Headache Medicine for the Non NeurologistHeadache Medicine for the Non‐ ... had tension-type...

Headache Medicine for the Non‐Neurologist

Justin DeLange, DO, FAHSNorthern Arizona Healthcare Medical Group-

Neurology

ObjectivesAt the end of this talk you should be able to:

• Explain why headache medicine matters• Diagnose migraine and diagnose cluster

headache• Recognize red flag features • Know primary work-up for secondary headaches• Know available abortive and preventive

treatment options for migraine as an outpatient• Know why abortive and preventive treatment is

important• Know management options for headache on an

inpatient basis

Lecture Outline• Outpatient Management

o Migraineo Clustero Other common headache types

• Inpatient /ED Management of Migraine• Secondary Causes of Headache in the Hospital/ED

o Diagnostico Recognition

DisclosuresOff-Label: Numerous medications used for

headache or migraine do not carry an FDA indication.

Financial: none

Conflict of interest: none

Why Headache Matters

The Numbers

• Migraine is a global problem (1 Billion people affected) .

• In the U.S. migraine affects around 12% of the population.

• 36 MILLION AMERICANS WITH MIGRAINE

• One in Four Households• Prevalence of Chronic

Daily Headache: 4%

Why Migraine Matters

The Burden• Migraine costs are in upwards of 20 billion dollars a year.

This includes office visits, ER visits, medications, and missed work/lost productivity.

• 4% of all visits to doctor are for headache.• World Health Organization places migraine in the Top 10

most disabling diseases on the planet. • Pain is not the only disabling factor.

o Nausea/vomitingo Aura symptomso Light/sound/smell sensitivity

Why Migraine Matters in Primary Care

• The Landmark Study showed 94% of patients complaining in the office to primary care doctors of stable, episodic headaches had migraine or probable migraine. Only 3%had tension-type headache as the primary diagnosis.

• Migraine causes disability. Tension type headaches do not generally result in disability and seldom do patients with tension type headache seek medical attention.

• 40% of pts with migraine qualify for preventive treatment BUT only 13% actually get preventive treatment (Lipton RB et al. Neurology; 68:343-349.)

Diagnosis/Management of Headaches

Outpatient

MIGRAINES

Migraine without auraInternational Headache Society 2013 Diagnostic Criteria

• A. At least five 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 four characteristics:

o 1. unilateral locationo 2. pulsating quality o 3. moderate or severe pain intensityo 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:

o 1. nausea and/or vomitingo 2. photophobia and phonophobia

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

Migraine Diagnosis Simplified

• Think: PUMA• Pulsating• Unilateral (60%)• Moderate to Severe on pain

scale• Activity makes worse

• Other sx’s of photophobia, nausea, vomiting, phonophobia, osmophobia.

• May occur with or without Aura.

More Simplification:

ID Migraine Brief Screener• Yes or No Answers• With your Headaches

o 1. Do you have a dislike for light?o 2. Do you have nausea?o 3. Do your headaches have impact on work, home, school, or recreational

activities?

• 2/3 “Yes” Answers suggest Migraine• Sensitivity of 0.81 and Specificity of 0.75

Lipton (2003)

Clinical Pearls Regarding Migraine

ResponseTo Triptans

or ErgotsNot dx

Can be Chronic orEpisodic.

Bilateral LocationIn 40%

History of motion

sickness

Family historyOf HA

Neck Paincommon

Aura seenIn 20%

Red wine WeatherStress

Menstrualtriggers

Disabling

Migraine

Adapted from Tepper SJ and Tepper DE 2011 and Ward TN 2012

What is Migraine with Aura?• Gradually progressive neurologic impairment that last 5-60 minutes,

precedes or coincides with headache, and is completely reversible.o Typical aura may include:

• Visual• Sensory• Language

o Atypical may include:• Weakness• Ataxia• Prolonged• Bulbar symptoms• Monocular visual disturbances/blindness

Migraine Aura is Important to Recognize

• Stroke Risk doubled in patients with Migraine with Aura (RR 2.16)

• OCP (estrogen) + Migraine with aura= 10-13 fold increase in stroke risk (relative risk)

o Absolute risk of stroke is low howevero Additive risk not multiplicative

• OCP (estrogen) + Migraine with Aura + Smoking=DANGEROUS (Odds Ratio 34)

• Stroke Risk mainly noted in woman less than age 45. • Migraine with Aura may also be associated with other

cardiovascular disease too.

If estrogen needed for compelling indication in

patient with migraine with aura patient: lowest dosage recommended.

