Guideline for Management of Primary Headache in Adults

Transcription

1 Guideline for Management of Primary Headache in Adults July 2012 This summary provides an evidence-based practical approach to assist primary health care providers in the diagnosis and management of adult patients with a long term history of headache. For more details, refer to Guideline for Primary Care Management of Headache in Adults Primary headache disorders are not due to another medical condition, and include primarily migraine and tension-type headache. Cluster headache, hemicrania continua, and new daily persistent headache are much rarer primary headache types and will not be discussed further in this summary. Secondary headache disorders are due to another medical disorder. Practice Point Rule out secondary headache when making a diagnosis of a primary headache disorder. Headache onset (thunderclap, association with head or neck trauma), headache progression, duration of attacks, and days per month with headache. Pain location (unilateral, bilateral, associated neck pain). Headache associated symptoms (nausea, vomiting, photophobia, phonophobia). Relationship of headache to possible precipitating factors (stress, posture, cough, exertion, straining, neck movements, jaw pain, etc.). Headache severity and effect of the headaches on work and family activities. Headache response and side effects to acute and preventive medications tried in the past. Presence of co-existent conditions that may influence treatment choice (insomnia, depression, anxiety, hypertension, asthma, and history of heart disease or stroke). 1 health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making

2 Practice Points Neuroimaging is not indicated in patients with recurrent headache with the clinical features of migraine, a normal neurological examination, and no red flags. Neuroimaging, sinus x-rays, cervical spine x-rays, and EEG are not recommended for the routine assessment of the patient with headache. History and physical / neurological examination is usually sufficient to make a diagnosis of migraine or tension-type headache. Migraine: If patients have at least two of: 1) nausea during the attack; 2) light sensitivity during the attack; 3) some of the attacks interfere with their activities. Practice Points Migraine is by far the most common headache type in patients seeking help for headache from physicians. Migraine is historically under-diagnosed and under-treated. Many patients with migraine are not diagnosed with migraine when they consult a physician. Migraine should be considered in patients with recurrent moderate or severe headaches and a normal neurological examination. Patients consulting for bilateral headaches which interfere with their activities are likely to have migraine rather than tension-type headache and may require migraine specific medication. Consider a diagnosis of migraine in patients with a previous diagnosis of recurring sinus headache. Chronic migraine: If headache is present on 14 days a month or more, and headaches meet migraine diagnostic criteria or are quickly aborted by migraine specific medications (triptans or ergots) on 8 days a month or more. Consider whether medication overuse is present in all patients with chronic migraine (chronic migraine with medication overuse) 2

3 Practice Point Medication overuse is considered present when patients with migraine or tension-type headache use combination analgesics, opioids, or triptans on 10 or more days per month or acetaminophen or NSAIDs on 15 or more days a month. Episodic tension-type headache: If headache attacks are not associated with nausea, and have at least two of the following: 1) bilateral headache; 2) non-pulsating pain; 3) mild to moderate intensity; and 4) headache is not worsened by activity. Migraine management is complex and a comprehensive approach may be needed. All of the following should be considered. Training the patient in self-management: Self-management involves patients partnering with the health professional and taking an active role in management of their migraine. Patients may require some or all of the following skills. Self-monitoring to identify factors that influence their migraine. Managing migraine triggers effectively. Pacing activity to avoid triggering or exacerbating migraine. Maintaining a lifestyle that does not worsen migraine. Relaxation techniques. Maintaining good sleep hygiene. Stress management skills. Cognitive restructuring to avoid catastrophic/negative thinking. Communication skills to talk effectively about pain with family and others. Using acute and prophylactic medication appropriately. Headache diaries: Encourage patients to keep a headache diary to monitor headache frequency, intensity, triggering factors and medication use so that treatment can be adjusted as needed. Refer to Headache Diary Sheets. 3

4 Comprehensive migraine therapy includes management of lifestyle factors and triggers, acute and prophylactic medications, and migraine selfmanagement strategies. Acute pharmacological therapy: NSAIDs (including ASA), acetaminophen and triptans are the primary medications for acute migraine treatment. A triptan should be used when NSAIDs are not effective. Patients who do not respond well to one triptan may respond to another. Advise patients to take their medications early in their migraine attack, where possible, to improve effectiveness. For severe migraine attacks, consider providing an additional rescue medication if the patient s usual acute medication does not work consistently with every attack. Refer to medication tables in Guideline for Primary Care Management of Headache in Adults for drugs and dosages. Practice Points ASA, acetaminophen, NSAIDs, and triptans are the primary medications for acute migraine treatment. A triptan should be used when NSAIDs are not effective. Opioid containing analgesics are not recommended for routine use for migraine. Butalbital-containing combination analgesics should be avoided. Vast amounts of over-the-counter analgesics are taken for headache disorders and treatment is often sub-optimal. Prophylactic pharmacological therapy: Consider migraine pharmacological prophylaxis when: Recurrent migraine attacks are causing significant disability despite optimal acute drug therapy. The frequency of acute medication use is approaching levels that place the patient at risk for medication overuse headache. 4

