Recognition and management of common headaches encountered in Primary Care. By Alan Gindoff DHSc, PA-C

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1 Recognition and management of common headaches encountered in Primary Care By Alan Gindoff DHSc, PA-C

2 Disclosure Statement Dr. Gindoff has no relevant financial or non financial relationships to disclose.

3 Objectives #1. Compare and contrast the history and physical exam findings of patient s who present with migraine, tension, and cluster headaches. #2. Define the terms commonly used to describe the symptoms and phases of Migraine. #3. Discuss the pathophysiology of the Primary Headache syndromes. #4. Outline the management of Primary Headache syndromes using evidence based medicine.

4 Oscillococcinum

5 Homeopathy Mass of the observable universe: estimated at ~3 x 1055 g # of particles present ~ Slide adapted from presentation by Martin Mayer PA-C

6 Take Home Point What kind of drug is Oscillococcinum and what condition/s is it used to treat? Homeopathic Medicines - Flu How is Oscillococcinum made? Derived from duck liver and heart Name some place were Oscillococcinum can be bought in North Carolina and how much it costs CVS Pharmacy $15.29 ($2.55/ea) What is the name of the company who makes Oscillococcinum and much do makes it gross annually? Boiron 2014 figures ~875 million euros

7 Who has headaches? With a lifetime prevalence of 99% in women and 94% in men, headaches are ubiquitous. Primary headache disorders Headache that is not associated with an underlying pathology Tension-type headaches - prevalence 38.3%, Migraine- prevalence 6% to 17% Cluster- prevalence 0.4%, 7

8 Case #1 Ron the tax accountant at the peak of tax season

9 Ron is a 40 year old accountant who presents at the height of tax season complaining of a headache that occurs in the afternoons and last 2-3 hours. He reports the pain is usually moderately intense and describes it as tightness with a dull aching pressure.

10 The pain feels like a tight band extending from the forehead across the sides of the head to the back of his skull then radiates down his neck and into his upper shoulders.

11 Ron denies light or sound sensitivity, nausea, vomiting or worsening of his pain with activity. He also denies fever, recent trauma, change in vision or loss of feeling/ motor in any part of his body or pain in the TMJ region.

12 Tension-Type Headache Mild to moderate intensity, bilateral, nonthrobbing headache without other associated features. American Family Physician Sep #5 12

13 Tension-type headache (TTH) Infrequent episodic headache episodes less than one day a month A. At least 10 episodes occurring on <1 day/month and fulfilling criteria B D B. Headache lasting from 30 minutes to 7 days C. Headache has at least 2 of the following characteristics: 1. bilateral location 2. pressing/tightening (non-pulsating) quality 3. mild or moderate intensity 4. not aggravated by routine physical activity such as walking or climbing stairs D. Both of the following: 1. no nausea or vomiting (anorexia may occur) 2. no more than one of photophobia or phonophobia Frequent episodic 1 to 14 days a month, Chronic > 15 days a month 13

14 The pathophysiology of TTH is incompletely understood, the main mechanism is sensitization of dorsal horn neurons due to increased nociceptive (pain signals) inputs from pericranial myofascial tissues. Thus, stimuli that normally are innocuous are misinterpreted as pain. The increased nociceptive stimulation of supraspinal structures results in increased facilitation and decreased inhibition of pain transmission at the level of the spinal dorsal horn/trigeminal nucleus, and in increased pericranial muscle activity. UpToDate 14

15 Tension-Type Headache Most common type of primary headache disorder (Female > Male) Chronic disorder that usually begins after age 20 Infrequent attacks (less than 1 day per month on average) Duration is from hours to days. Pericranial tenderness, poor concentration, other vague nonspecific symptoms Non-throbbing, bilateral occipital head pain, often vise-like or tight in quality Not associated with nausea, vomiting, or prodromal visual disturbance. Not associated with focal neurologic symptoms. May be exacerbated by emotional stress, fatigue, noise, or glare.

16 Acute Treatment Take Home Point 1 NSAIDs first-line drugs of choice Ibuprofen, Naproxen, Tylenol (1 st line) NSAID + Caffeine (2end line) Excedrin - acetaminophen, aspirin, and caffeine Muscle relaxants Cyclobenzaprine (Flexeril) Opioid Agonist Tramadol (Ultram) Narcotics can be problematic in patient s with chronic pain.