Case • A 24-year-old

woman presents to her PCP complaining of throbbing, disabling headaches 2 days/month.

• She notes nausea and photophobia with her attacks

• Pain is 8/10 and lasts for 6 hours.

• She notes that Tylenol and Aleve are not helping her headaches.

• She denies any aura symptoms prior to headache onset.

• Exam normal

What is the diagnosis?Are there any other questions we need to ask?

Algorithm for Headache Diagnosis

Detailed history and exam

Headache Red Flags Present?

Exclude Secondary headache using appropriate testing if necessary

Consider Primary HA.Atypical features present?

Reconsider Secondary Headache

Diagnose primary headache disorder

From Wolff’s Headache

Yes No

Yes

NoIf clearly migraine then imaging is not warranted!

Make sure you are treating migraine!

Secondary Headaches

2SNOOP4 Headache Red Flags

• SYSTEMIC SYMPTOMS (fever, weight loss) or SECONDARY RISK FACTORS (HIV, systemic cancer)

• NEUROLOGIC SYMPTOMS or abnormal signs (confusion, impaired alertness or consciousness)

• ONSET: sudden, abrupt, or split-second (thunderclap)

• OLDER: new onset and progressive headache, especially in middle age >50 yr (giant cell arteritis)

• PREVIOUS HEADACHE HISTORY: first headache or different (change in frequency, severity, or clinical features), POSITIONAL, PAPILLEDEMA, or PRECIPITANTS (cough, sneeze, sex, Valsalva)

Dodick DW. Adv. Stud Med 2003;3:S550-555

History must be taken, not just accepted

Yellow flags for Secondary

Headache Disorders

• Wakes patient from sleep at night• New onset side-locked headache

De Luca and Bartleson, Seminars in Neurology, 2010

Physical exam of headacheCheck Looking for To clue you towards

Vital signs Fever, hypertension, obesity

Infection, hypertensive HA, pseudotumor cerebri

Funduscopy Papilledema Elevated intracranial pressure

Cranial auscultation Orbital bruits Vascular malformation, thyrotoxicosis

Palpate temporal arteries Tenderness, nodularity, absence of temporal pulse

Giant cell arteritis

Inspection and palpation of HEENT

Lymphadenopathy, meningismus, inflamed mucosa, TMJ tenderness

Infection, TMD

Neurologic examination Horner’s syndrome, facial numbness, neurologic deficit

Carotid dissection, intracranial lesion

Adapted from Smith JH

If Red Flags Present? Need Imaging!

If Thunderclap headaches are present then vessel imaging (MRA head/neck or

CTA head/neck) is necessary!

MRI Brain in non-emergent (outpatient)

settings

CT Head and/or MRI Brain in

emergent settings

Case

• After a thorough history and examination you determine that she has not red flags or atypical features.

• She is asking for further treatment.

What should we recommend for treatment?

Acute Pharmacotherapy for

Migraine• Guidelines published showing evidence base

for acute migraine therapies. (Marmura M, Silberstein SD, Schwedt TJ. Headache. 2015;55:3–20)

• Answers the question of which medications are effective in acute migraine treatment.

• Acute treatment is very important as ineffective acute treatmentchronic migraine (Lipton et al. Neurology 2014)

• Acute medications not only help pain but also help migraine-associated disability.

Acute Pharmacotherapy for Migraine

Strength of Evidence• Level A: established as effective (First Line

agents)• Acetaminophen 1000 mg for non-

incapacitating attacks.• DHE Nasal Spray 2mg• DHE Pulmonary inhaler 1 mg• Aspirin 500 mg• Diclofenac 50, 100 mg• Ibuprofen 200, 400 mg• Naproxen 500, 550mg

Marmura M, Silberstein SD, Schwedt TJ. Headache. 2015;55:3–20.

Note: Opiates/Opioids should never be used as a first line agent!


Strength of Evidence• Level A: established as effective (First Line agents)• Triptans

• Almotriptan-Expensive, but less side effects• Eletriptan-Expensive, Quick and Effective• Frovatriptan-Expensive, long-acting (not quick)• Naratriptan-cheap, long-acting (not quick)• Rizatriptan-cheap, Quick and Effective• Sumatriptan-cheap, quick, most side effects.

Injectable form is gold standard but side effects.• Zolmitriptan-consistent, quick• Sumatriptan/naproxen-expensive, more effective

than sumatriptan alone.


Use full doses!


