Sean Kelcey CCPA EM PA Selkirk Regional Health Center

Selkirk, MB CAPA 2017

I HAVE NO FINANCIAL DISCLOSURES TO MENTION AND DO NOT REPRESENT ANY DRUG DEALERS, LEGAL OR OTHERWISE

ANY MENTION OF BRAND NAME AGENTS IS PURELY BY ACCIDENT OR BECAUSE THEY’RE EASIER TO SAY – GENERIC

NAMES WILL ONLY BE SHOWN HERE IN TEXT FORM

CASE INTRODUCTIONS

MIGRAINE TYPES TYPICALLY SEEN

NON-SINISTER HEADACHES THAT MIMIC MIGRAINE

SINISTER HEADACHES THAT MIMIC MIGRAINE

PHARMACOLOGIC AGENTS USED IN TREATMENT OF ACUTE MIGRAINE

CANADIAN AND US HEADACHE SOCIETY GUIDELINES

SEAN’S MIGRAINE APPROACH AND COCKTAILS

CASE RESOLUTIONS

MIGRAINE AFFECTS ~ 4 MILLION PEOPLE IN CANADA

~25% OF CANADIAN WOMEN AND ~7-10% OF CANDIAN MEN ARE THOUGHT TO BE AFFECTED

A TOP 20 REASON FOR MEDICAL DISABILITY WORLDWIDE

LOTS OF THEORIES…NOT MANY ANSWERS, YET

EVER NOTICE HOW EVERY H/A IN THE ER IS “A MIGRAINE”?

AND EVER NOTICE HOW MANY OF THESE HEADACHES CAUSE US MIGRAINES IN THE ER?

EVER NOTICE MONDAYS SUCK?

35 YO F, H/A X 5/7

KNOWN MIGRAINEUR, Dx By FMD, 6/12 post-partum, otherwise healthy; H/A’s started during pregnancy

(+) Phono/photosensitivity, N/V; pain hemispheric to (L), pounding; visual disturbance prior - “dancing lights”

Onset was insidious; usual abortive therapy not effective

Denies N/T or focal loss of function, Fever/chills/ns/neck stiffness or sick contacts/bad habits/known triggers

“I had a bad reaction to something they gave me last time”

LOOKS UNWELL; eyes covered, wants lights out

42 YO F, 2/52 Hx HA “I have a migraine”

No formal Dx Migraine; generally healthy

Pain is unilateral but changes side, squeezing /c scalp burning; some relief with NSAID’s

(+) phonosensitivity and some nausea; ^ personal stressors

Denies fever/chills/NS/URTI symptoms/vomiting/focal neuro symptoms/bad habits/aura

Looks tired in a well lit room

26 YO F, H/A x 1/7

No known migraine Hx, healthy

Pain is (L) scalp/eye with pain increasing /c turning head – “I get a shock when I do that”; insidious onset; little change with NSAID’s

(+) photo/phonosensitive, mild nausea; moves keeping head still

Denies Fever/chills/ns/vomiting/focal neuro symptoms/aura

Looks in pain in a well lit room, squinting but cooperative

A. At least 5 attacks fulfilling criteria B-D

B. Headache attacks lasting 4-72 hours (untreated or

unsuccessfully treated)

C. Headache has at least two of the following characteristics:

- unilateral location

- pulsating quality

- moderate or severe pain intensity

- aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)

D. during headache, at least one of the following is present:

- nausea and / or vomiting

- photophobia and phonophobia

E. not attributed to another disorder

A. At least 2 attacks fulfilling criteria B-D

B. Aura consisting of at least one of the following, but no motor

weakness:

1. fully reversible visual symptoms including positive

features (e.g., flickering lights, spots or lines) and/or negative

features (i.e., loss of vision)

2. fully reversible sensory symptoms including positive

features (i.e., pins and needles) and/or negative features (i.e.,

numbness)

