Essential Headache Management NOMA Symposium Saturday ...€¦ · Essential Headache Management 7...

1Essential Headache Management

NOMA Symposium

Saturday October 5, 2019

Summerlin Hospital

Michael J. Olek, DO

Associate Professor of Neurology

Touro University Nevada

College of Osteopathic Medicine


Objectives

1. To recognize different headache types

2. To understand the pathophysiology of headache

3. To learn about traditional and new headache treatments

4. To be aware of non-pharmacological treatments for

headache

Dr. Olek has nothing to disclose financially

The Scream, Edvard Munch: 1893

Downloaded from Pinterest


Classifications of Headaches

Prevalence of Headache

Non-Sinister versus Sinister Headaches

Headache-Associated Conditions

Migraine Etiology and Treatment

Status Migrainosus

FDA approved devices for Headache

Cluster Headache

Medication Overuse Headache (MOH)

Headache and pregnancy

Outline:


International Headache Society(HIS) International Classification of

Headache Disorders Third Edition (ICHD-3 alpha: 2018)

Part 1: The Primary Headaches

1. Migraine

1.1 Migraine without aura*

1.2 Migraine with aura*

1.2.3 Hemiplegic Migraine

1.2.4 Retinal Migraine

1.4.1 Status Migrainosus*

2. Tension-Type

3. Trigeminal Autonomic Cephalgia (TAC)

3.1 Cluster HA*

3.2 Paroxysmal Hemicrania

4. Other Primary Headache Disorders (Cough, Exercise,

Sexual Activity, Thunderclap, etc.)

*To be discussed

in detail


International Headache Society(HIS) International Classification of Headache

Disorders Third Edition (ICHD-3 alpha: 2018)

Part 2: The Secondary Headaches

5. HA attributed to Trauma of Head/Neck

6. HA attributed to Vascular Disorder

7. HA attributed to Non-vascular Intracranial Disorder

8. HA attributed to a Substance or its withdrawal

8.2 Medication Overuse Headache (MOH)*

9. HA attributed to Infection

10. HA attributed to Disorder of Homeostasis

11. HA attributed to disorders of the cranium, neck, eyes, ears, nose,

sinuses, teeth, mouth or other facial structure

12. HA attributed to Psychiatric Disorder

*To be discussed in detail


International Headache Society(HIS) International Classification of Headache

Disorders Third Edition (ICHD-3 alpha: 2018)

Part 3: Painful Cranial Neuropathies and Facial Pain

13. Painful Cranial Neuropathies and Other Facial Pain

13.1 CN V

13.2 CN IX, X

13.3 CN VII

13.4 Occipital Neuralgia

13.6 Painful Optic Neuritis

14. Other HA Disorders


Headache (HA) Prevalence

▪ ½ to ¾ of adults have suffered with a HA within the past year

▪ 30% had a migraine in the past year

▪ 1-5% have had a HA at least 15 days or more each month

▪ Severe HA or Migraine reported in 1 out of 6 over a 3 month period

▪ Fifth leading cause of ER visits

▪ 1.3% of Outpatient visits

▪ Lifetime prevalence in Women: 25%

▪ Lifetime prevalence in Men: 8%

▪ Peak age is 25-50

▪ 70% of patients have relatives with Headache

▪ Third highest cause nationwide of years lost to disability (YLD)


Headache Prevalence

▪ 12% found to have a severe disability related to migraine

▪ 14% of women experience HA with menses

▪ Women on OCP-Migraine frequency increases 10X

▪ Migraine frequency decreases 2/3 in women after menopause

▪ Migraine is most often seen by Primary Care Providers

▪ 15% of persons with migraine see a HA specialist

▪ 15% of persons with migraine see a Pain specialist

▪ Most frequently prescribed medication: Opioids

▪ 23.1% of ER patients received opioids for headache and 58% of the time

they were used as first-line treatment

▪ 63.7% of persons with migraine used Over The Counter (OTC) medications


Headaches: Non-Sinister: Major Causes

▪ Medication Overuse Headache (MOH)

▪ Post-Trauma (Without skull fracture)

▪ Errors of Refraction

▪ Tempo-Mandibular Joint (TMJ) Dysfunction

▪ Sinus Related

▪ Hypertension

▪ Occipital Neuralgia


Headaches: Sinister

▪ Clinical Clues

▪ “Worst Headache of My Life”

▪ First Severe HA

▪ Subacute worsening over days

▪ Abnormal neurological examination

▪ Fever or unexplained systemic signs

▪ Vomiting that Precedes HA

▪ Pain induced by valsalva

▪ Pain that awakens from sleep

▪ Known systemic illness

▪ Age > 55

▪ Pain localized to temporal artery


Headaches: Sinister: Major Causes

▪ Vascular

▪ Thunderclap [Sub-Arachnoid Hemorrhage (SAH) or Aneurysm]