Strength of Evidence• Level A: established as effective (First Line agents)• Triptans

• Almotriptan-Expensive, but less side effects• Eletriptan-Expensive, Quick and Effective• Frovatriptan-Expensive, long-acting (not quick)• Naratriptan-cheap, long-acting (not quick)• Rizatriptan-cheap, Quick and Effective• Sumatriptan-cheap, quick, most side effects.

Injectable form is gold standard but side effects.• Zolmitriptan-consistent, quick• Sumatriptan/naproxen-expensive, more effective

than sumatriptan alone.


Use full doses!


Triptans• Different Modalities/Delivery:• Consider alternate route if patient has bad

nausea • Tab

• All triptans• Disintegrating tab

• Zolmitriptan• rizatriptan

• Nasal Spray• Sumatriptan• zolmitriptan

• Injectable• Sumatriptan

• Iontophoretic Patch (FDA warning: skin burns!!!)pulled off market

• Sumatriptan• Intra-nasal powder (breath-powered) now FDA-approved

• Sumatriptan

Contraindications to triptans

• Known or suspected ischemic heart disease• Cerebrovascular disease• Peripheral vascular disease• Uncontrolled HTN• Severe hepatic disease• Use of ergot-alkaloid or other 5-HT1 agonist (i.e. a

different triptan) within preceding 24 hours• Patients should avoid sumatriptan, rizatriptan, and

zolmitriptan within 2 weeks of MAO inhibitor use (phenelzine)

• Hemiplegic attacks • Typically avoid during pregnancy (FDA Category C)


DHE Nasal Spray

• DHE Nasal Spray is often overlooked and is useful if patient does not respond to triptans or NSAIDs.

• Does not need to be dosed at the onset of the attack to be effective.

• Drawbacks: Taste, medication going down the back of the throat.

• Can be expensive depending on patient’s insurance.

Contraindications to DHE

• Black box: Serious/life-threatening peripheral ischemia has been associated with the coadministration of DHE with potent CYP3A4 inhibitors including protease inhibitors and macrolide antibiotics

• Coadministration with other pressor/vasoconstrictivemedications

• Hypersensitivity to ergot alkaloid products • Myocardial infarction • Uncontrolled hypertension, ischemic heart disease, angina• Cerebrovascular disease, peripheral vascular disease • Onset of chest pain following test dose• Other ergot or 5-HT derivatives (triptan) within last 24 hr• Pregnancy and lactation (FDA Category X)• Prolonged hypotension, shock • Sepsis • Severely impaired liver/renal function • Following vascular surgery• Hemiplegic/basilar migraine


Anti‐Emetics• Good for Rescue when nothing else is helping. • May help keep patient out of the ED.• May also help headache too!• Prochlorperazine 5-10 mg PO x1 (or suppositories at 25

mg PR x1)• Metoclopramide 10 mg PO X1• Promethazine 12.5-25 mg PO x1• Metoclopramide and Prochlorperazine have best

evidence in setting of migraine (IV forms). Watch for EPS!• Should only be used for Rescue therapy!

• Ondansetron if unable to tolerate anything else or has tremor history.

Primer on Acute Treatment• Significant nausea?: try triptan

injection or disintegrating tabs or nasal spray

• If no response to Triptans, Try NSAIDs alone or DHE nasal spray.

• Try to limit abortive medications to no more than 2 days/week (no more than 9 days/month) to avoid analgesic or triptan overuse headache.

• Make sure patient has anti-emetics for Rescue therapy (may help with headache along with nausea)

• In absence of vascular disease, consider migraine specific medication (e.g. triptans, DHE)

• For Triptans should be dosed at headache ONSET.

• Try adding NSAID with Triptans at onset for synergy or for breakthrough pain.

• NSAIDs do not need to be taken at headache onset to be effective

Preventive Therapy for Migraine

o When to Initiate Migraine Prophylaxis:• >3 migraine days/month• >2 migraine days/week• Abortive medication overuse• Severe disability from headaches• Patient preference• Abortive medication side effects• Atypical cases: Hemiplegic Migraine, Prolonged aura,

Brainstem aura.


o Preventive therapy helps to avert chronification of migraine.

o Start Low and go slowo 2-3 month trialo Reassure patient they are not “married” to a certain

drug.• If side effects or no response after 2-3 months then try

another drug.o Realistic Goals:

• Goal is less disability, halving of frequency, and less abortive med usage.


o Try to kill two birds with one stone if possible. • Topiramate for the obese patient• Propranolol for the anxious or tremulous patient• Amitriptyline for the insomnia patient.• Depakote or Topiramate for the Bipolar patient• Propranolol, Metoprolol, or Atenolol in the

hypertensive patient• Amitriptyline in the fibromyalgia or chronic pain

patient.


