Getting ahead of headaches

GETTING AHEAD OF GETTING AHEAD OF HEADACHESHEADACHES

Ruben T. Dela Cruz MD FPNARuben T. Dela Cruz MD FPNA

Acute Stroke Unit - Manila Adventist Medical Acute Stroke Unit - Manila Adventist Medical CenterCenter

HEADACHES OR HEADPAINSHEADACHES OR HEADPAINS

• 90% OF INDIVIDUALS – AT LEAST ONE HEADACHE PER YEAR90% OF INDIVIDUALS – AT LEAST ONE HEADACHE PER YEAR

• 40% OF INDIVIDUALS WORLDWIDE – SEVERE, DISABLING HA 40% OF INDIVIDUALS WORLDWIDE – SEVERE, DISABLING HA ANUALLYANUALLY

• 5% OF EMERGENCY CASES OF HA – SERIOUS UNDERLYING 5% OF EMERGENCY CASES OF HA – SERIOUS UNDERLYING NEUROLOGICNEUROLOGIC

DISORDERDISORDER

COMMUNITY PREVALENCE OF COMMUNITY PREVALENCE OF HEADACHEHEADACHE

• PRIMARY HEADACHESPRIMARY HEADACHES

TYPETYPE PREVALENCEPREVALENCE

MigraineMigraine 16% 16% Tension- typeTension- type 69% 69% Cluster headacheCluster headache 0.1% 0.1% Idiopathic- stabbingIdiopathic- stabbing 2% 2% Exert ionalExert ional 1% 1%

COMMUNITY PREVALENCE COMMUNITY PREVALENCE OF HEADACHESOF HEADACHES

• SECONDARY HEADACHESSECONDARY HEADACHES

TYPETYPE PREVALENCEPREVALENCE

Systemic infectionSystemic infection 63%63%

Head injuryHead injury 4% 4%

Subarachnoid hemorrhageSubarachnoid hemorrhage 1% 1%

Vascular disorderVascular disorder 1% 1%

Brain tumorBrain tumor 0.1% 0.1%

PAINFUL BUT BENIGN HEADACHES PAINFUL BUT BENIGN HEADACHES (PRIMARY HEADACHES)(PRIMARY HEADACHES)

• MIGRAINEMIGRAINE

• CLUSTER HEADACHECLUSTER HEADACHE

• TENSION-TYPE HEADACHETENSION-TYPE HEADACHE

• BENIGN EXERTIONAL HABENIGN EXERTIONAL HA

• ORGASMIC HAORGASMIC HA

SERIOUS HEADACHE SERIOUS HEADACHE (SECONDARY HEADACHES)(SECONDARY HEADACHES)• Raised Intracranial pressure from any causeRaised Intracranial pressure from any cause• CNS infections (meningitis, encephalitis)CNS infections (meningitis, encephalitis)• Subarachnoid hemorrhageSubarachnoid hemorrhage• Cranial arteritis (eg. Giant cell arteritis)Cranial arteritis (eg. Giant cell arteritis)• Metabolic disturbances (ie. hypoglycemia, carbon Metabolic disturbances (ie. hypoglycemia, carbon

monoxide poisoning)monoxide poisoning)• Pheochromocytoma and malignant hypertensionPheochromocytoma and malignant hypertension• Acute glaucomaAcute glaucoma• Head traumaHead trauma• Focal CNS ischemia or hemorrhageFocal CNS ischemia or hemorrhage

GENERAL CONSIDERATIONS IN EVALUATING GENERAL CONSIDERATIONS IN EVALUATING HEADACHESHEADACHES

• QUALITYQUALITY

• SEVERITYSEVERITY

• LOCATIONLOCATION

• DURATIONDURATION

• TIME COURSETIME COURSE

• CONDITIONS THAT PRODUCE, EXACERBATE, OR RELIEVE ITCONDITIONS THAT PRODUCE, EXACERBATE, OR RELIEVE IT

HEADACHE SYMPTOMS- SUGGESTING SERIOUS HEADACHE SYMPTOMS- SUGGESTING SERIOUS DISORDERDISORDER

• “Worst” headache ever

• First severe headache

• Sub acute worsening over days or weeks

• Abnormal neurologic examination

• Fever or unexplained systemic signs

• Vomiting precedes headache

• Induced by bending, lifting, coughing

• Disturbs sleep or present immediately upon awakening

• Known systemic illness

• Onset after age 55

SYMPTOMS OF SERIOUS UNDERLYING CAUSES OF SYMPTOMS OF SERIOUS UNDERLYING CAUSES OF HEADACHEHEADACHE

CAUSE SYMPTOMS

Meningitis Nuchal rigidity, headache, photophobia, and prostration; may not be febrile, lumbar puncture is diagnostic

Intracranial hemorrhage

Nuchal rigidity and headache; may not have clouded consciousness or seizures. Hemorrhage may not be seen on CTscan. Lumbar puncture shows “bloody tap” that does not clear by the last tube. A fresh hemorrhage may not be xanthochromic.

