Understanding Headaches

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Understanding Headaches

• Grace Forde, M.D
• Assistant Professor of Neurology
• New York University
• Director of Neurological Services
• North Shore Pain Service

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Migraine Epidemiology
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Migraine Prevalence

• Approximately 26 million patients with migraine
  in the United States (gt age 18)
• One in 4 households has at least 1 migraine
  sufferer

Lipton RB, et al. Neurology. 2007
68(5)343-349. National Headache Foundation.
http//www.headaches.org/education/Headache_Topic_
Sheets/Migraine. Accessed December 1, 2009.
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Migraine PrevalenceAge and Gender
Migraine prevalence peaks in the 25-55 age range
Lipton RB, et al. Neurology. 200768(5)343-349.
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Migraine Economic Impact, Productivity, and
Quality of Life
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Economic Burden of Migraine in US

• Lost productivity is the greatest contributor to
  migraine economic burden
• Productivity losses cost US employers up to 13
  billion annually
• Direct costs of migraine per patient range from
  500-7000/year
• Total medical costs in households with at least 1
  member with migraine are 70 higher than families
  without a member with migraine

Hu XH et al. Arch Int Med. 1999159(8)813-818. Ha
wkins K et al. J Occup Environ Med.
200749(4)368-374. Edmeads J and Mackell JA.
Headache. 200242(6)501-509. Stewart WF et al.
JAMA. 2003290(18)2443-2454. Osterhaus JT et al.
Pharmacoeconomics. 19922(1)67-76.
Etemad LR, et al. JMCP. 200511(2)13744. Pesa J
and Lage MJ. Headache. 200444(6)56270. Lafata
JE, et al. J Gen Intern Med. 200419(10)100512.
Hawkins K, et al. Value Health. 20069A85. Stang
PE, et al. Am J Manag Care. 200410(5)31320.
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Timing and Impact of Migraine
58 of Migraines Occurred During Typical Work
Hours
Landy SH, et al. Poster presented at 50th Annual
American Headache Society Meeting, June 26-29,
2008 Boston, MA.
N200 Full-Time Employees
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Impact of Migraine Productivity
74 of Patients With Migraine Reported
Productivity Levels Below 80
Productivity Levels
N157 Full-time employees
Landy SH, et al. Poster presented at 50th Annual
American Headache Society Meeting, June 26-29,
2008 Boston, MA.
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Migraine Diagnosis and Treatment
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International Headache Society Criteria for
Migraine
Migraine Is an Episodic Recurrent Headache
Lasting 4-72 Hours with
Features such as osmophobia and posterior head
and neck pain can also be present in a headache
that meets IHS criteria for migraine.
Headache Classification Subcommittee of the
International Headache Society. The International
Classification of Headache Disorders. 2nd
edition. Cephalalgia. 200424(suppl1)117-118,138.
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Many Migraine Sufferers Remain Undiagnosed
56
Diagnosed Migraine
44
Undiagnosed Migraine
Diamond S et al. Headache. 200747(3)355-363.
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Patients with Recurrent Headache May Meet
Criteria for Migraine
87 of patients presenting to PCP with recurrent
headache met IHS criteria for migraine
Episodic Tension-type Headache (n1)0.4
Other (n3)1
Probable Migraine (n31)
11
Migraine (n237)
87
Tepper SJ et al. Headache. 200444(9)856-864.
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Focusing on Migraine Diagnosis

• Opportunities for accurate diagnosis of migraine
  patients still exist
• 80 of sinus headache patients met IHS criteria
  for migraine
• 85 of tension/stress headache patients met IHS
  criteria for migraine

Schreiber CP et al. Arch Intern Med.
2004164(16)1769-1772. Kaniecki R et al. CMRO.
200622(8)1535-1544.
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Phases of a Migraine Attack
Treatment Phase
Pre-HA
Post-HA
Headache
Premonitory/ Prodrome
Aura
Postdrome
Moderate to Severe
Mild
Migraine symptoms occurring hours/days after
headache resolution
Focal neurological symptoms preceding headache
(lt1 hour)
Migraine symptoms occurring hours/days prior to
headache
Migraine when headache is moderate to severe
Migraine when headache is mild
Migraine Intensity