AAN Guidelines for Migraine Preventive Therapy

o FIRST LINE!o Level A: Meds with established efficacy (should be

offered)o Topiramate 100-200 mg/dailyo Metoprolol 50-100 mg/dailyo Propranolol 80-240 mg/dailyo Level B: Meds are probably effective (should be

considered)o Amitriptyline 10-150 mg/daily


AAN Guidelines for Migraine Preventive Therapy

o SECOND LINE!o Level A: Meds with established efficacy (should be

offered)o Divalproex sodium or sodium valproate 250 mg-1500

mg/dailyo Level B: Meds are probably effective (should be

considered)o Venlafaxine 37.5 mg-225mg/dailyo Atenolol 50-100 mg/daily


AAN Guidelines for Migraine Preventive Therapy:

Vitamins, Supplements, and Herbal Therapies

o Level A: Meds with established efficacyo Petasites (Butterbur): no longer safely recommended due

to liver toxicity issues!

o Level B: Meds are probably effective (should be considered)

o Magnesiumo Feverfewo Riboflavin


onabotulinumtoxinA

o If patient has had 15 or more headache days/month for at least 3 months=Chronic Migraine

o If Chronic migraine patient has tried two or three different preventives and is still having 15 or more headache days/month then onabotulinumtoxinA may be indicated

o OnabotulinumtoxinA is only FDA-approved medication for Chronic Migraine

o Refer to Neurology or Headache Specialist.

Addressing Risk Factors for Developing Chronic Migraine

• Caffeine• Depression• Allodynia• Anxiety• Other chronic

pain

• Medication overuse

• Attack frequency• Obesity• Head Injury• Snoring

New and Emerging Migraine Treatments

• Transcranial Magnetic Stimulation*

• Non-invasive Vagal nerve stimulation for Cluster and

Migrane*• Trigeminal nerve stimulation*

• Sumatriptan intranasal powder*

• CGRP monoclonal antibodies (Awaiting FDA

approval)

Photos credit: National Headache Foundation

*FDA approved

New and Emerging Migraine Treatments

• Transcranial Magnetic Stimulation*

• Non-invasive Vagal nerve stimulation for Cluster HA*

• Trigeminal nerve stimulation*• Sumatriptan intranasal

powder*

• CGRP monoclonal antibodies (Awaiting FDA

approval)

Photos credit: National Headache Foundation

*FDA approved

New Migraine Preventives: Monoclonal Antibodies to CGRP

Erenumab(fully human)

Eptinezumab(humanized)

Galcanezumab(humanized)

Fremanezumab(humanized)

Indication EM, CM EM, CM EM, CM, CH EM, CM, CH

Dosing Monthly SC Q 3 month IV Monthly SC Monthly or Q3 month SC; IV load for CH

Target CGRP Receptor CGRP peptide or ligand

CGRP peptide or ligand


DevelopmentalStatus

Submitted to FDA; TargetAction date: 5/17/2017

Submission in Late 2018?

Submitted to FDA; Target Action Date: 10/11/2018 (est.)

Submitted to FDA; Target Action Date:?

Adapted from SJ Tepper 2017

New Migraine Preventives: Monoclonal Antibodies to CGRP

Erenumab(fully human)

Eptinezumab(humanized)

Galcanezumab(humanized)

Fremanezumab(humanized)

Indication EM, CM EM, CM EM, CM, CH EM, CM, CH

Dosing Monthly SC Q 3 month IV Monthly SC Monthly or Q3 month SC; IV load for CH

Target CGRP Receptor CGRP peptide or ligand



DevelopmentalStatus

Submitted to FDA; TargetAction date: 5/17/2017

Submission in Late 2018?

Submitted to FDA; Target Action Date: 10/11/2018 (est.)

Submitted to FDA; Target Action Date:?

Adapted from SJ Tepper 2017

CGRP Monoclonal Antibodies

• 50% Responder Rate: ~40%-50 (similar to current preventives)

• Onset of Effect: days (same day response noted for eptinezumab IV)

• Current Migraine preventive therapies take weeks-months to have effect.

Image credit: Practical Neurology Nov/Dec 2017


Outpatient

CLUSTER HEADACHE

Cluster Headache• Most severe pain a patient can experience other than

childbirth and/or passing kidney stones• Part of a group of headache known as trigeminal

autonomic cephalalgias (TACs)o TACs=typically short, severe unilateral headaches with autonomic features

• Any headache meeting criteria for a TAC or cluster headache needs imaging

o Pituitary lesion?o Dissection?o Posterior fossa lesion?o Hypothalamic lesion?