17 Take Home Point - 2 Treatment Tension Headache Psychotherapy, physical therapy, acupuncture, massage, meditation, and biofeedback. Relaxation techniques may be helpful in teaching patients how to deal with underlying anxiety and stress. Prophylactic Treatment Amitriptyline (TCA) Benzodiazepines should be used sparingly because of their addictive potential.

18 Case #2 Barney a grain silo worker during harvest season with a headache that wakes him up at 2am.

19 Barney is a 25 year old Caucasian male who presents with what he calls an "alarm clock" headache because it has woken him up for the past 3 days at 2 AM. He describes it as an excruciating pain that feels like a hot-poker stabbing me behind the right eye as well as intense pain in the forehead and temple on right side. He reports the pain which is currently an 8 radiates to the upper teeth, and jaw. Barney has noted that his right : eye is tearing eyelid is drooping has a runny nose

20 Barney denies sore throat, cough, recent illness, fever, chills, nausea/vomiting, light or sound sensitivity, any recent trauma, change in vision or loss of feeling/ motor in any part of his body. Barney reports he s been having these headaches five times a day and that each episode lasts anywhere from 15 minutes to 3 hours, drinking beer seems to bring on the headache and taking Tylenol or Motrin have no effect. He reports feeling agitated and just sort of having to pace around gritting his teeth until the headache goes away.

21 Of interest Barney works in a grain silo and harvest season has just begun. He repots he s had these same headaches every year at the beginning of harvest season in the spring and deer season in the fall. He stated that each spell of these dam headaches lasts about 3-4 weeks and then just goes away.

22 Cluster Headache Mean age at onset of 25 years Much more frequently in men than in women (men 8 X > women) Clusters of brief, very severe, unilateral, constant, non-throbbing headaches. Last from 15 minutes to 2 hours Unilateral and usually recur on the same side in any given patient Commonly occur at night, awakening the patient from sleep Recur daily, often at nearly the same time of day, for a cluster period of weeks to months Between clusters, the patient may be free from headaches for months or years

23 Treatment Cluster Take Home Point Measures involve both aborting acute attacks and preventing subsequent ones. Acute relief of pain: 100% oxygen (8 10 L/min for minutes) Sumatriptan, Zolmitriptan, or Dihydroergotamine (DHE) Preventing recurrent symptoms: Prednisone at the beginning of a cluster cycle: mg/d orally for 1 week, discontinued by tapering the dose over the following week 5-HT agonists (Suma/Riza/Zolmi/Almo/Ele/triptan) calcium channel antagonists (verapamil) Ergotamine rectal suppositories or subcutaneous dihydroergotamine at bedtime

24 Terminology Aura- A subjective sensation or motor phenomenon that commonly occurs shortly before the headache. Fortification Spectra -A zigzag pattern of lights in the visual fields resembling a fort. Photopsia -Bright shimmering or wavy lines of flashing lights Prodrome -A precursor or symptom indicating the onset of a headache. Scotoma - An area of lost or depressed vision within the visual field, surrounded by an area of less depressed or of normal vision

25 Case # 3 Adam a 45 year old college professor complaining of an episodic headache associated with nausea, light and sound sensitivity, that is made worse with physical activity since high school.

26 Adam is a 45 year old college professor who presents with a 100/10 headache for the past 3 days. He reports the pain is so bad, being cut 100 times with a sharp knife, rubbing salt into his wounds, dipping him in alcohol, and lighting him on fire would hurt less. He reports he has had similar headaches on and off since High School that they occur 2-3 times a month. His mother, brother and 3 sisters have similar headaches. Adam reports that minutes before the headache starts he usually sees flashing spots, then a zigzag pattern of lights, followed by tunnel vision that resolves as the pain begins.

27 He describes the pain as usually occurring on left side of his head and has a throbbing, pulsing pain sensation that is relentless in nature associated with nausea, sound and light sensitivity, that is made worse with physical activity. Adam reports once the pain starts he has to stop what he is doing and find a dark quiet cool room and lay down. The pain from the headache usually takes 3-4 hours to peak and can last anywhere from 3 hours to 3 days. Once the pain wares off he usually feels worn out and is unable to function normally for about 24 hrs.

