EVALUATING THE PATIENT WITH CHRONIC HEADACHES

Dr. Fallon Schloemer, DO Assistant Professor Department of Neurology Medical College of Wisconsin

WHAT IS HEADACHE?

1 WHAT’S THE BIG DEAL?

• Headache accounts for: • 4.4% of all consultations in general practice • 5% of all medical admissions to the hospital • 20% of neurology outpatient consultations

• Migraine specifically affects over 20% of people at some point in their lives

• 2% of the world has chronic migraine! • In Top 40 of conditions causing worldwide disability

HEADACHE CLASSIFICATION SYSTEM

• International Classification of Headache Disorders, Third (Beta) Edition (ICHD-3 beta) • Designed to provide diagnostic consistency for research purposes • Provides diagnostic criteria to guide treatment and management

• Divided into 3 parts: • Part one: the primary headaches • Part two: the secondary headaches • Part three: painful cranial neuropathies, other facial pains and other headaches • Appendix

2 GENERAL HEADACHE EPIDEMIOLOGY

• As many as 90% of all benign headaches fall under a few categories • Migraine • Prevalence: 18% in women and 6% in men • Tension-type • Prevalence: 38% (episodic), 2-3% (chronic) • Cluster • Prevalence: <1% • New daily persistent headache • Prevalence and incidence are unknown

CHRONIC DAILY HEADACHE (CDH) • Is this a diagnosis???

• Descriptive term than encompasses several different specific headache diagnoses characterized by frequent headaches. • Long duration: chronic migraine, chronic tension-type, medication overuse, hemicrania continua, and new daily persistent headache • Short duration: chronic cluster, chronic paroxysmal hemicrania, hypnic headache, and primary stabbing headache

• What defines “chronic”? • Frequency is 15 or more headaches per month for at least 3 months • Persistence of headache subtypes for at least one year without remission

3 EPIDEMIOLOGY OF CDH • Prevalence of chronic daily headache: 4% • Majority suffer from chronic tension-type, chronic migraine or medication overuse headache

• Women>>Men

• Burden: • Results in significant pain and suffering, reductions in quality of life, and enormous economic costs to society

CASE

• A 25 year-old female with history of migraine without aura since age 16. Until 1 year ago, was getting headaches 2-3 days per month, relieved with butalbital/aspirin/caffeine.

• Over the past year, headaches have increased in frequency and her use of butablital/aspirin/caffeine has also increased.

• She presents now with 25 headache days per month, 12 of which are severe. Severe headaches are described as right-sided, throbbing, with associated photophobia, phonophobia, and nausea. Headaches last most of the day. Triggers are stress and sleep deprivation.

4 CASE

• On severe headache days, she took 4-6 tablets of her acute medications and on less severe days took 2 tablets. 25 days per month she was taking her combination analgesic.

• Preventative therapy in the past included amitriptyline (stopped years ago due to sedation).

• Family history is notable for mother and sister with migraine

• Neurological exam including fundi and visual fields was normal.

• Work-up with MRI and routine labs was normal.

CASE

• Diagnosis ? • Chronic Migraine with Medication Overuse

5 CHRONIC MIGRAINE

• Previously listed as a complication of migraine, transformed migraine, chronic daily headache • >15 or more headache days/month for >3 months

• The broader acceptance of the concept that migraine can be a chronic condition has led to increasing interest in the pathophysiology, epidemiology, and treatment of this condition

• Migraine accounts >50% of the disability attributable to all neurological diseases

• Cost to society in the USA alone >>$20 billion annually

DIAGNOSIS OF CHRONIC MIGRAINE

• Recognize the pattern: • How did the headaches originally develop? • Primary headache disorder (episodic migraine)increasing attack frequency no headache freedom

• Headache starts one day and ever goes away  New daily persistent headache • Important to rule out

secondary causes Ther Adv Chronic Dis. 2015 May; 6(3): 115–123

6 DIAGNOSIS OF CHRONIC MIGRAINE

• Recognize the disorder: • Commonest cause of recurrent, severe headache • 20% of women, 10% of men • Genetic basis with internal and external influences

