Download A Family Doctors Approach To 'That Nagging Headache'

A Family Doctors
Approach To
"That Nagging Headache"
DR JANE MCDONALD
INTRODUCTION
• Headache is one of
the most frequent
diseases seen in
clinics by the primary
care physician
TYPES OF HEADACHES
ANATOMY
Table 2. Comparison of key features distinguishing migraine,
tension, and cluster headaches
Migraine
Tension
Cluster
Laterality
Unilateral
(60%)
Bilateral
Unilateral (exclusive)
Intensity
Moderate or
severe
Mild or moderate
Severe
Pain
descriptor
(variable)
Pulsating
(50%)
Pressing or
tightening
Boring, piercing
Physical
activity
Aggravation by
physical activity
Does not worsen with
physical activity
Restlessness or agitation during attack
Associated
Nausea and/or
photophobia/
phonophobia
No nausea, but may
rarely have photophobia
or phonophobia
Ipsilateral symptoms; conjunctival injection, lacrimation,
nasal congestion, rhinorrhea, forehead and facial
sweating, miosis, ptosis, eyelid edema
Duration
4–72 hr
Minutes to days
15- to 180-min cluster periods
symptoms
• 72.2% of all migraine sufferers went to
their primary care physician
• Migraine is the most common headache
disorder seen by primary care
physicians
• One half go undetected
WHY?
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Lack of appropriate screening tools
Constraints on physician time
Misdiagnosed as a sinus headache
Poor communication
More likely if female/upper income
bracket vs. men/lower income bracket
COSTS
Did you know…
• In the USA, migraine and the
associated disability cost
employers 13 Billion annually
Posted: 21/January/2009 at
7:19am
•
"Canadians who have pursued post-secondary studies now
owe the federal government $13 billion in loans, according to
new figures from the Canadian Federation of Students."
• "the $13-billion figure does not include $5 billion students owe to
provinces, banks, credit companies and their parents."
• http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20090121
/student_loans_090121/20090121?hub=TopStories
Lorraine Sommerfeld
TENSION HEADACHES
TENSION HEADACHES
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Mild to moderate pain
Bilateral
Steady
No autonomic symptoms
No nausea, vomiting
May have photophobia and phonophobia
Normally do not need to rest
QUESTION
• Are tension headaches just mild
migraines?
• Both are worse with stress
• Both get worse as day goes on
• Both respond to the same
medications
• Usually there is no aura
• It is believed that primary headaches
exist in a spectrum from mild to
severe
RED FLAG HEADACHES
WARNING SIGNS
“WORST HEADACHE OF THEIR LIFE”
• Warning signs of possible disorder other than primary headache
are:
- Subacute and/or progressive headaches that worsen over time
(months)
- A new or different headache
- Any headache of maximum severity at onset
- Headache of new onset after age 50
- Persistent headache precipitated by a Valsalva maneuver
- Evidence such as fever, hypertension, myalgias, weight loss or
scalp tenderness suggesting a systemic disorder
- Presence of neurological signs that may suggest a secondary
cause
- Seizures
Thunderclap Headache:
Sudden and Serious
Definition
By Mayo Clinic staff
Thunderclap headaches live up to their name,
grabbing your attention like a boom of thunder.
The pain of these sudden, severe headaches
peaks within 60 seconds and usually fades over
several hours. Some of these headaches,
however, can last for more than a week.
Thunderclap headaches are uncommon, but they
can be a warning sign of potentially lifethreatening conditions — usually having to do
with bleeding in and around the brain. That's
why it's so important to seek emergency
medical attention if you experience a
thunderclap headache
SNOOP
Table 3. Indicators of possible secondary headache: SNOOP*
• Systemic systems/signs (fever, myalgias, weight loss)
• Systemic disease (malignancy, AIDS)
• Neurologic symptoms or signs
• Onset sudden (thunderclap headache)
• Onset after age 40 yr
• Pattern change
—Progressive headache with loss of headache-free periods
—Change in type of headache
AIDS = acquired immunodeficiency syndrome.
Adapted from Advances in the Study of Medicine. 26
* Mnemonic for systemic, neurologic, onset sudden, onset after 40, and
pattern change.
MIGRAINES
• Migraine-associated symptoms are often
misdiagnosed as "sinus headache" by patients and
health care providers.
This has led to the under diagnosis and treatment of
migraine.
• Appropriate pharmacological or analgesic treatment of
acute headache should generally not exceed more than
two days per week on a regular basis. More treatment
other than this may result in medication-overuse chronic
daily headaches.
