Download Headache and Chronic Pain: Opiate Prescribing 2

7/11/2013
Primary Care
for
Primary Headaches
or
Everything you wanted to know about headaches
but
were afraid to ask
Michael Ready, MD FAHS
Director, Headache Clinic
Scott & White
Temple TX
[email protected]
Disclosures & Shameless Plug
• Advisory board for
Novartis (A/A/P)
• Just one blind man at
the elephant
• Family Physician
• You can learn a lot at a
Headache meeting
Objectives
• Increase awareness of the burden of
Headache
• Increase your comfort level with the Primary
Headaches
• Increase your desire to care for these
patients.
• Really if I can… Honest it’ll be easier for you
• Make it worth your time
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Case 1
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61yo H ♂ TBI /c LOC >30y HAs 25/30 days
Primarily L sided /c N/V, Allodynia, Neck Pain
Sleep Non-restorative, Onset delayed 1 hour
Often awakens with headaches
No prior preventive meds. Uses APAP
Case 2
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27yo C♀ ICU nurse. Onset @ 5y +FH
Episodic to CDH over last 2 years
2 prior hospitalizations for headache no DHE
Sleep non-restorative, Schedule erratic
Awakens with HAs,
N/V, Photophobia,
Darvocet / Excedrin Migraine
Recently started on Topirimate
IHS Criteria for Migraine without Aura
• At least 5 attacks
• Headache attacks lasting 4-72 hours
• Headache with at least 2 of the following:
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Unilateral location
Pulsating quality
Moderate to severe pain
Aggravation or avoidance of physical activity
• During headache at least one of the following:
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Nausea and/or vomiting
Photophobia and phonophobia
• Not attributed to another disorder
Intl Classification of Headache Disorders: 2 nd ed. Cephalalgia. 2004;24(Suppl 1):24-25.
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7/11/2013
Migraine – The Most Common Headache Seen in
Clinical Practice
• Patients seen in primary care
• IHS diagnosis based on diary review
94%
Migraine-type
Episodic Tension-type
Unclassifiable
N = 377
3%
3%
IHS, International Headache Society
Tepper SJ, et al. Headache. 2004;44:856-864.
Why Migraine
Why Should I Care
• 6% ♂, 18% ♀, 33-37% reproductive ♀,
4% CDH
• Returning armed forces 38% ♂, 58% ♀,
20% CDH
• Most common 25 – 55yr (most productive
years)
• There are 420 UNCS certified HA specialists
• 25-45 million people with migraine
Couch JC, et al. Headache. 2003;43:570-571
Lipton et. Al Headache 2001 .
Primary Care and
Chronic Migraine
• Over ½ of the 2 million chronic migraine
pts are seen by PCPs
• Of those who see a consultant, they still
return to PCPs for management of
comorbidities and often their migraine
• There are less than 300 UNCS certified
HA physicians; there are 25-45 million
people with migraine
• So you do the math
US Census 2011 adults over 18 (235,004,320) by chronic migraine prevalence rate. http://2010.census.gov/2010census
United Council for Neurologic Subspecialties (UCNS), http://www.migraineresearchfoundation.org/resources-links.html
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Severe Migraine Is Ranked in the Highest
Disability* Class by WHO
Disability
Class
Severity
Weights
1
0.00-0.02
Vitiligo of face, weight for height less than 2 SDs
2
0.02-0.12
Watery diarrhea, severe sore throat, severe anemia
3
0.12-0.24
Radius fracture in a stiff cast, infertility, erectile dysfunction,
rheumatoid arthritis, angina
4
0.24-0.36
Below-the-knee amputation, deafness
5
0.36-0.50
Rectovaginal fistula, mild mental retardation, Down syndrome
6
0.50-0.70
Unipolar major depression, blindness, paraplegia
7
0.701.00
Active psychosis, dementia, severe migraine,
quadriplegia
Indicator Conditions
*Assessments of disease severity determined by Global Burden of Disease researchers
using the person trade-off method, which includes judgments about the trade-off between
quality and quantity of life. Spectrum ranges from 0 (perfect health) to 1 (death).