▪ Carotid or Vertebral Dissection

▪ Giant Cell Arteritis

▪ Acute Severe Hypertension

▪ Acute or Chronic Sub-Dural Hematoma (SDH)

▪ Non-Vascular (Space-Occupying Lesions)

▪ Infective (Meningitis or Encephalitis)

▪ Homeostasis (Central Venous Sinus Thrombosis)

▪ Carbon Monoxide Poisoning

▪ Acute Glaucoma

▪ Idiopathic Intracranial Hypertension (Pseudo Tumor Cerebri)


Headache Pathophysiology

▪ NO Pain receptors in Brain Parenchyma

▪ Extra-Cranial Structures with Pain Receptors

▪ Sinuses

▪ Eyes

▪ Ears

▪ Teeth

▪ Skin

▪ Skull

▪ Muscles

▪ Exiting cranial nerves V, VII, IX, X

▪ TMJ

▪ Blood vessels


Headache Pathophysiology

▪ NO Pain receptors in Brain Parenchyma

▪ Intra-Cranial Structures with Pain Receptors

▪ Arteries in the Circle of Willis

▪ Proximal Dural Arteries

▪ Dural Venous Sinuses and Veins

▪ Meninges (Pia, Arachnoid, Dura)


Headache Associated Medical Conditions to Remember

▪ Mitral Valve Prolapse (MVP)

▪ Patent Foramen Ovale (PFO)

▪ Hypertension (HTN)

▪ Stroke (CVA)

▪ Epilepsy

▪ Atopic allergies

▪ Asthma

▪ Irritable Bowel Syndrome (IBS)

▪ Depression

▪ BiPolar Disease

▪ Anxiety

▪ Panic Attacks

Headache Comorbidity and Coexisting Conditions

Therapeutic Opportunities and Limitations

Disorder with Migraine Consider Avoid/Caution

Depression TCA, SSRI (Selective Serotonin Reuptake

Inhibitors), SNRI (Serotonin and Norepinephrine

Reuptake Inhibitors)

Beta-blockers

Anxiety TCA, SNRI, Beta-Blockers

Bi-Polar Valproate, Topiramate TCA, SSRI,SNRI

Sleep Disturbance TCA (Tri-Cyclic Antidepressant)

Stroke ASA

Hypertension Beta-Blockers, Calcium Channel Antagonists

such as Verapamil or Diltiazem

Ergot or Triptans if uncontrolled

Obesity Topiramate, SNRI TCA, Valproate, Gabapentin

Epilepsy Topiramate, Valproic Acid, Gabapentin TCA, SSRI, SNRI

Raynauds Calcium Channel Antagonists Beta-Blockers, Ergots

15


Rare complications of Migraine

▪ Prevalence of Migrainous Infarct: 0.5 to 1.5% of all ischemic strokes

▪ Relative Risk for Ischemic Stroke with Migraine 1.73

▪ Usually occurs in younger women (<45 years of age) with a history of

migraine with aura

▪ Women on OCP with Migraine with aura: Relative Risk of 7

▪ Patients that have migraine with aura and smoke: Relative Risk of 9


Migraine Headaches

▪ Characteristics

▪ Phases

▪ Pathophysiology

▪ Acute Treatment

▪ Prophylactic Treatment


Characteristics of a Migraine

▪ Attacks last from 4-72 Hours

▪ Patient history and physical exam best for diagnosis

▪ Often occur in the AM

▪ Unilateral location in 50%

▪ Pain can be throbbing, pounding, pulsating, aching, ice-pick

▪ Associated nausea, photophobia, blurred vision, phonophobia, dizziness

▪ May be associated with menses

19

Downloaded from

migrainebuddy.com

Four Phases of a Migraine

20

1. Prodrome (30%): Irritable/Depression/Problems focusing

2. Visual Aura Phase in Migraine:

▪ Affects 15-20% of patients

▪ Can develop over 5-15 minutes and last up to 1 hour

All images downloaded from Pinterest

Four Phases of a Migraine

21

3. Migraine Attack Phase:

▪ May last hours to days

▪ Unilateral pain in 56-68%

▪ 90% have coexisting nausea

4. Post Drome Migraine Phase:

▪ Drowsiness

▪ Depression

▪ Difficulty with concentration

▪ Cognitive changes

▪ Memory loss

Four Phases of Migraine

22

Migraine Pathophysiology Sequence

Hargreaves RJ et al. Can J Neurol Sci. 1999;26(suppl 3):S12-S19


Headache Pathophysiology: CNS Activation (Red Areas)

Pain Perception:

Anterior Cingulate Cortex

Migraine Generators:

Raphe Nuclei

Locus Coeruleus

Periaqueductal Gray

Weiler C, et al. Nat Med 1995;1:658-660


Migraine: International Class. of Headache Disorders, Third Edition

A. At least five attacks fulfilling criteria B–D

B. Headache attacks lasting 4–72 hours (when untreated or unsuccessfully

treated)