• Migraine and Greek word hemicrania  ‘half of the head’

• Not everyone’s migraine has ‘read the textbook’

DIAGNOSIS OF CHRONIC MIGRAINE

• Take a detailed history: • Accurate history taking is vital • Give patients time to describe attacks • Fill the gaps • It’s all in the history!! • Pattern of pain • Triggers or exacerbating factors • Nature of pain • Associated symptoms • Current and previous treatments • Other medical history and family history

7 DIAGNOSIS OF CHRONIC MIGRAINE

• Investigate appropriately: • Driven by cultural myths • 1. Headaches are due to brain tumors • 2. Abnormal scan or blood test is needed

• When to image?? • Abnormal exam • Papilledema on fundoscopic exam • Focal neurologic deficits • History of cancer • New onset headache >50 years old • Significant change in headache pattern/characteristics

DIAGNOSIS OF CHRONIC MIGRAINE

• Make a diagnosis: • Even if presumptive, make one • Reassurance is important

• But doc, “Something is wrong up there.”

8 PATHOPHYSIOLOGY OF MIGRAINE • Activation of Trigeminovascular system • Innervates the meninges, and provides sensory innervation to the intracranial vessels • Upon stimulation: • dilatation of the meningeal blood vessels • release of neuropeptides – Substance P, NO, neurokinin A and CGRP, a potent vasodilator

• Plasma protein extravasation and sterile neurogenic inflammation

• Reactive impulses to travel back to the brainstem to the trigeminal nucleus caudalis and pain modulation centers (peri-aqueductal gray, locus ceruleus)

• This information travels via the thalamus to cortex causing central pain perception, central sensitization

Headache Continuum August 2012

MIGRAINE WITHOUT AURA • 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: • 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 2013;33(9):629-808

9 MIGRAINE WITH AURA • A. At least two attacks fulfilling criteria B and C • B. One or more of the following fully reversible aura symptoms: • 1. Visual • 2. Sensory • 3. Speech and/or language • 4. Motor • 5. Brainstem • 6. Retinal • C. At least two of the following four characteristics: • 1. At last one aura symptom spreads gradually over >5 minutes, and/or two or more symptoms occur in succession • 2. Each individual aura symptom lasts 5-60 minutes • 3. At least one aura symptom is unilateral • 4. The aura is accompanied, or followed within 60 minutes, by headache • D. Not better accounted for by another ICHD-3 diagnosis, and TIA has been excluded

Cephalalgia 2013;33(9):629-808

PHASES OF MIGRAINE

10 PREMONITORY PHASE (PRODROME) • Occurs hours to days before headache

• Occurs in ~60% of migraineurs

• Consists of psychological, neurologic, or general symptoms in various combinations • Depression, euphoria, irritability, hyperactivity, fatigue • Photophobia, phonophobia, hyperosmia • Stiff neck, cold feeling, increased thirst, increased urination, anorexia, diarrhea, constipation • Food cravings

AURA • Comprised of focal neurologic phenomena that precede or accompany an attack

• Occurs in 20%

• Develop slowly over 5-20 minutes and last <60 minutes

• Usually visual

• Headache follows 80% of the time and usually begins within 60 mins

• Migraine aura status can rarely occur

11 THE AURAS – WHAT ARE THEY?

• Visual: scotoma; photopsia or phosphenes; geometric forms; fortification spectra; objects may rotate, oscillate, or shimmer; brightness appears often very bright

• Visual Hallucinations or Distortions: metamorphopsia; macropsia; zoom or mosaic vision

• Sensory: paresthesia, often migrating, often lasting for minutes, and can become bilateral

• Olfactory hallucinations

• Motor: weakness or ataxia

• Language: dysarthria or aphasia

• Delusions and Disturbed Consciousness: déjà vu, multiple conscious trance-like states

VISUAL AURAS

12 HEADACHE

• Unilateral, throbbing, moderate-severe, aggravated by routine activity • Radiate • Stabbing

• Onset can vary, but often gradual

• Usually lasts 4-72 hours

• Patients prefer to lie down in a dark, quiet room • Scalp tenderness may prevent this  allodynia