WHO = World Health Organization.
Menken M. Arch Neurol. 2000;57:418-420.
Murray CJ, Lopez AD. Lancet. 1997;349:1347-1352.
Headaches in Primary Care
• Primary – nervous system you are
born with or acquire (trauma) and the
environment you are in
• Migraine, Cluster, Tension Type
• Secondary – headaches that are
caused by something else
• Infection, Mass, Vascular, Trauma
Headaches in Primary Care
• Primary Headaches are the result
of the nervous system you were Born
With & the Environment you are in.
• Secondary Headaches are
headaches that are Caused by
Something
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Profiling Headache
Pattern Recognition
Primary Headaches
• Secondary Headaches
• Migraine
• Post-traumatic
• Vascular disorders – CVA, Aneurysm
• Tension-type
• Nonvascular intracranial disorder
• Cluster
• Misc. headaches
unassociated with
structural lesions
– Neoplasm, meningitis, low
or high CSF pressures
• Substances/withdrawal
• Systemic infection or metabolic d/o
• Cranial, extracerebral lesions
CSF, cerebral spinal fluid
Intl Classification of Headache Disorders: 2 nd ed. Cephalalgia. 2004;24(Suppl 1):31-32.
SNOOP4: Ruling Out Secondary Causes of
Headache in Migraine
Systemic symptoms and signs
Neurologic symptoms or signs
Onset: peak at onset or <1 minute
Older: after age 50 years
Previous headache: pattern change
Postural, positional aggravation
Precipitated by valsalva, exertion, etc.
Papilledema
Silberstein SD, Lipton RB. In: Silberstein SD et al, eds. Wolff’s Headache and Other Head Pain. 8th ed.
New York: Oxford University Press; 2008:315-377.
Dodick D. N Engl J Med. 2006;354:158-165.
Bigal ME et al. J Headache Pain. 2007;8:263-272.
Headache Pattern Recognition
Minutes
Vascular
Hours/Days
Weeks/Months
Infectious
Inflammatory,
Neoplastic
Months/Years
Primary
headache
Secondary Headache Disorders
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The Migraine Brain
• Genetic hyperexcitability:
– Lower threshold for activation
– Longer retention of sensory information
• Between episodes of migraine
• During episodes of migraine
• Hyper-vigilant 24/7
• A sensitive brain that doesn’t like change
• Always more than a headache!
The Convergence Hypothesis
Are you a Lumper or a Splitter?
Spectrum Study
Trial Design
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3 centers
Randomized DB-PC-CO
IHS migraine (1.1; 1.2)
Up to 10 HAs; 6 months
273 patients; 1,727 HAs
Suma 50mg vs. placebo
Study Populations
Migraine
Migrainous
Tension-type
Disability in top 50%
Compare clinical and
diary diagnosis
• Compare treatment
response based on
diagnosis
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Lipton RB, et al. Headache. 2000;40:783-791
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Headache Response at
4 Hours for Migraine Population
Sumatriptan 50 mg
Placebo
80%
Percentage of Headaches
60%
71%
**
66%
*
78%
*
50%
48%
39%
40%
20%
0%
Migraine
n=1110
* P < 0.001
** f < 0.01
Migrainous
n=103
ETTH
n=363
Headache Attack Type
Lipton RB, et al. Headache 2000;40:783-791.
Convergence Hypothesis
Physiological
Phases of
Migraine
Central
Sensitization
Neurovascular
Activation
Trigeminal
Disinhibition
Electrical
Disinhibition
Neurochemical
Disruption
Headache Diagnosis if
Process Terminates at
Different Stages
1
2
1 Premonitory
3
2 Aura w/o
Headache
4
3 Mild Headache
(tension-type)
Pre-headache
phase
5
4 Migrainous
Headache
5 Migraine
Headache
phase
Migraine Evolution
Time (hours)
Cady RK, et al. Headache. 2002;42:204-216.