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

1. unilateral location

2. pulsating quality

3. moderate or severe pain intensity

4. aggravation by or causing avoidance of routine physical activity (e.g.

walking or climbing stairs)

D. During headache at least one of the following:

1. nausea and/or vomiting

2. photophobia and phonophobia

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

Cephalalgia 2018, Vol. 38(1) 1–211


Headache: General Treatment Strategies for Any Headache Type

▪ Avoid Triggers (I use migraine trigger handout with HA calendar)

https://uhs.berkeley.edu/sites/default/files/HeadachesMigraines.pdf

▪ Maintain regular sleep schedule (I use sleep hygiene handout)

https://www.thoracic.org/patients/patient-resources/resources/healthy-sleep-

in-adults.pdf

▪ Limit caffeine intake (coffee, tea, chocolate)

▪ Limit nitrates/nitrites/MSG

▪ Reduce Stress (I use meditation handout)

https://www.health.harvard.edu/PDFs/Stress_Relief_Guide.pdf

▪ Adequate Water Intake

https://uhs.berkeley.edu/sites/default/files/HeadachesMigraines.pdf

https://www.thoracic.org/patients/patient-resources/resources/healthy-sleep-in-adults.pdf

https://www.health.harvard.edu/PDFs/Stress_Relief_Guide.pdf


Common Migraine Triggers

▪ Stress

▪ Emotions

▪ Sex

▪ Glaring lights

▪ Altered Sleep

▪ Menses

▪ Physical exertion

▪ Alcohol

▪ TOB

▪ Excessive or withdrawal from

caffeine

▪ Physical exertion

▪ Odors (perfume, exhaust

fumes, paint, solvents)

▪ Allergens

▪ Drugs (OCP, Nitroglycerin,

Excessive OTC analgesic

use, theophylline,

cimetidine, cocaine)

▪ Foods (tyramine, nitrates,

chocolate, aspartame, MSG)


Headache: General Treatment Strategies

▪ Ice and/or Heat

▪ Massage

▪ Regular Exercise

▪ Cognitive Behavioral Therapy (CBT)

▪ Weight Reduction

▪ Meditation

▪ Stress reduction

▪ Psychotherapy


Headache: Migraine Treatment Strategies

▪ Abortive Treatments

▪ Preventative Treatments


Headache: Migraine Treatment Strategies

▪ Abortive Treatments

▪ OTC medications

▪ Non-Triptans and Other Prescription medications

▪ Triptans

▪ Parenterals

▪ Anti-emetics (IV Metoclopramide 20 mg every 30 minutes up to 4

doses/Prochlorperazine PO, PR, IV, IM)

▪ Rescue Therapies

▪ Opioids (Meperidine 75 mg IM or 1.5 mg/Kg IV)

▪ Corticosteroids (Dexamethasone IV 6-24 mg single dose)

▪ Neuroleptics

▪ Electronic Devices


Treatment of Acute Migraines: Over The Counter

▪ Excedrin Migraine (Acetominophen 250 mg/ASA 250 mg/Caffeine 65 mg)

▪ Bayer Migraine (Acetominophen 250 mg/ASA 250 mg/Caffeine 65 mg)

▪ Tylenol Migraine (Acetominophen 250 mg/ASA 250 mg/Caffeine 65 mg)

▪ Advil Migraine (Liquid Ibuprofen 200 mg/Potassium 20 mg)

▪ Motrin Migraine (Liquid Ibuprofen 200 mg)

▪ Anacin Max Strength (ASA 500 mg/Caffeine 32 mg)

▪ Migralex (ASA 500 mg/Magnesium oxide 75 mg)


Treatment of Acute Migraines: Non-Triptans and Other Prescription

Medications

▪ Cafergot

▪ Migrainol

▪ Midrin

▪ Fioricet/Fiorinal, Esgic

▪ NSAIDS-Cambia (Diclofenac 50 mg)

▪ COX-2 Inhibitors (Celebrex, Vioxx, Bextra)

▪ Codeine/Hydrocodone

▪ Stadol Nasal Spray


Treatment of Acute Migraines: Triptans

▪ Imitrex (Oral, Intranasal, SQ-Autoinjector)

▪ Zomig (Oral, ODT)

▪ Maxalt (Oral, ODT)

▪ Amerge (Oral)

▪ Axert (Oral)

▪ Frova (Oral)

▪ Relpax (Oral)


Treatment of Acute Migraines: Parenteral

▪ Magnesium sulfate: 1 gram IV

▪ Sumatriptan: 4-6 mg SQ

▪ Ketorolac: 60 mg IV

▪ Dexamethasone: 8 mg IV

▪ Metoclopramide: 10 mg IV

▪ Dihydroergotamine: 1 mg IV

▪ Valproate sodium: 500 mg IV

▪ Droperidol: 2.5-5 mg IV

34

Medication Route Dose (mg)

