Headaches and Migraines

PEBC

red flags

1. Thunderclap onset = severe HA with peak intensity at onset

2. Positional HA = gets worse when standing up

3. Progressive severity or increased frequency (pattern change)

4. Papilledema (feels like nausea, throwing up, tinnitus)

5. Stiff neck, focal signs, reduced/altered LoC

6. Post-traumatic onset (like hematoma)

7. painful eye with eye redness, tearing, facial flushing

8. HA caused by sneezing, coughing

9. HA with paralysis, weakness, numbness, slurred speech, behavioural changes, or seizure

10. unilateral eye pain with diminished vision

important questions to ask

1. onset of HA

2. Pain location (where does it hurt?)

3. Headache associated symptoms (any other symptoms present?)

4. Precipitating factors?

5. Remitting factors (drug therapy?)

6. Presence of comorbidities?

tension type headache

• mild, dull constant aching, pressure

• occurs bilaterally

• NO AURA

• not triggered by food or activity; precipitated by stress

• duration= hrs - days (up to 7 days)

• at least 2 of:

  • bilateral HA

  • non-pulsating

  • mild-mod pain

  • not worsened by activity

• no nausea and cant have photophobia or phonophobia

cluster headache

• severe attack of piercing pain —> behind the eye or over lateral aspect of nose

• unilateral

• accompanied with nasal secretions, lacrimation

• possible aura

• precipitated by: alcohol, changes in season, naps

• duration = < 3 hrs (several times a day)

migraine

• pulsing, throbbing (may start as tension type)

• unilateral

• temporal, eye region

• accompanied with GI sx (nausea) and/or light sensitivity

• AURA = 10-30 mins before

• triggered by food (cheese, chocolate), fatigue, stress

  • aggravated by activity

• duration = 4-72 hrs

• at least 2 of:

  • nausea

  • light sensitivity

  • interference with activities

• presence of nausea or vomiting and/or photophobia and phonophobia

risk factors (TTH)

• stress

• excessive caffeine

• excessive alcohol

• lack of sleep

• poor nutrition/ dehydration

• poor posture

• odours

• smoke

• sunlight

risk factors (migraines)

• stress

• caffeine

• alcohol

• fatigue

• fasting

• genetics

• menses

• changes in atmospheric pressure

• altitude changes

• trigger foods (changes per individual)

medication overuse headache

• HA occurring at least 15 days per month

• cycle where HA returns as soon as effects of analgesics wear off, causing patient to use more medication for relief

• occurs with:

  • simple analgesics (acetaminophen, NSAIDs) used ≥15 days/ month for > 3 months

  • Opioids, triptans, analgesic opioid combinations used ≥10 days/month for >3 months

• symptoms present as tension type HA

• recommended treatment:

  • gradual D/C opioid containing agents

  • abrupt or gradual D/C with simple analgesics/triptans

• may need to start prophylactic medications = triptans

• manage comorbidities that contribute to HA like depression

drug causes

• alcohol

• cocaine

• methylphenidate

• caffeine withdrawal

• corticosteroids

• nitrates (nitroglycerin) and nitrate containing deli meats

• SSRIs

• oral contraceptives

drugs associated with intracranial HTN (leading to HA)

• tetracyclines

• isotretinoin

• tamoxifen

oral contraceptives

• precipitate migraine attacks in females w no Hx of migraines

• onset = first few months - years of OC use

• D/C OC = see improvement in HA w/in few months

• cause = estrogen content

• estrogen containing OC = CONTRAINDICATED IN MIGRAINE WITH AURA = Increased STROKE risk

goals of therapy

• identify red flags and immediate referral

• prevent medication overuse headache

• identify drug-induced/ reversible causes

• relieve pain and associated sx with drug and non drug therapy

• reduce frequency, severity, duration and disability of attacks

non pharm

• headache diary = trigger management/ avoidance if possible

• apply ice and rest in a dark, noise free room

• stress management = CBT, relaxation therapy, psychotherapy

• acupuncture and/or nerve blocks

• routine = healthy diet, regular exercise, good sleep hygiene

• good posture, ergonomics at work (TTH)

algorithm

NSAIDs

• 1st line for mild-moderate migraines (not requiring bedrest) or as adjunct with triptan

• 1st line for tension-type HA

• COX-2 Selective = Celecoxib

• non-selective = ASA

• semi-selective = Increased affinity for COX-2 but still retain activity for COX-1

  • diclofenac

  • indomethacin

  • Meloxicam

  • Piroxicam

  • Ibuprofen

  • Naproxen (closer to non-selective)

• Pregnancy = avoid in third trimester because they may cause constriction of the fetal ductus arteriosus

Celecoxib

• COX-2 selective NSAID

• low GI bleed risk

• HIGH CV risk

• s/e = Constipation, diarrhea, stomach pain, upset stomach, or throwing up, Heartburn, Gas, Dizziness or headache

aspirin

• non-selective NSAID

• cardioprotective at low doses

• HIGH GI BLEED RISK

triptans

• 1st line for migraines

• administration = Take at first sign of migraine —> repeat dose after 2 hrs if partial relief (EXCEPT Frovatriptan, Naratriptan)

• onset = 30-60 mins

• 2nd triptan dose unlikely to be effective if 1st dose was not helpful

  • EARSZ = have 2 ears therefore can rpt dose in 2 hrs = Eletriptan, Almotriptan, Rizatriptan, Sumatriptan and Zolmitriptan

• Do not use a different triptan within 24 hrs of another triptan

• use 3 diff options before deeming class ineffective

• use <10 days/ month to avoid medication overuse headache

• formulations:

  • oral wafer = rizatriptan 10mg or Zolmitriptan 2.5 mg - if fluid ingestion worsens nausea

  • Nasal spray = zolmitriptan 5mg or sumatriptan 20mg - if pt nauseated

  • Subcutaneous = sumatriptan 6mg - if vomiting early in attack/ resistant to oral triptans

• s/e = chest discomfort, fatigue, dizziness, paresthesia, drowsiness, nausea, throat irritation

• CAUTION:

  • Serotonergic drugs (SSRI, SNRI, MAOI, Ergots, triptans) = increased risk serotonin syndrome

• CI: HUMP

  • Heart disease (incl. angina)

  • Uncontrolled HTN

  • Migraine (Basilar or hemiplegic)

  • Pregnancy

sumatriptan

• earliest repeat dose = 2h (2 doses/day)

• formulations:

  • PO = onset 30-60 mins

  • SC = onset 10 mins

  • Nasal = onset 10 mins

• SC has the fastest onset of action and is the most effective of all triptans, followed by the nasal spray

• do NOT use with MAOIs

• available in combo with Naproxen sodium

zolmitriptan

• earliest repeat dose = 2h (2 doses/day)

  • EARSZ = have 2 ears therefore can rpt dose in 2 hrs = Eletriptan, Almotriptan, Rizatriptan, Sumatriptan and Zolmitriptan

• formulations:

  • orally dispersible tabs = can take without water

  • Nasal spray = faster onset and greater efficacy

• do NOT use with MAOIs

rizatriptan

• earliest repeat dose = 2h (2 doses/day)

  • EARSZ = have 2 ears therefore can rpt dose in 2 hrs = Eletriptan, Almotriptan, Rizatriptan, Sumatriptan and Zolmitriptan

• formulations:

  • fast melt wafers = for those who have worsening nausea with fluid ingestion; can be taken without water and have rapid onset

  • has one of the fastest onsets vs other oral triptans

• use with caution in patients taking propranolol = increased bioavailability of this drug

• do NOT use with MAOIs

almotriptan

• earliest repeat dose = 2h (2 doses/day)

  • EARSZ = have 2 ears therefore can rpt dose in 2 hrs = Eletriptan, Almotriptan, Rizatriptan, Sumatriptan and Zolmitriptan

• do NOT use with MAOIs

• inhibitors of CYP3A4 may increase bioavailability

• can be used in children 12+. → Almo = Elmo = kids

eletriptan

• Earliest repeat dose = 2h (2 doses/day)

  • EARSZ = have 2 ears therefore can rpt dose in 2 hrs = Eletriptan, Almotriptan, Rizatriptan, Sumatriptan and Zolmitriptan

• contraindicated within 72 hrs of potent CYP3A4 inhibitors

other triptans

• Frovatriptan = prophylactic for menstruation related migraines

• Naratriptan = lowest efficacy and slowest onset vs any other triptan

• 2nd dose = 4 hrs later

CGRP antagonists

• newest class of migraine meds —> 2nd line treatment

• blocks action of CGRP = stops/ prevents migraine

  • can be used as preventative therapy

• injection once a month

antiemetics

• target nausea and vomiting

• dimenhydrinate, metoclopramide, domperidone

dimenhydrinate

• gravol

• s/e = sedation, anticholinergic effects, confusion

metoclopramide

• anti-emetic/ prokinetic

• s/e = diarrhea, cramping, HA, drowsiness, extrapyramidal sx, tardive dyskinesia

domperidone

• anti-emetic/ prokinetic

• s/e = diarrhea, cramping, HA, QTc prolongation

chronic migraine prophylaxis

• criteria:

  • attacks have significant impact on QoL despite appropriate use of abortive therapy

    or

  • frequency of attacks puts patient at risk of MOH

    or

  • ≥4 headaches/ month

• used in pts with contraindication to medications for acute migraine attacks = symptomatic treatment difficult

• duration of therapy

  • continue for 6-12 months then consider tapering dose

  • assessment of benefit= min 2 months following dose titration (takes at least 2 months for benefit)

• successful prophylaxis = ≥ 50% reduction in HA or days with HA

propylaxis options

tension type headaches treatment

• acute treatment

  • mild = non-pharm

  • if meds needed = acetaminophen or NSAIDs (ibuprofen, Naproxen)

  • if frequency ≥15 days/month = chronic = prophylaxis

• prophylaxis (AN MVp)

  • 1st line = Amitriptyline, Nortriptyline

  • 2nd line = Mirtazepine, Venlafaxine

pregnancy

• 1st line = non-pharm

• aborptive therapy:

  • acetaminophen

  • NSAIDs - ibuprofen/ naproxen = AVOID IF POSSIBLE, ESP 1st and 3RD TRIMESTER!

• severe nausea = metoclopramide or prochlorperazine

• prophylaxis = propranolol = DC few days before delivery and monitor neonates (bc it can cause fetal growth restriction: bradycardia, hyperglycemia)

• triptans = generally avoided —> growing evidence for sumatriptan

• ergots = contraindicated

breastfeeding

• 1st line = non pharm

• abortive therapy:

  • acetaminophen = preferred

  • ibuprofen = avoid if possible but can use

  • sumatriptan = can be used but it is crucial to avoid vasoconstricting agents in initial postpartum period

    • pump and dum! holding breastfeeding for 8-12 hrs after dose = reduce exposure to infant

• prophylaxis = propranolol

• avoid ergots, barbiturates, opioids and ASA

children