Best Practices for Diagnosis and Treatment of Headache Sadly, I - PDF document

Disclosures Best Practices for Diagnosis and Treatment of Headache • Sadly, I still have nothing new to disclose from yesterday John Engstrom, M.D. April 2017 Old Headaches vs. New Headaches (HA) Headaches • Severity or location of headaches only • HAs requiring timely medical intervention occasionally helpful with diagnosis • Secondary HAs • Historical risk factors: • Primary Headache Clinical Diagnosis – New-onset – elderly, immunosuppressed • Management of specific headache types – Focal neurologic signs – Altering the environment – Postural – supine or standing – Acute management – Fever, rash, stiff neck-meningitis – Chronic management – Sudden onset over 1-2 seconds-hemorrhage 1

Postural Headaches and Q1: Which Statement Regarding Intracranial Pressure (ICP) Postural Headaches is False? • Low ICP-head worse with standing and 1) Due to low or high intracranial pressure resolves with supine position but not meds 2) Common after an LP – Post-LP (risk about 5-10%) 3) May require brain imaging to see if CSF pathways are obstructed – Spontaneous/traumatic leaks 4) Usually require a follow-up LP • Elevated ICP-Headache worse when supine 5) Low ICP headache may require a search – Mass lesions that obstruct flow CSF pathways for the anatomic source of the leak – Meningitis-infection, hemorrhage, cancer – Nocturnal-CO 2 retention with vasodilatation Low ICP Headache-Management High ICP Headache-Management • Not post-LP – Neurologic exam and medical history • Neurologic exam and medical history – Brain/spine MRI for sagging brain/spinal block • Ophthal eval for papilledema + visual fields – CSF to measure opening pressure • Brain MRI with MR venogram – CT/MR myelogram-source of leak • MRI neg, LP-for opening pressure (OP) • Post LP • IIH (Idiopathic Intracranial Hypertension) – Bed rest for 5-7 days, generous caffeine – Preserve vision and relieve symptoms – Persistent-anesthes/radiol epidural blood patch – Diamox, Lasix, steroids 2

Q2: Which one of the following Primary Headaches (HA) is not a primary headache type? • Migraine-with or without aura 1) Cluster HA • Tension-type headache 2) Cervicogenic HA • Trigeminal autonomic cephalgias (Cluster) 3) Migraine with aura 4) Migraine without aura • Other primary headache disorders 5) Tension HA Migraine Without Aura Migraine with Aura • HA attacks last 4-72 h (untreated or • Need more than one aura symptom-visual, refractory to treatment) sensory, speech or language, motor, brainstem, retinal • HA Features-unilateral and pulsating • Aura spreads gradually over more than 5 – Worse with usual physical activity (climbing minutes (not a sensory seizure over 1-5 stairs, walking) seconds) and lasts 5-60 minutes – Accompanied by nausea or emesis, photophobia, and phonophobia • Aura accompanied or followed by headache – Patient feels better in a dark room in < 60 minutes 3

Chronic migraine Tension type HA • Meets diagnostic criteria for migraine on • More than 2 of the following 4 traits: 15+ days per month for more than 3 months – bilateral location – pressing or tightening (non-pulsating) quality • More than 5 attacks over 3 months – mild or moderate intensity • Affected more than 8 days/mo x 3 months – not aggravated by routine physical activity • Both of the following: • HA responsive to ergot or triptan – no nausea or vomiting • Does not meet criteria other HA diagnosis – no more than one: photophobia or phonophobia Cluster HA-I Trigeminal Autonomic Cephalgias • Severe/very severe unilateral orbital, supraorbital and/or temporal pain lasting • Cluster headache 15-180 min • Paroxysmal hemicrania • Frequency from 1-2/d to 8/d for > half the • Short-lasting unilateral neuralgiform HA time when active • Hemicrania continua • Either or both of the following: – A sense of restlessness or agitation – One of following ipsilateral symptoms or signs 4

Cluster HA-II Other Primary Headache Disorders One of following ipsilateral symptoms or signs: • Exertional-Cough, exercise, thunderclap, • Conjunctival injection and/or lacrimation orgasmic or pre-orgasmic • nasal congestion and/or rhinorrhea • Head stimulation-cold/external compression • eyelid edema • forehead and facial sweating • forehead and facial flushing • sensation of ear fullness • miosis and/or ptosis Secondary Headaches-Associated Diagnosis of Primary Headaches with Medical Comorbidities • Trauma or injury to the head and/or neck Migraine - unilat, throbbing, nausea, +/- aura • Intracranial vascular or infectious cause • Non-vascular intracranial Tension-type HA - milder, no nausea, no aura • Use or withdrawal of a substance • Headache/facial pain attributed to disorder Cluster - Unilateral, male predom, brief, cyclic of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, other facial/cranial structure • Psychiatric disorder 5