28 Migraine - Essentials of Diagnosis Headache, usually pulsatile. Pain is typically, but not always, unilateral. Nausea, photophobia, and phonophobia, and pain worse with activity are commonly associated with migraine. Some patients may have transient neurologic symptoms (commonly visual) preceding headache of classic migraine. Serene Branson No preceding aura is common

29 PATHOPHYSIOLOGY The mechanism appears to be a primary neuronal dysfunction that leads to a sequence of intracranial and extracranial changes. Both genetic and environmental factors are important. UpToDate A primary event may occur in the brainstem involving diffuse projections from the locus coeruleus to other parts of the brain. This causes an unstable trigeminovascular reflex, and allows excessive discharge of part of the spinal nucleus of the trigeminal nerve and basal thalamic nuclei. UpToDate

30 Pathophysiology A migraine is triggered when a wave of electrical depolarization starts in the trigeminal nerve on the side of the face and spreads across the surface of the brain. This wave called cortical spreading depressions stimulates the release of vasoactive neuropeptides such as substance P, calcitonin gene-related peptides, and nitric oxide that cause inflammatory changes in the pain-sensitive meninges and vasodilatation of the blood vessels that supply areas of the cerebral hemispheres such as the cingulate, auditory, visual association cortices, and the brainstem.

31 Phases of Migraine The clinical anatomy of a migraine can be broken into three parts. 1. Pre-headache phase 2. Headache phase 3. Post-headache phase (Resolution) 31

32 The Pre-Headache phase Prodrome Aura 32

33 Prodrome A precursor or symptom indicating the onset of a headache. Experienced by 33% of pts. from hours to days before the attack. Common examples include changes in mood (23%): Depression Fatigue Food cravings or anorexia 33

34 Aura ~20% of migraine pts. A subjective sensation or motor phenomenon that commonly occurs shortly before the headache. Auras usually take the form of a variety of focal neurological symptoms that last < 1 hour and are followed by the headache. Scotoma Fortification Spectra 34

35 Headache phase Begins with mild pain that gradually slopes upward towards moderate to severe pain over the course of 30 min. to 4 hours. During the subsequent 4 hours to 3 DAYS, the slope of the pain curve gradually reaches a plateau, then the patient waits in a quiet, dark place for the descending slope of the pain curve. 35

36 The Phases of Migraine 36

37 The Post-Headache Phase (Resolution) Begins with the resolution of pain and is typified by a state of recovery during which the migraineur feels tired and worn out. These symptoms may last 24 to 48 hours, during this time patients are often irritable, have trouble concentrating, and continue to show EEG abnormalities. 37

38 A if more than one randomized controlled study confirmed effectiveness B if one randomized controlled study was positive C if expert consensus or uncontrolled data were present Abortive Migraine Medications Medication Class Examples Level of Evidence Migraine nonspecific NSAIDS ASA, ibuprofen, naproxen B Butalbital Compounds Butalbital/ASA/caffeine C Combination Analgesics ASA/APAP/caffeine A Abortive Migraine Medications Isometheptene compound B Opioids Butorphanol A APAP with codeine A Meperidine B Dopamine antagonists (D2) Metoclopramide, prochorperazine A Migraine specific Triptans Almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan A Ergots Dihydroergotamine A (nasal spray) B (parenteral) Ergotamine/caffeine B Headache Consortium US. American Academy of Neurology Headache guidelines. Available at: Accessed Jan 19, 2009

39 Acute Migraine Headache Specific Treatment A to Z SELECTIVE 5-HT1B/1D RECEPTOR AGONIST Generic almotriptan eletriptan frovatriptan naratriptan rizatriptan sumatriptan zolmitriptan Brand Axert Relpax Frova Amerge Maxalt Imitrex Zomig

40 The Serotonin story Serotonin plays a large role in the pathophysiology of migraines. Many of the drugs that treat both acute and chronic migraines are in some way linked to the metabolism of serotonin. 40

41 5HT Receptor? In the family of serotonin receptors there are at least 2 receptor types thought to be relevant to headache. 5HT1 (subtype 5HT1B and 5HT1D) At the 5HT1 receptor Triptans act like serotonin when it is absent or depleted. 5HT3 Associated with the nausea/vomiting center in the medulla 41

42 5HT1 subclass 5HT1B The 5HT1B receptors act on blood vessel walls. Cerebral blood vessels have a rich supply of these receptors, and this is where 5HT1B exerts their effect. To a small degree, these drugs also affect coronary blood vessels, and this is why Triptans are contraindicated in people with coronary vascular disease or uncontrolled HTN. 42