Metoclopramide (Reglan) PO, IM, IV 5-20

Prochlorperazine (Compazine) PO 5-10

PR 25

IV 5-10

Droperidol (Inapsine) IM, IV 0.625-2.5

Chlorpromazine (Thorazine, Largactil) PO 25-100

PR 50-100

IV 10-50

Haloperidol (Haldol) IM 5

IV 2-5

Olazepine (Zyprexa) PO 2.5-20

Treatment of Acute Migraines: Neuroleptics

35

▪ Extrapyramidal, tardive dystonias

▪ Hyperprolactinemia

▪ Anticholinergic symptoms

▪ Weight gain, metabolic syndrome

▪ Sedation

▪ Hypotension (chlorpromazine)

▪ QTc prolongation (droperidol,

haloperidol, chlorpromazine)

▪ Lowered seizure threshold

The Side Effects of Neuroleptics


Treatment of Migraines: When to Use Prophylaxis

▪ > 2 migraines/month

▪ Attacks lasting several days per week

▪ Severity/Frequency that critically impacts patient’s daily life

▪ Abortive therapies are contraindicated, ineffective, overused or not tolerated

▪ Uncommon Migraine Type

▪ Hemiplegic

▪ Basilar

▪ Prolonged Aura


Treatment of Migraines: Classes of Prophylactics

▪ 4 Classes of Medications

▪ Anti-Epileptic Medications (Topiramate, Valproate, et al)

▪ Anti-Hypertensives (Beta-Blockers, Calcium channel blockers)

▪ Anti-Depressants (Amitriptyline, Nortriptyline, Venlafaxine)

▪ Calcitonin Gene-Related Peptide (CGRP) MAB (Monoclonal Antibodies)

▪ Other Oral Medications

▪ Electronic Devices

▪ Subcutaneous Medications: BOTOX



4 Classes of Medications

▪ Class I: Anti-Hypertensives (Beta-Blockers, Calcium channel blockers)

▪ Propranolol (Inderal) 120-400 mg/day *

▪ Timolol (Blocadren) 20-40 mg/day *

▪ Naldolol (Corgard) 40-160 mg/day

▪ Metoprolol (Lopressor) 50-200 mg/day

▪ Atenolol (Tenormin) 25-100 mg/day

▪ Verapamil 240-620 mg/day

▪ Flunarazine 5-10 mg daily

* FDA Approved

These medications are contra-indicated in patients

with CHF, Heart Block, Hypotension and Sick

Sinus Syndrome




▪ Class II: Anti-Epileptics

▪ Topiramate (Topamax) 25-100 mg/day either QD or BID *

▪ AE: Weight loss, neuralgia, kidney stones

▪ Valproic Acid (Depakote) 500-3000 mg/day *

▪ AE: Nausea, Sedation, Hair loss, Low PLT, Hepatic dysfunction,

Weight gain, Cognitive problems

▪ Need to follow CBC and LFT’s

* FDA Approved




▪ Class III: Anti-Depressants

▪ Tri-Cyclic Antidepressants (Amitriptyline, Nortriptyline)

▪ SSRI’s (Celexa, Lexapro, Prozac, Paxil, Zoloft, Viibryd)

▪ SNRI’s (Venlafaxine 150 mg daily, Duloxetine 60 mg daily, Effexor,

Cymbalta, Savella, Pristiq, Fetzima, Irenka, Khdezla)

▪ MAOI’s (Selegeline, Phenelzine, Isocarboxazid, Tranylcypromine)

▪ Avoid foods with tyramine and all alcohol to avoid blood pressure

crisis

None are FDA approved for migraine




Class IV

▪ CGRP Antagonists*

▪ Erenumab (Aimovig): Dose 70 mg or 140 mg SQ monthly

▪ Binds to CGRP receptor

▪ Fremanezumab (Ajovy): Dose 225 mg SQ monthly or 675 mg quarterly

▪ Blocks the ability of CGRP to bind to the CGRP receptor

▪ Galcanezumab (Emgality): Dose 240 mg SQ initially then 120 mg monthly

▪ Blocks the ability of CGRP to bind to the CGRP receptor

* ALL FDA Approved


Treatment of Migraines: Other Prophylactics

Other Preventative Medications for Migraines:

▪ Cyproheptadine: 4 mg every 8 hours then 4-20 mg/day given q8hr

▪ Serotonin antagonist (5-HT1a and 5-HT2 receptors)