HEADACHE ASSOCIATED PHENOMENA

• Anorexia or food cravings • Nausea (90%) and vomiting (1/3), Diarrhea (16%) • Gastroparesis (Poor Gastric motility) • GI distress and poor absorption of meds • Photophobia (sensitive to light) • Phonophobia (sensitive to sound) • Lightheadedness and vertigo • Premonitory/Prodrome symptoms can continue • Blurry vision, nasal stuffiness, sweating • Neck pain/discomfort (59-61%) • Sinus pain/pressure (33-44%)

13 POSTDROME

• Following the headache, patient may have impaired concentration or may feel tired, washed out, irritable, and listless

• Some feel unusually refreshed or euphoric

• Muscle weakness and aching

• Anorexia or food cravings can occur

COMPLICATIONS OF MIGRAINE

• Status migrainosus • A debilitating migraine attack lasting for more than 72 hours

• Persistent aura without infarction • Aura symptoms persisting for 1 week or more without evidence of infarction on neuroimaging

• Migrainous infarction • One or more migraine aura symptoms associated with an ischemic brain lesion in the appropriate territory demonstrated by neuroimaging

14 TREATMENT AND MANAGEMENT

SO WHAT CAN WE DO?? • Headache management is a multidisciplinary approach

• Effective treatment begins with making an accurate diagnosis • Rule out alternative causes • Order appropriate studies • Address effect on patient

• Treatment plan should consider diagnosis, symptoms, and comorbid conditions but also expectation, needs and goals

15 COMPREHENSIVE HEADACHE TREATMENT PLAN

• Education and Reassurance • Avoiding triggers • Keep Headache diary!! • Nonpharmacologic treatments • Relaxation, cognitive behavioral treatment and biofeedback • Life style regulation • Maintaining a regular schedule • Getting adequate sleep and exercise • Stopping smoking! • Physical and alternative medicine • PT, acupuncture, etc. • Pharmacologic treatment • Acute and preventative

MIGRAINE TRIGGERS

16 MIGRAINE TREATMENT

• Goals: • Restoration of function • Reduction of disability and suffering • Reduction of disease progression and future expression

• Treatment often centers on: • Pharmocotherapy • Non-medication • Alternative and interventional therapies • Combinations of above

• Involves acute and prophylactic treatment

GOALS OF SPECIFIC TREATMENT • Acute • Quickly restore the patient to normal functioning in a safe, side effect-free, cost effective manner • Minimize need for additional medication exposure or resource use

• Preventative • Reduce the frequency, duration and severity of individual events • Reduce progression of disease

17 ACUTE THERAPY

PRINCIPLES OF ACUTE TREATMENT

• Success of treatment defined by: • Frequency with which patient returns to headache-free, fully functional state within 2 hours • No recurrence within 24 hours

• Treat early!! • Can be challenging Migraine may not always begin with pain • Patients often reluctant to treat early

18 PRINCIPLES OF ACUTE TREATMENT

• What should patient do? • Treat early in attack • Use adequate dose and formulation of medication appropriate to the circumstances • Maintain hydration • Seek rest if necessary • Restrict acute treatment to 2-3 days per week to avoid medication overuse

HISTORY OF ACUTE TREATMENT • Initially acute treatment based on vascular model for headache • Advanced by Wolff and Graham (1938)

• Led to development of vasoconstrictive agents • Ergots • Triptans • Mechanism: may inhibit neurogenic inflammation peripherally, inhibit nociceptive inputs to the central pain system, or act as peripheral vasoconstrictors

19 THE TRIPTANS

DRUG DOSE/FORMULATION MAX DAILY DOSE Almotriptan 6.25mg and 12.5mg tablets 25mg Eletriptan 20mg and 40mg tablets 80mg Rizatriptan 5mg and 10mg tablets 30mg (15mg if on 5mg and 10mg orally dissolving wafers propranolol) Sumatriptan 25mg, 50mg and 100mg tablets 200mg oral 5mg and 20mg intranasal 40mg intranasal Single dose vial, 6mg/0.5ml for SQ injection 12mg SQ 4mg and 6mg cartridges for autoinjector 6mg needle free devices for SQ injection Fixed-dose combination tablet of 85mg sumatriptan with 500mg naproxen sodium Zolmitriptan 2.5mg and 5mg tablets Two tablets or 10mg 2.5mg and 5mg orally dissolving wafers maximum oral daily dose 5mg intranasal Two sprays or 10mg intranasal