43 More Receptors 5HT1D receptors act on the nerve fibers that release vasoactive neuropeptides which lead to neurogenic inflammation. 43

44 Selective Triptans 5HT1B and 5HT1D Imitrex (sumatriptan) Lipophilic Second Generation Zomig (zolmitriptan) Maxalt (rizatriptan) Amerge (naratriptan) long half-life Axert (almotriptan malate) 44

45 Comparative Pharmacology of Oral Triptans Drug Dose Peak hr ½ life hr Bioavailability % Efficacy at 2h Rizatriptan Maxalt Zolmitriptan Zomig Sumatriptan Imitrex 10 mg mg mg Naratriptan Amerge 2.5mg Goodman & Gilman's Pharmacology, Elaine Sanders-Bush and Steven E. Mayer, Chapter Hydroxytryptamine (Serotonin): Receptor Agonists and Antagonists 45

46 Rizatriptan Take Home Point Zolmitriptan Sumatriptan ~ 83% experience at least one side effect after SQ. (Ref G/G) 46

47 Contraindications (Triptans) Patients with ischemic heart disease or signs or symptoms of ischemic heart disease (vasospastic coronary artery disease (Prinzmetal's angina), angina pectoris, myocardial infarction, silent myocardial ischemia). Cerebrovascular syndromes (including strokes, transient ischemic attacks). Peripheral vascular syndromes (including ischemic bowel disease). Uncontrolled hypertension. Use within 24 hours of ergotamine derivatives or another 5-HT 1 agonist. 47

48 5HT3 receptors are associated with the nausea/vomiting center in the medulla, drugs that modulate the 5HT3 receptor decrease nausea and vomiting. Compazine (prochlorperazine) effects are related to dopamine receptor blocking in the CNS. Reglan (metoclopramide) exerts its antiemetic properties through antagonism of central and peripheral dopamine receptors. 48

49 5HT3 Compazine and Reglan are used therapeutically as abortive and/or adjunct medications for acute migraine. Their use in this setting requires an IV for administration. Some patients may experience a dystonic reaction with this class of medications and clinicians often pre-medicate with mg of Benadryl IV before Reglan or Compazine are given.

50 Nonselective 5HT1 Agonists Ergotamine is a vasoconstrictor that works by reducing vasodilatation of blood vessels. This drug is no longer widely used as its side effects include; nausea and vomiting, abdominal cramps, diarrhea, dizziness, muscle cramps and peripheral vasoconstriction. It also has a potential for the more serious side effects of vasospasm and ergotism, which can lead to myocardial ischemia and claudication of the legs and arms 50

51 Dihydroergotamine (DHE) DHE is chemically related to ergotamine, but has little effect on peripheral arteries. It is a potent venoconstricter. DHE (like ergotamine) also has an affinity for a wider range of receptors and is thought to exert its actions on dopaminergic receptors. Nausea and vomiting is a common side effect of DHE, an antiemetic with synergistic central action (5HT3) is often co-administered. 51

52 Prophylactic Treatment of Migraine First-line agents Beta blockers (propranoll, metoprolol, timolol) Amitriptyline Topiramate Valproic acid and its derivatives Second-line agents -refractory to adequate trials of first-line agents Botulinum toxin Butterbur Calcium channel blockers Feverfew Fluoxetine Gabapentin Levetiracetam Magnesium Memantine Pregabalin Riboflavin Serotonin-norepinephrine reuptake inhibitors Tizanidine Dodick, DW. Clinical practice. Chronic daily headache. N Engl J Med 2006; 354:

53 Narcotics Narcotic analgesics have a contentious role in the management of acute migraine. Opioids such as codeine, meperidine and oxycodone are commonly prescribed for treatment of migraine. However these narcotics carry the risk of dependence, tolerance and addiction. For this reason, they should be limited to patients experiencing severe but infrequent headaches, or the occasional headache that is unresponsive to either DHE or serotonin agonists 53

54 Treat comorbid conditions Migraineurs also suffer from 1 or more of a wide spectrum of neuropsychophysiological conditions in addition to Headache. Depression (*57%) Sleep Disturbance OC, Bipolar Panic and Anxiety attacks Many others *Juang KD; Wang SJ; Fuh JL; Lu SR; Su TP, Headache Nov-Dec;40(10):

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