Photo: National Library of Medicine (NIH); Medline Plus

Suspect Cluster?MRI Brain w/wo contrastConsider Vessel imaging

Cluster Headache • Simplified Diagnosis

o Think SSS (sharp, short, severe)• 15-180 minutes

o Most likely in V1 (trigeminal) or C2 (occipital distribution)

o Attack frequency: QOD to 8/dayo EtOH trigger commono Agitation/Restlessness in 90% o Circadian/circannual periodicity

(‘alarm clock periodicity’)o Autonomic symptoms: ptosis,

miosis, tearing, rhinorrhea, nasal congestion, conjunctival injection, diaphoresis

• International Headache Society Criteria 2013

• A. At least five attacks fulfilling criteria B–D• B. Severe or very severe unilateral orbital, supraorbital• and/or temporal pain lasting 15–180 minutes (when• untreated)1• C. Either or both of the following:• 1. at least one of the following symptoms or signs,• ipsilateral to the headache:• a) conjunctival injection and/or lacrimation• b) nasal congestion and/or rhinorrhoea• c) eyelid oedema• d) forehead and facial sweating• e) forehead and facial flushing• f) sensation of fullness in the ear• g) miosis and/or ptosis• 2. a sense of restlessness or agitation• D. Attacks have a frequency between one every other• day and eight per day for more than half of the time• when the disorder is active• E. Not better accounted for by another ICHD-3• diagnosis.

Stillman 2011

Cluster Headache Treatments

• Abortiveo Oxygen 10-15 L/min via NRB

mask x15 minuteso Sumatriptan 6 mg SC

• Oral triptans suboptimal in cluster!

o DHE injection or nasal sprayo Sumatriptan or zolmitriptan

nasal spray• Preventive

o Verapamil 240-480 mg/do Sodium valproate 500-1500

mg/do Topiramate 100-200 mg/do Melatonin 9-25 mg daily

• Bridging (pain relief while waiting for preventive to “kick in”)• Prednisone 60-80

mg/d tapered over 14 days

• Greater occipital nerve block


Outpatient

OTHER HEADACHE TYPES

Other Common Headache Types

Tension-type Headache Post-Traumatic Headache• Usually does not present to

clinic (not disabling) unless chronic

• Typically bilateral, pressure-like• No migrainous features

o No nausea and vomitingo May have photophobia or

phonophobia but not both!• Activity does not make worse• Treatment

o Amitriptyline is preventive of choice if bothersome.

o NSAIDs for abortive care

• New-onset headache that appears after head injury, concussiono MRI Brain needed +/- vessel

imaging• Treat the phenotype

o Migrainouso Clustero Tension-type


Inpatient/ED

MIGRAINES

Inpatient Treatment Principles

ED/Inpatient

• Place the patient in a darkened, quiet room• Provide reassurance• Treat fluid depletion• Treat nausea and vomiting!!!• Implement treatment with parenteral medication• Use non-dependence producing agents when possible

(no opioids if possible)• Utilize doses which are likely to be effective

Inpatient Treatment Principles

ED/Inpatient

• Do not restrict antiemetics just to patients with nauseao Dopamine-blockade may be implicated in migraine relief

• Use “migraine-specific” therapy (DHE, Triptans)o But 50% of patients presenting to ED in 1 study had a

potential contraindication to migraine-specific therapy (Friedman et al. Headache 2009)

• Response to therapy is not a diagnostic tool!

Inpatient/ED TreatmentMigraines

Migraine‐specific treatments Inpatient

Triptans

Sumatriptan 6 mg SC (Max 12 mg/24

hours)

Side effects: injection site reaction, paresthesias, hot/cold sensation, chest pressure/pain/tightness, dizziness, flushing, limb pain, vasoconstriction, and nausea.

Ergotamine derivatives

Dihydroergotamine mesylate (DHE) 0.5

mg‐1 mg IV ( Max 2‐3 mg/24 hours) (May

be dosed every 8 hours in hospital)

Side effects: paresthesias, dizziness, flushing, nausea/vomiting, diarrhea, dyspnea, rash, diaphoresis, elevated blood pressure, anxiety, and vasoconstriction.

For DHE: pre-treatment with anti-emetic +/-

diphenhydramine often needed!


Migraine‐specific treatments Inpatient

Triptans

Sumatriptan 6 mg SC (Max 12 mg/24

hours)

Side effects: injection site reaction, paresthesias, hot/cold sensation, chest pressure/pain/tightness, dizziness, flushing, limb pain, vasoconstriction, and nausea.

