Ch 13: Headache Flashcards
What is the most common form of pain experienced by Americans?
Headache
Over 95% of population experiences it at some point
What is the most common type of headache?
What is the most likely headache type to present in clinic?
While tension type headaches are the most common…
migraines are the most likely to present in clinic.
Good to note : Over time, most patients with one type of headache will have cross-over symptoms of another type
What are the most common triggers for migraine
- Stress (80%)
- Hormones
- Skipped meals
- Weather
- Sleep disturbacnes
- Perfume/odor (44%)
Other triggers: neck pain, lights, alcohol, smoke sleeping late, heat, food, exercise
What are the most common comorbidities found in migraine disorder?
- Insomnia
- Depression
- Anxiety
- Gastric ulcer/ GI bleed
- PAD
- Angina
Others: allergies, epilepsy, arthritis, stroke/TIA, RA, asthma, Vit D deficiency
Most common food triggers for migraine?
- Alcohol
- Caffeine
- MSG
- aspartame
- cocoa
- cheese / dairy
- sulfate and nitrate containing foods (aged & processed meats and cheese, dried fruits)
Most frequently used CAM types for headache
- Manipulative therapy
- dietary supplements
- acupuncture
- mind-body therapies
What 3 questions / signs have 93% PPV in diagnosing migraine
- Has a headache limited your activities for a day or more in the last 3 months?
- Are you nauseated or sick to your stomach when you have a headache?
- Does light bother you when you have a headache?
SNOOP4
A Mnemonic to rule out emergent secondary causes of HA
S = systemic symptoms (fever, myalgia, weight loss) –> cancer, infxn
N = neuro sx –> stoke, lesion
O = older age (> 50 yrs old ) at onset –> TA, glaucoma, mass
O = onset thunderclap –> bleed
P = papillodema –> elevated ICP
P = positional –> intracranial hypotension
P = precipitated by valsalva or exertion –> elevated ICP
P = progressive or pattern change –> any secondary cause
Pathophysiology of Migraine
Tigerring of trigeminal (sensory), parasympathetic, and sympathetic nerve fibers
PLUS
Release of **vasoactive neuropeptides **(like CGRP, serotonin, substance P, NO-synthase, VIP, neuropeptide Y, acethylcholine, NE, and orexin)
LEADING TO
vasodilation
sterile inflammation
cortical spreading / propogation of aberrant electrical signaling
EXTENDING TO
brainstem, cortex, dura, and other cranial structures such as the vagal nerve
LEADING TO
neuro sx, autonomic sx, GI sx
CGRP = calcitonin gene-related peptide
Beta Blockers
Propranolol, timolol
Consider: HTN
Caution: renal or hepatic impairment, chronic fatigue, POTS
as a preventative
Anticonvulsants
Divalproate, topiramate
Consider: epilepsy, obesity (topiramate)
Caution: hepatic impairment, concomitant alcohol use, depression
as a preventative
Valproic acid is not FDA approved but likely also efficacious.
Calcitonin gene-related peptide (CGRP) inhibitors
Erenumab
Galcanezumab
Fremanezumab
Eptinezumab
Consider: previous failed preventatives
Caution: history of constipation, hypertension, injection hypersensitivity
a preventative
OnabotulinumtoxinA
Consider: chronic migraine, failed preventatives
Caution: history of muscle weakness, injection sensitivity
as a preventative
Antihypertensives, Not FDA approved, for migraine
CCB, ACE inhibitors, ARBs
probably efficacious
ANtidepressants, Not FDA approved, for migraine
TCAs, SSRI, SNRI
Amitryptiline, fluoxetine, venlafaxine
Consider: sleep disruption, depression, anxiety, amplified pain syndromes
Caution: fatigue. Polypharmacy because of cytochrome P450 pathway and caution regarding serotonin syndrome if using triptans,
Selected: renal and hepatic impairment; alcohol use
Memantine
Consider: chronic migraine. Not FDA approved but likely efficacious.
Cognitive dysfunction, amplified pain syndromes
Caution: can initially worsen headache; dizziness
First line abortive meds for all headache types
NSAIDs
APAP
Caffeine
most common abortive Rx for migraine
Triptans.
5-HT1 receptor agonists
Other abortive meds for migraines
- Calcitonin gene-related peptide receptor antagonists or gepants (e.g., ubrogepant, rimegepant)
- 5-HT1F receptor agonists or ditans (e.g., lasmiditan) have been released and will likely expand in the near future.
- Older agents, including ergotamine derivatives (e.g., DHE), can be helpful in selected cases and
- opioids (e.g., butorphanol) have been historically used but are typically avoided because of risk and lack of specific targeting of migraine pathological features.
All acute medications have risk of contributing to rebound headache as well as medication overuse headache, which affects up to 50% of patients with chronic headache
Exercise dichotomy in migraines
- Exercise can be a trigger but can also decrease migraine intensity, frequency, duration, and improve QOL
Graded aerobic exercise program. Emphasize proper nutrition and hydration. Exercise in a therapeutic setting. Can work even in POTs or comorbid dysautonomia.
Yoga also beneficial. And HIIT too - but caution when progressing.
Stepwise Approach to dietary management for headaches
- Increase awareness: dietary hx, log.
