migraine and chronic daily headache laurence j. kinsella, m.d., f.a.a.n

Migraine and Chronic Daily Headache

Laurence J. Kinsella, M.D., F.A.A.N.

You Make the Call: Case 1

37-year-old man with lifelong migraine and develops 6 weeks of unremitting headache (HA)

Bitemporal, throbbing, 3-7/10, morning HA Relieved with acetaminophen/aspirin/caffeine

(Excedrin Migraine®) No visual disturbances, scotomata, nausea,

photophobia 3 months of cyclosporin (Neoral®) for alopecia

universalis

What is the diagnosis?

Audience Question

1. Transformed migraine

2. Medication overuse headache

3. Cyclosporin induced headache

4. Chronic tension type headache

55-year-old woman 10/10 throbbing right periorbital HA awakens her

every night at 3 a.m. Gets relief after 45 minutes with combination of

icepack, T#3 x2, acetaminophen/aspirin/caffeine x2, acetaminophen/pseudoephedrine (Tylenol Sinus®) x2


Diagnosis?

Audience Question

1. Cluster headache

2. Thunderclap migraine

3. Raeder’s Paratrigeminal headache

4. Aneurysmal headache

5. Temporal arteritis

75-year-old woman with right occipital/ burning 8/10 HA, radiating to vertex

No nausea/photophobia/visual disturbances Present for 2 months, constant No relief with over-the-counter medications Exam is normal


Diagnosis?

Audience Question

1. Occipital Neuralgia

2. Cervicocephalgia

3. Temporal arteritis

4. Post herpetic neuralgia

History, History, History

P - Precipitating/palliative factors - diet, exercise, caffeine, OTC drugs

Q - Quality of the pain - burning, aching, stabbing, squeezing, pressure, throbbing

R - Radiation/location of pain

S - Severity - range of pain (least to the most) on analog scale 1-10

T - Temporal factors - what time of day

International Headache Classification

Primary headaches - “benign” disorders Migraine (with and without aura) Tension type (episodic or chronic) Cluster, chronic paroxysmal hemicrania Other benign HA (cough, coital, cold, ice-

pick, exertional HAs)

Headache Classification Subcommittee of the International Headache Society (2004), Cephalalgia 24:1-150

International Headache Classification (Cont.)

Secondary headaches - symptomatic of organic disease or medication overuse Posttraumatic Medication overuse HA Subarachnoid hemorrhage Temporal arteritis Meningitis High pressure/low pressure


Cranial neuralgias, nerve trunk pain Headache or facial pain associated with disorders

of the cranium, neck, eyes, nose, sinuses, teeth, mouth or other facial or cranial structures

International Headache Classification (Cont.)


Chronic Daily Headache

Not a diagnosis but a category of primary and secondary headache types

> 15 days/month for > 3 months > 4 hours/day 4% prevalence; 5% of all women 40-80% of patients referred to HA centers

Matthew NT et al. (1987), Headache 27:102-106; Colas R et al. (2004), Neurology 62:338-342


Subtypes include: Transformed migraine/chronic migraine Chronic tension-type headache New daily persistent headache Hemicrania continua All may be complicated by:

Medication overuse headache

Silberstein SD et al. (1996), Neurology 47:871-875

Transformed Migraine (TM)

> 15 days/month head pain Headache > 4 hours/day At least 1 of:

Previous HA fulfills IHS criteria for migraine Increasing frequency > 3 months

Medication overuse in 80% with TM

Silberstein SD et al. (1996), Neurology 47:871-875; Bigal ME et al. (2002), Cephalalgia 22:432-438

Migraine Without Aura - Common Migraine

Headache has at least 2 of the following characteristics: S = severe UL = unilateral T = throbbing A = activity worsens HA

And at least 1 of the following during headache: N = nausea or vomiting S = sensitivity to light/sound

Mnemonic: SULTANS


Diagnostic Criteria for Migraine With Aura (Classic Migraine)

