headache over age 50) • Headache is predominant feature in 65‐80% of patients with temporal arteritis
• T4, TSH, Thyroid Peroxidase Antibody Unger Jeff, Cady Roger K, Farmer‐Cady Kathleen. Migraine Headaches, Part 1: Presentation and Diagnosis. The Female Patient. May 2003: Vol.28. 14‐21
Heather History
Recurrent disabling headaches Light Sensitivity Nausea Vomiting + Family History Lasts 4‐72 hours
Unger J, Cady R, Farmer K. Migraine headaches, Part 1; The Female Patient. 2003. 8; 32‐39.
Secondary Headache Warning Signs & Signals • • • • • •
“A” headache (versus recurrent headaches) Sudden onset (thunderclap headache) Onset after age 50 years Systemic signs (fever, myalgias, weight loss) Systemic disease (malignancy, AIDS) Change in headache pattern • Progressive headache with loss of headache free periods
• Neurologic symptoms or abnormal physical findings • Cognitive changes • Asymmetry Silberstein et al. (eds.) Headache in Clinical Practice. 1999
Headache Comfort Signs + Family History Menstrual trigger Responds appropriately to specific treatment Periodic pattern Presence of an aura
Cady R. Lessons from Patient Care: Case Studies of Migraine Patients. In: Unger J (Ed) Clinics In Family Practice. 579‐602. Elsevier (Philadelphia). Sept. 2005.
Alarm Features Based on History • • • • • • • • •
Changes in headache pattern/freq/intensity Daily headache Blurred vision Dizziness/syncope/discoordination/focal neuro deficits Sudden/explosive onset Pain worse with coughing Change in personality Headache that wakes you up from sleep Onset after 50 years of age
Alarm Features Based on Physical • • • • • • • • •
Vitals: fever or hypertension (diastolic >120) Mental status change Meningeal signs Diminished pulse or tenderness of temporal artery Focal neurologic deficits: including visual acuity Papilledema Intraocular pressure Necrotic or tender scalp lesions Other signs of infection
Primary vs. Secondary Headache Disorders
Neuro‐Imaging • Consider if: ◦ ◦ ◦ ◦
Atypical migraine features Substantial change in headache pattern Signs or symptoms of neurologic abnormalities 0.18% of migraineurs with normal physical exam will have intracranial pathology
Frishberg BM, et al. www.aan.com. Accessed 2004.
Neuroimmage courtesy of Jeff Unger MD with permission
Is This Migraine? ‐ 45 y/o man with nightly headaches x 2 weeks. Pain so severe he extracted his own teeth!
Unger J, Cady R, Farmer K. Migraine headaches, Part 1; The Female Patient. 2003. 8; 32‐39.
One Nerve Pathway: Multiple Symptoms of Migraine
Does Peter Have Sinus Headaches?
Unger J, Cady R, Farmer K. Migraine headaches, Part 1; The Female Patient. 2003. 8; 32‐39.
Diagnosis of Sinusitis is Based on the Presence of at Least 2 Major or 1 Major + > 2 Minor Symptoms Major Symptoms
Minor Symptoms
• Purulent nasal discharge
• Headache
• Nasal congestion or obstruction
• Ear pain, pressure or fullness
• Facial congestion or fullness
• Halitosis
• Facial pain or pressure
• Dental pain
• Loss of taste or smell
• Cough
• Fever (acute sinusitis only)
• Fever (for subacute or chronic sinusitis) • Fatigue
Chow AW et al. IDSA clinical practice guidelines for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Disease. 2012: http://www.idsociety.org/uploadedFiles/IDSA/Guidelines‐ Patient_Care/PDF_Library/IDSA%20Clinical%20Practice%20Guideline%20for%20Acute%20Bacterial%20Rhinosinusitis%20in%2 0Children%20and%20Adults.pdf
Nasal Endoscopy No Headache
With a moderate to severe “sinus” headache
Reference: Schreiber CP et al. Arch Intern Med. 2004;164:1769‐1772. Photos courtesy of Jeff Unger, MD
1 hour after treatment with sumatriptan 6 mg SC
Strategies for Migraine Treatment
Lipton RB, et al. Headache. 1998;38:87–96. Silberstein SD, et al. Cephalalgia. 1997;17:67‐72.
Behavioral Approach to Migraine
No meal skips Exercise Sleep hygiene Avoid triggers Stop smoking Stop analgesics > 2 times weekly 2 cups java per day Relaxation exercises Have a written plan!!
Caffeine Withdrawal! Photo courtesy of mtoz
Educate Patient Regarding the Diagnosis of Migraine Emphasize biologic and behavioral aspects of migraine Reassure patient regarding migraine pathogenesis Discuss treatment expectations: reduction in frequency, intensity, duration of headaches as well as limiting migraine disability Engage patient in treatment plan Answer questions
Acute Migraine Treatment Goals • • • • • •
Headache‐free in 2 hours Back to full function in 2 hours Little to no side effects from medication Headache does not come back for 24 hours Relief of associated symptoms Acute medication not needed >2 times/week
Triptans Sumatriptan ◦Oral – 25, 50, 100 mg ◦Nasal – 5, 20 mg ◦Auto‐injector – 4 or 6 mg ◦Needle‐free injector – 6 mg ◦11mg nasal powder ODT, orally disintegrating tablet Physicians' Desk Reference, 2016. 70th ed. Montvale, NJ: PDR Network, LLC; 2016.