3. fully reversible dysphasic speech disturbance

C. At least two of the following:

1. homonymous visual symptoms and/or unilateral sensory

symptoms

2. at least one aura symptom develops gradually over ≥ 5

minutes and/or different aura symptoms occur in succession

over ≥ 5 minutes

3. each symptom lasts ≥ 5 and ≤ 60 minutes

D. Headache fulfilling criteria B-D for Migraine without aura

begins during the aura or follows aura within 60 minutes

E. not attributed to another disorder

Migraine lasting > 72 hours, despite or without treatment

SINISTER MIMICS

SAH

MENINGITIS/ENCEPHALITIS

STROKE/TIA

GCA

NON SINISTER MIMICS CLUSTER HEADACHES

SINUSITIS

TENSION HEADACHE

DRUG OVERUSE HEADACHE

OCCIPITAL NEURALGIA

WHILE NOT TRUE MIGRAINE, ARE DEBILITATITING AND DO PRESENT TO ER…AND SOMETIMES RESPOND TO TYPICAL MIGRAINE MEDS

CRITERIA FOR CLUSTER H/A:

FREQUENT (up to 8/day)

BRIEF (<3hours)

RECURRENT (Days/weeks at a time, then stop)

UNILATERAL

CONJUCTIVAL INJECTION/TEARING/FACIAL SWELLING TO IPSILATERAL SIDE

MALE>FEMALE ~4:1 (women do get them though – don’t ignore)

HEADACHE CAN BE UNILATERAL OVER AFFECTED SINUS OR BILATERAL OVER AFFECTED SINUSES

CAN BE AT THE VERTEX (sphenoidal sinuses)

ASSOCIATED WITH PHOTOPHOBIA, SOMETIMES FEVER, USUALLY URTI/ALLERGIC RHINITIS SYMPTOMS

SINUSES USUALLY TENDER; IF MAXILLARY, OFTEN ASSOCIATED WITH DENTAL PAIN

USUALLY DON’T MEET CRITERIA FOR MIGRAINE

TYPICALLY ARE:

BILATERAL, SQUEEZING, WITH MILD TO MODERATE INTENSITY

NON-PULSATING

NOT WORSENED BY ACTIVITY

USUALLY NON-NAUSEATING

Often seen in migraine patients, undiagnosed migraine patients or patients with tension H/A’s that are using primary meds at least 15

days a month

Some chronic migraineurs are on the wrong abortive meds and haven’t discussed changing with their PCP

Some patients have an underlying “dyscopia” – chronic pain, depression, PD, etc

Common offenders are triptans, NSAID’s, ASA/APAP preps, especially those with caffeine, and opiods.

These people need a withdrawal strategy, with a frank discussion regarding expectations of pain management

They also need to try a new abortive med – new triptan, DHE or alternative with an adjunct until the H/A’s lessen in frequency, as well as exercise, stress management and management of underlying D/O