I can name that HA in 3 Questions
or
What is ID Migraine?
• Has a HA limited your activities for a day or
more in the last three months?
• Are you nauseated or sick to your stomach when
you have a HA?
• Does light bother you when you have a HA?
• Disability + nausea = IHS migraine = 80%
• Disability + 2 of 3 associated symptoms
(Nausea, photophobia, or phonophobia) =
IHS migraine approximately 95%
• Movement* -- LOE -- SIMU
Lipton RB, et al. Headache. 2004;44:387-398.
Cady RK, et al. Headache. 2004;44:323-327.
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Until proven otherwise, A stable pattern
of disabling HA that disrupts function
is _____
• That would be …
”What is Migraine?”
The Headache “Patient”
• Most likely has migraine because
– Secondary headaches are rare
– Episodic tension-type headache not a
common presenting complaint
– Other primary headaches are rare
• If the pt. has migraine, they will likely be
engaged with the medical system for
decades…they will need a good primary
care physician
Cluster vs. Migraine
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LOE = SIMU
Cluster is “side-locked”
Periodic nature
Awaken from sleep: middle of night vs
early morning
• Movement: avoidance vs. pacing
• Thoughts of harm
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Imaging
• Pattern recognition
– Abnl Neuro exam
• When to get a CT
• When to get an MRI
• Remember a radiologist is talking
– WMLUS
– Degenerative Disk Disease
Staging Migraine
• Developed by Lipton, Cady,
Farmer, & Bigal
• First doctor/patient book
• Based on frequency not
severity of HA
www.managingmigraine.org
Stage1: Episodic Migraine
• Emphasis on acute abortive therapy
– OTCs
– Triptans
– NSAIDs
• Early intervention – complete response
• Evaluation on mechanism of injury and pre-morbid
biology of patient
• Education focused on resuming normal function
• Acute medication limits as headache progress
• Preventive pharmacology
• Behavioral interventions
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Stage 2: Transforming Headache
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Preventive pharmacology
Targeted use of abortives
Strong emphasis on behavioral intervention
Screen and treat co-morbidities
Perpetuating Factors > Precipitating Factors
Stage 3: Chronic Daily Headache
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Behavioral intervention -- absolutely essential
Preventive pharmacology -- unavoidable
Screen & aggressively treat co-morbidites
Educate, educate, educate
Establish reasonable goals and expectations
Targeted use of abortive medications
Emphasis of Quality of Life
Chronic Migraine
Risk Factors
Modifiable
• Attack frequency
• Obesity
• Snoring/OSA
• Stressful life events
• Medication overuse
• Caffeine overuse
Not modifiable
• Age
• Female sex
• Low education or
socioeconomic status
• Genetic factors
• Head injury
Ashina S, et al. Curr Treat Options Neurol. 2008;10:36-43.
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Migraine Stages
Episodic
Chronic
Severe Impairment
Stage 3
Moderate Impairment
Stage 2
Stage 1
Mild Impairment
Normal Neurological Function
Cady RK, et al. Headache. 2004;44:426-435.
Headache Treatments
• Preventive –reduce frequency, intensity,
and improve response to acute meds
• Abortive – pain freedom in 2 hours
• Rescue – when the stop medicine didn’t
Headache Treatments
•Preventive –reduce
frequency, intensity, & improve
response to acute meds
• Abortive – pain freedom in 2 hours
• Rescue – when the stop medicine didn’t
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Migraine Prevention Utilization
53% of migraineurs
meet disability and
frequency criteria for
prevention
< 5% of migraineurs are
on preventive therapy
25%
Frequency
28%
Disability
Lipton RB et al. Headache. 2001; Lipton RB et al. Neurology. 2002
Saves You Money!
