Download Luzma Cardona, MD Harvard Medical School Brigham and

3/12/2010
Luzma Cardona, MD
Harvard Medical School
Brigham and Women
Women’ss Hospital
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none
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3/12/2010
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Migraine has a lifetime prevalence of 12-28%
Quick tool for evaluation of headache
St d d questions
Standard
ti
that
th t target
t
t hi
high
h yield
i ld
information
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How often do you get severe headaches?
H
How
often
ft do
d you gett other
th (milder)
( ild )
headaches?
How often do you take headache relievers or
pain pills?
Has there been any recent change in your
h d h ?
headaches?
How often do you miss work or leisure
activities because of headache?
Are you satisfied with your current headache
medicine?
Are you on preventive medicine for
headache? If not, would you like to be?
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Migraine
T i t
Tension-type
h
headache
d h
Cluster headache and other trigeminal
autonomic cephalalgias
Other primary headache
Headache attributed to head and/or neck
trauma
Headache attributed to cranial or cervical
vascular disorder
Headache attributed to non-vascular
intracranial disorder
Headache attributed to a substance or it’s
withdrawal
Headache attributed to infection
Headache attributed to disorder of
homoeostasis
Headache or facial pain attributed to disorder
of cranium, neck, ears, eyes, nose, sinuses,
teeth, mouth or other facial or cranial
structures
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Headache attributed to a psychiatric disorder
C i l neuralgias
Cranial
l i and
d central
t l causes off facial
f i l
pain
Other headache, cranial neuralgia, central or
primary facial pain
*International Headache Society
http://ihs-classification.org/en/
S-U-L-T-A-N-S
Severe
S
UniLateral
Throbbing
Activity Worsens Headache
((need at least two from this list))
Nausea
Sensitivity to light/sound
(need one from this list)
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At least 5 attacks
Headache attacks lasting
g 4-72 hours ((untreated or
unsuccessfully treated)
Headache has at least two of the following
characteristics:
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During headache at least one of the following:
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At least 2 attacks
Aura consisting of at least one of the following, but no motor
weakness:
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fully reversible visual symptoms including positive features (eg, flickering
lights, spots or lines) and/or negative features (ie, loss of vision)
fully reversible sensory symptoms including positive features (ie, pins and
needles) and/or negative features (ie, numbness)
fully reversible dysphasic speech disturbance
At least two of the following:
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nausea and/or vomiting
photophobia and phonophobia
Not attributed to another disorder
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unilateral location
pulsating quality
moderate or severe pain intensity
aggravation by or causing avoidance of routine physical
activity (eg,
(eg walking or climbing stairs)
homonymous visual symptoms and/or unilateral sensory symptoms
at least one aura symptom develops gradually over ≥5 minutes and/or
different aura symptoms occur in succession over ≥5 minutes
each symptom lasts ≥5 and ≤60 minutes
Headache begins during the aura or follows aura within 60
minutes
Not attributed to another disorder
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NSAID’s
A i i / ff i
Aspirin/caffeine
(Anasyn)
(A
)
Phenylephrine or
Pseudoephedrine/Acetaminophen (Sudafed)
Acetaminophen/Aspirin/caffeine (Excedrin)
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3/12/2010
Probably okay
Not okay
Relief
complete
Partial or none
Frequency
2-3 days a week
>3 days/week
around the clock
Disability
none
Partial or total
Co-morbidities
none
Mood, immune,
insomnia,depress
ion
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Triptans are the first line agents
C target
Can
t
t use b
based
d on h
half
lf lif
life
Side effects may not transfer
Contraindications: ischemic heart disease,
peripheral vascular syndromes, use within 24
hours of ergotamine derivatives, severe hepatic
i
impairment,
i
management off hemiplegic
h i l i or
basilar migraine
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Almotriptan (Axert)
El t i t
Eletriptan
(R l
(Relpax)
)
Naratriptan (Amerge)
Rizatriptan (Maxalt)
Sumatriptan (Imitrex)
Sumatriptan/Naproxen
p / p
(Treximet)
(
)
Zolmitriptan (Zomig)
Second line agents
Butalbital, acetaminophen, and
caffeine(Fioricet)
Tolerance, high addictive potential,
high prevalence of MOH
Acetaminophen,
p
, isometheptene,
p
, and
dichloralphenazone (Midrin)
For migraine and tension-type headache
Multiple drug interactions
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Third line agents
Contraindications: peripheral vascular disease; hepatic
or renal disease; coronary artery disease; hypertension;
sepsis, triptan within 24hrs and pregnancy.
