Headache

1
Headache

• By Dr. Andrew Gutwein

2
We all get em!

• So why do patients come to the doctor?
• Severity
• Worried about brain tumor

3
Headache History
Be mute! Its all pattern recognition.
4
Headache Physical
Not your internists general physical exam! Its
not about the lungs, heart, and abdomen!

• examine the head
• look at and feel the scalp
• look at the fundi
• listen to the orbits with the stethoscope
• check the visual fields
• is their language normal

• can they tell a coherent story
• can they walk on a narrow base
• check the reflexes and the plantar response
• focus on the neurologic systems

5
Diagnostic Testing

• Only to prove a specific diagnosis (such as MRI
  for suspected MS or CT scan with contrast for
  suspected tumor)
• 99 of headache patients do not need imaging or
  blood tests of any kind.
• Consider the non-contrast CT if it is going to
  be the only way the patient will stop worrying
  (likely cost effective)

6
(No Transcript)
7
Headache Case 1a

• 34 y.o. W no PMH, c/o HA that are unilateral and
  throbbing. They happen once or twice a week and
  last for 7-8 hours. When they occur she feels a
  little nauseated and must go lie down for a while
  away from loud noises. They usually go away after
  she takes Excedrin OTC from her local pharmacy.
  Red wine occasionally causes a HA.

8
Headache Case 1b

• 34 y.o. W no PMH, c/o HA that are bilateral and
  dull and happen every two days and last for 3-5
  hours. She also feels the pain in her neck. She
  keeps working during the HA but is less
  productive. Tylenol and Excedrin work sometimes
  to relieve the pain but not always.

9
Migraine Overview

• 18 of women and 6 of men are migraneurs
• Described as pulsating or pounding and
  unilateral but can be bilateral
• Frequently associated with neck pain dont be
  fooled!

Cause
neurologic, not vascular vasoconstriction and
vasodilation. It is the spreading depression/
depolarization of neurons across the cortex that
results in a release of neurotransmitters which
causes normal vascular pulsation to be felt as
nociception.
10
Migraine History
3 Keys to the history

• photophobia/ phonophobia
• nausea/ vomiting
• disability (the patient must stop what they are
  doing and frequently they need to lie down in a
  quiet room)

Timeline Lasts 4 hours to 3 days Any hemicranial
HA, any pulsating headache, and any neurologic
phenomenon lasting over 20 minutes may also help
clue you in on this diagnosis. 10 of migraine
patients have aura and 50 of the time the aura
is not followed by HA. When this happens it is
called the dissociated migraine.
11
Migraine Cycle

• Migraneur life cycle
• infantile colic
• childhood abdominal pain
• menstrual accompaniment
• motion sickness
• red wine headache
• benign sex headache
• ice cream headache

• worsening of headache with life stressors
• cerebrovascular disease
• transient global amnesia
• Depression, bipolar disorder, generalized
  anxiety disorder and social phobia are all more
  common in the migraneur.

12
Migraine - Mild
Treatment of mild to moderate Migraine
2/3 of patients with migraine headache have mild
migraine and never come to complain to you about
the headache. They self treat with massage,
relaxation techniques, avoiding light, going to
bed, acetaminophen, low dose NSAIDs, or
combination products like Excedrin Migraine which
has aspirin, acetaminophen and caffeine in it.
These medications work well for many people but
be wary of using any of these (especially ones
with caffeine) too frequently for too long.
13
Migraine - Triptans
Acute treatment of the moderate to severe
Migraine

• Triptans
• expensive (about 20-25 per dose for PO) but
  safe.
• Use as early in the headache as possible and
  beat the headache until it is gone or it will
  come back.
• When taken early pain free 50 at 2 hours, 85
  at 4 hours.
• If you wait until the headache is moderate to
  severe you get only about half that response.
• If the headache continues for 1 hour after
  taking the triptan take another dose.

14
Migraine - Triptans

• One can even prevent the HA when taken during
  the prodrome but do not take during an aura as
  it does not work.
• Avoid in pregnant patient - pregnancy category C
• Chest pain side effect that can occur is not
  myocardial (lt1 in a million)
• Triptans can be used in a patient on an SSRI
  (serotonin syndrome is very rare)
• Triptans are not contraindicated in women on
  oral contraceptives with migraine with aura but
  you should advise smoking cessation as all these
  things add up to increased relative risk of CVA.

15
Migraine - Triptans

• All triptans are available PO but only a few have
  other routes.
• Injectable (expensive) sumatriptan
• Intranasal (nasty aftertaste) sumatriptan,
  zolmitriptan, rizatriptan
• Sublingual zolmitriptan, rizatriptan
• Of the PO frovatriptan and naratriptan are slower
  to act - this may be good in the patient that
  has a slow growing headache and patients who get
  a rebound headache after using the more rapid
  acting triptans.
• Eletriptan and almotriptan are the other
  triptans.

16
Migraine - Triptans

• If the patient does not respond to one triptan,
  they will still have an 80 chance of responding
  to another.
• They can take 10mg of metoclopramide, wait 10
  minutes, and then take the oral medication if
  there is severe nausea or vomiting. Otherwise
  use the sublingual route.
• Triptans are to be used no more than twice a
  week on average.
• Triptans are contraindicated in patients with
  CAD,CVA, PAD, and uncontrolled HTN.

