Headache Prevention. Michael Ready, MD FAHS Director, Headache Clinic Scott & White Temple TX DMReady@medicine.tamhsc.edu

Transcription

1 Headache Prevention Michael Ready, MD FAHS Director, Headache Clinic Scott & White Temple TX Disclosures & Shameless Plug Just one blind man at the elephant Family Physician You can learn a lot at a Headache meeting 1

2 Objectives Increase awareness of the burden of Headache Increase your comfort level with the Primary Headaches Increase your desire to care for these patients. Really if I can Honest it ll be easier for you Make it worth your time What is Pain? 2

3 Cartesian Pain Model Rene Decarte French Philosopher / Mathmatician Cognito ergo sum Mind / Body exist as separate Dominated medical thought for almost 400yr Henry K. Beecher, MD Wall/Melzack Gate Control Limbic Influences in Migraine All Pain has meaning The Sorrow that hath no vent in tears may make organs weep Henry Maudsley (When) the mind is hurt the body cries out Italian Proverb The body remembers what the mind forgets J.L. Moreno 3

4 Not All Pain is Nociceptive San Francisco Spine study 1992 Five childhood traumas: Loss of parent, Hx of Substance abuse, emotional neglect, physical abuse, sexual abuse No risk factors = 95% chance surgical cure 1-2 risk factors = 73% chance surgical cure 3 or more risk factors = 15% chance of a surgical cure Increased incidence of Chronic Daily HA in victims of Sexual Abuse. Osler s Razor It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has Sir William Osler 4

5 Case 1 61yo H TBI /c LOC >30y HAs 25/30 days Primarily L sided /c N/V, Allodynia, Neck Pain Sleep Non-restorative, Onset delayed 1 hour Often awakens with headaches No prior preventive meds. Uses APAP Case 2 27yo C ICU nurse. 5y +FH Episodic to CDH over last 2 years 2 prior hospitalizations for headache no DHE Sleep non-restorative, Schedule erratic Awakens with HAs, N/V, Photophobia, Darvocet / Excedrin Migraine Recently started on Topirimate 5

6 The Name of the Game Pattern Recognition! Headaches in Primary Care Primary nervous system you are born with or acquire (trauma) and the environment you are in Migraine, Cluster, Tension Type Secondary headaches that are caused by something else Infection, Mass, Vascular, Trauma 6

7 Profiling Headache Pattern Recognition Primary Headaches Migraine Tension-type Cluster Misc. headaches unassociated with structural lesions CSF, cerebral spinal fluid Secondary Headaches Post-traumatic Vascular disorders CVA, Aneurysm Nonvascular intracranial disorder Neoplasm, meningitis, low or high CSF pressures Substances/withdrawal Systemic infection or metabolic d/o Cranial, extracerebral lesions Intl Classification of Headache Disorders: 2 nd ed. Cephalalgia. 2004;24(Suppl 1): SNOOP4: Ruling Out Secondary Causes of Headache in Migraine Systemic symptoms and signs Neurologic symptoms or signs Onset: peak at onset or <1 minute Older: after age 50 years Previous headache: pattern change Postural, positional aggravation Precipitated by valsalva, exertion, etc. Papilledema SilbersteinSD, LiptonRB. In: SilbersteinSD et al, eds. Wolff sheadacheandother Head Pain. 8th ed. New York: OxfordUniversityPress; 2008: Dodick D. N Engl J Med. 2006;354: Bigal ME et al. J Headache Pain. 2007;8:

8 Headache Pattern Recognition Minutes Hours/Days Weeks/Months Months/Years Vascular Infectious Inflammatory, Neoplastic Primary headache Secondary Headache Disorders American College of Rheumatology Criteria for Giant Cell Arteritis Age at onset 50 years New-onset or new type of headache Temporal artery tenderness to palpation or decreased pulsation, unrelated to cervical artery arterioslerosis ESR >50 mm/hour by Westergren method Abnormal temporal artery biopsy showing vasculitis characterized by a predominance of mononuclear cell infiltration or granulomatous infiltration, usually with multinucleated giant cells Source: Melson et al. (2007). 8