• 18-month comparison study
• Acute vs acute/preventive therapies
– Office visits  51%
– ED visits  82%
– CT scans  75% MRI scans  88%
– Medication costs  $48 $138/month/patient
Silberstein SD et al. Headache. 2003.
Prevention
• Consider when Migraine significantly disrupts
ADLs, despite acute treatment
• Attack frequency >1/wk
• Five FDA approved drugs for Migraine
• One FDA approved drug for Chronic Migraine
• Many off label choices
• Start low and titrate as tolerated
• Two-fers overrated --SIMU
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AAN Preventive Recommendations
Level A
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Divalproex Sodium
Sodium valproate
Topiramate
Metoprolol
Propranolol
Timolol
Frovatriptan (MRM)
Level B
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Amitriptyline
Venlafaxine
Atenolol
Nadolol
Naratriptan (MRM)
Zolmitriptan(MRM)
Prevention –Pound of Cure
• Supplements – Mg 500mg, Riboflavin 400mg,
CoQ 10 200mg BID (www.puritan.com),
Butterbur (should be PA free Petadolax)
• Membrane Stabilizing medications-Valproate,
Toprimate, Gabapentin…
• Anti-HTN Beta Blockers, CCB, ACE
• TCA (off label) most data is with amitriptyline –
SSRIs not thought to be effective
• OnabotuliniumtoxinA -- FDA approved for
Chronic Migraine Oct 2010
Migraine preventive therapy
Possible reasons for lack of efficacy
• Inadequate duration (<6-8 wk) at
suboptimal dose
• Poor Pt. adherence (side effects, half-life,
unrealistic expectations)
• Concomitant drug-induced headache –
Prevention unlikely to work in MOH
• Newly developed medical condition causing
a secondary headache
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Headache Treatments
• Preventive –reduce frequency, intensity
and improve response to acute meds
•Abortive – pain freedom in 2
hours
• Rescue – when the stop medicine didn’t
Abortive Therapy
• Goal is pain freedom in 2 hours
• Treat at mild pain (prior to central
sensitization)
• May use polypharmacy
Triptan Pearl: Treat @ Mild Pain
Early Intervention Improve Efficacy
2 Hour Pain Free Response
Cady RK et al Headache 38:173-83 - Pascual J et al Headache 42[supl 1]:S10-S17
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Oral Therapies
• Non-triptan
– NSAIDS
– Combinations
• APAP/ASA/caffeine
• Analgesics
– Antiemetics
• Triptans
• Ergotamines
• When to consider
– First-line therapy
– Adjunctive therapies
There is no
medication that is
perfect for all
migraine attacks or
all circumstances
in which treatment
is needed.
What I do
• Soooooo Off-Label & Remember my patients
aren’t yours
• 3 tablets Effervescent ASA + Mg 500mg or
• Ibuprofen 1000-1200mg + Mg
• Naproxen 500mg + Mg
• Augment /c Metoclopramide or
Prochlorperazine
• Triptan – Suma & Nara generic. Generic
Suma $3/pill www.healthwarehouse.com
Headache Treatments
• Preventive –reduce frequency, intensity
and improve response to acute meds
• Abortive – pain freedom in 2 hours
•Rescue – when the stop medicine
didn’t
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Why should I treat
Acute Headaches?