At least 2 attacks Aura must exhibit at least 3 of the following

characteristics: Fully reversible Gradual onset Lasts less than 60 minutes Followed by headache within 60 minutes HA may begin before or simultaneously with the aura Normal neurologic exam and no evidence of organic

disease that could cause headaches


Migraine: Abortive Therapy

Aspirin/APAP/caffeine (Excedrin®) Sumatriptan (Imitrex), zolmitriptan (Zomig®),

rizatriptan (Maxalt®) Isometheptene/dichlo/apap (Midrin®) Ergot tart/caffeine (Cafergot®) Butalbital NSAID Do not exceed 2-3 days treatment in 1 week

rebound

Silberstein SD (2000), Neurology 55(6):754-762

Individual Attacks at Home

ED management of migraine is ineffective

57 patients in ED 95% met migraine

criteria (SULTANS) by questionnaire

Only 32% given a dx of migraine

59% “cephalgia”, “HA NOS”

65% txed with “migraine cocktail”- benadryl, reglan, toradol

24% opioids Only 7% given specific

Tx- triptan, DHE 60% had HA 24 hrs

later

Headache 2003;43:1026-31.

Migraine: Abortive Therapy

Dihydroergotamine mesylate (DHE 45) .5-1 mg q 8 hrs

Metoclopramide (reglan) 10 mg IV

Dexamethasone (Decadron) 16-24mg IV x1

Reduces recurrent HA at 72 hours

Sumatriptan (SC Imitrex®) 4-6 mg SQ, 5 mg Nasal

Ketorolac injection (Toradol®) 15mg IV/IM

Emergency Room

Cochrane Review: Steroids and Migraine. BMJ 2008 Jun 14; 336:1359


ED Management of Migraine

Prochlorperazine (Compazine®) 10 mg IV vs. metoclopramide* (Reglan®) 20 mg IV

Both given with 25mg IV diphenhydramine (Benadryl®) Randomized, controlled trial; 77 patients Mean VAS change of 5.5 vs 5.2 Similar at 2 and 24 hours later Compazine assoc with non-statistical increase in side

effects

A randomized controlled trial of prochlorperazine versus metoclopramide for treatment of acute migraine.

Ann Emerg Med. 2008; 52(4):399-406

Triptans

Major advance in migraine therapy 5-HT1B/1D agonists Vasoconstriction All act by suppressing nausea, confusion,

autonomic dysfunction and pain associated with migraine attack

Differ only in pharmacokinetics

Johnston MM, Rapoport AM. Triptans for the management of migraine. Drugs. 2010 Aug 20;70(12):1505-18

Triptans List

Sumatriptan 25-100 mg po/6 mg sq/5 mg nasal at HA onset, rpt 1 hr sq, 2 hr po/nasal

Zolmitriptan 2.5-5 mg Rizatriptan 10 mg SL Eletriptan (Relpax®), frovatriptan (Frova®),

almotriptan (Axert®), others

Johnston MM, Rapoport AM. Triptans for the management of migraine. Drugs. 2010 Aug 20;70(12):1505-18

Migraine Prophylaxis

-blockers (C): propranolol LA (Inderal-LA) FDA 60 mg qd, timolol 20 mg qd FDA

Anticonvulsants: topiramate FDA (Topamax®) (was C, now D- 3/28/11 due to cleft palate) 25-100 mg bid Lower toxicity than divalproex (Depakote®),

no weight gain

Tricyclics antidepressants (D): nortriptyline (Pamelor®) 10-60 mg

NSAID: naproxen sodium (Anaprox DS®) (C) (menstrual migraine - 550 mg bid x 10 days)


First Line (Pregnancy Class)

Migraine Prophylaxis

Divalproex (Depakote®) (D) FDA Gabapentin (Neurontin®) (C) Baclofen (Lioresal®) (C) “MigreLief”1,2 $20 /60 pills

Riboflavin (Vitamin B2) 400 mg/day (A) Magnesium oxide 360 mg/day (B) Feverfew 100 mg/day

Petadolex 1 tid (Butterbur extract) (A)

Other Options

1Pfaffenrath V, Wessely P, Meyer C, et al. Magnesium in the Prophylaxis of Migraine - A Double-Blind, Placebo-Controlled Study. Cephalalgia 1996;16:436-40.