Frovatriptan 2.5mg tablet 7.5mg Naratriptan 1mg and 2.5mg tablets 5mg

NONSPECIFIC ACUTE THERAPIES

• Many less specific or nonspecific agents continue to be used • OTC containing acetylsalicylic acid, acetaminophen, ibuprofen, or naproxen

• Butalbital-containing combination products • Controversial! • Poorly studied

• Neuroleptics/antiemetics • Prochlorperazine (Compazine) • Metoclopramide (Reglan) • Promethazine (Phenergan) • Ondansetron (Zofran)

• Corticosteroids

20 A WORD ON THE OPIOIDS • Poor Migraine Drug

• Limited to short term as these can cause produce tolerance, dependence and addiction

• Can even worsen primary headache disorders

OPTIONS IF ACUTE TREATMENT IS INADEQUATE

• Change dose or formulation • Treat early • Add adjunctive therapy (NSAIDs) • Screen for caffeine or other acute medication overuse • Screen for prescription medications that can promote headache (eg, nitroglycerin) • Add preventative

21 PREVENTATIVE TREATMENT • When to use migraine preventative? • Three or more headache episodes per month

• Significant interference of headache with daily activity

• Acute medication ineffective, contraindicated or overused

• Adverse effects from acute medications

• Patient preference

PRINCIPLES OF PREVENTATIVE TREATMENT

• Start low, increase slowly • Use adequate trial (2 to 3 months)

• Avoid medication interactions/contraindications • Consider comorbid conditions

• Monitor with calendar/diary

• Consider combinations in refractory patients

• Taper when headaches are controlled

22 CLASSES OF HEADACHE PREVENTATIVES

• Beta-adrenergic blockers • Nonsteroidal Anti-inflammatory • Propranolol, Metoprolol Drugs • Calcium Channel Antagonists • Indomethacin • Verapamil • Antiserotonin/Antihistamine • Antiepileptic Drugs • Cyropeptadine • Topamax, Depakote, • Alpha-Agonists Gabapentin • Tizanidine • Antidepressants • Angiotensin-converting enzyme • Amitriptyline, inhibitors/ARBs Nortriptyline, venlafaxine • Lisinopril, Candesartan

NEWER, NATURAL, ALTERNATIVE THERAPY

23 BOTOX (ONABOTULINUMTOXIN A)

• Development for headache began in 1997 after reports from plastic surgeons of curing migraine

• Pooled results from two RCTs showed efficacy compared to placebo • Reduced headache days

• Series of 31 injections given at intervals of 12 weeks

• Likely works on chemical mediators implicated in migraine

• Currently our only FDA approved treatment for chronic migraine

BOTOX INJECTION SITES

24 NATURAL SUPPLEMENTS

• Magnesium

• Riboflavin (vitamin B2)

• Coenzyme Q10

• Petadolex (butterbur)

• Feverfew

WHEN TO CONSIDER BEHAVIORAL INTERVENTIONS

• Preference for nonpharmacologic interventions • Poor tolerance of pharmacologic treatment • Medical contraindications for pharmacologic treatment • Inadequate response to pharmacologic treatment • Pregnancy, planned pregnancy or nursing • Life stress, deficient coping skills or comorbid psychological disorder

25 BEHAVIORAL INTERVENTIONS

• Relaxation Training

• Cognitive-behavioral Therapy

• Biofeedback Training

• Mindfulness Meditation

CONCLUSIONS

• Chronic migraine is an improvement treatable cause for neurological disability.

• It is vital to make a diagnosis and ensure that any coexisting medical or psychological conditions are treated in parallel with interventions aimed at reducing the biological tendency to headaches.

• Set expectations.

• Do not expect “cure”.

• New therapies are on the horizon • CGRP antagonists and antibodies

26 THANK YOU!

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