• Have to keep these people out of the ED
• Primary HAs are not an emergency
• Not the best place – too bright, too loud,
often ignored
• Can’t risk exposure to opiates
• More likely to V.O.M.I.T. in ED
Migraine Rescue
• E.B. first-line treatments should replace
opioids, which often do not meet
current guidelines1
• Opioids are potentially ineffective, often
suboptimal1, and can lead to abuse
and/or drug-seeking behaviors1,2
1. Colman et al. Neurology. 2004;62:1695-1700. 2. Ward et al. Med Clin North Amer. 2001;85:971985.
Clinical Headache Rescue
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Assoc. Neurologist of S. CT AHS SA Poster
Drop in HA Clinic – Prevent ED visits
9/05 - 8/07 500 pts
Time to Present = 104 hours (8-240h)
VAS pain: Entry 8.5 Discharge 1.5
Txt: IVF (94%), Ketoralac (84%), Suma sq
(78%), Prochlorperazine (52%),
Metoclopromide (21%), DHE (8%), Mg (4%)
• Average charge $426 Average payment
$272.64
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Clinical Headache Rescue
UAB experience
• 200 pts. Randomized Optimal Self Admin
or Optimal Self Admin + Optional in-clinic
Headache rescue
Optimal Self Adm
Clinic Rescue
423 visits
33.6K ($80)
73
ED Visits
27
147.9K($2027)
ED Direct Cost
45.3K ($1609)
79% no d/a > 24’
Clinical Headache Rescue
UAB experience
• 89% very satisfied
Drug
#
Droperidol 2.75mg
218 3.00
Drug Cost
Diphenhydramine 50mg
201 1.25
DHE 1mg
167 42
Prochlorperazine 5-10mg
141 11.5
Promethazine 50mg
68
4.
Ketoralac 30mg
38
9 + 11 (saline)
Acute Headache Interventions
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IV >> IM >> PO
Sumatriptan 6mg IM/SC
Dihydroergotamine 1mg IM/SC/IV
Ketorolac 30mg IV / 60mg IM
Neuroleptics – Dopamine Antagonists (Droperidol,
Metoclopramide, Prochlorperazine)
• Steroids
• Others – Mg++, Valproic Acid, Diphenhydramine
• Procedures – Occipital Nerve Block, Lower Cervical
Intramuscular Injections
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Procedures
• Lower Cervical Intramuscular Injections
• Occipital Nerve Block
• Sphenopalentine Ganglion Block
Lower Cervical Intramuscular
Injections
Headache 10/06
417 ED Pts / 1 yr
65% relief in 15m
Repeat injection
brought additional
relief
• Worsened HA in 1%
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Lower Cervical Intramuscular
Injections
• 3mL bupivicane 0.5%
• 25g 1.5” / 27g 1.25”
• 2-3cm lateral to the
spinous processes
between C6 & C7
• AE /CI
• Vasovagal, Neck
stiffness, usual injection
risks
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Occipital Nerve Block
• Local anesthetic (bupivicaine ).5%
xylocaine 1% --Duration of anesthesia
doesn’t correlate to duration of relief
• Steroid (triamcinolone 40mg/mL) evidence
doesn’t support general use
• 3mL total per side
• 25 or 27 gauge needle
• May place as a “ridge” of anesthesia,
“trigger points”, or fixed.
Occipital Nerve Block
Occipital Nerve Block
• AEs & CIs
• Prior hx of craniotomy over injection site
• AEs primarily related to steroid- fat atrophy,
alopecia, pigment change
• Vagal response – Happened to me X 3 in
over 6000 blocks
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Occipital Nerve Block
Sphenopalentine Ganglion Block
Over 100 years old
Fell into disfavor
Reemerged in ‘80s
Patients may self
administer
• Lidocaine
• May use cannula
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Sphenopalentine Ganglion Block
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Case 1 - 61yo H♂ /c hx TBI
• Initial placed on Magnesium, Tizanidine
• Placed B ONB
• ↓ Freq 3/7 days, + Memantine (NMDA
receptor blocker)
• @ 1 yr HAs 1/7 days mild
• Severe HAs 1/60 days responds to ONB
Our Patients Speak
Injectable
Treatments
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Subcutaneous Sumatriptan
• Dose: 6mg subcutaneous
• Contra-indications/ Cautions:
– Cardiac risk-stratification
– Severe hypertension
– Pregnancy
– Recent use
• What to expect:
– Worsening of headache
– Palpitations/ flushing
– Address recurrence
Dihydroergotamine
• Underutilized
• Dose, route: 0.5-1mg IV, IM, SQ
• Cautions/ contra-indications
– Similar to sumatriptan
– Cardiac risk factors (class effect, not specific)
– Hypertension
– Recent use of sumatriptan (theoretical risk)
– Pregnancy (Category X)
• What to expect
– Nausea. Un-treated you will throw your toenails
up)
Dihydroergotamine IV
• Largely replaced by sumatriptan, still has a
role
• Duration of headache not important
consideration
• Combine with anti-emetic (usually
metoclopramide)
• Dilute in 50mL NS & infuse over 30min to
improve tolerability*
* SIMU
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DHE vs. Suma
Are you Ready 2 Rumble?