Formulations:
Sublingual Ergotamine (Ergomar)
Dihydroergotamine IM, IV,
intranasal(Migranal)
Ergotamine tartrate/caffeine PO(Cafergot)
PR(Migergot)
Prochlorperazine (Compazine)
Prochlorperazine--treatment
p
for acute confusional
migraine Headache. 2009 Mar;49(3):477-80
Randomized evaluation of octreotide vs
prochlorperazine for ED treatment of migraine
headache. Am J Emerg Med. 2009 Feb;27(2):160-4
The relative efficacy of phenothiazines for the
treatment of acute migraine: a meta-analysis.
Headache. 2009 Oct;49(9):1324-32.
( )
Epub
p 2009 Jun 2.
Review
Migraine. Treating acute migraine in the
emergency department. Nat Rev Neurol. 2009
Oct;5(10):529-31.
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For migraines with prolonged visual or speech
aura or hemiplegic migraine
migraine, avoid triptans.
triptans
Can use NSAID’s or narcotics as abortives.
Target of therapy is prevention.
Using abortive agents 3 days a week or more
D bilit ti
Debilitating
migraines
i i
Migraines with prolonged auras or hemiplegic
Preferably choose agents that are FDA
approved (Propranolol, Divalproex Sodium,
Topiramate, Timolol )
Consider co-existing diseases
Can be as easy as tracking triggers
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3/12/2010
Condition
Consider using
Anxiety
Tricyclic Anti-depressant
Beta Blocker
Asthma
Bipolar Disorder
Consider avoiding
Beta Blocker
Divalproex sodium
Coronary Artery Disease Beta Blocker
Calcium Channel
Blocker
Depression
Tricyclic Anti-depressant Beta Blocker
Diabetes
Epilepsy
Beta Blocker
Divalproex sodium
Condition
Consider using
Hypertension
Calcium Channel
Blocker
Beta Blocker
Raynaud’s Disease
Calcium Channel
Blocker
Mitral Valve Prolapse
Beta Blocker
Pregnancy
g
y
Non-pharmacologic
p
g
therapy
Stroke
Nonsteroidal antiinflammatories
Aspirin
Renal Disease
Tricyclic Anti-depressant
Consider avoiding
Beta Blocker
Nonsteroidal antiinflammatories
Methysergide
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Tracking headaches and headache “triggers”
can assist in determining what helps and what
brings on a migraine attack.
Include:
Date and time of onset
Severity, 1-10 pain scale
Disability, 1
1-5
5 scale
Duration
Medications
Possible triggers
Alcoholic Beverages
C ff i and
Caffeine
d caffeine
ff i withdrawal
ithd
l
Environmental Changes
Foods
Food Additives: MSG, Aspartame, Tyramine,
Sodium Nitrite
Lifestyle Factors
Hormones
Medications
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History of long-term, frequent, or excessive use of
analgesic
g
that can aggravate
gg
headache p
problems or
lead to decreased responsiveness to other
pharmacotherapies
Insufficient or no response to pharmacologic
therapy
Medical contraindications to specific
pharmacologic
p
a aco og c treatments
t eat e ts
Prefers non-pharmacologic interventions
Pregnancy, planned pregnancy, or nursing
Significant stress, deficient stress-coping skills
Cognitive-behavioral therapy
EMG biofeedback
bi f db k
Relaxation training
Thermal biofeedback combined with relaxation
training
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3/12/2010
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Acupuncture
C i l manipulation
Cervical
i l ti
Hyperbaric oxygen
Hypnosis
TENS
At least 10 episodes occurring on ≥1 but <15 days per month
for at least 3 months (≥12 and <180 days per year)
H d h lasting
Headache
l ti from
f
30 minutes
i t tto 7 d
days
Headache has at least two of the following characteristics:
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Both of the following:
g
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bilateral location
pressing/tightening (non-pulsating) quality
mild or moderate intensity
not aggravated by routine physical activity such as walking or
climbing stairs
no nausea or vomiting (anorexia may occur)
no more than one of photophobia or phonophobia
Not attributed to another disorder
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1.