2Schoenen J, Lenaerts M, Bastings E. High-dose Riboflavin as a Prophylactic Treatment of Migraine: Results of an Open Pilot Study. Cephalalgia 1994;l14:328-9

Transformed Migraine/Status Migrainosus

Unremitting headache > 72 hours fulfilling criteria for migraine

80% associated with medication overuse

Transformed Migraine/Status Migrainosus

Withdraw all medication Raskin protocol: DHE IV 0.5 mg/metoclopramide

(Reglan®) 10 mg IV q 8 hours for 3 days1

Dexamethasone (Decadron-LA®) 10-24 mg IV x1 Dexamethasone (Decadron®) 2 mg bid for 3-5 days Prednisone (Deltasone®) 60 mg daily for 3-5 days

BMJ 2008 Jun 14; 336:1359

Am Fam Physician. 2011;83(3):271-280.

1Raskin NH (1986), Neurology 36(7):995-997

Treatment

*FDA boxed warning 2/26/09 – Long-term or high-dose use of metoclopramide has been linked to tardive dyskinesia.

Complicated Migraine

Persistent neurologic residue of a migraine attack

Migraine with dramatic focal neurologic features (include ophthalmoplegic, hemiplegic, basilar migraine)


Subtypes include: Transformed migraine/chronic migraine Chronic tension-type headache New daily persistent headache Hemicrania continua All may be complicated by:

Medication overuse headache

Silberstein SD et al. (1996), Neurology 47:871-875

Chronic Tension Type HA

Head pain > 15 d/mo for at least 6 months Last hours, or may be continuous Pressing, tightening quality Mild-to-moderate intensity Bilateral, often occipital/posterior May have mild nausea, photophobia Do not fulfill migraine criteria Consider other causes: ICP (Intracranial Pressure), SDH (Subdural Hematoma), CO

poisoning

Tension-Type Headache (TTH)

Considered the most common HA type (ICHD)

30-78% prevalence Squeezing, band-like or global headache Environmental stressors May or may not limit function


TTH Frequent overlap with other HA subtypes

Migraine Medication overuse

Ask about over-the-counter medication especially those with caffeine (Excedrin/Anacin/APC)

How many cups/pots of coffee/tea daily? How many 2-liter bottles of soda?

Chronic Daily Headache Subtypes include

Transformed Migraine/Chronic Migraine Chronic Tension Type Headache New Daily Persistent Headache Hemicrania continua All may be complicated by:

Medication Overuse Headache

Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised HIS criteria. Neurology 1996;47:871-875

New Daily Persistent HA > 3 mo, daily within 3 days of onset 82% recall exact day of HA onset Bilateral, pressing quality Mild-moderate Nausea, photophobia MRI, MRV to exclude venous thrombosis LP with opening pressure to exclude intracranial

hypotension

Li, D & Rozen, TD (2002). "The clinical characteristics of new daily persistent headache." Cephalalgia 22 (1), 66-69.

Cerebral Venous Thrombosis

54 yo M with new onset headaches, syncope with exertion

Sudden onset bi-occipital HA 8/10 aching without relief, worsened supine

Exam normal, except loss of venous pulsations.

MRI normal, MRV abnl. IV Venogram shows

stenotic left lateral sinus.

Chronic Daily Headache Subtypes include

Transformed Migraine/Chronic Migraine Chronic Tension Type Headache New Daily Persistent Headache Hemicrania continua All may be complicated by


Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised HIS criteria. Neurology 1996;47:871-875

Hemicrania Continua

Cluster variant Unilateral pain without side-shift Daily and continuous Moderate to severe At least 1 of:

Conjunctival injection or lacrimation Nasal congestion or rhinorrhea Ptosis or miosis

Complete response to indomethacin

Cluster Headache

Uncommon (69/100,000) Men:women 6:1 Headaches begin 20-50 years of age (mean 30) High incidence of smoking, Peptic Ulcer Disease

(PUD) Familial cases unusual

Cluster Headache (Cont.)