▪ Adverse events: Dry mouth and lightheadedness

▪ Gabapentin: 1800 mg daily in divided doses

▪ Adverse events: Somnolence, weight gain, edema, lightheadedness

▪ Cadesartan

▪ Angiotensin receptor blocker

▪ 16 mg daily

▪ Adverse events: lightheadedness


Treatment of Migraines: Prophylactics

A Closer Look at the Calcitonin Gene-Related Peptide (CGRP) Antagonists

▪ Pathways

▪ Pathophysiology

▪ Short and Potential Long Term Side Effects

44

Benarroch EE. Neurology. 2011;77(3):281-287

CGRP Receptors

Occur at All Sites

Involved in

Migraine

Pathogenesis

Calcitonin Gene-Related Peptide (CGRP) Pathways

45Calcitonin Gene-Related Peptides (CGRP’s)

▪ Actions of CGRP’s

▪ Vasodilation

▪ Mast cell degranulation/Dural Inflammation/Peripheral Sensitization

▪ Pain Transmission/Central Sensitization

▪ CGRP are released into the jugular venous system during migraine which in turn

evokes the migraine

▪ Antibodies to CGRP or its receptor prevent Migraines by:

▪ Removing excess CGRP released from Trigeminal Nerve endings

▪ Receptor Antibodies Block the receptor from signaling transmission

▪ Anti-CGRP monoclonal Antibodies are:

▪ Specific for Migraine

▪ > 75 % responder rate

▪ Rapid onset (< 1 week)/Consistent serum levels for 30 days

▪ Good patient adherence with well tolerated safety profile

▪ To date, No Neutralizing Antibodies have been detected

46

Short-term effects of CGRP

▪ Injection site reactions

▪ Constipation

▪ Hyper-sensitivity reactions

▪ URI

▪ Nausea

Anti-CGRP monoclonal Antibodies

Potential Long-term effects since CGRP receptors

are widespread

▪ Pituitary Gland dysfunction

▪ Cardio-vascular (Ischemia, HTN)

▪ GI (Ulcers, IBS, constipation/diarrhea)

▪ Skin (Erythema, Inflammation, Wound healing)


Treatment of Migraines: Other Prophylactics

Downloaded from Pinterest

▪ Botox (Botulinum Toxin Type A)

▪ Reduces Sensory Input to CNS

▪ Reduces Input to Muscle Spindle

▪ FDA-approved in 2010 for Chronic Migraine

▪ Chronic means > 15 HA/month

▪ Fail 2 Classes of Prophylactic Medications

▪ Decreases Nocioceptor Pathways

▪ C and A delta fibers

▪ Substance P

▪ CGRP

▪ Glutamate release

▪ Mechano- and Chemo-receptors

▪ Approx 30-40 injections each treatment

▪ Administered every 12 weeks

▪ Cost: Between $300-$600 per treatment

American Headache Society Guidelines for Preventative Therapies

Level A

(> 1 Class I Trial)

Level B

(1 Class I or 2 Class

II)

Level C

(1 Class II Trial)

Level U

(Inadequate or conflicting data)

Ineffective

Anti-Epileptics

(VPA, Topamax)

SSNRI/TCA

(Effexor, Elavil)

ACE Inhibitors

(Lisinopril)

Carbonic Anhydrase Inhibitors

(Diamox)

NOT Effective:

AED-Lamotrigine

Beta-Blockers

(Metoprolol,

Propranolol,

Timolol)

Beta-Blockers

(Atenolol, Naldolol)

Angiotensin Receptor Blockers

(Candesartan)

Antithrombotics (Coumadin,

Pictamide, Acenocoumarol)

Probably NOT Effective:

TCA-Clomipramine

Triptans

(Frovatriptan)

Triptans

(Naratriptan,

Zolmitriptan)

Alpha Agonists

(Clonidine, Guanfacine)

SSRI

(Prozac)

Possibly NOT Effective:

Beta-Blocker-Acebutolol

AED-Clonazepam

NSAID-Nabumetone

AED-Oxcarbazepine

ARB-Telmisartan

Onabotulinum Toxin A AED (Tegretol) AED (Gabapentin)

Anti-CGRP mAb Beta-Blockers

(Nebivolol, Pindolol)

TCA (Protriptyline)

Anti-Histamines

(Cyproheptadine)

Beta-Blocker (Bisoprolol)

48

49Status Migrainosus

▪ Migraine > 72 Hours

▪ Refractory to conventional treatment

▪ May try:

▪ Steroid Burst:

▪ Oral Prednisone 60 mg x 1 day with rapid taper

▪ Oral Dexamethasone 4-8 mg x 1 day with rapid taper

▪ IV Methylprednisolone 100-200 mg

▪ IV Dexamethasone 4-16 mg

▪ Headache Cocktail #1

▪ Ketorolac 60 mg IM

▪ Diphenhydramine 50 mg IM

▪ Prochlorperazine 10 mg IM



▪ Metoclopramide 10 mg PO

▪ Benadryl 25 mg PO

▪ Ibuprofen 600 mg PO


▪ DHE Nasal Spray 0.5 mg each nostril to max 4 mg/day

▪ Prochlorperazine 10 mg PO or 25 mg PR

▪ IV Valproate

▪ DHE-DiHydroErgotamine: Most hospitals have specific

protocols for this medication


▪ Emergency Room Treatment

▪ IV-NS 2-3 liter bolus or 80-100 cc/hr

▪ IV Diphenhydramine 12.5-25 mg

▪ IV Metoclopramide 10 mg

▪ IV Magnesium Sulfate 500-1000 mg

▪ IV Ketorolac 30 mg

▪ If no response:

▪ IV Sodium Valproate 500 mg OR

▪ IV Levetiracetam 500 mg OR

▪ IV Methylprednisolone 200 mg

▪ IV Dihydroergotamine 0.5-1.0 mg if patient has not used a

triptan within 24 hours and no other contraindications exist

Non-pharmacologic therapies for Headache

tested in clinical trials

Behavioral Treatments

▪ Relaxation training

▪ Hypnotherapy

▪ Thermal Biofeedback training

▪ EMG Biofeedback

▪ Cognitive/Behavioral management

therapy

▪ New App called RELAXaHEAD

developed by NYU

Physical Treatments

▪ Accupuncture

▪ Heat

▪ TENS

▪ Occlusal adjustment

▪ OMM

▪ Yoga

52

Over The Counter (OTC) Treatments for Headaches

OTC Supplements

▪ Magnesium Glycinate 400 mg BID

▪ Riboflavin 400 mg daily

▪ Melatonin 3 mg nightly

▪ CoQ10 90-400 mg daily

▪ Butterbur 50-75 mg BID with meals

▪ Feverfew 18.75 mg daily

▪ Petadolex

▪ Topical Menthol 10%

▪ Other

▪ Neti Pot

53

Lifestyle Modifications

▪ Diet

▪ Exercise

▪ Sleep

▪ Stress Management

▪ Stop Tobacco

▪ Environment

FDA-Approved Devices to Treat Headaches

▪ TENS Unit (Cefaly Device)

▪ FDA approved for Prevention of Migraines (with or without aura) AND

▪ FDA approved for Acute Migraine (with or without aura)

▪ Vagus Nerve Stimulator (VNS) called gammaCore

▪ FDA approved for acute treatment of pain associated with episodic cluster HA

▪ FDA approved for prevention of cluster HA (No FDA approved medications)

▪ Also FDA approved for epilepsy and depression

▪ Transcranial Magnetic Stimulation (TMS) called SpringTMS

▪ Approved in 2008 to treat depression

▪ Approved in 2014 to treat acute migraines

▪ Approved in 2017 or prevention of migraines

▪ Approved in 2018 for Obsessive Compulsive Disorder

▪ Approved in 2019 for children > 12 for migraine prevention

▪ 2019-Only device FDA approved for both acute and prophylactic treatment of

migraine in adults and children > 12 years old

54

Cefaly Device 55▪ Transcutaneous

electrical stimulation

▪ Acute: Works at

trigeminal nucleus

caudalis

▪ Chronic: Slow

modulation of

cortical areas

▪ Daily 20 minute

sessions for prophylaxis

▪ 60 minute session for

acute treatment

▪ Approximately $500

▪ Although FDA

Approved, most

insurances do not coverImages from www.cefaly.us

56

Images from www.gammacore.com

▪ Prophyllaxis: 2 self-administered treatments

consisting of three consecutive 2-minute

stimulations should be applied daily

▪ Acute TX-Three 2 minute stimulations

applied consecutively and may repeat in 3

minutes and may treat up to 4 attacks or 8

treatments/day

▪ $7,200 but hard to get covered by insurance

VNS Device: gammaCore

57Single-pulse Transcranial Magnetic Stimulation sTMS

Images from www.eneura.com

▪ Presumed Mechanism of Action:

▪ Blocks Cortical Spreading Depression (CSD)

▪ Inhibits firing rate of VPM neurons

▪ Acute Migraine Treatment

▪ 3 sequential pulses at onset of migraines and

wait 15 minutes and if needed 3 additional

pulses and wait 15 minutes and if needed 3

more pulses

▪ Preventative Migraine Treatment

▪ Treat with 4 pulses each morning and

evening given as 2 consecutive pulses then

wait 15 minutes then 2 additional pulses and

repeat this in the evening

Cluster Headache: ICHD-3 alpha

Classification

A. At least 5 attacks fulfilling criteria B-D

B. Severe or very severe “suicide headache” unilateral orbital, supraorbital

and/or temporal pain lasting 15-180 min (when untreated)

