Headache Management Multi-modality TNP sept 2016v1[1] · in headaches •Rule out a systemic...
Transcript of Headache Management Multi-modality TNP sept 2016v1[1] · in headaches •Rule out a systemic...
8/11/16
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HeadacheManagementMulti-ModalityApproach
KarenWilliams, MSN,RN, FNP-BCTempleVA
Neurology/Headache Clinic
Patientexperience• 51yr oldmalewithahistoryofrefractoryheadachesfor20+yrs
(since1992)
• Started withparachutejump,hardlanding,hitheadtotheleft,hadLossofConsciousness-
• DescribedasLefthemicranial throbbing/achingassociatedwithphotophobia/phonophobia,Nausea/Vomiting&worsewithexertion.Ratedas10/10
• Occurring2-4timespermonthlasting3-6days
Disclosures• Off label useofmedications
• Theviews expressed in this presentation are those of theauthor anddonot reflect theofficial policyof theDepartment of theVeterans Affairs,Department ofDefense, orU.S.Government
Objectives
• Epidemiology/Socioeconomics ofheadaches
• Briefly describe themostcommon types ofheadaches
• Review essentials ofevaluation
• Review treatments
• Case presentation
Epidemiology ofHeadaches
• Primary headache disorder isestimated toaffect45(+)million individualsin theUS1
• World-wide, the percentageof theadult population with anactiveheadache disorder is46%2
– 42%suffer fromtension-type– 11%frommigraine
– 3%fromchronic dailyheadache
Socioeconomic
• Headache is themostcommon pain-related complaint among workers3
• Most commoncauseofabsenteeism fromworkandschool 1
• Oneof themost commoncomplaints in theER, with over3million ERvisits in 20003
• Estimated $17 billion annually, forthe costofhealthcare associated withmigraines4
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Types ofHeadacheDisorders
• Primary- notassociated with anycause orpathology– Migraine, Tension, cluster migraine
• Secondary- associated with some underlying pathology– Traumatic, Drug/substance related, infection, malignancy, vascular
Tension- TypeHeadache• Themost commonprimary headache
• Pain isbilateral, often described as pressing, band–like orvise-like. In theforehead, temples orbackofhead andneck
• Intensity - Mild tomoderate
• Can last from30minutes to7days
• Canbeassociated with photophobia orphonophobia but notboth
Tension (cont)• Oftenaccompanied by fatigue, inadequate sleep
• Triggered bystress, fatigue oremotional bursts
• Usually not aggravatedbyphysical activity
• Usually relieved with OTCanalgesics, relaxation, reduction of stress
• Frequently coexists with migraine2
Migraine
• World wide prevalence of11%and is the2nd most commonprimaryheadache2
• Affecting women 3times more thanmen, with acomparison of17%femalevs6%male6
• Occurs fromchildhood toadulthood with the peakprevalence occurring inmid-adulthood6
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Migraine(cont)
• Recurrent episodes ofgenerally unilateral (maybebilateral),pulsating/throbb ing pain
• Usually aggravatedbyphysical activityand often relieved with sleep
• Pain ismoderate tosevereanddebilitating
• Associated symptoms ofnausea, vomiting, photophobia andphonophobia
• Time frameof4 to72hours, ifuntreated
MigrainewithAura
• Aura- aconstellation ofvisual andsensory symptoms thatoccur justbeforeorat theonset ofamigraine
• Visual aura (mostcommon)- blind spots, flashes oflight, zigzag lines
• Sensory aura- numbness or tingling ofanarmor face
• Reversible aphasia
• Duration of symptoms of1hour, but motor symptoms canlast longer2
CommonTriggersofMigraine
• Hormonal-– menstruation, ovulation, oral contraceptives with estrogen
• Dietary-– ETOH,nitrates, caffeine, agedcheese, MSG, aspartame, chocolate,
skipping meals
• Psychological-– stress, anxiety,depression
CommonTriggersofMigraine(Cont)
• Environmental-– glare, flashing lights, strongodors, barometric changes, highaltitude
• Sleep-– lackofor too muchsleep
• Drug-related –– Nitroglycerin, Histamine, Hydralazine, Ranitidine, Estrogen
HeadacheEvaluationandDiagnosis
• Accurate andthrough headache history
– FamilyHx,Personal medical Hx,Hx ofhead trauma, Time frameofheadache, ageofonset, how frequent, duration, triggers, aggravatingfactors, co-morbid illnesses, impacton family andwork/school
– Clinical description of theheadache: Location, intensity, nature ofthepain, preceding symptoms, auraorneurologic symptoms
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Helpfulquestions Diagnosis ofMigraineorTTH
• Helpful questions:– Howdoheadaches interfere with your life?
– HowFrequently doyouexperience headaches ofany type?