Brain tumor May present with prostrating pounding headaches May present with prostrating pounding headaches that are associated with nausea and vomiting. that are associated with nausea and vomiting. Should be suspected in progressively severe new Should be suspected in progressively severe new “migraine” that is invariably unilateral“migraine” that is invariably unilateral

Temporal arteritis

Glaucoma

May present with a unilateral pounding headache. Onset generally in older patients (>50 years) and frequently associated with visual changes. The ESR is the best screening test and is usually markedly elevated (>50). Definitive diagnosis made by arterial biopsy

Usually consists of severe eye pain. May have nausea and vomiting. The eye is usually painful and red. The pupils may be partially dilated.

PAIN-SENSITIVE CRANIAL PAIN-SENSITIVE CRANIAL STRUCTURESSTRUCTURES

• SKIN, SC TISSUE, MUSCLES, EX-SKIN, SC TISSUE, MUSCLES, EX-CRANIAL ARTERIES, PERIOSTEUM OF CRANIAL ARTERIES, PERIOSTEUM OF SKULLSKULL

• EYE, EAR, NASAL CAVITIES, SINUSESEYE, EAR, NASAL CAVITIES, SINUSES

• INTRACRANIAL VENOUS SINUSESINTRACRANIAL VENOUS SINUSES

• BASAL DURA, CIRCLE OF WILLISBASAL DURA, CIRCLE OF WILLIS

• MIDDLE MENINGEAL A., SUPERFICIAL MIDDLE MENINGEAL A., SUPERFICIAL TEMPORAL ARTERIESTEMPORAL ARTERIES

PAIN – SENSITIVE STRUCTURES OF THE PAIN – SENSITIVE STRUCTURES OF THE HEADHEAD

• Distention, traction, or dilatation of intracranial or extracranial Distention, traction, or dilatation of intracranial or extracranial arteriesarteries

• Traction, or displacement of large intracranial veins or their dural Traction, or displacement of large intracranial veins or their dural envelopeenvelope

• Compression, traction, or inflammation of cranial and spinal nervesCompression, traction, or inflammation of cranial and spinal nerves

• Spasm, inflammation, or trauma to cranial and cervical musclesSpasm, inflammation, or trauma to cranial and cervical muscles

• Meningeal irritation and raised intracranial pressureMeningeal irritation and raised intracranial pressure

• Activation of brainstem structures Activation of brainstem structures

NEUROANATOMY OF HEADACHENEUROANATOMY OF HEADACHE

PERIPHERAL INNERVATIONPERIPHERAL INNERVATION

• Trigeminal ganglion (Ophthalmic)- supratentorial Trigeminal ganglion (Ophthalmic)- supratentorial structuresstructures

• Branches of Cervical 2- posterior fossa structuresBranches of Cervical 2- posterior fossa structures

CENTRAL TERMINATIONCENTRAL TERMINATION

• Trigeminocervical complex-caudalis neurons and Trigeminocervical complex-caudalis neurons and neurons of superficial laminae of C1-C2neurons of superficial laminae of C1-C2

• Non-trigeminal projections- brainstem periaqueductal Non-trigeminal projections- brainstem periaqueductal gray and ventroposterior thalamusgray and ventroposterior thalamus

PHYSIOLOGY OF HEAD PAINPHYSIOLOGY OF HEAD PAIN

• Craniovascular vasodilatationCraniovascular vasodilatation• Peripheral trigeminal nerve activationPeripheral trigeminal nerve activation

* Elevation of neuropeptide levels- CGRP (calcitonin * Elevation of neuropeptide levels- CGRP (calcitonin gene-related peptide); substance Pgene-related peptide); substance P* Plasma protein extravasations* Plasma protein extravasations

