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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 1 7/11/2013 Case 1 • • • • • 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 • • • • • • • • 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: ▪ ▪ ▪ ▪ Unilateral location Pulsating quality Moderate to severe pain Aggravation or avoidance of physical activity • During headache at least one of the following: ▪ ▪ 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. 2 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 3 7/11/2013 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 4 7/11/2013 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 5 7/11/2013 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 • • • • • • 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 • • • • • Lipton RB, et al. Headache. 2000;40:783-791 6 7/11/2013 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. 7 7/11/2013 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 • • • • LOE = SIMU Cluster is “side-locked” Periodic nature Awaken from sleep: middle of night vs early morning • Movement: avoidance vs. pacing • Thoughts of harm 8 7/11/2013 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 9 7/11/2013 Stage 2: Transforming Headache • • • • • 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 • • • • • • • 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. 10 7/11/2013 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 11 7/11/2013 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 12 7/11/2013 AAN Preventive Recommendations Level A • • • • • • • Divalproex Sodium Sodium valproate Topiramate Metoprolol Propranolol Timolol Frovatriptan (MRM) Level B • • • • • • 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 13 7/11/2013 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 14 7/11/2013 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 15 7/11/2013 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 • • • • • • 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 16 7/11/2013 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 • • • • • 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 17 7/11/2013 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% • • • • 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 18 7/11/2013 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 19 7/11/2013 Occipital Nerve Block Sphenopalentine Ganglion Block Over 100 years old Fell into disfavor Reemerged in ‘80s Patients may self administer • Lidocaine • May use cannula • • • • Sphenopalentine Ganglion Block 20 7/11/2013 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 21 7/11/2013 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 22 7/11/2013 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 23 7/11/2013 QT issues & Phenothiazines • • • • 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 • • • • • 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 24 7/11/2013 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 • • • • • • • • 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 25