HEADACHE DISORDERS

Question 1

THE INTERNATIONAL CLASSIFICATION OF
HEADACHE DISORDERS (ICHD-III)

Answer 1

 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

Question 2

TENSION-TYPE HEADACHE (TTH)

Answer 2

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

Question 3

TENSION-TYPE HEADACHE (TTH)

 Diagnostic Criteria

Answer 3

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

Question 4

MIGRAINE

Answer 4

 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

Question 5

MIGRAINE TRIGGERS

Answer 5

 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

Question 6

MIGRAINE
 Diagnostic Criteria – Migraine without Aura

Answer 6

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

Question 7

CLUSTER HEADACHE

Answer 7

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

Question 8

CLUSTER HEADACHE
 Diagnostic Criteria

Answer 8

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

Question 9

CONTRAST OF PRIMARY HEADACHE
DISORDERS

Answer 9

tth vs migraine vs cluster

Question 10

ASSESSMENT OF HEADACHE

Answer 10

 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

Question 11

RED FLAGS

Answer 11

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?

Question 12

GOALS OF THERAPY

Answer 12

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

Question 13

NON-PHARMACOLOGICAL TREATMENT

Answer 13

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

Question 14

PHARMACOLOGICAL TREATMENT –
GENERAL PRINCIPLES

 Acute headache:

Answer 14

 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.

Question 15

PHARMACOLOGICAL TREATMENT –
GENERAL PRINCIPLES

 Consider prophylaxis when:

Answer 15

 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

Question 16

TENSION-TYPE HEADACHE
 Treated with analgesics:

Answer 16

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)

Question 17

DO TTH PATIENTS NEED PROPHYLAXIS?

Answer 17

 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

Question 18

TTH PROPHYLAXIS OPTIONS

Answer 18

 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

Question 19

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

Answer 19

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

Question 20

PHARMACOLOGICAL ALTERNATIVES FOR
ACUTE MIGRAINE

Answer 20

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.

Question 21

ANALGESICS (migraines)

Answer 21

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?

Question 22

TRIPTANS

indications
AE

Answer 22

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

Question 23

TRIPTANS

contra

Answer 23

 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.

Question 24

Seven triptans are available
All have demonstrated efficacy
Minor differences among them
Which one to choose?

Answer 24

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

Question 25

Sumatriptan (Imitrex®)
Naratriptan (Amerge®

Answer 25

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.

Question 26

Almotriptan (Axert®)
Eletriptan (Relpax®)
Frovatriptan (Frova®)

Answer 26

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

Question 27

Rizatriptan (Maxalt®) Zolmitriptan (Zomig®)

Answer 27

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