HEADACHE DISORDERS Flashcards
THE INTERNATIONAL CLASSIFICATION OF
HEADACHE DISORDERS (ICHD-III)
Primary Headaches
Migraine
Tension-type headache
Trigeminal autonomic cephalalgias (including cluster headache)
Other primary headaches
rimary headaches, This means that are not related to or not secondary to a systemic illness or psychiatric illness.
Painful cranial neuropathies, other facial pains and
other headaches
Cranial Neuralgias and central causes of facial pain
Other headaches
Secondary Headaches
As a symptom of organic disease
Head and neck trauma
Cranial or cervical vascular disorders
Non-vascular intracranial disorders
Substance or its withdrawal
Infection
Disorders of Homeostasis
Facial pain due to disorders of the cranium, neck,
nose, eye, ear, sinuses, mouth or teeth
Psychiatric disorders
TENSION-TYPE HEADACHE (TTH)
Epidemiology
Experienced, with at least one attack in a life-time,
by 90 % of all females and 70% of all males
Classification
Episodic infrequent TTH: <1 /month for no greater
than 10 attacks/year
Episodic frequent TTH: up to 14 attacks/month
Chronic TTH: 15 days or more per month for > 6
months
Onset
May occur at any age but less common in those
who are over 50
Can be precipitated by mental stress and tension,
smoking, fatigue, prolonged poor body posture e.g.
excessive computer use
TENSION-TYPE HEADACHE (TTH)
Diagnostic Criteria
A. Episodes fulfilling criteria B-D. The frequency of the episodes
determine the TTH class.
B. Headache lasting from 30 min – 7 days
C. Headache has at least 2 of the following characteristics:
Bilateral location
Pressing/tightening (non-pulsating) quality
Mild or moderate intensity
Not aggravated by routine physical activity such as walking or climbing
stairs
D. Both of the following:
No nausea or vomiting (anorexia may occur)
No more than one of photophobia or phonophobia
E. Not attributed to another disorder
MIGRAINE
Epidemiology
~15-18% in females and 5-8% in males.
~3.5 million Canadians experienced migraine
Strong family history relevance
Ranked by WHO as one of the top 20 conditions causing disability
Classification
With aura (Classic Migraines) - 25%
Without aura (Common Migraines) - 75%
Onset
Onset is always below the age of 50
MIGRAINE TRIGGERS
Stress
Smoking
Fatigue
Altered sleep patterns
Some medications
Weather changes
Menses
Odors
Caffeine withdrawal
Some food such as cheese, wine, chocolate, MSG and hot
dogs
MIGRAINE
Diagnostic Criteria – Migraine without Aura
A. At least 5 attacks fulfilling criteria B-D
B. Headache lasting from 4 – 72 h (untreated or successfully
treated)
C. Headache has at least 2 of the following characteristics:
Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by or causing avoidance of routine physical activity (e.g.
walking, climbing stairs)
D. During headache at least one of the following:
Nausea and/or vomiting
Photophobia and phonophobia
E. Not attributed to another disorder
CLUSTER HEADACHE
Epidemiology
The most severe of primary headache disorders
A rare condition (0.1% incidence)
More predominant in males than females (reported
4:1 to 12:1)
Classification
Episodic CH: cluster attacks with remission in
between (80-85%)
Chronic CH: cluster attacks with no significant
remission (15-20%
Onset
Occurs at any age – most common onset 28-30
years
Nitroglycerin, other vasodilators and alcohol may
precipitate the attack
orbital supraorbital (above the eyes) or temporal.
Trigeminal neuralgia it’s actually the main differential diagnosis for cluster headache.
If someone presents with a cluster headache, it’s a red flag. Because say if I have the worst headache, like severe, very severe, it needs to be assessed
CLUSTER HEADACHE
Diagnostic Criteria
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or
temporal pain lasting 15-180 minutes if untreated
C. Headache is accompanied by at least 1 of the following:
Ipsilateral conjunctival injection and/or lacrimation
Ipsilateral nasal congestion and/or rhinorrhea
Ipsilateral eyelid edema
Ipsilateral forehead and facial sweating
Ipsilateral miosis and/or ptosis
A sense of restlessness or agitation
D. Attacks have a frequency from 1 every other day to 8 per day
E. Not attributed to another disorder
trigeminal autonomic. So it does have autonomic symptoms, which is actually like it’s associated with on the same side of the pain ipsilateral.
using oral medications are not the best optionsm won’t work fast enough for the headache
CONTRAST OF PRIMARY HEADACHE
DISORDERS
tth vs migraine vs cluster
ASSESSMENT OF HEADACHE
Medical history
Headache history – (SCHOLAR or SCHOLAR-E)
Headache diary
Age of onset, frequency, duration, severity, location
Associated symptoms
Precipitating, aggravating and relieving factors
Important to determine the presence of red flags
Physical examination
Normal physical examination is expected, otherwise thorough
investigation will be needed e.g. CT-scan, lumber puncture, lab
tests
Dental examination
Dental pain, bruxism
Laboratory and imaging
RED FLAGS
Onset: ages > 50 or < 5 years
Severe and abrupt onset of headache
“Thunderclap”
Increased frequency or increased severity
Significant change in pattern (atypical)
Other signs such as stiff neck, reduced
consciousness, fever, sick appearance
WHAT SHOULD YOU DO?