17
Migraine Other Treatments

• Other acute treatment options
• Ergotamines not used almost at all because of
  toxicity
• Steroids PO for 2-3 days (prednisone 20mg, no
  taper needed)
• Fioricet or Fiorinal and other medications that
  have caffeine or narcotics are ok for migraine
  headaches, but on a limited basis

18
(No Transcript)
19
Migraine Prophylaxis
Who needs prophylaxis against migraines headaches?

• If the patient is having headaches more
  frequently than twice a week they likely need
  prophylaxis.
• If the patient is having headaches less than
  twice a week but it interferes significantly you
  can still consider prophylaxis.

20
Migraine Prophylaxis
Chronic prophylaxis against moderate to severe
Migraine

• Tricyclic Antidepressants
• Beta-blockers
• Anti-seizure Medications
• Candesartan/Lisinopril some evidence
• CCB weak evidence

21
Migraine Prophylaxis

• TCAs amitriptyline, imipramine, nortriptyline,
  desipramine
• They work well but can have anticholinergic side
  effects
• Listed them in order of most to least
  anticholinergic side effects
• The first three should be taken before bed as
  they can be sedating and desipramine should be
  taken in the morning
• Start at 10-25mg depending on whether they are
  elderly and titrate up if needed to max 150mg
• Check EKG for QT before starting
• TCAs are a good first/second line choice for men
  and women.

22
Migraine Prophylaxis

• Beta Blockers propranolol or nadolol
• Use non-selective as they cross the blood brain
  barrier and can work on the brain.
• Propranolol or nadolol are excellent but side
  effects can include impotence, fatigue, and
  depression.
• Start low and titrate up.
• These are a good first/second line in women.

23
Migraine Prophylaxis

• Anti-seizure medications valproic acid,
  topiramate
• Valproic acid 250-500mg BID with food works very
  well but side effects include hair loss and
  weight gain and it is contraindicated in
  pregnancy.
• Topiramate 25mg BID titrated to 100mg BID as
  needed is now starting to be used for this
  indication as well. Topiramate can cause mental
  slowing and paresthesias.
• These are good first/second line choices for
  men.

24
Headache Case 1a

• 34 y.o. W no PMH, c/o HA that are unilateral and
  throbbing. They happen once or twice a week and
  last for 7-8 hours. When they occur she feels a
  little nauseated and must go lie down for a while
  away from loud noises. They usually go away after
  she takes Excedrin OTC from her local pharmacy.
  Red wine occasionally causes a HA.

25
Headache Case 1b

• 34 y.o. W no PMH, c/o HA that are bilateral and
  dull and happen every two days and last for 3-5
  hours. She also feels the pain in her neck. She
  keeps working during the HA but is less
  productive. Tylenol and Excedrin work sometimes
  to relieve the pain but not always.

26
(No Transcript)
27
Headache Case 2

• 37 y/o M Program Director of an Internal Medicine
  Residency gets daily HA. These HAs frequently
  occur in the afternoon after hearing multiple
  complaints from housestaff all day. They are
  bilateral temporal and he can continue working
  right through them. They are sometimes relieved
  with tylenol.

28
Tension Type Overview

• This type of headache is frequently described as
  neck discomfort, or band like pain around the
  head but can be only front, back or top of the
  head.

Cause

• This is not caused by actual muscle tension
  (found on testing) but is really psychogenic
  headache. Any muscle tension is usually a
  secondary phenomenon.

29
Tension Type Treatment

• The real cause is stress. Find out what kind of
  stress is going on in their life and see if you
  can find a way to help them alleviate the
  stress.
• The answer is not the pills. Patients can use
  acetaminophen or NSAIDs PRN but the real answer
  is stress reduction. They can do this any way
  then want.

30
Headache Case 3

• 37 y/o M Program Director of an Internal Medicine
  Residency gets almost daily HA. These HAs
  frequently occur in the morning. They are
  bilateral temporal and he can continue working
  right through them. They are sometimes relieved
  with drinking his large mug of tea.

31
Chronic Daily Headache (CDH)
Cause
Taking medications for their headache! People
think the pills help the headache - the pills
cause the headache.
These are people that may have started out with
tension type or migraine headaches but now have
almost daily headaches, frequently the whole day
long. This is really rebound headache. CDH can be
caused by any analgesic taken too frequently. It
is worse in drugs with caffeine added (Fioricet,
Excedrin) .
32
Chronic Daily Headache Treatment

• You should withdraw all meds (except
  barbiturates, opioids and benzodiazepines which
  need tapering).
• You can use clonidine to avoid opioid
  withdrawal, phenobarbital to avoid butalbital
  (found in Fioricet/ Fiorinal) withdrawal.
• If you have to, NSAIDs and antiemetics or even
  triptans can be used while withdrawing
  everything else.
• 8 of 10 respond eventually
• Last ditch treatment is one month of steroids
  20-100mg prednisone x2 weeks then taper for 2
  weeks

33
(No Transcript)
34
Differential Diagnosis

• About 99 of all headaches seen in the internists
  office fall into these three categories
• Migraine
• Tension Type
• CDH (Chronic Daily Headache)

35
Fin