Chronic Migraine: Observations from a Referral

Headache Center

President and CEO, The Carolina Headache Foundation, Chapel Hill , NCDirector, Carolina Headache Institute , Chapel Hill, NC

Professor, University of North CarolinaContractor for Defense and Veteran Brain Injury Centers

TNS Ft Worth 2015

Disclosures

• With regards to this talk the speaker has no financial conflicts to Disclose– In the course of this talk I will mention off label

use of medications – THE ARE NO APPROVED TREATMENTS FOR MANY

OF THE HEADACHES I WILL DISCUSS

CHRONIC DAILY HEADACHE

4.1% of 13,000GeneralPublic

30%-80%Headache Clinic

Population

Scher Al et al. Headache. 1998.Sanin LC et al. Headache. 1993.

©International Headache Society 2003/5

1.5.1 Chronic migraine (ICHD-II +/- R1)New entrant to classification

A. Headache fulfilling criteria C and D for 1.1 Migraine without aura on 15 d/mo for >3 mo

B. Not attributed to another disorder

1.3 Chronic migraine (ICHD-3 beta)A. Headache (TTH-like and/or migraine-like) on ≥15 d/mo for >3

mo and fulfilling criteria B and C

B. In a patient who has had ≥5 attacks fulfilling criteria B-D for 1.1 Migraine without aura and/or criteria B and C for 1.2 Migraine with aura

C. On ≥8 d/mo for >3 mo fulfilling any of the following:1. criteria C and D for 1.1 Migraine without aura2. criteria B and C for 1.2 Migraine with aura3. believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative

D. Not better accounted for by another ICHD-3 diagnosis

Which of which is Chronic Migraine?

0

5

10

Never goes away

0

5

10

Never goes away Comes and Goes

Is it a matter of scale?

Or Factors?Modifiable Non-modifiable (?)

Triggers (?) Gender/Age

Medication use (?overuse) Mood states/comorbidities

BMI (?) Trauma including abuse/neglect and PTSD

Sleep (snoring) (?) Concurrent illness – immune/inflammatory

Neck Pain (?) Comorbidites

? ?

Distinguish Primary from Secondary Headache Disorders

Atypical Features

Investigations

Diagnosis

Headache

Secondary Headache

YesNoRed Flags

Primary Headache

History and examination

Systemic symptoms (fever, weight loss) or Secondary risk factors (HIV, cancer)Neurologic symptoms or signs Onset: abrupt, peak <1 minOlder: >50 (GCA; glaucoma)Previous headache history (new or change) Postural, positionalPrecipitated by Valsalva, exertion, etcPapilledema

Screen for red flags SNOOP4

Assess for worrisome signs and symptoms Look for atypical features

Step 1: Exclude Secondary HeadacheStep 1: Exclude Secondary Headache

Yes Evaluate for secondary headache

5-minute Examination of Headache Patient

• Vitals - every patient needs them (BP, temp, BMI)• Head and neck

– Palpate (skull base, TMJs, temporal arteries, upper cervical facets, pericranial muscles, paranasal sinuses)

– Listen (auscultate the head, orbits, and neck)• Focused neurological examination

– Talk to patient (mental status), watch them walk– Cranial nerves (fundi, visual fields, ocular motility, facial

symmetry, palate/tongue)– Upper motor neuron exam (arm extensor and leg flexor

strength, DTRs, plantar responses)

Diagnostic Criteria for Migraine vs. Tension-type Headache

Migraine Tension-type

Frequency Variable Variable

Duration 4-72 H 30 min – 7 days

Location Unilateral (40% bilateral) Bilateral

Description Pulsating (50% non-pulsating)

Pressing/tightening (nonpulsating)

Intensity Moderate-severe Mild-moderate

Effect of routine physical activity

Aggravated by or cause avoidance of

Not aggravated by

Nausea or vomiting Yes No

Photophobia or phonophobia

One or both No more than one

Attributable Not attributable to another disorder

Not attributable to another disorder

Headache Classification Subcommittee of the IHS. ICHD-III (beta). Cephalalgia. 2013; March.

Step 2: Identifying Primary Headache Syndrome

Episodic short duration headache <4 hours or

multiple discrete episodes

Episodic short duration headache <4 hours or

multiple discrete episodes

Episodic long duration headache

lasting >4 hours

Episodic long duration headache

lasting >4 hours

Episodic headache frequency <15 days/month

(eg, migraine)

Episodic headache frequency <15 days/month

(eg, migraine)

Identify primary headache syndrome

Identify primary headache syndrome

Chronic headachefrequency

≥15 days/month

Chronic headachefrequency

≥15 days/month

Tension-typeTension-typeMigraineMigraine

Progressive Headache

• When episodic migraine progresses, chronic migraine is the most likely diagnosis– Evolution of EM to CM

2.5% per year in general population• When is diagnostic testing necessary in progressive

headache?– Not always…Consider a therapeutic trial

• What is considered an adequate workup?– Neuroimaging?– Lumbar puncture?– Laboratory testing?