Abrupt onset of pain, builds in 2-15 minutes

Pain is excruciating, severe (deep, constant, stabbing, explosive or pulsatile)

Location: in and around 1 eye

Unilateral, usually same side

Patient up and pacing due to pain

Cluster Headache (Cont.)

Duration: 30 minutes - 2 hours 75% of attacks between 9 p.m.-10 a.m.1

Awakens from sleep 1-2 clusters per year, 4-8 weeks or longer

1Russell D (1981), Cephalalgia 1:209-216

Cluster Headache

Lacrimation Blocked nostril Rhinorrhea Conjunctival injection Temporary ipsilateral Horner’s (2/3) Sweating of forehead Pallor or flushing Nausea Bradycardia

Associated Symptoms and Signs

Other Cluster Variants

Chronic paroxysmal hemicrania Multiple short, severe HA occurring daily Short episodes of cluster 1-2 minutes Average 14 daily

SUNCT (Short-Lasting, Unilateral, Neuralgiform headaches with Conjunctival injection and Tearing)

30-100 attacks daily Usually < 30 seconds Responds to indomethacin

Cluster Headache: Treatment

Stop smoking

Prophylactic treatment of chronic cluster

Indomethacin (Indocin®) 75 mg SR, 25-100 mg tid

Avoid over age 60 Lithium carbonate 300-900 mg daily Methysergide (Sansert®) 2-8 mg daily Propranolol, Nifedipine (Procardia®), verapamil

(Calan®)


Cluster Headache: Treatment (Cont.)

Abortive therapy Rectal ergot for nocturnal attacks 100% oxygen Sumatriptan injection Prednisone or dexamethasone: burst and

taper



Subtypes include Transformed Migraine/Chronic Migraine Chronic Tension Type Headache New Daily Persistent Headache Hemicrania continua All may be complicated by:


Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised HIS criteria. Neurology 1996;47:871-875.


Prevalence 1-2% Morning headaches Chronic daily headache > 15 days/month Simple analgesics > 15 days/month Ergots, triptans, opioids, combo NSAIDS > 10

days per month Most have baseline migraine HA

Dodick DW (2006), N Engl J Med 354(2):158-165; Zwart JA (2003), Neurology 61:160-164


Stop all OTC analgesics, caffeine consumption Wean butalbital, opioids, benzodiazepines Ketorolac PO 60 mg x1, 10 mg q 6 hours x 3

days Tizanidine (Zanaflex®) 2-8 mg tid1

May require hospitalization Raskin protocol: DHE 0.5-1 mg IV q 8 hours/

metoclopramide 10 mg for 3 days

Treatment

1Saper JR et al. (2002), Headache 42(6):470-482

Steroids ineffective for MOHNeurology 2007

Randomized controlled trial of 100 patients 51 rcvd prednisone 60 mg taper, 49 placebo No change in mean HA (MH) severity or frequency

Boe, M. G. et al. Neurology 2007;69:26-31

©

“Sinus Headaches”?

Over-diagnosed and over-treated Not a recognized form of HA by the IHS except in setting

of acute bacterial sinusitis 74% fulfill IHS migraine criteria 45-50% of asymptomatic adults have evidence of sinus

mucosal thickening or edema Utility of routine CT sinuses not established

Gupta M, Silberstein SD. Expert Opin Pharmacotherapy 2005;6:715-722.

Mehle ME, Kremer PS. Sinus CT scan findings in “sinus headache “ migraneurs. Headache 2008;48:67.

How often is “Sinus” Headache Really Migraine?