Ergotamine derivatives

Dihydroergotamine mesylate (DHE) 0.5

mg‐1 mg IV ( Max 2‐3 mg/24 hours) (May

be dosed every 8 hours in hospital)

Side effects: paresthesias, dizziness, flushing, nausea/vomiting, diarrhea, dyspnea, rash, diaphoresis, elevated blood pressure, anxiety, and vasoconstriction.

For DHE: pre-treatment with anti-emetic +/-

diphenhydramine often needed!

**AHS Guidelines for Acute Migraine in ED (2016): Should Offer


Nonspecific Migraine treatments Inpatient

Antiemetics (D‐2 Antagonists)

Chlorpromazine 12.5‐25 mg IV/IM

Prochlorperazine 10 mg IV/IM **

Promethazine 25 mg IM

Haloperidol 5 mg IV in 500 ml normal saline over 20

minutes

Droperidol 2.5 mg IV

Metoclopramide 10 mg IV/IM

Side effects: drowsiness, dizziness, blurred vision, akathisia, dystonia, parkinsonism, fluid retention (metoclopramide), QT prolongation (Droperidol has Black Box warning due to risk of QT prolongation*), neuroleptic malignant syndrome, hypotension (especially chlorpromazine)



Antiemetics (D‐2 Antagonists)

Chlorpromazine 12.5‐25 mg IV/IM

Prochlorperazine 10 mg IV/IM **

Promethazine 25 mg IM

Haloperidol 5 mg IV in 500 ml normal saline over 20

minutes

Droperidol 2.5 mg IV

Metoclopramide 10 mg IV/IM**

Side effects: drowsiness, dizziness, blurred vision, akathisia, dystonia, parkinsonism, fluid retention (metoclopramide), QT prolongation (Droperidol has Black Box warning due to risk of QT prolongation*), neuroleptic malignant syndrome, hypotension (especially chlorpromazine)

**AHS Guidelines for Acute Migraine

in ED (2016):Should Offer



Antiepileptics

Valproate sodium 500‐1000 mg IV (one

time dose)

Side effects: drowsiness, asthenia, nausea/vomiting, injection site reaction, dizziness, hepatotoxicity, hyperammonemia, pancreatitis.

• Useful for patients with cardiovascular or cerebrovascular contraindication to triptans,

DHE.



Antiepileptics

Valproate sodium 500‐1000 mg IV (one

time dose)

Side effects: drowsiness, asthenia, nausea/vomiting, injection site reaction, dizziness, hepatotoxicity, hyperammonemia, pancreatitis.

• Useful for patients with cardiovascular or cerebrovascular contraindication to triptans,

DHE.

**AHS Guidelines for Acute Migraine in ED

(2016):May Offer

Inpatient/ED TreatmentMigrainesNonspecific Migraine

treatments Inpatient

NSAIDs

Ketorolac 30 ‐60mg IV/IM

• Side Effects: GI bleeding, GI ulceration, dyspepsia, abdominal pain, nausea, vomiting, injection site reaction, bleeding, rashes, nephrotoxicity, cardiovascular risk, anaphylaxis.

Useful for Break‐through pain while inpatient

Inpatient/ED TreatmentMigrainesNonspecific Migraine

treatments Inpatient

NSAIDs

Ketorolac 30 ‐60mg IV/IM

• Side Effects: GI bleeding, GI ulceration, dyspepsia, abdominal pain, nausea, vomiting, injection site reaction, bleeding, rashes, nephrotoxicity, cardiovascular risk, anaphylaxis.

Useful for Break‐through pain while inpatient

**AHS Guidelines for Acute Migraine in ED (2016):

May Offer


Nonspecific Migraine treatments

Inpatient

Corticosteroids

Dexamethasone 10‐25 mg IV

(prevents recurrence)

Side effects: nausea, vomiting, dyspepsia, dizziness, mood swing, insomnia, anxiety, hypertension, hyperglycemia, avascular necrosis of bone (rare)

Others

Magnesium sulfate 1‐2 g IV (for

MwA, light/sound phobia)

Side effects: hypotension, flushing, drowsiness.


Nonspecific Migraine treatments

Inpatient

Corticosteroids

Dexamethasone 10‐25 mg IV

(prevents recurrence)

Side effects: nausea, vomiting, dyspepsia, dizziness, mood swing, insomnia, anxiety, hypertension, hyperglycemia, avascular necrosis of bone (rare)

Others

Magnesium sulfate 1‐2 g IV (for

MwA, light/sound phobia)

Side effects: hypotension, flushing, drowsiness.