A TYPE OF HEADACHE THAT CAN OFTEN BE SEEN WITH MIGRAINE OR AS STAND ALONE

POOR UNDERSTANDING OF MECHANISM – OFTEN ASSOCIATED WITH TENSION/SPASM OF TRAPS/PARACERVICAL MUSCLES

PAIN CAN BE UNILATERAL OR BILATERAL, BURNING/STABBING IN QUALITY, INCREASING WITH MOVEMENT, OFTEN AN ELECTRIC SHOCK

SENSATION

TENDERNESS ALONG GREATER/LESSER OCCIPITAL NERVE DISTRIBUTION

SOME PEOPLE EXHIBIT PHOTOSENSITIVITY AND NAUSEA

CAN BE TREATED WITH CONSERVATIVE MEASURES, PHYSIO +/- A NERVE BLOCK /C OR /S STEROIDS

ONE OF THOSE CAN’T MISS H/A’S

ACCOUNT FOR LESS THAN 1% OF ER VISITS…BUT MISSED ONES ARE A LEADING CAUSE OF ACTIVATION OF MALPRACTICE COVERAGE

DON’T GET SUCKERED BY A MIGRAINEUR WITH HEADACHE IF IT’S A CHANGE IN PATTERN, ESPECIALLY ABRUPT ONSET AND AURA MIMICS

IN FORM OF FOCAL NEURO SYMPTOMS

HEADACHES THAT ARE ABRUPT, “THUNDERCLAP” OR “ABSOLUTE WORST HEADACHE OF MY LIFE” (ESPECIALLY IN A MIGRAINEUR),

SUSPECT SAH

S&S CAN MIMIC MIGRAINE WITH AURA, ALONG WITH SORE/STIFF NECK, DECREASING LOC, OTHER FOCAL NEURO SYMPTOMS

MAY HAVE HX OF TRAUMA, HTN, SMOKING, AVM, OR ON ANTICOAGULANTS…

IF YOU EVEN REMOTELY SUSPECT IT,

CT THE HEAD!!!!!!!!!

ANOTHER CAUSE OF ACTIVATION OF MALPRACTICE INSURANCE

USUALLY PRESENT WITH PRODROMAL SYMPTOMS – FEVER, MYALGIA, ANTECEDENT URTI, POSSIBLE EPIDEMIC EXPOSURE

CAN MIMIC MIGRAINE /C OR /S AURA; OFTEN HAVE STIFF NECK ASSOCIATED, BOTH TO ACTIVE/PASSIVE MOVEMENT…REMEMBER FORMAL BRUDZYNSKI AND KERNIG SIGNS ARE ONLY (+) 50% ISH

IF YOU’RE CONCERNED, ORDER LABS, CT/LP AND TREAT EMPIRICALY FOR WHAT YOU’RE SUSPECTING

ODDLY ENOUGH, CAN MIMIC MIGRAINE WITH AURA…AND VICE VERSA…KEY IS AURA ON/OFF TIMINGS

IF PATIENT PRESENTS LIKE MIGRAINE WITH AURA, BUT HAS NO PREVIOUS HX, ASSUME STROKE UNTIL PROVEN OTHEWISE

IF MIGRAINEUR PRESENTING WITH ATYPICAL H/A FOR THEMSELVES, ACTIVATE STROKE PROTOCOL

IF MISSED, CAN RESULT IN VISION LOSS

KEY POINTS – USUALLY AN OLDER PERSON (>60 YO)

PAIN IS ASSOCIATED WITH JAW CLAUDICATION, USUALLY NO N/V

PATIENTS OFTEN HAVE COMORBID PMR – PROXIMAL MUSCLE PAIN/WEAKNESS

TRIPTANS :

SELECTIVE SEROTONIN 5-HT1B/D AGONISTS

MOST RECOMMENDATIONS ARE FOR SC SUMITRIPTAN 6MG, RIZATRITPAN 10MG WAFER OR ZOLMATRIPTAN 5MG I/N SPRAY

(MORE STUDIES VS SUMITRIPTAN 20MG I/N)