Zolmitriptan ◦Oral – 2.5, 5 mg ◦ODT – 2.5, 5 mg ◦Nasal – 5 mg Naratriptan ◦Oral – 1, 2.5 mg
Triptans Rizatriptan ◦Oral – 5, 10 mg ◦ODT – 5, 10 mg Almotriptan ◦Oral – 6.25, 12.5 mg
Frovatriptan ◦Oral – 2.5 mg Eletriptan ◦Oral – 20, 40 mg Sumatriptan/Naproxen ◦Oral – 85 mg/500 mg
ODT, orally disintegrating tablet Physicians' Desk Reference, 2016. 70th ed. Montvale, NJ: PDR Network, LLC; 2016.
Triptan Dosing Rules • • • • • • • • •
Treat early after migraine onset Use highest dose formulation Expect to be pain‐free and associated symptom‐free within 2 hours If headache worsening after 2 hours, repeat dose x 1 If headache worsens typically after initial dosing, reduce dose of triptan by 50% and add NSAID Can dose ondansetron 4‐8 mg for nausea In presence of nausea, consider SQ injection or nasal spray If no response to triptan, use “rescue” therapy Keep a migraine diary to record frequency, intensity and duration of migraine
Early Treatment of Migraine Improves Pain‐Free Outcomes • 80% of patients who treat mild migraine are pain‐free within 2 hours and experience less reoccurrence • 35% of patients who treat severe headaches are pain‐free at 2 hours and have a 70% reoccurrence rate within 24 hours. Cady RK et al SPECTRUM Study. Headache 2000 38:173‐8
When to Consider Preventive Therapy Migraine significantly interferes with patient’s daily routine, despite acute treatment Attack frequency >1/wk Acute medication ineffective, contraindicated, overused, or not tolerated Patient preference Presence of uncommon migraine conditions
Basic Rules For Migraine Prevention Pharmacology Start low, advance slow (migraineurs are drug‐sensitive) Consider comorbidities when prescribing preventive agents Re‐assess or increase dose of single agent after 6 weeks of use Advise patients when they should expect to feel some improvement with preventive care Consider tapering or discontinuing meds after 6 months Goal is to reduce pain index by 50% PTI= Intensity (0‐10) x duration (hrs) + frequency/30 days 7 x 8 hours over 10/30 days= 66
Selecting Preventive Treatment
Use Drug Best for Patient Take advantage of drug’s side effects Underweight patient: Pick a drug that produces weight gain Overweight: Select drug that is not associated with weight gain Insomniac: Use sedating tertiary TCAs at HS Elderly or cardiac patient: Use divalproex or topiramate Athlete: Avoid ‐blockers Graff‐Radford, S. Migraine Prophylaxis. In: Unger, J (ed). Clinics in Family Practice. Elsevier (Philadelphia). 445‐462. Sept 2005
Preventive Medications Anticonvulsants NSAIDs Divalproex* Antipsychotics Topiramate * Olanzapine Antidepressants Quetiapine TCAs (amitriptyline*) SSRIs (escitalopram) Neurotoxins SNRIs(venlafaxine, duloxetine) Botulinum toxin A* Beta blockers Other Propranolol* Riboflavin, feverfew, Timolol* Coenzyme Q10 Nadolol Magnesium oxide Calcium channel blockers ASA Verapamil Amlodipine * FDA approved for migraine prevention Silberstein S et al. Neurology. 2000;55(9 suppl 2):S46‐52. Biondi D. Chronic Daily Headache. In: Unger, J (ed). Clinics in Family Practice. Elsevier (Philadelphia). 463‐492. Sept. 2005.
Herbal Preventives • Butterbur (Petadolex) 75 mg twice a day • B2 (Riboflavin) 400 mg a day* • Magnesium 250‐400 mg a day* • Feverfew 3 dried leaves daily* • Coenzyme Q‐10 150‐300 mg a day * Effective for pediatric migraine Matchar DB, et al. AAN. US Headache Consortium. 2000:1‐58. Level A evidence. Levin M. Headache 2012;52;S2:76‐80. Markley H. Headache 2012;52:S2:81‐87.
Injection Pattern for OnabotulinumtoxinA – PREEMPT Technique (155‐200 Units)
Liberini et al. Neurol Sci. 2014 May;35 Suppl 1:41‐3
Video courtesy of Jeff Unger MD with permission
Menstrual Migraine Prevention Option • Frovatriptan 2.5 mg BID x 6 days beginning 2 days prior to onset of period • Frovatriptan 10 mg at onset of period • Frovatriptan 2.5 mg qd x 6 days beginning 2 days prior to onset of period Tepper, SJ. Treatment of menstrual migraine: evidence‐based review. Manag Care. 2007 Jul;16(7 Suppl 7):10‐4; discussion 15‐7. Cady, RK, et al. Two center randomized pilot study of migraine prophylaxis comparing paradigms using pre‐emptive frovatriptan or daily topiramate: research and clinical implications. Headache. 2012; 52 (5) 749‐764
Migraine Rescue Drugs • Olanzapine 10 mg PO • Quetiapine 100 mg PO • Magnesium Sulfate 1 gram IV Push • Occipital nerve block
Krusz JC. Aggressive Interventional Treatment of Intractable Headaches In The Clinic Setting. In: Unger, J (ed). Clinics in Family Practice. Elsevier (Philadelphia). 545‐567. Sept. 2005.
Occipital Nerve Block
Inject bupivacaine 0.5% 4 cc + triamcinolone 40 mg into the occipital notch on the side where patient perceives the majority of their head pain. Patient will note paresthesias lasting 6‐12 hours on the side of the head where the injection was performed followed by significant headache relief lasting days to weeks. Unger Jeff, Cady Roger K, Farmer‐Cady Kathleen. Understanding Migraine: Strategies for Prevention. Emergency Medicine. Oct. 2003. 39‐45
IV Magnesium 1 gram IV push over 1‐2 minutes Side effect: severe hot flash lasting