**AHS Guidelines for Acute Migraine in ED (2016):

Should Offer


Inpatient

SECONDARY HEADACHES

Algorithm for Headache Diagnosis

Detailed history and exam

Headache Red Flags Present?

Exclude Secondary headache using appropriate testing if necessary

Consider Primary HA.Atypical features present?

Reconsider Secondary Headache

Diagnose primary headache disorder

From Wolff’s Headache

Yes No

Yes

NoIf clearly migraine then imaging is not warranted!

Secondary Headaches

2SNOOP4 Headache Red Flags

• SYSTEMIC SYMPTOMS (fever, weight loss) or SECONDARY RISK FACTORS (HIV, systemic cancer)

• NEUROLOGIC SYMPTOMS or abnormal signs (confusion, impaired alertness or consciousness)

• ONSET: sudden, abrupt, or split-second (thunderclap)

• OLDER: new onset and progressive headache, especially in middle age >50 yr (giant cell arteritis)

• PREVIOUS HEADACHE HISTORY: first headache or different (change in frequency, severity, or clinical features), POSITIONAL, PAPILLEDEMA, or PRECIPITANTS (cough, sneezing, sex, Valsalva)

Dodick DW. Adv. Stud Med 2003;3:S550-555

History must be taken, not just accepted

Serious Secondary Causes of Headache• Subarachnoid hemorrhage

(SAH)• Giant cell arteritis• Cerebral venous sinus

thrombosis• Cervical artery dissection• Reversible cerebral

vasoconstriction syndrome• Hypertensive emergency• Acute strokes: hemorrhagic or

ischemic• Pituitary apoplexy

• Mass lesionso Tumoro Abscess (including

parameningeal infections)o Intracranial hematomas

(parenchymal, subdural, epidural)

o Colloid cyst of 3rd ventricle• Meningitis and encephalitis• Idiopathic intracranial hypertension• Spontaneous intracranial

hypotension• Carbon monoxide poisoning• Cardiac cephalalgia• Acute narrow angle closure

glaucomaAdapted from: Bounes and Edlow, Eur Review Med Pharm Sciences, 2011

Serious Secondary Causes of Headache• Subarachnoid hemorrhage

(SAH)• Giant cell arteritis• Cerebral venous sinus

thrombosis• Cervical artery dissection• Reversible cerebral

vasoconstriction syndrome• Hypertensive emergency• Acute strokes: hemorrhagic or

ischemic• Pituitary apoplexy

• Mass lesionso Tumoro Abscess (including

parameningeal infections)o Intracranial hematomas

(parenchymal, subdural, epidural)

o Colloid cyst of 3rd ventricle• Meningitis and encephalitis• Idiopathic intracranial hypertension• Spontaneous intracranial

hypotension• Carbon monoxide poisoning• Cardiac cephalalgia• Acute narrow angle closure

glaucomaAdapted from: Bounes and Edlow, Eur Review Med Pharm Sciences, 2011

More common causes of

thunderclap headache

Aneurysmal Subarachnoid Hemorrhage

• Thunderclap headache, seizures, meningismus, altered consciousness

• Sensitivity of CT for detecting aneurysmal SAH within 6 hours=92-100%

• If CT negative and SAH suspected then LP indicated

o Should be performed as soon as possible

o Looking for xanthochromia• Spectrophotometry J. van Gijn, and G. J. E. Rinkel Brain 2001;124:249-278

© Oxford University Press 2001

Aneurysmal Subarachnoid Hemorrhage

• MRI Brain useful in patients who present days after sx onset

o FLAIR, GRE sequences sensitive for SAH

o MRI more sensitive than CT outside acute phase

• Blood vessel imaging needed to look for aneurysm

o CTAo MRA

• If negative then invasive angiography indicated

J. van Gijn, and G. J. E. Rinkel Brain 2001;124:249-278

© Oxford University Press 2001

Reversible Cerebral Vasoconstriction

Syndrome (RCVS)

• Often recurrent Thunderclap HA over a period of 1-2 weeks

o With or without focal Neuro Sx’s

• Monophasic course• Vessel

imaging=reversible beading/vasospasm

o Normalization within 12 wks.