UP TO 2 DOSES IN 24HRS FOR MOST OF THESE DRUGS

DOPAMINERGICS

MOST RECCOMENDED/STUDIED ARE PROCHLORPERAZINE 10-20MG IV OR METOCLOPRAMIDE 10-20MG IV

CAN BE USED IN COMBINATION OR AS STAND ALONE…METOCLOPRAMIDE HAS ADDED BENEFIT OF ACTING ON 5-HT

RECEPTORS

ERGOT DERIVATIVES

DIHYDROERGOTAMINE (DHE45) CAN BE USED I/N (2MG), SC/IM/IV 1MG

POTENT VASOACTIVE AGENT; PREG TEST ALL FEMALE PATIENTS IF CONSIDERING AGENT

SHOWN GOOD RESULTS IN LONG TERM RELIEF

NSAID’S

CAN USE PO MEDS IF NOT VOMITING – BEST STUDIED ARE NAPROXEN, IBUPROFEN AND ASA; DICLOFENAC SHOWED POOR RESULTS IN

STUDIES

HOWEVER, IN THE ER, MOST PATIENTS AREN’T WILLING TO TRY PO – INJECTABLE KETOROLAC IS AVAILABLE IN MOST ER’S

OXYGEN

EFFECTIVE FOR USE IN CLUSTER HEADACHES, HIGH FLOW (12-15LPM) FOR ~15 MINUTES

STEROIDS

EFFECTIVE FOR PREVENTING RELAPSE OR FOR CONCOMITANT USE WITH OCCIPITAL NERVE BLOCKS; NOT FOR ACUTE H/A

LOCAL ANAESTHETICS

USUALLY USED FOR OCCIPITAL NERVE BLOCKS – COMBO LIDO/BUPIVICAINE +/- STEROID

CAN ALSO BE USED IN TRIGGER POINT INJECTIONS FOR PROLONGED TENSION/DRUG OVER USE H/A

SMALL STUDIES FOR I/N LIDOCAINE, POOR EVIDENCE

CANADIAN AND US GUIDELINES ARE PRETTY SIMILAR

BOTH SUGGEST TRIPTANS AS FIRST LINE AGENTS FOR ACUTE ABORTIVE THERAPY IF AVAILABLE AND WITHIN DOSING TIMELINES

BOTH ALSO SUGGEST DOPAMINERGIC ANTI-NAUSEANT AGENTS +/- AN NSAID

DHE IS ALSO RECOMMENDED AS AN AGENT OF CHOICE

ALL UNIVERSALLY RECOMMEND AGAINST OPIOIDS AS FIRST LINE AGENTS

STEROIDS ARE RECOMMENDED ONLY TO PREVENT RECURRENCE, NOT AS ACUTE THERAPY

SUGGEST H/A DIARY IF NEW PATIENT OR IF TRIGGERS STILL NOT KNOWN, DISCUSS SELF CARE, DRUG OVER USE, ETC WHEN D/C

EYEBALL THE PATIENT AND GET A QUICK, TARGETED HX, INCLUDING MEDS USED

RAPID NEURO ASSESSMENT…INCLUDING TRYING TO GET A LOOK AT THEIR FUNDI AND CHECK THEIR NECK AND LISTEN FOR BRUITS

GET IV ACCESS IF NOT ALREADY THERE, GIVE SOME FLUID AND DECIDE ON ABORTIVE THERAPY

ONCE H/A IS SETTLING, DO A CLOSER EXAM, ESPECIALLY THE FUNDI

ALWAYS HAVE A BACK UP PLAN IN PLACE WITH SECONDARY/TERTIARY MEDS

COCKTAIL #1=> 1OOOcc N/S or R/L + ketorolac 15mg/metoclopramide 10mg/diphenhydramine 25mg IV

COCKTAIL #2=> see #1, replace metoclopramide with prochlorperazine

COCKTAIL #3=> Sumatriptan 6mg sc (if available); may add fluid/ketorolac/antinauseant/diphenhydramine prn

COCKTAIL #4=> More fluid, DHE 1mg im/iv, dexamethasone 10mg iv

(status migrainosus cocktail or non-responder)

Offer occipital nerve block(s) and/or trigger point injections if residual pain in the nerve distribution

MRS A

DX=?

STATUS MIGRAINOSUS

TMT:

TRIAL OF COCKTAIL #1; PARTIAL RESOLUTION…RECEIVED #4 AND WAS PAIN FREE AFTER 4 HOURS AND D/C

SAW THEM AGAIN 2/52 LATER, RECEIVED #1 + DEX, OCCIPTAL NERVE BLOCK; WAS GIVE Rx for CCB as a preventative

MISS B

DX?:

TENSION TYPE HEADACHE

TMT: Ketorolac IV, trigger point injections/occipital nerve block, stretching exercises, stress management regimen.

Returned a few days later requesting another nerve block to opposite side of head…was much happier

MISS C

DX?:

OCCIPITAL NEURALGIA

TMT:

Initially received Cocktail #1, 2/10 change on pain scale…observably improved with occipital nerve block with steroid. Discharged ~ 2hours post initial assessment.

QUESTIONS?

QUERIES?

RUDE COMMENTS?

https://headachesociety.ca/guidelines/

https://americanheadachesociety.org

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