5 When prescribing a prophylactic medication: 1. Educate patients on the need to take the medication daily and according to the prescribed frequency and dosage. 2. Ensure that patients have realistic expectations as to what the likely benefits will be; that is: a. Headache attacks will likely not be abolished completely. b. A reduction in headache frequency of 50% is usually considered worthwhile and successful. c. It may take 4 to 8 weeks for significant benefit to occur. d. If the prophylactic drug provides significant benefit in the first 2 months of therapy, this may increase further over several additional months of therapy. 3. Evaluate the effectiveness of therapy through the use of patient diaries that record headache frequency and drug use. 4. For most prophylactic drugs, initiate therapy with a low dose and increase the dosage gradually to minimize side effects. 5. Increase the dose until the drug proves effective, until dose-limiting side effects occur, or a target dose is reached. 6. Provide an adequate drug trial. Unless side effects mandate discontinuation, continue the prophylactic drug for at least 6 to 8 weeks after dose titration is completed. 7. Gradual discontinuation of the drug should be considered for many patients after 6 to 12 months of successful therapy, but preventive medications can be continued for much longer in some patients. The most commonly used prophylactic drugs are the beta-blockers, the tricyclic antidepressants, and topiramate, but many other drugs are also used, including divalproex sodium, candesartan, pizotifen, flunarizine, and others. OnabotulinumtoxinA is used for chronic migraine (migraine with headache on 15 days a month). Non-drug compounds which also have some prophylactic value include butterbur, riboflavin, magnesium citrate, and co-enzyme Q10. (Refer to medication tables in Guideline for Primary Care Management of Headache in Adults for more detail on drugs and dosages). Selective serotonin reuptake inhibitors are not recommended for migraine prophylaxis. 5

6 Practice Point A substantial number of people who might benefit from prophylactic therapy do not receive it. Non-pharmacological therapies: Recommended therapies include relaxation training, biofeedback, cognitive behavioural therapy, and acupuncture. Migraine Treatment in Pregnancy: Drugs for migraine should be avoided during pregnancy where possible. Acetaminophen 1000 mg and metoclopramide 10 mg can be used if necessary. If necessary, acetaminophen - codeine combination analgesics are an option. Ibuprofen 400 mg can be used but only during the second trimester of pregnancy. Sumatriptan should not be used routinely in pregnancy, but may be considered for use when other medications have failed and the benefits outweigh the risks. Preventive drugs should be gradually discontinued prior to the commencement of a planned pregnancy; or stopped as soon as possible during an unplanned pregnancy. Obtain specialist advice if it is necessary to continue migraine prophylaxis. Menstrual Migraine: Acute pharmacological treatment is similar to nonmenstrual migraine. For patients with refractory menstrual migraine, consider frovatriptan 2.5 mg twice a day starting 2 days before the anticipated onset of the menstrually associated migraine attack and continuing for a total of 6 days. 6

7 Careful monitoring of acute medication use by both the patient and the physician is important in the prevention of medication overuse headache. Headache diaries should be used by patients with frequent migraine to monitor acute medication use. When medication overuse headache is suspected, the patient should also be evaluated for: Psychiatric comorbidities (depression and anxiety); these may need to be considered in planning an overall treatment strategy. Psychological and physical drug dependence. Use of inappropriate coping strategies. Expanding the patient s repertoire of adaptive coping strategies may facilitate reduction of medication use and ultimate improvement in headache. Treatment plans for the patient with medication overuse headache should include: 1. Patient education with regard to medication overuse headache. Patients need to understand that: a. Acute medication overuse can increase headache frequency. b. When medication overuse is stopped, headache may worsen temporarily. c. Many patients will experience a long-term reduction in headache frequency after medication overuse is stopped. d. Prophylactic medications may become more effective. 2. Formulation of a plan for cessation of medication overuse. 3. A strategy for the treatment of remaining severe headache attacks with limitations on frequency of use (i.e. a triptan for patients with analgesic overuse, DHE for patients with triptan overuse, etc.). 4. Patient follow-up and support. 5. Pharmacological prophylaxis with the prophylactic medication started prior to or during medication withdrawal. 7

8 Stopping Medication Overuse: Withdrawal of the overused medication should be attempted in all patients with suspected medication overuse headache. Abrupt withdrawal should be advised for patients with suspected medication overuse headache caused by simple analgesics (acetaminophen, NSAIDs) or triptans, although gradual withdrawal is also an option. Gradual withdrawal should be advised for patients with suspected medication overuse headache caused by opioids and opioidcontaining analgesics. Practice Point Monitor for medication overuse Many patients with tension-type headache do not require medication. Reassurance, identification of trigger factors, adjusting lifestyle factors, and stress management are often helpful. Use Headache Diary Sheets for assessment and monitoring. Monitor for medication overuse. Acute Pharmacological Therapy: Recommended medications include: ibuprofen, aspirin, naproxen, diclofenac potassium, and acetaminophen. Pharmacological Prophylaxis: Consider prophylaxis if tension-type headaches are frequent. Efficacy of preventive medication is often limited and treatment may be hampered by side effects. Drug of first choice is amitriptyline. Non-pharmacological Therapy for Tension-type Headache: Recommended therapy includes: cognitive behaviour therapy, biofeedback, relaxation training, therapeutic exercise, and physical therapy. Primary headache disorders present many treatment challenges. Refer to Guideline for Primary Care Management of Headache in Adults for more management details. July