Comfort Signs that a Chronic Headache Condition is NOT Secondary Headache

• Long duration of illness• Typical clinical features• Family history of similar primary headache• Typical treatment response• Normal neurological examination• Menstrual exacerbations• Evolution of EM to CM with medication overuse

Differential Diagnosis of Primary Chronic Headache of Long Duration

Hemicrania Continua

New Daily Persistent HA

Chronic Tension Type

Chronic Migraine

Frequency ≥15 day/month ≥15 day/month ≥15 day/month ≥15 day/month

Duration Continuous Constant or intermittent

2-72 hours (H); constant or intermittent

4-72 H; constant or intermittent

PainHemicranial; steady ache; some throbbing

Like migraine or tension type headache (TTH); pressure

Like TH; tightening

Like migraine; throbbing

Associated symptoms

Ipsilateral, autonomic features

Variable NoneNausea, photophobia, Phonophobia

Treatment response Indomethacin Variable Variable Variable

Patient Characteristics Episodic Migraine Chronic MigraineHeadache frequency, days/month <15 ≥15

Report Severe headache pain (%) 78.1 92.4*

Duration of headache pain without medication (mean h)

38.8 65.1*

Duration of headache pain with medication (mean h)

12.8 24.1*

Patient Characteristics of EM vs CM

Headache: The Journal of Head and Face Pain pages 103-122, 6 FEB 2015 DOI: 10.1111/head.12505_2

Sociodemographic characteristics

EM CM

Race (% white) 87.3 90.7Women, % 80.0 78.6

Low household income (% < $22,500/year) 24.9 29.9*

Comorbidities Depression, % 17.2 30.2*Anxiety, % 18.8 30.2*Obesity, % 21.0 25.5*Cutaneous allodynia, % 63.2 68.3*

Headache: The Journal of Head and Face Pain pages 103-122, 6 FEB 2015 DOI: 10.1111/head.12505_2

TREATMENT: FDA Approved

Acute Management of Migraine Prevention of EM Prevention of CM

Triptans (oral, nasal, injectable, transdermal): almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan

Propranolol (tablets, liquid) OnabotulinumtoxinA injections

Timolol (tablets)

Divalproex sodium ERSodium valproate

Topiramate

Dihydroergotamine mesylate (tablets, nasal sprays)

Diclofenac potassium oral solutionTranscutaneous Supraorbital NeuroStimulation (tSNS) headband

Headache: The Journal of Head and Face Pain pages 103-122, 6 FEB 2015 DOI: 10.1111/head.12505_2

Current treatments• Neurotoxins• Medications

– Episodic migraine prevention for chronic migraine?

• Procedures– The worst of the worst?

• Multidisciplinary• Neil Raskin

– “You are intractable”

21

Acute Medication Overuse• A diagnosis of “Medication-

overuse Headache” (MOH) is NOT synonymous with medication overuse

• Acute medication overuse is a behavior, defined by days of medication talking

• MOH is headache attributed to the overuse of medications

Frequent Attacks

Acutetherapy

“Rebound”/ medication-overuse

headache

Treatment of suspected MOH involves the discontinuation of the overused medication(s) and initiation of preventive therapy

Figure Rates and odds ratios of transition from EM to CM by treatment efficacy category in the fully adjusted model (model 3)CI = confidence interval; CM = chronic migraine; EM = episodic

migraine; OR = odds ratio.

Richard B. Lipton et al. Neurology 2015;84:688-695

© 2015 American Academy of Neurology

Complete history and examinationComplete history and examination

Evaluate for secondary headache

Screen for red flags SNOOP

Screen for red flags SNOOP

Yes

Assess headache signs and symptoms & look for atypical features

Ste

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Chronic headache of long duration

frequency ≥15 d/mheadache lasting >4

hours

Chronic headache of long duration

frequency ≥15 d/mheadache lasting >4

hours

Episodic headache of long duration

frequency <15 d/m >4 hours

Episodic headache of long duration

frequency <15 d/m >4 hours

YesIf headache frequency & severity

are progressing, watch for and warn against risks for chronic migraine

Identify primary headache syndromeIdentify primary headache syndrome

No

Assess for acutemedication overuse

Assess for acutemedication overuse

Ste

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enti

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rim

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hea

dac

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me

MigraineMigrainous

Tension-type

MigraineMigrainous

Tension-type

Chronic migraineChronic tension-type

NDPHHemicrania continua

Chronic migraineChronic tension-type

NDPHHemicrania continua

Ste

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: D

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Refractory Headache

• Continuous Headache• New Daily Persistent Headache• Side Locked Headache• Focal Headache

– With migraine features– Without migraine features

• Stress and Distress

Headache Index

In the last 28 days I had (write a best guess number in each blank below):

_______ Days where my worst headache was severe+_______ Days where my worst headache was moderate+_______ Days where my worst headache was mild +_______ Days with absolutely no headache, neck discomfort,

facial/ jaw discomfort whatsoever?TOTAL= ________ (total should equal 28)

Pain Diagrams

FRONT BACK

SIDE

Continuous Headache

• Is it really?• Is it severe?• Is it Migraine?