• Central trigeminal neuronal activationCentral trigeminal neuronal activation* Trigeminal nucleus* Trigeminal nucleus* Non-trigeminal transmission- medial thalamic and* Non-trigeminal transmission- medial thalamic andventroposterior thalamic neuronsventroposterior thalamic neurons

STEPS IN THE OPTIMUM MANAGEMENT STEPS IN THE OPTIMUM MANAGEMENT OF PRIMARY HEADACHESOF PRIMARY HEADACHES

• Make a confident diagnosisMake a confident diagnosis• Assess headache-related disability and impact on Assess headache-related disability and impact on

patients quality of life (QOL).patients quality of life (QOL).• Address behavioral and educational issues in Address behavioral and educational issues in

headache managementheadache management• Discuss and prescribe preventive medications, if Discuss and prescribe preventive medications, if

indicatedindicated• Prescribe an acute treatment based on diagnosis, Prescribe an acute treatment based on diagnosis,

disability assessment and patient’s preferencedisability assessment and patient’s preference• Monitor patient outcomes and modify treatment Monitor patient outcomes and modify treatment

as necessaryas necessary

DRUGS EFFECTIVE IN THE TREATMENT OF TENSION-DRUGS EFFECTIVE IN THE TREATMENT OF TENSION-TYPE HATYPE HA

DRUGDRUG TRADE TRADE NAMENAME

DOSAGEDOSAGE

NONSTEROIDAL ANTIINFLAMMATORY NONSTEROIDAL ANTIINFLAMMATORY AGENTSAGENTS

AcetaminophenAcetaminophen

AspirinAspirin

DiclofenacDiclofenac

IbuprofenIbuprofen

Naprosyn sodiumNaprosyn sodium

COMBINATION ANALGESICSCOMBINATION ANALGESICS

Acetaminophen + butalbitalAcetaminophen + butalbital

Aceta + butalbital + caffeineAceta + butalbital + caffeine

Aspirin + butalbital + cafeineAspirin + butalbital + cafeine

PROPHYLACTIC MEDICATIONSPROPHYLACTIC MEDICATIONS

AmitriptylineAmitriptyline

NortriptylineNortriptyline

DoxepinDoxepin

TylenolTylenol

GenericGeneric

CataflamCataflam

Advil, MotrinAdvil, Motrin

Naproxen,AleNaproxen,Aleveve

PhrenelinPhrenelin

Fioricet, Fioricet, FiorinalFiorinal

ELAVILELAVIL

PamelorPamelor

SinequanSinequan

650 mg PO q4-6h650 mg PO q4-6h


50-100 mg q4-6h 50-100 mg q4-6h max 200mg/dmax 200mg/d


220-550mg bid220-550mg bid

1-2 tbs mx 6 tbs/d1-2 tbs mx 6 tbs/d

1-2 tbs mx 6 tbs/d1-2 tbs mx 6 tbs/d

1-2 tbs mx 6tbs/d1-2 tbs mx 6tbs/d

10-50 MG at 10-50 MG at BedtimeBedtime

25-75 mg at 25-75 mg at bedtimebedtime

10-75 mg at bt10-75 mg at bt

Symptoms Accompanying Severe Migraine Attacks

• Nausea 87%

• Photophobia 82%

• Lightheadedness 72%

• Scalp tenderness 65%

• Vomiting 56%

• Visual disturbances 36%– Photopsia 26%– Fortification spectra 10%

• Paresthesias 33%

• Vertigo 33%

• Alteration of consciousness 18%– Syncope 10%– Seizure 04%– Confusional state 04%

• Diarrhea 16%

NONPHARMACOLOGIC APROACHES TO NONPHARMACOLOGIC APROACHES TO MIGRAINEMIGRAINE

• Identify and then avoid trigger factors such as:Identify and then avoid trigger factors such as:– Alcohol (e.g. Red wine)Alcohol (e.g. Red wine)– Foods (e.g. chocolate, certain cheeses, monosodium Foods (e.g. chocolate, certain cheeses, monosodium

glutamate, nitrate containing foods)glutamate, nitrate containing foods)– Hunger (avoid missing meals)Hunger (avoid missing meals)– Irregular sleep patterns (both lack of sleep and excessive Irregular sleep patterns (both lack of sleep and excessive

sleep)sleep)– Organic odorsOrganic odors– Sustained exertionSustained exertion– Acute changes in stress levelsAcute changes in stress levels– Miscellaneous (glare, flashing lights)Miscellaneous (glare, flashing lights)