• Disability from headaches is an important issue for
migraineurs.
MIGRAINES
• All patients should be considered for prophylactic
therapy.
• Migraines occurring in association with menses
and not responsive to standard cyclic prophylaxis
may respond to hormonal prophylaxis with the
use of estradiol patches or estrogen-containing
contraceptives.
• Women who have migraines with aura should
avoid use of estrogen-containing contraceptives.
Headaches occurring during perimenopause or
after menopause may respond to hormonal
therapy.
• Most prophylactic medications should be started in
a low dose and titrated to a therapeutic dose to
minimize side effects and maintained at target
dose for 8-12 weeks to obtain maximum efficacy
Diagnosis and Treatment of Headache
Eighth Edition/January 2007
What do Family Doctors
Do?
Detailed History
Functional disabilities at work, school, housework or
leisure activities during the past three months
Assessment of the headache characteristics requires
determination of the following:
Temporal profile:
• Time from onset to peak
• Usual time of onset (season, month, menstrual cycle,
week, hour of day)
• Frequency and duration
• Stable or changing over past six months and lifetime
LOOK FOR
Autonomic features:
• Nasal stuffiness
• Rhinorrhea
• Tearing
• Eyelid ptosis or edema
Ask Questions About
Descriptive Characteristics: pulsatile, throbbing,
pressing, sharp, etc.
Location: uni- or bilateral, changing sides
Severity 1/10
Precipitating features and factors that aggravate and/or
relieve the headache
History of other medical problems
Pharmacological and non-pharmacological treatments
that are effective or ineffective
Aura (present in approximately 15% of migraine
patients)
AURA
Reversible
Visual symptoms (flickering lights, spots, lines
and or loss of vision
Sensory symptoms “pins and needles”
Dysphasic speech disturbance
Homonymous visual symptoms
(Pertaining to the corresponding vertical halves
of the visual fields of both eyes.)
Gradually develops over more than 5 minutes but
last less than 60 minutes
TRIGGERS
• Strong odors, perfumes, bright light or loud noises
• Changes in weather or altitude
• Being really tired, stressed or depressed or the letdown after an intense or stressful event
• Changes in sleeping patterns or sleeping time,
especially sleeping late or sleeping less or longer
than usual
• Missing meals or fasting
• Menstrual periods, birth control pills or hormones for
some women
• Medications including analgesics
TRIGGER FOODS
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Aged, canned, cured or processed meat, including bologna, game, ham, herring,
hot dogs, pepperoni and sausage.
Meat tenderizer
Aged cheese
Monosodium glutamate (MSG)
Alcoholic beverages, especially red wine
Nuts and peanut butter
Aspartame
Onions, except small amounts for flavoring
Avocados
Papaya
Beans, including pole, broad, lima, Italian, navy, pinto and garbanzo beans
Passion fruit
Brewer's yeast, including fresh yeast coffee cake, donuts and sourdough bread
Pea pods
TRIGGER FOODS
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Caffeine in excess
Pickled, preserved or marinated foods, such as olives and pickles, and some
snack foods
Canned soup or bouillon cubes
Raisins
Caffeine-containing foods and drinks
Red plums
Chocolate, cocoa and carob
Sauerkraut
Cultured dairy products, such as buttermilk and sour cream
Seasoned salt
Figs
Snow peas
Lentils
Soy sauce
TREATMENT OF
MIGRAINE
PATHOPHYSIOLOGY
“INFLAMMATORY SOUP”
Can be started by triggers.
• Inflames the meninges (causes throbbing)
• Activates the parasympathetic system
• Sends signals to the trigeminal nucleus and cortex
• Signal mediated by neural receptors
• Serotonin is depleted and the receptor gates open
causing inflammation
• Goal:Fool the receptor sites and reduce inflammation
and stop the “soup”
TRIPTANS
• Designer serotonin compounds that fool
the receptor and shut it of NSAIDS
reduce the inflammation
TRIPTANS
•Tablets
•Melt
•Nasal Spray
•Subcutaneous
•Short and Long Acting
As stated earlier, teaching points for the migraine
patient must stress the earliest use of headache
medicine in an attack to prevent central
sensitization. Treating headache early is the best
prognosticator of success.