4

8

8

80

0 20 40 60 80 100

Schreiber CP, et al. Arch Intern Med. 2004;164:1769-1772

Subject (%)

Migraine with or w/oAura (IHS 1.1, 1.2)

Migrainous (IHS 1.7)

Episodic Tension-type (IHS 2.1)

Other

Recurrent episodes (at least 6 in the past 6 months)No fever or purulent discharge

No history of abnormal sinus radiographs

Treatment of Transformed Migraine and Medication Overuse Headache

Education, close followup for 8-12 weeks Lifestyle changes: caffeine, smoking, sleep Behavioral therapy Abrupt withdrawal of analgesics except:

Barbiturates: wean over 1 month Opioids: clonidine withdrawal

Dodick DW (2006), N Engl J Med 354(2):158-165

Bridging Medications for Outpatient Treatment

Tizanidine 2-6 mg po TID Baclofen 10-20mg TID Hydroxyzine 25-50mg PO, IM NSAIDS (Naproxen 500 mg, Ketorolac 10-30 po) Dihydroergotamine 0.5-1 mg nasal, IM, subq Antiemetics: metoclopramide 10-20 mg

Intravenous Therapies for Intractable Headaches

IV DHE 1 mg (FDA)/ Reglan 10 mg q8 x 3 days

IV DHE 3mg/L NS over 24 hrsx3

IV decadron 12-24 mg IV x1

IV Magnesium 1 gm x 1 IV depacon 250 mg q

12 hr IV Keppra 500 mg q

12 hr Propafol, others

Saper J. Intravenous management of intractable headache. American Academy of Neurology Course. 2010

Emerging Therapies

• Calcitonin gene-related peptide (CGRP) antagonists Olcegepant (Phase II) Telcagepant (withdrawn due

to increased LFTs)

• Combinations

• Sumatriptan and naproxen (Treximet®) - (FDA)

• Anticonvulsants Pregabalin Zonisamide Levetiracetam Lacosamide Carabersat lamotrigine

Arulmozhi DK et al. (2009), Vascul Pharmacol 43(3):176-187; Rapoport AM, Bigal ME (2005), Neurol Sci 26(suppl 2):S111-S120; Available at:

www.clinicaltrials.gov

Physical Examination

Blood pressure Funduscopy: papilledema in idiopathic

Intracranial hypertension, tumor; subhyaloid hemorrhage in SAH

Temporal artery tenderness: temporal arteritis Neck stiffness, Kernig’s/Brudzinski’s, orbital

tenderness: meningitis

SAH = subarachnoid hemorrhage

Worrisome HA Red Flags

Systemic symptoms: fever, weight loss

Neurologic symptoms or signs: confusion, depressed alertness or consciousness

Onset: sudden, abrupt, split-second

Older: new HA > 50 years old - temporal arteritis

Previous HA history: change in usual HA pattern - change in frequency, character, severity

Secondary risk factors: HIV, cancer

“SNOOPS”

Headaches to be Considered for Emergency Referral

Abrupt onset of “the worst HA of my life” Change in an established HA pattern Headache plus:

Stiff neck Fever Confusion, alteration of consciousness Focal neurologic signs Inability to walk

Headaches to be Considered for Emergency Referral (Cont.)

Any patient over 50 years old with new onset of headaches Get a sedimentation rate (ESR)

Headaches that last more than 72 hours

Summary

Chronic daily headache is common Transformed migraine, tension type and cluster variants Medication overuse HA is seen in all subtypes History is critical SULTANS and SNOOPS

Questions from the Audience?

References1. Dodick DW. Chronic Daily headache. NEJM 2006;354:158-165.2. Headache Classification Subcommittee of the International Headache

Society (2004), Cephalalgia 24:1-1503. Edlow JA. Diagnosis of subarachnoid hemorrhage in the emergency

department. Emerg Med Clin North Am 2003;21:73-87.4. Silberstein SD. Practice parameter: evidence-based guidelines for

migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000 Sep 26;55(6):754-62.

5. Freitag FG. Acute treatment of migraine and the role of triptans. Curr Neurol Neursci Rep 2001;1:125-132.

6. Silberstein SD, Liu D. Drug overuse and rebound headache. Curr Pain Headache Rep 2002;6:240-247.

7. Snow V, et al. pharmacologic management of acute attacks of migraine and prevention of migraine headache.Ann Intern Med 2002;137:840-849.

8. Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised HIS criteria. Neurology 1996;47:871-875

migraine and chronic daily headache laurence j. kinsella, m.d., f.a.a.n

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