Post-Traumatic Headache Cervicogenic Headache • Key component persistent post ‐ concussive syndrome • HA due to lesion in cervical spine or neck • Need to prove cause and effect (2 required): • Can resemble other headache types including migraine – HA onset temporally related to structural lesion • Resistant to treatment – HA improved with resolution of the lesion – Cervical ROM reduced and HA worse with • Divided by cause or severity of head injury exam maneuvers – HA resolves with diagnostic block of the lesion or nerve supply of the lesion Headaches from Vascular Dz Clinical Approach to HA patient • Stroke-hemorrhagic, thrombotic, embolic • Exclude urgent headaches (e.g.-infection, neoplasm, vascular dz, High ICP, low ICP) • Vascular anomalies-AVM, aneurysm • Exclude other secondary causes of headache • Arteritis by exploring comorbidities (med dz, drugs) • Dissection • If hx negative, does presentation fit primary • Cerebral venous thrombosis HA syndrome (migraine, tension, cluster) • Post-endarterectomy • Prevention, prophylaxis, treatment 6

Headache Disorders-History I Headache Disorders-History II • Location, frequency, duration-primary HA • Relieving factors-sleep, dark room, walking disorder? around • Aura prior to HA-visual/sensory symptoms • Past/current meds and substances are the most common • Family history • Diurnal periodicity-divide day in quarters, # • Neurological and psych symptoms and HA beginning in AM or PM history • Triggers-foods, alcohol, sleep deprivation Headache Disorders - Labs Headache Disorders - Exam • Blood tests – Consider CBC, lytes, Ca, Mg, BUN, • General - Vital signs, cardiac creat, liver enzymes, thyroid, ESR, HIV • C-spine X-ray, sinus X-rays • Head and Neck - trauma, carotids, paranasal/other • MRI or CT - if new HA/risks for structural disease sinuses, C-spine, greater occipital/supraorbital nerve TMJ, funduscopic exam, otoscopic exam • Lumbar puncture-suspect subarach hemorrhage, high/low ICP, or meningitis/encephalitis • Neurological – complete neurologic examination on • Consider MRA, MRV, CTA, cerebral angiography the first visit 7

HA Prevention Strategies Q3: HA aura/predictable timing of HA can inform when to Rx. • Anticipatory Treatment – If aura predictably precedes HA, take acute medication during aura 1) True – If HA occurs in a narrow time band, then take medication 1 hour before “at risk” time 2) False • Lifestyle-exercise, sleep, avoid triggers • Relaxation-Yoga, biofeedback, meditation • Other-Manual therapy, acupuncture, TENS Acute Migraine-Non-Specific Rx Common Acute Migraine Rx- Adverse Events Dose Generic Trade Naproxen sodium Alleve 550 mg po Medication Adverse Events Indomethacin Indocin 50 po, pry Ketorolac Toradol 30-60 mg IM Opioids Addiction, tolerance Promethazine Phenergan 5 mg IM, IV Prochlorperazine Compazine 5-10 mg IV, IM NSAIDs GI, renal Chlorpromazine Thorazine 10-25 mg IV, IM Butorphanol Stadol 1 mg nasal DA antagonists Dystonia, akathisia Meperidine Demerol 50-150 mg IM Ergots Vasoconstriction Morphine 5-10 IM, 2-5 IV Valproate Depacon 500 mg Mg Sulfate 1 g 8

Acute Migraine-Specific Rx Common Triptan Adverse Symptoms and Contraindications Generic Trade Dose Sumatriptan Imitrex 6mg IM, 20mg NS, 50-100 po Adverse Symptoms: Contraindications Naratriptan Amerge 2.5 po • Tingling Rizatriptan Maxalt 1-10 mg po Hemiplegic or “basilar migr” • Warmth Zolmitriptan Zomig 2.5-5 mg po • Uncontrolled hypertension Flushing Almotriptan Axert 12.5 mg po • Frovatriptan Frova 2.5 mg po Chest discomfort Concomitant use of MAO Eletriptan Relpax 40-80 mg po • Dizziness Use within 24 hrs of an ergot Dihydroergotamine DHE-50 1 mg IV, IM • Somnolence Migranal 2 mg NS Pregnancy category C • HA recurrence Migraine Prophylaxis Rx Options Migraine Prophylaxis-Dosing • Decrease the frequency and severity of • Anticonvulsants-topiramate 100-200 mg hs chronic migraine HA • Beta blockers-propranolol 80 mg bid – Anticonvulsants-topiramate, valproate – Beta blockers-propranolol, atenolol • Tricyclic antidep-nortriptyline 30-70 mg hs – Tricyclic antidep-amitriptyline, nortriptyline • Ca channel blockade-verapamil 80 mg tid – Ca channel blockers-verapamil, flunarizine • Angiotens receptor bl-candesartan 4-16 mg – Angiotensin receptor blockers-candesartan – Antispasmodics-baclofen, tizanidine 9