– Has there beenachange inyourheadache pattern over the last6months?
– Howoften andhow effectivelydoyouusemedications totreatheadaches?7
HeadacheAssessment Tools
• HeadacheCalendar- iHEADACHE (freephone app)
• Headache Impact test (6questions)– Helps patientscommunicatetheseverity of theheadache paintotheirprovider
• TheMigraine Disability Assessment Questionnaire (5questions)– Measures headache-related disability in:work/school,householdandfamily/social
• Migraine SpecificQuality of LifeQuestionnaire (MSQ) (14questions)– RoleFunction-Restrictive– RoleFunction- Preventive– EmotionalFunction
PhysicalExam
• Neurological exam:Cranial nerves, Strength, Coordination, DTR’s (rule-outpapilledema, diploplia, facialweakness, gaitdisturbances, nuchal rigidity)
• ROM ofneck/Palpation of theTMJandoccipital nerves (looking fortenderness oredema, trigger points inparaspinal, shoulder areas)-
• Blood Pressure: diastolic over120mmHgareassociated with an increaseinheadaches
•Rule out a systemic illness or other organic cause
RedFlagsAssociated withSecondaryHeadaches
• Systemicsymptoms ordisease (fever, weight loss, jawclaudication)
• Neurologic signs or symptoms (papilledema, motor weakness, memoryloss, papillary abnormality, sensory loss)
• Onset sudden
• Onset beforeage5orafterage50
• Pattern change fromprior headaches
DiagnosticsforRedFlags
• Imagingstudies: Ctofhead, MRI– Looking forstructural abnormalities
• Blood chemistries andBlood counts– Sed rateshould bemeasured inadults thatare50andolder
• Lumbarpuncture (afterobtaining brain imaging): in suspected meningitis,subarachnoid hemorrhage, Pseudotumor cerebri, encephalitis or systemicillness (lupus, sarcoidosis, vasculitis)7
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MigraineTreatments TreatmentsforMigraine
• Abortives:– First line:NSAIDSorAcetaminophen
– First line ifmoderate tosevere:Tripitans• Constrict dilated blood vessels, reduce neuropeptide release andinhibit impulse transmission centrally within the trigeminovascularsystem
– Ergotamine/Dihydroergotamine (DHE)
– Oxygen inhalation (100%) forcluster migraine8
PreventativeTreatmentsforMigraines
• Consider if4ormoreheadaches per month, consider co-morbidconditions– Propranolol*– Topiramate*– Divalproex*
– Antidepressants – TCA’s– NSAIDS– Calcium Channel Blockers- Cluster migraine
*FDAapproved formigraine prevention
Preventives(continued)
• Riboflavin (Vit B2) - Dosed at100mg, 2tabs twiceper day
• Magnesium 400mgperday (dose inevening)
• Botox*• Cefaly*
• Acupuncture
• Occipital NerveBlocks
• Biofeedback and Cognitive therapy
Headache
EpisodicHeadache•Characterize type•Abortivetherapy
•Maximum 6 doses/week
ChronicDailyHeadache•> 15HAdayspermonth•Analgesic rebound•Prophylaxisiskey
Abortive ProphylaxisOnset of action ~4wks
Avoidnarcotics&Benzos
NSAIDs•GI sid eeffects
Ibup ro fenNap ro xen Sod iumAcetaminophenAsp irin
Triptans• Con traind icated in p atien tswith CAD
Imitrex in j/o ral/NSZomig o ral/NSMaxalt/Relp ax/AxertAmerge/Fro va
CombinationMedications• R isko fW/D
Fio ricetFio rin alExced rin
Beta & AlphaBlockersP rop rano lo l -h elp w/an xietyP razo sin - h elp w/Nigh tmares and po ssib lyETOHabu se
Anti-depressants•May imp rove mood• Imp roves sleep
To fran i l /No rtrip tyl l in e/Amitryp ti l l in eVen lafaxin e/Du lo xetin eP aro xetin e/Fluo xetin e/M irtazap in eTrazodone
AEDS•Neu ropath icp ain
Gabapen tin
•Mood lab i l i tyValp ro ic acidTop irimate
AlternativesP romethazin eMeto clop ramideP ro ch lo roperazin eOndan setronTizan id in eOccip i tal b lo ckAcupun ctu re
CAMB io -feedbackVit B2 /MagnesiumAcupunctu reBOTOXPT/Ch irop racticCefalyCES-Alpha-stim
Sleep Headache
Irritability/Mood
Cognitive
Symptom Interaction
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Education
• Headachecalendar• Sleep hygiene techniques
• Abstinence/limite d alcohol use• Proper nutrition/limite d caffeine/proper water consumption• Coping strategies/Journaling/St ress management• Limited useofabortive medication/avoid overuse or rebound
headaches
• Realistic expectations
OccipitalNeuralgia:themigrainelookalike(sorta)