• Attempt to manage environmental shiftsAttempt to manage environmental shifts– Time zone shiftTime zone shift– High altitudeHigh altitude– Barometric pressure changesBarometric pressure changes– Weather changesWeather changes

• Assess menstrual cycle relationshipAssess menstrual cycle relationship

A staged Approach to Migraine Pharmacotherapy

Mild Migraine Occasional throbbing Occasional throbbing headachesheadaches

No major impairment of No major impairment of functioningfunctioning

NSAIDsNSAIDs

Combination Combination analgesicsanalgesics

Oral 5-HT1 agonistsOral 5-HT1 agonists

Moderate Migraine Moderate or severe Moderate or severe headachesheadaches

Nausea commonNausea common

Some impairment of Some impairment of functioningfunctioning

Oral, nasal, or SC 5-Oral, nasal, or SC 5-HT1 agonistHT1 agonist

Oral dopamine Oral dopamine antagonistantagonist

Severe Migraine Severe headaches Severe headaches >3x per month>3x per month

Significant functional Significant functional impairmentimpairment

Marked nausea Marked nausea and/orand/or

vomitingvomiting

SC, IM, or IV 5-HT1 SC, IM, or IV 5-HT1 agonistagonist

IM or IV dopamine IM or IV dopamine antagonistantagonist

Prophylactic Prophylactic medicationsmedications

StageStage DiagnosesDiagnoses TherapiesTherapies

STEP-CARE vs STRATIFIED-CARE in STEP-CARE vs STRATIFIED-CARE in HEADACHE MANAGEMENTHEADACHE MANAGEMENT

• STEP-CARE : Begins at the bottom of therapeutic STEP-CARE : Begins at the bottom of therapeutic pyramid- simple, least expensive agent and pyramid- simple, least expensive agent and escalated according to patient’s need.escalated according to patient’s need.

• STRATIFIED- CARE: Provides a systematic method to STRATIFIED- CARE: Provides a systematic method to match the treatment needs of the patient with the match the treatment needs of the patient with the intensity of treatment.intensity of treatment.

A STAGED APPROACH TO MIGRAINE A STAGED APPROACH TO MIGRAINE PHARMACOTHERAPYPHARMACOTHERAPY

STAGESTAGE DIAGNOSISDIAGNOSIS THERAPIESTHERAPIES

Mild MigraineMild Migraine Occasional throbbing Occasional throbbing HAHA

No major impairment No major impairment of functioningof functioning

NSAIDsNSAIDs

Combination Combination analgesicsanalgesics

Oral 5-HT1 agonistOral 5-HT1 agonist

Moderate MigraineModerate Migraine Moderate or severe Moderate or severe HAHA

Nausea commonNausea common

Some impairment of Some impairment of functioningfunctioning

Oral, nasal r SC 5-HT1 Oral, nasal r SC 5-HT1 agonistagonist

Oral dopamine Oral dopamine antagonistsantagonists

Severe migraineSevere migraine Severe HA >3x / moSevere HA >3x / mo

Significant functional Significant functional impairmentimpairment

Marked nausea Marked nausea and/or vomitingand/or vomiting

SC, IM, or IV 5-HT1 SC, IM, or IV 5-HT1 agonistagonist

IM or IV dopamine IM or IV dopamine antagonistantagonist

Prophylactic Prophylactic medicationsmedications

DRUGS EFFECTIVE IN ACUTE TREATMENT OF DRUGS EFFECTIVE IN ACUTE TREATMENT OF MIGRAINEMIGRAINE

DRUG TRADE NAME DOSAGEDOSAGE

NSAIDs________________NSAIDs________________

Acetaminophen, aspirin, Acetaminophen, aspirin, caffeinecaffeine

Excedrin- MigraineExcedrin- Migraine 2 tab q6h max 8/day2 tab q6h max 8/day

5-HT1 AGONIST5-HT1 AGONIST

ORAL:ORAL:

ErgotamineErgotamine

Ergotamine-Ergotamine-caffeinecaffeine

NaratriptanNaratriptan

RizatriptanRizatriptan

SumatriptanSumatriptan

ZolmitriptanZolmitriptan

ErgomerErgomer

Ercaf; WigraineErcaf; Wigraine

AmergeAmerge

MaxaltMaxalt

Imitrex, ImigranImitrex, Imigran

Zomig (Rapimelt)Zomig (Rapimelt)