– If not……………………– What?

• Is it a headache?

New Daily Persistent Headache

• Is it really new?– Prior history of headache– How should we ask?

• Leading the witness• Following the leads

• Does it have to be continuous?• Is it a primary headache disorder?

THE 50% RULE?

If in many of your patient’s with NDPH you find SOMETHING

Then: Is NDPH an Other Primary Headache?

Comorbidities and Predictive Factors in NDPH

Infection39%

Trauma25%

Rheumatologic8%

Surgery3%

Vaccine3%

None22%

Preceding Event

Hindiyeh, N et al, Presented at the 56th Annual Scientific Meeting of the AHS, 27JUN2014

n = 3678% HAD SOMETHING

Side Locked Headache

• Location– Surface area– Radiation– Associations

• Duration– TAC?

• Interictal headache

– HC w &w/o features

Side Locked Headache

• Severity• Examination findings

– Hyperesthesia– Hypalgesia– TMD/TMJ– Cervicogenic

• Primary• Secondary

Side Locked Headache• Cervicogenic (11.2.1)

– Primary– Secondary

OR

• Is it 11.2.3 (Headache Attributed to Craniocervical Dystonia– Inclinometry

Focal Headache

• Without migraine features– Nummular headache– Neuralgiform pain

• With migraine features– Peripheral v central sensitization– Phantom head pain

Stress and Distress

• Diseases and drugs– If nothing works– Then do we know what we are treating?

• Don’t ask….Don’t tell• Testing for distress

– P_SD?– Aphysiology

• What to do when there is no on else to care!

What To Do?

• Examine the history– I have notes – quality?– If available look at headache calendars (some

actually keep them on their own)• Examine the treatments

– Drugs that did work• What if daily triptans render them headache free?

– Drugs that didn’t work• Dosing, etc.

– Drugs that might work– Drugs that don’t work !!!

What Do I Do?- Biopsychosocial Models• Examine the patient

– The neurologic examination is GROSS– Test, touch and move

• The sensory examination of the head– Named nerves

» GON/LON, Supraauricular/Superficial Temporal/SON– Inject if necessary

• TM Joints?• Cervical ROM

– Inclinometry?

Biopsychosocial ModelsUse validated instruments - Adapt as necessary

• Lot’s of neurologic stuff: Neurobehavioral Symptom Index (NSI)

• PTSD = Post Traumatic Checklist – Civilian (PCL-C)

• Mood/Behavioral– Patient Catastrophizing Scale (PSC)– BAI, BDI

Current treatments• Neurotoxins• Medications

– Episodic migraine prevention for chronic migraine?

• Procedures– The worst of the worst?

• Multidisciplinary• Neil Raskin

– “You are intractable”

The Goal• Validate the Model

– Is the patient credible?• The best evidence still exists for N= 1• 1 is the loneliest #

– Are there confounds?• Medical

– ?MOH

• Behavioral– “Intractability”– Is the HEADACHE credible?*******************

• AND THEN

What Do I Do?Biopsychosocial Models

• Examine the history– Phenomenology: What would it be if it could be?

• Examine the patient– Include the mind: What would it do if it could do?

• Examine myself– “we were people before we were clinicians”

• Defaults• Heuristics

What Do I Do?Biopsychosocial Models

• Examine the patient – Psycho Social– I was not trained to look into people’s souls

• Use validated instruments• Adapt as necessary

What Do I Do?Biopsychosocial Models

• Examine myself– “we were people before we were clinicians”

• Heuristics• Defaults

– MOH– Psychology and the soul

Conclusions – What should we ALL do?

• Chronic migraine is the same no matter where I see it

• Manage people– Not drugs

• Include your biases - Intractability– Cathexis

• Treat what you think/know

– Counter – transference• Not what you feel

Conclusions

• The refractory headache patient is:– Challenging– Exciting– Frustrating

• And

– Satisfying

Thank you for your attention

President and CEO, The Carolina Headache Foundation, Chapel Hill , NCDirector, Carolina Headache Institute , Chapel Hill, NC

Professor, University of North CarolinaContractor, Defense and Veteran Brain Injury Center

TNS 2015