• Occipital pain thatmayormaynotbeononeside &sudden inonset
• Sharp, shooting pain radiating fromthebackof thehead into the templesand forehead
• Pain aboveandbehind the eye
• Nausea when thepain is severe
• Pain transiently relieved byoccipital block2
OccipitalNerve Anatomy
Common causes
• Entrapment of theoccipital nerves by theneckandscalpmuscles 9-11
• Trauma:Fall,MVC, blow to thehead, whiplash
• Seatbelt use:Right occipital pain indrivers and left inpassengers due toseatbelt 12
OccipitalBlockInjectionSites
GONaimingslightlyupmaintainingasubcutaneouscourseLOCaiminglateralandup,maintainingasubcutaneouscourse
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Additional Treatments• NeckRange ofMotion exercises
• Ice/heat to thebackofthe head
• Nervemodulating medications (Gabapentin, Topamax, Depakote)
• NSAID,Lidocaine gel toneckarea,Epsom salt bath
• Breathing/relaxation techniques
• PT/Chiropractic manipulation ofthe neck
AdditionalModalities
Whenmedication isnotworking ornot tolerated
Botox Injection Paradigm:31Injection SitesAcross7MuscleAreas
BOTOX* P rescrib in g In fo rmation ,Feb ruary 2 0 1 4 ;2 .B lumen feld ,Heada ch e. 2 0 1 0
Trancutaneous SupraorbitalNeurostimulation/Cefaly
• FDAapproved forprevention ofmigraine (March2014)• Varying results- need touse it daily for20min• Currently notcoveredby Insurance
– Cost $349.00, packof3electrodes $25.00 (good for20treatmentseach),2AAA batteries
CranialElectrotherapyStimulationAlpha-stim
• FDAapproved for treatment ofAnxiety, Depression, Insomnia
• Utilized inover70VA’s and in theDoD
• Cansee reduction ofanxiety in1st treatment, maytake3-4weeks forPTSD/Depression
• Noneed tomonitor labs/minimal side effects/no dependency
• Cost savings in reduction ofothermeds/treatments
Acupuncture
Qi, orenergy, travels along12main pathways ormeridians within thebody
Health is influenced by thequality, quantity andbalance ofour Qi
Provides power for– Growth andDevelopment– Movement
– Maintenance ofbody temperature– Protection against illness– Regulation
Qi is profoundly disturbed by traumatic stress
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DifferentTypesofAcupuncture
• Traditional Chinese Acupuncture (TCM)
• Medical Acupuncture
• Japanese Acupuncture
• Korean Hand Acupuncture
• Scalp Acupuncture
• Auricular Acupuncture andAuriculotherapy
• Veterinary Acupuncture
MedicalAcupuncture• Simplified version ofTCM frequently addresses more acuteissues.
• 300-500 hours of training.
• Physician, Nurse Practitioners andPhysician Assistants using this modality.
• Added treatment modality inWestern medicine – gaining momentum inmilitary andVA facilities forpain treatment, PTSD/mood disorders, headinjury
Auriculotherapy/Auricular Acupuncture
With permiss ion from Terry Oleson, Ph.Dwww.auriculotherapy.org
CasePresentation
Posttraumaticheadaches
Veteran with20+yearsactiveduty
Background• 51yr old malewith ahistory of refractoryheadaches for20+yrs (since
1992)
• Startedwith parachute jump, hard landing, hit head to the left, hadLossofConsciousness-
• Described asLefthemicranial throbbing/aching associated withphotophobia/phonophob ia, Nausea/Vomiting &worse with exertion.Rated as10/10
• Occurring 2-4 times permonth lasting 3-6days,daily mild headache
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Background(continued)• Triggered bylight
• Treatedwith Imitrex 100mg/ Fioricet- notusually helpful. Layingin adark,quiet room
• Preventative: Depakote500mg2 tabs
• Interferes completely with activities when hewould haveanattack
• Past treatments: Nortriptyline, Inderal, Verapamil, Topamax, Maxalt,Zomig- none helpful. Botox- reducednumber &severity
SocialHistory• 51yrold male- Retired fromArmyafter20yrs asE7 (SergeantFirst
Class) MOSTransportation/Snipper, 5deployments toOIF/OEF
• Married, 2children/BA inGeneral studies
• Tobacco- 3cigarettes /NoETOH/NoCaffeine/Diet balanced/Walking &household duties/No current hobbies
• Spiritual affiliation- Baptist
• Current stressors: things hehasgone through “ I had todosomebadthings Doc”
MedicalHistory• Migraines, OSA, HTN,PTSD,Diabetes, Ataxicgait, testicular crush injury