• Symptoms
• Sensitivity to light
• Sensitivity to sound
• Nausea
• Pain in the back of the head and neck

• Symptoms
• Same as mild but more intense

• Symptoms
• Flashing lights or wavy lines
• Numbness
• Tingling in face
• Disturbed senses

• Symptoms
• Tiredness
• Confusion
• Lowered appetite
• Stiff or sore muscles

• Symptoms
• Food cravings
• Mood changes
• Yawning
• Fatigue

Time
Adapted from Cady RK. Headache.
200848(9)1415-1416. Headache Classification
Subcommittee of the International Headache
Society. Cephalalgia. 200424(suppl 1)117-118.
Cady RK. Diagnosis and treatment of migraine.
Clinical Cornerstone. 19991(6)21-32.
National Institutes of Health. National Institute
of Neurological Disorders and Stroke.
http//www.ninds.nih.gov/disorders/headache/detail
_headache.htm. Accessed December 7, 2009.
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Possible Triggers of a Migraine Attack

• Food and food additives
• Bright lights/glare
• Smells/odors
• Dieting/hunger
• Loud noises/sounds
• Changes in altitude/air travel

• Stress
• Weather changes
• Caffeine
• Alcoholic beverages
• Changes in sleep habits
• Hormonal fluctuations/ menstrual cycle

Wober C et al. J Headache Pain.
20067(4)188-195. Friedman DI and De Ver Dye T.
Headache. 200949(6)941-952.
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Medication Options Available for Migraine

• Acute Medications
• May work quickly to relieve migraine pain and
  other symptoms
• Usually taken during a migraine attack
• Triptans
• NSAIDs
• Opioids
• Analgesics (Rx and OTC)
• Ergotamine/DHE
• Antiemetics
• Neuroleptics
• Corticosteroids

• Preventative Medications
• May prevent or reduce the number of migraine
  attacks
• Typically taken on a daily basis
• Antiepileptics
• Antidepressants
• Beta blockers
• Calcium channel blockers

Tepper SJ and Spears RC. Neurol Clin.
200927(2)417-427. Silberstein SD. Neurol Clin.
200927(2)429-443.
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Differences in Patients with Migraine

• Migraine patients brain is in a state of
  hyperexcitability
• Reduced threshold for stimuli
• Everyday things can trigger a migraine attack
• Migraine patients gut is slowed
• Gastric stasis is common and can delay tablet
  absorption
• Conventional tablets rely on surface erosion and
  gastric motility for dissolution in the stomach,
  which must occur before being absorbed

Hargreaves RJ and Shepheard SL. Can J Neurol Sci.
199926(suppl 3)S12-S19. Aurora S et al.
Headache. 200646(1)57-63.
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The Triptans

• Sumatriptan
• Zolmatriptan
• Naratriptan
• Rizatriptan
• Almotriptan
• Frovatriptan
• Eletriptan
• Sumatriptan and Naproxen sodium

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Triptan Prescribing InformationContraindications
and Precautions for ALL Triptans

• Ischemic cardiac disease
• Cerebrovascular disease
• Uncontrolled hypertension
• Hypersensitivity
• Use within 24 hours of other 5-HTs/ergots
• Hemiplegic/basilar migraine
• History of risk factors for CAD
• SSRI precaution

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Case Scenario 2

• 29-year-old single woman, sales clerk history
  of 8-9 migraines / month lasting for 12-14
  hours, frequent recurrence
• HA associated with nausea and sensitivity to
  light and sound
• Currently taking an oral triptan tablet
• Says that current treatment takes too long to act
  and does not fully relieve headache pain
• Looking for a way to prevent attacks

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Preventive Medication Groups

• Calcium channel antagonists
• Serotonin antagonists
• Others
• Botulinum toxin A
• coenzyme Q10
• NSAIDs
• Petasites
• Riboflavin
• Magnesium

• Anticonvulsants
• valproate
• topiramate
• Antidepressants
• TCAs
• SSRIs
• ß-adrenergic blockers
• propranolol
• timolol

Approved by FDA for this use.
SSRI selective serotonin reuptake inhibitor
TCA tricyclic antidepressant

• Silberstein SD. Lancet. 2004363381-391.