• DHE 1mg SQ vs sumatriptan 6mg SQ
– At 2 hours could receive second dose of same
medication
– Two hour relief: 85% Suma Vs. 73% DHE (p=0.002)
– 24 hour relief: 77% Suma Vs. 90%DHE (p=0.004)
Ketorolac
• Dose: 30mg IV or 60mg IM
• Cautions/ Contra-indications:
– Typical Non-steroidal risk
• What to expect:
– IM shots cause localized burning pain
Dopamine antagonists
• Prochlorperazine (Compazine): 10mg IV SIVP
• Metoclopramide (Reglan): 10mg IV SIVP
• Droperidol: 2.75mg IM, 2.5mg IV
– Black box warning for QT prolongation
• Haloperidol (Haldol) Drug of choice in many
countries
– 5 mg IV following 500 - 1000cc bolus of normal
saline
• Olanzapene 2.5-10mg po or im prn q 6- 8 hours
Wang,SJ. Silberstein SD Young WB Droperidol Treatment in Status Migrainosis and Refractory
Headache.Headache1997
Silberstein SD,Young WB, Acute Migraine Treatment with Droperidol. Neurology Vol60 number2 2003.
Honkaniemi,J. Headache 2006,May:46(5)781-7
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QT issues & Phenothiazines
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Screen patients for risk factors
Pretreatment ECG
Follow-up ECG
Usually only an issues with long-term
repetitive dosing
• Inconsistent warnings from the FDA
Alternate / Special Groups
1. Diphenhydramine 25-100mg PO/IM/IV
(pregnancy/kids)
2. MgSo4 1-2 gm IV over 30minutes
(pregnancy)
3. IV Valproic Acid 1000mg mix 50/50 in NS
infuse over 7-10 or less (not pregnant)
4. Procedures -- Occipital Nerve block
No Narcotics for Headaches
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Major risk factor for Medication Overuse HA
Once established it’s a self fulfilling prophesy
Jakubowsk,et al. 2005 Wolfe Award paper
64%-71% Migraine pts pain-free 1’ /p ketoralac iv
Only factor that predicted ketoralac failure: hx
of opioid txt in the nonresponders
• Rewires the brain to perpetuate the HA state by
inhibiting the breakdown of glutamate
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Reasons not to use opioids for Migraine Rescue
• Use of oral opioids associated with likelihood
of increased headache 1
• ED treatment with opioids associated with
more refractory headaches down the road 2
• Does not disrupt underlying pathophysiology
• Requires multiple successive doses
• Lastly – I will hunt you down!
1.Bigal, Headache, 2008
2.Jakubowski, Headache, 2005
Case 2 – 27yo C♀ ICU Nurse
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Dexamethasone 4mg BID X 7d
Magnesium, CoQ10, Tizanidine, B ONB
Metoclopramide to augment acute meds.
No improvement placed on DHE for 10d
Ketorolac 60mg IM rescue
F/U HAs ↓ 3/7 days started Topirimate
HAs reduced to 1/7 days /c severe 1-2/30d
Titrated off Topirimate after 9m of stability
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