0ne 2-mg sl tab at 0ne 2-mg sl tab at onsetand q 1/2h mx onsetand q 1/2h mx 3/d; 5/wk3/d; 5/wk

2.5 mg tb at onset, 2.5 mg tb at onset, rpt after 4 hrsrpt after 4 hrs

5-10 mg at onset rpt 5-10 mg at onset rpt after 2 hrs, mx-after 2 hrs, mx-10mg/d10mg/d

50 to 100 mg tb at 50 to 100 mg tb at onset, rpt after 2 hrs. onset, rpt after 2 hrs. mx 200 mg/dmx 200 mg/d

2.5 mg at onset, rpt 2.5 mg at onset, rpt after 2 hrs, mx after 2 hrs, mx 10mg/d10mg/d

DRUGS EFFECTIVE IN ACUTE TREATMENT OF MIGRAINEDRUGS EFFECTIVE IN ACUTE TREATMENT OF MIGRAINE

5-HT1 agonist5-HT1 agonist

NASALNASAL

DihydroergotamineDihydroergotamine


PARENTERALPARENTERAL

DihydroergotamineDihydroergotamine


Migranal nasal sprayMigranal nasal spray

Imitrex nasal sprayImitrex nasal spray

DHE-45DHE-45

Imitrex injImitrex inj

One spray per nostril One spray per nostril then 15 minutes afterthen 15 minutes after

5 to 20 mg spray as 4 5 to 20 mg spray as 4 sprays of 5 mg per sprays of 5 mg per nostril may rpt once nostril may rpt once after 2 hrs. mx after 2 hrs. mx 40mg/d40mg/d

1 mg IV<IM<or SC at 1 mg IV<IM<or SC at onset and q1h mx. onset and q1h mx. 3mg/d; 6mg/wk3mg/d; 6mg/wk

6 mg SC at onset, rpt 6 mg SC at onset, rpt once after 1 hr mx- 2 once after 1 hr mx- 2 doses/ddoses/d

DRUGS EFFECTIVE IN ACUTE TREATMENT OF MIGRAINEDRUGS EFFECTIVE IN ACUTE TREATMENT OF MIGRAINE

DOPAMINE ANTAGONISTDOPAMINE ANTAGONIST

ORALORAL

MetoclopramideMetoclopramide Reglan,genericReglan,generic 5-5-10 mg/d10 mg/d

ProchlorperazineProchlorperazine Compazine,Compazine, 1-25mg/d1-25mg/d

PARENTERALPARENTERAL

ChlorpromazineChlorpromazine genericgeneric0.1 mg/kg IV at 2 mg0.1 mg/kg IV at 2 mg/min mx 35mg/d/min mx 35mg/d MetoclopramideMetoclopramide ReglanReglan

10mg IV10mg IV

ProchlorperazineProchlorperazine CompazineCompazine 10 mg/IV10 mg/IV

DRUGS EFFECTIVE IN PROPHYLACTIC TREATMENT OF DRUGS EFFECTIVE IN PROPHYLACTIC TREATMENT OF MIGRAINEMIGRAINE

DRUGDRUG TRADE NAMETRADE NAME DOSAGEDOSAGE

B- Adrenergic agentsB- Adrenergic agents

PropranololPropranolol

TimololTimolol

AnticonvulsantAnticonvulsant

Sodium valproateSodium valproate

Tricyclic antidepressantTricyclic antidepressant

AmitriptylineAmitriptyline

NortriptylineNortriptyline

Monoamine oxidase Monoamine oxidase inhibitorinhibitor

PhenelzinePhenelzine

IsocarboxazidIsocarboxazid

Serotonergic drugsSerotonergic drugs

MethysergideMethysergide

CyproheptadineCyproheptadine

OtherOther

VerapamilVerapamil

InderalInderal

BlocadrenBlocadren

DepakoteDepakote

Elavil, genericElavil, generic

PamelorPamelor

NardilNardil

MarplanMarplan

SansertSansert

PeriactinPeriactin

IsoptinIsoptin

80-320mg qd80-320mg qd

20-60 mg qd20-60 mg qd

250 mg bid 250 mg bid (mx:1000mg/d)(mx:1000mg/d)

10-5-mg qhs10-5-mg qhs

25-75 mg qhs25-75 mg qhs

15 mg qd15 mg qd

10 mg qd10 mg qd

4-8 mg qd4-8 mg qd

4-16 mg qd4-16 mg qd

40-240 mg qd40-240 mg qd

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Getting ahead of headaches