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Nonpharmacologic Therapies Tested in Clinical
Trials
Behavioral Treatments Relaxation
training Hypnotherapy Thermal biofeedback
training Electromyographic biofeedback
therapy Cognitive / behavioral management
therapy

• Physical Treatments
• Acupuncture
• Transcutaneous electrical nerve stimulation
  (TENS)
• Occlusal adjustment
• Cervical manipulation

Proven effective in clinical trials
Adapted from US Headache Consortium Headache
Guidelines. www.aan.neurology.org. 2000
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Case Scenario 3
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Migraine Is Often Overlooked
Sinus headache is the most common misdiagnosis

• Sinus pain caused by inflammation induced
  allergens or by infection occurs when exudate in
  inflamed, blocked sinuses exerts pressure that
  stimulates local trigeminal nerve fibers
• Chronic sinusitis is not validated as a cause of
  headache unless it relapses into an acute stage

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Headache A Minor Criteria in AAO-HNS Sinusitis
Headache is a minor factor in the diagnosis of
rhinosinusitis, according to AAO-HNS

• Major factors
• Purulence in nasal cavity on exam
• Facial pain/pressure/congestion
• Nasal obstruction/blockage/ discharge
• Fever (in acute only)
• Hyposmia/anosmia

• Minor factors
• Headache
• Fever (chronic)
• Halitosis
• Fatigue
• Dental pain
• Cough
• Ear pain/pressure/fullness

Facial pain/pressure alone does not constitute
a suggestive history for rhinosinusitis in the
absence of another major nasal symptom or sign.
American Academy of Otolaryngology-Head and
Neck Surgery Lanza et al. Otolaryngol Head
Neck Surg 1997.117(pt 2) S1-S7.
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Sinus Features May Hide the Presence of Migraine
Headache Symptoms at Screen Among IHS Diagnosed
Migraineurs
96
87
84
84
82
70
65
n2257
57
42
38
IHS Migraine Symptom Criteria Sinus Like Features
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of Subjects
Schreiber et al. Poster Presented at American
Headache Society Meeting June 21-23, 2002
Seattle, WA. Data on file, GlaxoSmithKline.
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Why do so many Americans think they have Sinus
Headache?
In his 1988 review, Sinus Headache A
Neurologists Viewpoint, Couch writes In my
experience and in that of others, sinus
headache, as reported by patients, is a popular
conception that is often erroneous. Patients
reason that, since the sinuses are close to the
eyes (as depicted in advertisements in popular
magazines), headaches located in the frontal,
supraorbital, or infraorbital region are sinus
headaches These headaches frequently are
associated with some gastrointestinal
symptomatology, photophobia, and phonophobia, and
may have some visual or neurologic symptoms. In
short, these sinus headaches are usually
migraine headaches, most often of the common
migraine type.
Couch, J. Seminars in Neurology.
19888(4)298-302.
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Migraine Is Often Overlooked (contd)

• Tension headache is another common misdiagnosis
• Symptoms include
• Dull steady ache
• Physical activity does not worsen pain
• Nausea, photo/phonophobia are not usually
  present
• Vomiting never present
• Patients have likely tried OTCs and failed

Cady et al. Headache Free. 199336-38.
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Migraine Pain Can Be Felt in Peripheral Locations
Such as the Neck

• In Kanieckis study of 144 patients with migraine

• 75 reported neck pain with their migraine
• 43 described neck pain as bilateral and 57 as
  unilateral
• 69 described the neck pain as tightness and
  17 as stiffness

75 reported neck pain with their migraine
Kaniecki et al. Poster presented at 10th IHC
June 29-July 2, 2001 New York, NY.
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Activation of the TNC May Result in Referred Pain
that Could be Perceived Anywhere along the
Trigeminocervical Network
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Case Scenario 5

• 26-year-old man, computer programmer, married
  with 2 children
• Has severe, stabbing pain behind his right eye
• Headaches are accompanied by lacrimation and
  nasal congestion
• Pain lasts 30 to 45 minutes attacks occur
  daily for several weeks, then stop for months
  at a time

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Treatment of Hypnic Headach

• Lithium Carbonate (200-600mg)
• Indomethacin
• Verapamil (160my QHS)
• Methysergide
• Caffeine (60mg)
• Lamotrigene

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TRIGEMINAL NEURALGIA
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