GOALS OF THERAPY
Symptomatic treatment of headache and
associated symptoms e.g. N, V
Prevent recurrence of headache
Treat the secondary causes of headache
Prevent complications and adverse effects
of drug therapy
NON-PHARMACOLOGICAL TREATMENT
Patient education about their headache,
available treatments and the expected
results
Patient reassurance
Avoid triggers (especially in migraine) e.g.
stress, some kinds of food, poor sleep
habits, smoking
Ice pack, maintain adequate sleep pattern,
rest in a dark, quiet room
Informal psychotherapy
Biofeedback
Relaxation therapy
Cognitive-behavioral therapy
Acupuncture
PHARMACOLOGICAL TREATMENT –
GENERAL PRINCIPLES
Acute headache:
Start treatment as soon as possible
Use the minimum recommended dose, then titrate
Choose an agent case by case:
How severe is the attack?
Are there any associated symptoms?
Was a specific treatment effective in previous attacks?
Check for medical history and any contraindications
Patient preference
when they are in the middle of heading attack. Now it’s all full blown headache. Research showed that pain, reduced GI, motility, and could delay the absorption of drugs. So by the time it takes the med when you are in severe pain, what happens? The absorption, the drug will be absorbed. It will not affect the bioavailability, but it will take longer to kick in. By the time it takes n maybe you are severe pain. Maybe they’re already the headache already gone.
if the patient feels that they can get headache attack and it is a patient that actually known to have headaches take med asap so it will get absorbed quickly and kick in faster
migraine could be associated with nausea and vomiting. And depending on the patients and people like vomiting usually not with the start of the headache, usually vomit later on during the attack. And when you get the medication absorbed before vomiting, this is a great thing.
PHARMACOLOGICAL TREATMENT –
GENERAL PRINCIPLES
Consider prophylaxis when:
Consider prophylaxis when:
Frequent attacks – use analgesics >15 d/mo or 2 d/week
Severe disabling attacks
Short-lived especially with cluster headache
Principles of prophylaxis:
Initiate low and go slow
Use long acting medications to improve adherence
In cluster headache, initiate chronic prophylaxis while on
transitional prophylaxis
If patient is attack free for 6-12 month, consider tapering the dose
if the patient feels that they can get headache attack and it is a patient that actually known to have headaches take med asap so it will get absorbed quickly and kick in faster
TENSION-TYPE HEADACHE
Treated with analgesics:
NSAIDs, most commonly ibuprofen (200-600 mg), ASA
(325-975 mg) and naproxen (250-500 mg)
Caffeine combination with analgesics (2nd line)
Acetaminophen (500 -1000 mg) with or without codeine
Use should be avoided for TTH
Codeine combination should be limited because of the increased risk
of dependency and MOH (< 10 days/month)
Analgesic use should be limited to not more than 15 days
per month to avoid medication overuse headache (MOH)
DO TTH PATIENTS NEED PROPHYLAXIS?
Generally, they do not need prophylaxis because of
the mild to moderate nature of TTH and its short
duration; however; prophylaxis will be considered
if:
The attacks are severe enough to limit the usual daily activity
of the patient
Headache is frequent (>2-3 attacks per week)
Analgesics are contraindicated
Analgesics are ineffective or overused
TTH PROPHYLAXIS OPTIONS
Tricyclic Antidepressants (TCAs) e.g. amitriptyline 30-75 mg
qHS
Most commonly used in TTH prophylaxis
Titrate the dose till giving the effect – response is usually in 2-3
weeks
Common side effects: anticholinergic effects (dry mouth, blurred
vision), orthostatic hypotension
Other options
Venlafaxine
Mirtazapine
44 F has migraine. Other secondary causes
excluded. Frequency of attacks ~3 days per
month
What would be an appropriate abortive therapy
for her?
Stratified Care vs Stepped Care
stratified care model
stepped care
triptans, nsaids, and Tylenol are good options.
step-by-step, this means I start with some milder agent, tylenol or simple analgesic or an NSAID. Of course, given that there are no contraindications. And if they don’t work, I escalate the treatment to triptan or the newer agents
- Lowest side effect aproach
Straified
Depending on the severity, the patient will have two options. So we’ll have a Tylenol or NSAID and triptan at home. If they get a severe attack. Take a triptan right away. We get a mild attack. I take an analgesic. gauging based on the disability, letting the patient decide
PHARMACOLOGICAL ALTERNATIVES FOR
ACUTE MIGRAINE
First-line
NSAIDs
Acetaminophen
ASA
Second-line
Triptans
Third-line
Triptans +
NSAIDS
Fourth-line
Codeine
combination*
Ergot
derivatives
Combination more effective than either agent alone
- 3rd line due to AE
Ergot derivatives: many absolute contraindications. They actually similar to the triptan, but the work in other receptors in the body. So they are very effective, but they saved before severe migraine.