- Reduce triggers: regular meals, hydrate, reduce food triggers. Eliminations.
- Foundational dietary recs: antiinflammatory. HEI. Low glycemic index.
- Specialized dietary recs: keto, vegan, low fat, low histamine. Hard to maintain.
- Foundational supplements: Mg, CoQ10, Riboflavin, B vitamins, Vit D, Omega 3
- Specialized supplements: herbs and other nonvitamin supplements
Give the intervention at least 3 months before re-evaluation.
HEI = healthy eating index
Herbs are great way to match one therap with a complex clinical scenario (IE ginger for pt with OA, headaches, complicated by NSAID-gastritis or nausea)
Magnesium
DOSAGE: Adult: ≥2–600mg.
Pediatric: 9mg/kg
- serum and CSF levels in migraine more likely to be deficient
- Deficiency increases risk of migraines
- influences absorption of other nutrients such as Vit D
- GI tolerability can be an issue; many common forms available (oxide, sulfate)
- Consider chelated formulation (glycinate) and split dosing with food or dosing at bedtime
- May improve depression, myalgia, sleep
CoQ10
Ubiquinone
Lower levels in migraine patients
Dose: 100-300 mg
- Consider ubiquinol formulation (activated form), especially with higher comorbidities since they may have heightened oxidative stress
- may benefit fatigue, FMS
- generally well tolerated
Vitamin D3
Dose: >1000 IU (Dose to increase blood levels to 40ng/ml)
Levels found to be lower in patients with migraine
May work synergistically with magnesium and pharmacotherapy (enhances response of meds especially in pts who are deficient)
Riboflavin
Vitamin B2
50-400mg
* An antioxidant that modulates flavoenzymes in mitochondrial respiratory chain
* inconsistent results in kids (maybe due to large variability in dosages), many positive results in adults
strong yellow Urinary discoloration
mild-mod GI symptoms
B Vitamins:
B12, B9 (Folate), B6
B12: 400mcg-2mg
B9 Folate: 400mcg-2mg
Vit B6: 25-50mg
- Target elevated homocysteine;
- consider methylated forms
- Vitamin B6 confirm P5P form
- People with MTHFR are more prone to migraine with Aura
Alpha Lipoic Acid
600 mg
Reduces oxidative stress
Omega 3
Dosage: 1-3+ grams
Background diet is key, especially reducing inflammatory foods and excess omega-6s. Adjunctive benefit with pharmacotherapy
Trials of supplementation have mixed results
Beneficial when added to conventional preventatives
Ginger
Dosage: 0.5-2 grams
Helpful for nausea; comorbid gastropathy and inflammatory conditions
Abortive for acute migraines
Melatonin
3-10mg at bedtime
Caution: vivid dreams; daytime drowsiness. Rotate off periodically
May be helpful in amplified pain syndromes (like fibromyalgia and temporomandiubla disorder) and cluster headache, as well as migraine. May improve IBS and NSAID-gastropathy
Probiotics
Consider with comorbid IBS; look for research based formulations
Butterbur
Dosage:
Adults 150
Pediatrics 100mg
Antiinflammatory and mast cell stabilization (was used for allergies)
Use only pyrrolizidine alkaloid (PA) free forms (e.g., Petadolex) as these are potentially hepatotoxic and were found in several US formulations; avoid with history of liver dysfunction; monitor liver function and consider rotation off periodically
Enzogenol
1000-1200 mg/day
Monterey pine bark extract
Consider in TBI and cognitive dysfunction or post-concussive headache
Boswellia
350-1000 mg
Contains pentacyclic triterpene acids (antiiinflamnatoryl; inhibit 5-lioxygenase)
Prelim evidence in cluster headaches
May be helpful with asthma and arthritis comorbidities
Feverfew
Dosage: Varies typically 50–150mg dried leaf; 2.08–18.75mg of a CO2 extract
Mixed results based on formulation and product potency; may cause aphthous ulcers and withdrawal syndrome if abrputly stopped. COntraindicated in pregnancy
Iron
Helpful in menstrual migraine compounded by iron deficiency
May help comorbid depression and anxiety
Mind-body with good evidence
- Biofeedback: tension type and migraine. Improved efficacy of meds.
- Mindfulness Meditation: specifically MBSR. Canaactually change cognitive networks. Continuing a home practice has ongoing benefit.
- Others: CBT, relaxation (PMR), diaphragmatic breathing, guided imagery, hypnosis. Apps are good
Mind-body generally one of the most researched areas of therapy for migraine.
The benefit seems to be related to complying with a home practice.
Biomechanical Techniques with good evidence
- Manual therapy
- spinal manipulation - can work through endocannabinoid modulation
- ELectrical stimulation (like TENS). Transcutaneous vagal or trigeminal, transcutaneous magnetic, remote electrical neuromodulation (REN)
Is acupuncture beneficial for acute headache treatment or as a preventative?
BOTH!
The most recent reviews on acupuncture noted that it is better than placebo, at least as effective as other preventives, and potentially superior to current pharmacotherapy. In addition, recent trials of manual, electrical, and auricular acupuncture demonstrated that they may be effective in preventing migraine.
Energy-based therapies with some benefit in headache
Healing touch
Homeopathy
Note that some patients with headaches have significant hx trauma and/or sensitivity