Case Study
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60 year old female
Severe Headache
Unilateral
Distribution of the Trigeminal (5th nerve)
Thought it was “sinus’
No fever, chills, nasal discharge
No nausea or vomiting
Hurts to touch
Went to ER
No help with codeine or NSAIDS
Diagnosis
“Tic Douloureux”
NEURALGIA
NEURALGIA
Severe headache “knife like”
Treatment
Tegretol
Gabapentin
Lewis Carroll “Alice In
Wonderland “ syndrome
The patient complains of
distortions of objects. Objects
appear too big or too small.
You Are In Good
Company!
Migrainuer and Post-Impressionest
Dutch Painter Vincent Van Gogh's
'Self Portrait With Straw Hat'
Celebrities and historical figures
with Migraine disease include
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President, and architect of the Declaration of Independence Thomas
Jefferson
The great painters Vincent Van Gogh,
George Seurat (after which is named the Seurat effect, a current
medical term often used to describe the visual phenomena of
scintillating aura aka scotoma)
Claude Monet; great authors Virginia Woolfe, Cervantes (best known
as the author of the classic, 'Don Quixote‘
Lewis Carroll who's Migraines are said to have influenced his gifts of
literature still so popular today
Leaders such as Julius Caesar, Napoleon, Ulysses S. Grant, Robert E.
Lee, Mary Todd Lincoln
Scholars such as psychoanalyst Sigmund Freud,
Friedrich Nietzsche, the great German philosopher and poet who kept
his enemy Migraine closer
Icon Elvis Presley, the King of Rock & Roll who struggled with the king
of all 'headaches.'
Treatment of Migraine
• 5-HT-1 agonists (triptans) intervention during the mild phase
of headache; contraindicated with coronary heart disease
(4)[A]
• Triptans recommended if 1st-line therapy fails or pattern of
migraine is severe (4)[A]:
– Oral tablets more effective in early phase
– Sumatriptan (Imitrex): 6-mg self-administered injection
with efficacy of 70–85%. If initial injection fails to relieve
migraine after 1 hour, do not repeat injection. 20-mg, or
25-mg, 50-mg, and 100-mg tablets with efficacy of 65%.
If headache returns, may repeat, nasal spray, or oral
tablets.
– Zolmitriptan (Zomig, Zomig-ZMT): 2.5-mg tablet at onset
of migraine; 5-mg tablet available; efficacy ~65%
– Naratriptan (Amerge): 2.5 mg initially, 1-mg tablet
available (both oral); slower to act than other triptans, but
fewer adverse effects
– Source: 5minute Clinical Consult.2009
Treatment of Migraine
•Rizatriptan (Maxalt): Tablet and orally disintegrating
tablet—initial dose 10 mg; efficacy similar to other
triptans; reduce dose to 5 mg if patient using
propanolol
•Almotriptan: Oral tablets (6.25 or 12.5 mg); efficacy
similar to other triptans
•Frovatriptan (Frova): 2.5 mg at onset; up to 3 oral
doses in 24-hour period
•Eletriptan (Relpax): Oral tablets (20 mg and 40 mg);
similar efficacy to other triptans; avoid eletriptan
within 72 hours of ketoconazole, itraconazole,
nefazodone, troleandomycin, or clarithromycin.
Reference: 5 Minute Clinical Consult
2009
Treatment of Migraine:
Continued
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Contraindications:
– Avoid 5-HT-1 agonists (triptans) in coronary heart disease, peripheral
vascular disease, uncontrolled hypertension, and complex migraine
(e.g., basilar or hemiplegic migraine).
– 5-HT-1 agonists should not be used within 24 hrs of an ergot
derivative or other triptans.
– Selective 5-HT-1 agonists (triptans) are pregnancy category C.
Ergotamines are pregnancy category X.
– Avoid NSAIDs if danger of gastric erosion or renal or hepatic disease.
– Avoid narcotics or butalbital in addiction-prone patients and patients
with frequent migraines.
– Avoid vasoconstrictors in uncontrolled hypertension, coronary heart
disease, and peripheral vascular disease.
– Avoid sumatriptan, zolmitriptan, and rizatriptan within 2 weeks of
MAOI usage.