9 Temporal Arteritis New onset of headache 75% of pts Associated /c fever, arthralgia, myalgia, anorexia, weight loss, and fatigue. 40% have polymyalgia rheumatica. May also find abnls of the temporal aa. (beading, prominence, tenderness, pulselessness), jaw claudication, scalp tenderness, tongue or scalp necrosis, diplopia, elevated ESR, and visual changes. Has potential rapid sequential, bilateral blindness Vagaries in presentation make this disorder challenging. 20% of pts report no systemic sxs. Get a SED Rate & a CRP. Have a low threshold for biopsy Hemicrania Continua Persistent strictly UNILATERAL headache responsive to indomethacin. Headache for >3 months fulfilling criteria B-D All of the following characteristics: unilateral pain without side-shift daily and continuous, without pain-free periods moderate intensity, but with exacerbations of severe pain At least one of the following autonomic features occurs during exacerbations and ipsilateral to the side of pain: conjunctival injection and/or lacrimation nasal congestion and/or rhinorrhoea ptosis and/or miosis Complete response to therapeutic doses of indomethacin Not attributed to another disorder 9

10 Hemicrania Continua Prevention Prevention is only treatment Indomethicin Drug of choice Melatonin evening meal Boswellia TID /c meal New Daily Persistent Headache Headache that is daily and unremitting from very soon after onset (within 3 days at most). The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity. There may be photophobia, phonophobia or mild nausea. Headache that, within 3 days of onset, fulfils criteria B-D Headache is present daily, and is unremitting, for >3 months At least two of the following pain characteristics: bilateral location pressing/tightening (non-pulsating) quality mild or moderate intensity not aggravated by routine physical activity such as walking or climbing Both of the following: no more than one of photophobia, phonophobia or mild nausea neither moderate or severe nausea nor vomiting Not attributed to another disorder 10

11 Tension Type Headache Tension-type headache (TTH) 2.1 Infrequent episodic tension-type headache A.At least 10 episodes occurring on <1 day/month on average (<12 days/year) 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 E. Not attributed to another disorder Cluster A. At least 5 attacks fulfilling criteria B D B. Severe or very severe unilateral orbital, supraorbital +/- temporal pain lasting minutes if untreated C. Headache is accompanied by at least 1 of the following: ipsilateral conjunctival injection and/or lacrimation ipsilateral nasal congestion and/or rhinorrhoea ipsilateral eyelid oedema ipsilateral forehead and facial sweating ipsilateral miosis and/or ptosis a sense of restlessness or agitation D. Attacks have a frequency from 1 every other day to 8/day E. Not attributed to another disorder 11

12 Cluster Headache Prevalence: 0.1% Male : Female Ratio: 3 to 6:1 Age at onset: Late 20s (3 to 65) Periodicity: Spring and autumn Clusters: 1 to 2 cycles per year; lasting for 2 to 3 months. Remission: Average 2 years (2 months to 20 years) gu4 Cluster Headache Attack Profile Usually no aura Peak pain in 10 to 15 minutes Duration 15 minutes to 1 hours Always unilateral, Doesn t switch sides 1 to 3 attacks per day Described as excruciating, boring, burning pain; usually non-throbbing 12

13 Slide 24 gu4 Aura: 6-20%; visual george urban, 9/25/2005

14 Cluster vs. Migraine LOE = SIMU Periodic nature Awaken from sleep: middle of night vs early morning Movement: avoidance vs. pacing Thoughts of harm Cluster Headache Prevention Have a plan for when HA starts Steroid Burst vs. taper 60mg starting Occipital Block /c steriod Verapamil drug of choice use IR Push dose until HA improve or AE s intolerable Other options include Topirimate, Lithium, Melatonin, Gabapentin 13

15 Pattern recognition Abnl Neuro exam When to get a CT When to get an MRI Imaging Remember a radiologist is talking WMLUS Degenerative Disk Disease ICHD Criteria for Migraine without Aura At least 5 attacks Headache attacks lasting 4-72 hours Headache with at least 2 of the following: Unilateral location Pulsating quality Moderate to severe pain Aggravation or avoidance of physical activity During headache at least one of the following: Nausea and/or vomiting Photophobia and phonophobia Not attributed to another disorder Intl Classification of Headache Disorders: 2 nd ed. Cephalalgia. 2004;24(Suppl 1):