2.
Frontal headache accompanied by pain in one or more
regions of the face, ears or teeth
Cli i l nasall endoscopic,
Clinical,
d
i CT and/or
d/ MRI imaging
i
i and/or
d/
laboratory evidence of acute or acute-on-chronic
rhinosinusitis
Headache and facial pain develop simultaneously with
onset or acute exacerbation of rhinosinusitis
Headache and/or facial pain resolve within 7 days after
remission or successful treatment of acute or acute-onchronic rhinosinusitis
Notes:
Clinical evidence may include purulence in the nasal
cavity, nasal obstruction, hyposmia/anosmia and/or fever.
Chronic sinusitis is not validated as a cause of headache or
facial pain unless relapsing into an acute stage.
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3/12/2010
Botulinum Neurotoxin in the http://www.guideline.gov/
summary/summary.aspx?do
treatment of autonomic
disorders and pain
c_id=12948
American Academy on Neurology
Management of patients
presenting to the ER with
acute headache
American college of Emergency physicians
Management off
M
Concussion/mild
Traumatic Brain Injury
http://www.guideline.gov
/summary/summary.aspx?
doc_id=13115&nbr=6719&s
s=6&xl=999
http://www.healthquality.
h
//
h lh
li
va.gov/mtbi/concussion_m
tbi_full_1_0.pdf
VAMC/Dept of Defense
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3/12/2010
Consensus statement on concussions
American college of sport medicine
Practice Parameters: Pharmacological
treatment of migraine headache in
children and adolescents
http://www.acsm.org/AM/Template
p
g
p
.cfm?Section=Clinicians1&Template=
/CM/ContentDisplay.cfm&ContentI
D=4362
http://www.aan.com/professionals/
practice/guidelines/pda/Pediatric_he
adache.pdf
American Academy of Neurology
Prevention of post-lumbar puncture
headache
http://www.guideline.gov/summary
/summary.aspx?ss=15&doc_id=8102
&nbr=4514
American Academy of Neurology
Pharmacologic
g management
g
of acute
attacks of migraine
http://www.aan.com/professionals/
p
p
practice/pdfs/gl0087.pdf
American College of Physicians,American Academy of Family
Physicians,American Society of Internal Medicine
Practice parameters: Evidence based
guidelines for migraine pain
http://www.aan.com/professionals/
practice/pdfs/gl0085.pdf
American Academy of Neurology
Guidelines for evaluation of children
and adolescents with recurrent
headache
http://www.neurology.org/cgi/repri
http://www
neurology org/cgi/repri
nt/59/4/490.pdf
American Academy of Neurology
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Migraine is common
E
Easy
to
t diagnose
di
Rewarding to treat
Theoretical interactions between SSRI’s and
Triptans.
Triptans
No true clinical interaction.
The evidence is with MAOI’s and SSRI’s used
jointly, can cause serotonin toxicity.
Most case series and case reports of joint use of
SSRI’ and
SSRI’s
d Triptans
Ti
d ’ exhibit
don’t
hibi serotonin
i
toxicity
Triptans, Serotonin Agonist and Serotonin
syndrome: A Review. Headache 2009
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