C. Either or both of the following:

1. 1 of the following ipsilateral symptoms or signs:

a) conjunctival injection and/or lacrimation; b) nasal

congestion and/or rhinorrhoea; c) eyelid oedema;

d) forehead and facial sweating; e) miosis and/or ptosis

2. a sense of restlessness or agitation

D. Frequency from 1/2 d to 8/d for > half the time when active

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

58

Cluster Headache: Characteristics

▪ More common in men in a 2.5 to 1 ratio

▪ Onset 20 to 40 years of age

▪ Affects 0.4% of the population

▪ Usually occurs the same time of year with no headache between clusters

▪ Primarily nocturnal attacks (50%) and wake the patient from sleep

▪ Alcohol triggers the headaches

▪ Usually unilateral with ipsilateral autonomic features

▪ Patient usually agitated during attacks

▪ Relieved with activity, medication, oxygen

59

Cluster Headache: Treatment 60

▪ Level A (Based on Level I evidence)

▪ Oxygen-100% at 12-15 L/min by face mask for 15-20 minutes*

▪ Sumatriptan 6mg SQ or 20 mg NS*

▪ Zolmitriptan 5mg NS*

▪ Non-invasive VNS for episodic Cluster Headache

▪ Sub-occipital steroid injections (12.46 mg of betamethasone

dipropionate plus 5.26 mg of betamethasone disodium phosphate

plus 0.5 mL of 2% lidocaine)*

▪ Deep Brain Stimulation (DBS) for Chronic Cluster HA

▪ Level B (Based on Level II evidence or extrapolated Level I evidence)

▪ Sphenopalatine Ganglion (SPG) trans-oral stimulation in Chronic

Cluster Headache

▪ Steroids: 50-80 mg/day tapered over 10-12 days

▪ Ergotamine 3-4 mg orally in divided doses for up to 3 weeks

* Used for

Acute

Treatment


▪ Level C (Level III evidence or extrapolated Level I or II evidence)

▪ Lidocaine NS or 1 mL of 10% solution applied for 5 minutes

▪ Octreotide (Sandostatin) 100 mcg SQ*

▪ DHE 45 1 mg IM, SQ or IV at first sign of HA and may repeat x 2-3x*

▪ Lithium 900 mg daily for chronic cluster headache

▪ Verapamil 360 mg daily for prophylaxis or chronic cluster HA

▪ Warfarin to INR 0.9-1.5 for prophylaxis

▪ Melatonin 10 mg daily for prophylaxis

▪ Valproic acid 600-2000 mg daily for prophylaxis

▪ Topamax 25 mg daily x 7 then increase to 400 mg/day for prophylaxis

* Used for Acute

Treatment


▪ Level U (Unclassified-Inconsistent or Inconclusive studies)

▪ Frovatriptan 5 mg daily for prophylaxis

▪ Melatonin 10 mg PO at Bedtime for prophylaxis

▪ Capsaicin cream intra-nasaly 3-4/day for prophylaxis

▪ Prednisone 20 mg QOD for prophylaxis

▪ Tizanidine 2-4 mg every 6-8 hours up to 24 mg/day in divided doses

for prophylaxis

▪ Medications Tried for Cluster HA which do NOT work or NOT

recommended

▪ Opioids

▪ OTC medications

▪ Nimodipine

▪ Clonidine

Oxford Center for evidence-Based Medicine Levels of Evidence

Grade of

Recommendation

Level of

Evidence

Type of Study

A 1A Systematic Review (SR) with homogeneity of Randomized Controlled

Trials (RCT)

1B Individual RCT with narrow Confidence Interval (CI)

1C All or none studies

B 2A SR with homogeneity of cohort studies

2B Individual cohort study

2C Outcomes research/Ecological studies

3A SR of case control studies (CCS)

3B Individual case control study

C 4 Case/series case report/Poor quality cohort or case controlled study

D 5 Expert opinion or based on physiology, bench research or first principles

63

Source: www.cebm.net


8.2 Medication-Overuse Headache Classification

8.2.1 Ergotamine-overuse headache

8.2.2 Triptan-overuse headache

8.2.3 Non-opioid analgesic-overuse headache

8.2.4 Opioid-overuse headache

8.2.5 Combination-analgesic-overuse headache

8.2.6 Medication-overuse headache attributed to multiple drug classes

not individually overused

8.2.7 Medication-overuse headache attributed to unspecified or

unverified overuse of multiple drug classes

8.2.8 Medication-overuse headache attributed to other medication

Classifications of Medication Overuse Headaches: ICHD-3 alpha


Medication-overuse Headache: Diagnostic CriteriaA. Headache occurring on 15 days/month in a patient with a pre-existing headache disorder

B. Regular overuse for >3 months of one or more drugs that can be taken for acute and/or

symptomatic treatment of headache

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

• Regular intake on 10 days/month for >3 months:

• 8.2.1 Ergotamine-overuse headache

• 8.2.2 Triptan-overuse headache

• 8.2.4 Opioid-overuse headache

• 8.2.5 Combination-analgesic-overuse headache

• Regular intake on 15 days/month for >3 months

• 8.2.3 Non-opioid analgesic-overuse headache (Paracetamol (Acetaminophen), Acetylsalicylic acid, NSAIDS)


Headache Types

▪ Medication Overuse Headache

▪ Analgesic use > 2-3 days/week

▪ Headache present > 15 days/month

▪ Regular overuse > 3 months of one or more medication

that can be taken for acute and/or symptomatic treatment

of HA

▪ Headache has developed or markedly worsened during

medication overuse

▪ Primarily occurs in patients with a primary HA disorder

such as migraine, cluster or tension-type HA

▪ TX: Discontinuation of overused medication and a

combination of pharmacological, non-pharmacological,

behavioral and physical therapy interventions

Downloaded from www.doctormigraine.com


Medication Overuse Headache: Treatment

▪ Goal is to withdrawal from meds to establish baseline HA pattern

▪ This can be achieved by:

▪ Abrupt withdrawal (OTC analgesics, Triptans)

▪ Tapered withdrawal (BZD, Opioids, Barbiturates)

▪ Butalbital: Phenobarb taper for SZ prophylaxis with 30 mg

for every 100 butalbital and taper 30 mg every 2-3 days

▪ Opioid: Clonidine Patch 10.-0.2/24 hours x 1-2 weeks and

bridge with long-acting NSAID (Naproxen) daily


Medication Overuse Headache: Treatment

Possible In-patient or Outpatient Regimens

▪ Steroids (Prednisone 100 mg x 5 days)

▪ Ketorolac PO 60 mg x 1 then 10 mg q6h x 3 days

▪ Tizanidine 2-8 mg TID

▪ DHE 0.5-1 mg IV q8h with Reglan 10 mg x 3 days

▪ May bridge with Tizanidine/NSAIDs

▪ May bridge with IVMP 100-200 every 12 hours for 2-3 days

▪ Relapse rate is 20-40%

▪ Limit future abortive medications to 2/week

Migraine Management in Pregnant Patients

▪ Epidemiology

▪ In one retrospective study 30% of pregnant patients have

primary headaches

▪ Migraine without aura-64%

▪ Tension Headache-26%

▪ Evaluate for pre-eclampsia > 20 weeks gestation

▪ If HA sudden or severe or worst HA of my life: Send to ER

▪ Migraine does NOT affect any outcome measure of pregnancy


First Trimester

▪ Hormonal changes

▪ Lack of sleep

▪ Low blood glucose

▪ Hunger

▪ Dehydration

▪ Nasal congestion

▪ Caffeine/sugar withdrawal

▪ Stress


Second Trimester

▪ Occurrence is less

▪ Avoid strong smells and exhaust fumes

Third Trimester

▪ Similar to First Trimester

▪ Poor posture

▪ Muscle tension from excess weight

▪ Pre-eclampsia (Regular BP checks)


▪ Non-pharmacologic therapies preferred:

▪ Cold compresses -Rest/Stress reduction/Psycho therapy

▪ Warm bath -TMJ adjustment

▪ Massage -Certain Herbal Treatments

▪ Cefaly (TENS) Unit -Acupuncture

▪ Hyperbaric oxygen -OMM

▪ Short-term treatment

▪ Acetaminophen, metoclopramide, small doses of caffeine, NSAIDs, IV Fluids, IV anti-emetic

▪ If no effect may try Butalbital-acetaminophen-caffeine (Fioricet) 1-2 tabs q4h not to exceed 6/24h

▪ Discontinue NSAIDs before week 32

▪ No ASA in the third trimester

▪ Prednisone (category B) may help shorten active migraine

▪ Triptans (category C) used when benefits outweigh risks


▪ Severe Headaches-Most Opioid analgesics are safe-Pregnancy Category B

▪ Codeine

▪ Oxycodeine

▪ Meperidone

▪ Prophylactic treatment for frequent or disabling attacks

▪ Beta-blockers relatively safe (pregnancy category C) except atenolol (Preg Category D)

▪ Avoid Barbiturates and Benzodiazepines

▪ Avoid ergotamine or DHE

▪ Can try magnesium or riboflavin or fluoxetine

▪ Avoid Butterbur in pregnancy (Association with Budd-Chiari syndrome)

▪ Avoid feverfew and Co-Q 10

74Many Resources Online for Patients and Practitioners

https://americanmigrainefoundation.org/ https://americanheadachesociety.org/

http://www.achenet.org/

https://medlineplus.gov/headache.html

https://www.acponline.org/practice-resources/patient-

education/online-resources/migraine

https://www.aan.com/

https://headaches.org/http://www.migraines.org/

https://migraineresearchfoundation.org/

https://www.webmd.com/migraines-headaches/migraines-

headaches-finding-help

75

Thank you

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