16 Why Migraine Why Should I Care TTH & Migraine 2 nd & 3 rd most prevalent medical disorder Migraine accounts 30% of global burden of disability & 50% of all Neuro disability 4 th leading cause of disability in women & 7 th overall Lancet 2012 Severe Migraine Is Ranked in the Highest Disability* Class by WHO Disability Class Severity Weights *Assessments of disease severity determined by Global Burden of Disease researchers using the person trade-off method, which includes judgments about the trade-off between quality and quantity of life. Spectrum ranges from 0 (perfect health) to 1 (death). WHO = World Health Organization. Menken M. Arch Neurol. 2000;57: MurrayCJ, Lopez AD. Lancet. 1997;349: Indicator Conditions Vitiligo of face, weight for height less than 2 SDs Watery diarrhea, severe sore throat, severe anemia Radius fracture in a stiff cast, infertility, erectile dysfunction, rheumatoid arthritis, angina Below-the-knee amputation, deafness Rectovaginal fistula, mild mental retardation, Down syndrome Unipolar major depression, blindness, paraplegia Active psychosis, dementia, severe migraine, quadriplegia 15

17 Severe Migraine Is Ranked in the Highest Disability* Class by WHO Disability Class Severity Weights *Assessments of disease severity determined by Global Burden of Disease researchers using the person trade-off method, which includes judgments about the trade-off between quality and quantity of life. Spectrum ranges from 0 (perfect health) to 1 (death). WHO = World Health Organization. Menken M. Arch Neurol. 2000;57: MurrayCJ, Lopez AD. Lancet. 1997;349: Indicator Conditions Vitiligo of face, weight for height less than 2 SDs Watery diarrhea, severe sore throat, severe anemia Radius fracture in a stiff cast, infertility, erectile dysfunction, rheumatoid arthritis, angina Below-the-knee amputation, deafness Rectovaginal fistula, mild mental retardation, Down syndrome Unipolar major depression, blindness, paraplegia Active psychosis, dementia, severe migraine, quadriplegia Why Migraine & Why Should I Care >37% of women of reproductive age in a physician s waiting room have migraine People with episodic tension headache rarely seek medical advice If people want to make headache a medical condition, overwhelmingly they have migraine Couch JC, et al. Headache. 2003;43:

18 Migraine Epidemiology 6% Men, 18% women (33% during reproductive years) Most common 25 55yr (most productive years) million migraine sufferers in the US 50% are undiagnosed 4 million migraine sufferers with chronic migraine Societal burden >14 billion dollars per year Direct vs. indirect Lipton, et.al. Headache 2001 Migraine The Most Common Headache Seen in Clinical Practice Patients seen in primary care IHS diagnosis based on diary review 94% Migraine-type Episodic Tension-type Unclassifiable N = 377 IHS, International Headache Society Tepper SJ, et al. Headache. 2004;44: % 3% 17

19 Staging Migraine Developed by Lipton, Cady, Farmer, & Bigal First doctor/patient book Based on frequency not severity of HA Stage1: Episodic Migraine Emphasis on acute abortive therapy OTCs Triptans NSAIDs Early intervention complete response Evaluation on mechanism of injury and pre-morbid biology of patient Education focused on resuming normal function Acute medication limits as headache progress Preventive pharmacology Behavioral interventions 18

20 Stage 2: Transforming Headache Preventive pharmacology Targeted use of abortives Strong emphasis on behavioral intervention Screen and treat co-morbidities Perpetuating Factors > Precipitating Factors Stage 3: Chronic Daily Headache Behavioral intervention -- absolutely essential Preventive pharmacology -- unavoidable Screen & aggressively treat co-morbidites Educate, educate, educate Establish reasonable goals and expectations Targeted use of abortive medications Emphasis of Quality of Life 19

21 Chronic Migraine Risk Factors Modifiable Attack frequency Obesity Snoring/OSA Stressful life events Medication overuse Caffeine overuse Not modifiable Age Female sex Low education or socioeconomic status Genetic factors Head injury Ashina S, et al. Curr Treat Options Neurol. 2008;10: Migraine Stages Episodic Chronic Severe Impairment Stage 3 Moderate Impairment Stage 2 Stage 1 Mild Impairment Normal Neurological Function Cady RK, et al. Headache. 2004;44:

22 Headache Treatments Preventive reduce frequency, intensity, & improve response to acute meds Abortive pain freedom in 2 hours Rescue when the stop medicine didn t Migraine Prevention Utilization 53% of migraineurs meet disability and frequency criteria for prevention < 5% of migraineurs are on preventive therapy 25% Frequency 28% Disability Lipton RB et al. Headache. 2001; Lipton RB et al. Neurology