• MRI may show ICH, infarcts, PRES

• CSF normal or near normal

Image credit: The Lancet Neurology 2012 11, 906-917DOI: (10.1016/S1474-4422(12)70135-7) Image Copyright © 2012 Elsevier Ltd

Tx: CCBs

Internal Carotid or Vertebral Artery Dissection

• May present with or without thunderclap headache

o Often after head/neck trauma

• Neck pain (often unilateral) common

• Stroke symptoms often present

• MRI Brain w/o contrast to check for infarct

• MRA head/neck or CTA head/neck Dissection may be a Cluster

HA Mimic!

Cerebral Sinus Thrombosis• Usually presents with new

chronic daily headache• 5% may present with

Thunderclap headache• May also present with

weakness, seizures, AMS, visual issues (papilledema).

• Suspect with Risk Factors:o Pregnancyo Dehydrationo OCP useo Venous thrombosis historyo Children, young adults,

women>menDiagnosed with MRV or CTV

Spontaneous Intracranial Hypotension

• Postural Headacheo Worsens within 15 minutes of sitting

or standingo Improves when recumbent

• Thunderclap headache in 15%

• Auditory muffling, tinnitus, dizziness, blurry vision common

• May occur from LP, trauma, or connective tissue disease

Spontaneous Intracranial Hypotension

• MRI shows pachymeningeal enhancement, subdural hygromas, and/or “brain sagging”.

• CT or MRI myelogram may be needed to localize site of leak

• Treatment is blood patch

Giant Cell Arteritis• New onset headache in

patient above age of 50• Jaw claudication• Temporal artery

tenderness• New visual disturbances• Polymyalgia rheumatica

sx’s• Fever or anemia• ESR and/or CRP elevated

Headache: The Journal of Head and Face PainVolume 55, Issue 6, pages 866-868, 11 MAR 2015 DOI: 10.1111/head.12541http://onlinelibrary.wiley.com/doi/10.1111/head.12541/full#head12541-fig-0003

Photo: uveitis.org

Giant Cell Arteritis• Temporal Artery Biopsy is

diagnostic• Steroids should not be

delayed to avoid ischemic complications

o Vision loss is irreversible

• Prednisone 60 mg daily• ASA 81 mg daily should

also be startedo Wide spread vasculitis of medium

to large vessels

Conclusion• Migraine is a disabling, genetic brain disease• History is EVERYTHING in headache medicine• Be wary of red flag symptoms (2SNOOP4)• Migraine specific abortive therapy should be used when

possibleo Triptans or DHE if no risk factorso NSAIDs may be used for synergy with migraine specific therapy

• Migraine preventives are underutilized and important• Utilize Parenteral, non-opioid treatment in the

hospital/inpatient setting for migraine when possible• Be on the lookout for secondary causes of headache in

the ED/Hospital/Outpatiento Thunderclap Headache may herald an ominous cause!!!

Questions?

Pregnant Migraineur?• No preventives if possible.

• Magnesium 350 mg (FDA recommends no higher)• Propranolol FDA Category C-lowest dose possible if needed.• Amitriptyline (no more than 50 mg) FDA Category C -lowest dose possible if needed.

• Abortives:• Tylenol• Tylenol/Caffeine• Metoclopramide 10 mg PRN (use sparingly)• Naproxen or Ibuprofen in 1st and 2nd Trimesters only!• Prednisone (not in 1st Trimester)

• Avoid opiates/opioids or butalbital if possible!• Triptans are Category C and use as a third line agent should

only be considered if nothing else is helping.• Registry data showing sumatriptan may be safe.

• DHE is Category X and is always contraindicated!!!

Consensus Statements on OCP use

in Migraine with Aura• European community: More restrictive of OCP use in

migraine.• ACOG position: no OCPs in a patient with migraine with

aura above 35 year old.• IHS position: individually assess and evaluate risk for

stroke in each patient• WHO: women with migraine with aura should not use

OCPs.

In the clinic or at home:

Rescue Plan to Keep Out of ED!

Initial Therapy

Rescue Therapy

Back-up Therapy

First dose of triptan

And/Or NSAID

Repeat dose of triptan. Also try NSAID for breakthrough pain if not given initially.

Trying to keep out of ED Prochlorperazine PO or PR

(or other antiemetic of your choice)

Indomethacin 50 mg PR Ketorolac 30-60 mg IM or PO Consider steroids

If Fails

If Fails

Adapted from Whyte, Headache 2010; Turkewitz. Self-administration of parenteral ketorolac for head pain. Headache, 1992

Consider non-oral meds in patients with severe nausea/vomiting.

Injections/Nasal spray

Stop Status Migrainosus treatment if headache-free for 24 hours.

Adapted from Kriegler 2011

Headache Medicine for the Non NeurologistHeadache Medicine for the Non‐ ... had tension-type...

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