ANALGESICS (migraines)
Acetaminophen 1000 mg ± metoclopramide 10 mg
ASA 1000 mg ± metoclopramide 10 mg
Caffeine combination with analgesics
Ibuprofen 400 mg
Naproxen 500 mg
Diclofenac 50 mg
Ketorolac 30-60 mg IM injection (max 120 mg/d)
It may be tried if other agents failed to control the acute attack
Comments
Limit their use to less than 15 days per month to avoid MOH
Codeine and butalbital combination analgesics should be limited to
less than 10 days per month to avoid MOH and the risk of
dependency
Contraindications?
TRIPTANS
indications
AE
Indications
In moderate to severe migraine headache
When analgesics and NSAIDs are ineffective
When analgesics are used frequently
Triptans the work on the serotonin receptor. They are actually serotonin receptor agonists.
Mixing them with agents that enhance serotonin like SSRIs for examined, the vaccine as NRI’s might increase a theoretical risk for serotonin syndrome.
Adverse effects
Fatigue, dizziness, drowsiness
Paresthesia
Nausea, abdominal pain
Chest discomfort
TRIPTANS
contra
Contraindications
Absolute
Ischemic heart disease or any cardiac or cardiac-like symptoms
Stroke or TIA
Peripheral vascular disease such as ischemic bowel disease
Basilar or hemiplegic migraine
Relative
Uncontrolled hypertension
Pregnancy or breastfeeding
Smoking
When they are vasoconstrictors, they can actually, they are contraindicated in conditions that are associated with vasoconstriction
Do not use a triptan within 24 h after another triptan or
ergot (additive vasoconstriction)
There is no benefit of giving another dose if the given
triptan is ineffective but you can try another one
Use less than 10 days/month to avoid MOH
Use with caution when co-administered with SSRIs and
SNRIs due to the increased risk of “serotonin syndrome”.
Avoid:
Co-administration with ergot derivatives
Co-administration with MAO inhibitors
There is no benefit of giving another dose of the same triptan if the given triptan is ineffective. What does this mean? So if I try the dose now and it didn’t work, it’s less likely to work,
But again, other triptans could work, but you cannot do it the same day. You have to wait 24 h to use the other triptan.
Use less than ten days per month to avoid the medication overuse, headache. Use with caution was when co-administered with SSRIs, SNRIs due to increased risk for serotonin syndrome.
inhibiting that enzyme monoamine oxidase that actually metabolize quite a few members of the family of triptans. So this will increase the level of the triptans and also the serotonin syndrome risk.
Seven triptans are available
All have demonstrated efficacy
Minor differences among them
Which one to choose?
Patient preference is the major guidance of
choice
SE tolerability
Efficacy
Convenient dosing
Dosage form preference
Cost/drug coverage
And.. the minor differences\
Trials: headache response at 2h, pain free at 2h, sustained response over 24h
Non head to head trials
None of those triptans is better than the other. There are minor differences between them
Sumatriptan (Imitrex®)
Naratriptan (Amerge®
KNOW sumatriptan dose
Oral: 25–100 mg; may repeat in 2 h;
max. 200 mg/24 h
SC: 6 mg sc; may repeat in 1 h; max.
2 injections/24 h
Nasal spray: 5–20 mg may repeat in
2 h; max. 40 mg/24 h
Onset: SC>Inhalation>oral
SC route is very effective for severe
migraine and acute cluster (fastest onset)
headache (Fastest onset, Cluster has short duration for pt)
Max 2 doses of 100mg (200mg/day)
naratriptan:
The slowest onset triptan, kicks in slowly
Minimal side effects
Less HA recurrence rate
Best for patients who can’t tolerate
the SE of other triptans.
Almotriptan (Axert®)
Eletriptan (Relpax®)
Frovatriptan (Frova®)
Almotriptan (Axert®)
Fewer S/E
CYP3A4 inhibitors increase its
plasma concentration
Good tolerability, lower SE than
Sumatriptan and zolmitriptan
Eletriptan (Relpax®)
Contraindicated within 72 hours of
CYP3A4 inhibitors administration
as they increase its plasma
concentration
Frovatriptan (Frova®)
OCs and propranolol increase
frovatriptan levels
For migraines around menstrual cycle: can use a standing dose for a triptan like one or two days before menstruation and then continue for three to five days
Rizatriptan (Maxalt®) Zolmitriptan (Zomig®)
Rizatriptan (Maxalt®)
Faster relief compared to oral
triptans
It is available as fast melt wafers
Propranolol increases the
bioavailability of rizatriptan
better relief of nausea
Zolmitriptan (Zomig®)
Oral/Oral disintegrating tablet : 2.5–
5 mg; may repeat in 2 h; max. 10
mg/24 h
Nasal Spray: 2.5 or 5 mg; may
repeat in 2 h; max. 10 mg/24 h
CYP1A2 inhibitors e.g. fluvoxamine
and cimetidine increase its plasma
concentration. Its max dose should
be reduced into half
Least tolerated?
If pt had AE from other triptan, not recommended to use zolmitriptan, likely wont tolerate wither