23 Saves You Money! 18-month comparison study Acute vs acute/preventive therapies Office visits 51% ED visits 82% CT scans 75% MRI scans 88% Medication costs $48 - $138/month/patient Silberstein SD et al. Headache Prevention Consider when Migraine significantly disrupts ADLs, despite acute treatment Attack frequency >1/wk Five FDA approved drugs for Migraine One FDA approved drug for Chronic Migraine Many off label choices Start low and titrate as tolerated Two-fers overrated --SIMU 22

24 Behavioral Interventions Why do you need Behavioral/Relaxation? Biofeedback Thermal EMG Relaxation Response--Herbert Benson, MD Guided Imagery Web Based DawnBuse.com Application Based for smart phones / tablets Preventive Drugs for Frequent Episodic Migraine Level A Divalproex sodium* Oral mg Sodium valproate* Oral mg Topiramate* Oral mg Metoprolol Oral mg Propranolol* Oral mg Timolol* Oral mg Frovatriptan (MRM) Oral 2.5 mg Butterbur Oral 75 mg bid Level B Amitriptyline Oral mg Venlafaxine Oral mg Atenolol Oral mg Nadolol Oral mg Naratriptan (MRM) Oral 1, 2.5 mg Zolmitriptan (MRM) Oral 2.5, 5 mg ODT 2.5, 5 mg Nasal 5 mg Level B Magnesium Oral mg Feverfew Oral 6.25 mg Riboflavin 400 mg * FDA approved MRM, menstrually related migraine Silberstein SD, et al. Neurology. 2012;78;

25 Prevention polypharmacy β blockers plus TCAs for depression or insomnia β blockers plus SNRI for depression & fibromyalgia β blockers plus Topirimate in obesity β blockers plus valproate for bipolar disorder Topirimate plus antidepressants for bipolar or insomnia Topirimate plus pregabalin fibromyalgia in migraine Topirimate + SNRI + pregabalin in depression in fibromyalgia Valproate plus lithium or Lamotrogine in bipolar Tizanidine + amitriptyline OnabotulinumtoxinA* Only FDA approved intervention Preempt studies: Large PCDB (saline injection) studies of subject with CM Efficacy at 24 weeks was a mean decrease from baseline of headache days per month vs headache days per month with placebo Very low drop out rates (4%) and excellent tolerability with only neck pain (9%) and headache (5%) being reported greater than 5% Significant improvement in QOL BOTOX (onabotulinumtoxina) Prescribing Information. Irvine, CA: Allergan, Inc., * Refer to Physicians' Desk Reference. website for adverse events and contraindications. 24

26 Management of Chronic Migraine with Quarterly Pericranial Nerve Blocks: A Prospective 48-week Trial Robert Kaniecki, MD The Headache Center at the University of Pittsburgh 25

27 Results 218 subjects enrolled and treated Baseline Characteristics (n=218) Female (%) 87.1 Age (years) 40.4 History of migraine (years) 18.5 Headache days per 4 weeks 21.4 Severe headache days per 4 weeks 15.5 Acute treatment days per 4 weeks 18.3 HIT-6 score 66.2 Results 116 subjects (53.2%) met the primary endpoint with >50% reduction from baseline in monthly frequency of headache days at 48 weeks 77 subjects (35.3%) with response < 4 weeks 25 subjects (11.5%) with no response or lost to follow-up 26

28 Results Responder subgroup analysis (n=116) Mean monthly headache days from 22.8 to 9.0 Mean monthly severe headache days from 15.9 to 6.1 Mean monthly acute treatment days from 18.1 to 7.9 Mean HIT-6 score from 66.7 to 59.2 No clinical or demographic differences versus the nonresponder subgroup Prevention Pound of Cure Supplements Mg 500mg, Riboflavin 400mg, CoQ mg BID ( Butterbur (should be PA free Petadolax) Membrane Stabilizing medications-valproate, Toprimate, Gabapentin Anti-HTN Beta Blockers, CCB, ACE TCA (off label) most data is with amitriptyline SSRIs not thought to be effective OnabotuliniumtoxinA -- FDA approved for Chronic Migraine Oct

29 Migraine preventive therapy Possible reasons for lack of efficacy Inadequate duration (<6-8 wk) at suboptimal dose Poor Pt adherence (side effects, half-life, unrealistic expectations) Concomitant drug-induced headache Prevention unlikely to work in MOH Newly developed medical condition causing a secondary headache Failure to appreciate a migraine brain Prevention Pearls Pick the low hanging fruit Start with supplements Pick a med that helps a perpetuating factor. Start low and go slow. Consider Re Challenging you never step in the same river twice. 28