• 3concussions with LOC,2paratrooping, 1 IEDblast, multiple dazed withhard landing
• Allergic toSimvastatin
• Surgical- testicular crush
• FamilyHx- Mother- cancer, Fatherdied ofnatural causes
• Hadgone through vestibular and ocular-motor rehab forconcussions in2009
SignificantExamFindings• Neurologic examWNL, excepthasdiplopia inall rightperipheral gazes and
lefthead tilt
• Leftoccipital tenderness
• Teeth with signs ofbruxism
• CTofhead– WNL
• Wearing of sunglasses andhat in the examroom- extremephotophobia allthe time
Treatment• Education on findings, treatment considerations toinclude Acupuncture,
Botox, Occipital blocks
• Selfhelp strategies to include, ice to thebackofthe head, Breathing andneckexercises, Magnesium 400mg.Stopdaily useofFioricet
• Encouraged tocontinue with Mental health
• Startedwith acupuncture, occipital blocks andBotox (perheadacheprotocol andadded Masseters)- reduced migraines to4per week, shorterinduration and resolving with Imitrex, resolving daily mild headache
Treatment(continued)• Alpha-stim Aid introduced when becameavailable in theheadache clinic,
3months after1st appointment. Helped with further reduction ofanxiety
• After 2rounds ofBotox, daily useofalpha-stim andstopping his Fioricet,henoted heno longer needed towearsunglasses, migraines improving
• Migraines now 2per month, resolved afterabout 40 minutes with Imitrex100mgandalpha-stim aid
• “Ayearago itwas rough, but this program is ablessing, youchanged mylife! “
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Summary• Tension andMigraine are themost commonprimary headaches
• Rule outa systemic illness orother organiccause
• Treat themostdisturbing symptoms first
• Education is akeycomponent
• Hx of traumamay increase yoursuspicion ofoccipital neuralgia
HeadachetableMigraine Tension-Type OccipitalNeuralgia
Location Unilateral Bilateral OccipitalIntensity ModeratetoSevere Mild toModerate Mild tosevere
Duration 4to72 hours 30mins to7days Minutes tohoursPaintransientlyrelievedbyoccipitalblock
Quality Pulsating Pressure/Tightening Sharp,throbbing,pressure
AssociatedSymptoms
Nausea,vomiting,photophobia,phonophobia
Photophobia orphonophobia (butnotboth)
Painbehind theeyes,nauseawhenpainsevere,photophobia
Female:Maleratio 3:1 1.3:1 Nopreference,seenoftenafterhead/necktrauma
1. TheCleveland Clinic Health Foundation. Overview ofheadache inadults. Cleveland Clinic Health Information Center website. Accessed Feb122008
2. Stovner LJ,etal. TheGlobal Burden ofheadache:A Documentation ofHeadachePrevalence andDisability Worldwide. Cephalgia 2007;27:193-210.
3. Stewart WF, etal. LostProductive Time andCost Due toCommon PainConditions in theUSWorkforce. JAMA 2003;2902443-2454.
4. Goldberg LD.Thecostofmigraine and its treatment.AM JManag Care2005:11(2 suppl): 562-567.
5. HeadacheClassification subcommittee ofthe International headacheSociety.The International Classification ofheadacheDisorders:2ndedition. Cephalagia 2004;4Suppl 1:9.
6. Lipton RB, Bigal ME, etal. Migraine prevalence, disease burden, and theneed forpreventive therapy.Neurology 2007; 68:343-349.
References References(con’t)7. Martin V, Elkind A.Diagnosis and classification ofprimary headache
disorders. In:Standards ofCare forHeadache Diagnosis andTreatment.Chicago I ll:National headache Foundation 2004;4-18.
8. Silberstein SD.Practiceparameter:evidence-based guidelines formigraine headache (anevidence-based review): reportof theQualityStandards Subcommittee ofthe American AcademyofNeurology. Neurology 2000;55-754
9. Bogduk N.Theneckandheadaches. Neurol Clin 2004;22:151.10. Boes, CJ,Copobianco, DJ,Cuter, FM, etal. Headacheand other
craniofacial pain. In:Neurology inclinical practice, Bradley, WG, Daroff,RB, Fenichel, GM,etal (Eds), Butterworth Heinemann, Philadelphia, PA2004;2055.
References(con’t)11. Ashkenazi A, LevinM.Threecommonneuralgias. Howtomanage
trigeminal, occipital, and postherpetic pain.Postgrad Med 2004;116:16.12. Zasler N:Neuromedical Diagnosis andManagement ofPostconcussive
Disorders. In:HornL,Zasler N, (EDS).Medical Rehabilitation oftraumaticBrain Injury.Philadelphia, Pa:Hanley&Belfus 1996;145-148.
KarenWilliams,MSNCRNP