– Source: 5minute Clinical Consult.2009
Treatment of Cluster
Migraines
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Prophylactic therapy: If attacks significantly interfere with lifestyle or are
not adequately controlled by appropriate acute interventions (6)
– Propranolol (Inderal): 80–320 mg per day (6)[A]
– Atenolol (Tenormin): 50–100 mg per day (6)[B]
– Nadolol (Corgard): 40–80 mg per day (6)[B]
– Timolol (Blocadren): 10–20 mg per day (6)[A]
– Metoprolol (Lopressor): 100–450 mg per day (6)[B]
– Amitriptyline (Elavil): 10–150 mg per day (6)[A]
– Nortriptyline (Pamelor): 10–150 mg per day (6)[C]
– Valproic acid (Depakene) or divalproex (Depakote): 250–1,500 mg
per day (6)[A]
– Verapamil (Calan): 80–120 mg per day (6)[B]
– Topiramate: 100–200 mg per day (6)[A]
– Cyproheptadine (Periactin): 4–16 mg per day (6)[C]
– Source: 5minute Clinical Consult.2009
Treatment of Cluster Migraines: Continued
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General Measures
During cluster periods: Avoidance of alcohol, bright lights and glare,
and excessive emotion and stress, as these may precipitate attacks
• Treament of Cluster Migraine cont
• Avoidance of narcotic analgesics, especially oral preparations
• Avoidance of tobacco (high predilection for tobacco use in this
population); may make patient more refractory to therapy
Diet
• During cluster phase, alcohol, even in small amounts, frequently
precipitates attacks.
• Rarely, specific foods may trigger attacks.
Activity
• Pain is of such severity that some patients consider suicide during
attacks. Caution patient to avoid self-injury during bouts of excruciating
pain.
• Vigorous physical activity at 1st symptom may abort attack in some
patients.
• Compression of ipsilateral carotid or temporal artery may reduce pain in
some patients. Exercise caution in recommending carotid massage in a
patient at risk for occult carotid disease.
•
Source: 5minute Clinical Consult.2009
Treatment of Cluster Migraines:
Continued
Medication (Drugs)
• First-Line
• General information:
– Prophylactic therapy is paramount.
– Avoid pain therapy, especially narcotic analgesics, for acute
attacks.
– Assess cardiovascular risk before instituting a vasoactive
drug such as ergotamine or sumatriptan.
• For acute attacks:
– Oxygen 100% at least 7–10 L for 10–15 minutes,
administered through a tight-fitting face mask with patient in
sitting position and breathing at normal respiratory rate
– Source: 5minute Clinical Consult.2009
Treatment of Cluster Migraines:
Continued
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Sumatriptan (Imitrex): 6 mg SC, maximum 12 mg/24 hours with at least 1 hour
between injections (2)[A] (Sumatriptan 4 mg SC may be effective and allow
additional daily dose)
– Dihydroergotamine mesylate (DHE 45): 1 mg IM or IV; may teach SC selfadministration
Prophylaxis (to shorten cluster period or prevent expected attacks):
– Verapamil up to 80 mg PO q.i.d., spaced evenly through waking hours
(3)[B]
– Lithium carbonate (Eskalith): 300 mg b.i.d.–q.i.d.
– Ergotamine timed to be at peak serum level during anticipated attack (e.g.,
2 mg rectal or 1–2 mg PO 2 hours before); especially useful in preventing
nocturnal attacks
– Prednisone: Various schedules (e.g., 60–80 mg PO for 7 days followed by
rapid tapering over 6 days or 40 mg/d for 5 days tapered over 3 weeks).
This therapy is initiated during the use of a long-term agent such as
verapamil or lithium.
– Other agents with small or inconclusive studies include sodium valproate,
clonidine, zolmitriptan NS, eletriptan, and topirimate
– Source: 5minute Clinical Consult.2009
SUMMARY
• Headache is a common disorder, which is seen
throughout primary medical clinics in Canada. Each
practioner needs to develop an approach to this
difficult and potentially fatal disease in order that
patients are treated in a timely, yet compassionate
manner. Guidelines, algorithms and tools have been
developed to aid in the interaction between the
physician and patient.
• It will however always require exceptional
communication skills, patience and understanding of
the effects that headache has on someone’s life, in
order to reduce the burden of this disease on the
individual and society.
REFERENCES
1. ICSI:Health Care Guidelines,2007.p1-73.
2. Elrington,Giles,Commentary: Controversies in SIGN guidelines
on diagnosing and managing headache in adults.BMJ
2008;337:a2445.
3. Gladstein,Jack:Headache,Medical Clinics of North
America,volume90,issue2 (March 2006).
4. Sadovsky,R.,Dodick,D.W:Identifying migraine in primary care
settings, The American Journal of Medicine vol 118,issue
suppl, ( March 2005).
5. 5 Minute Clinical Consult, 2009.