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Migraine and Chronic Daily Headache Laurence J. Kinsella, M.D., F.A.A.N.

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Presentation on theme: "Migraine and Chronic Daily Headache Laurence J. Kinsella, M.D., F.A.A.N."— Presentation transcript:

1 Migraine and Chronic Daily Headache Laurence J. Kinsella, M.D., F.A.A.N.

2 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

3 What is the diagnosis? Audience Question 1.Transformed migraine 2.Medication overuse headache 3.Cyclosporin induced headache 4.Chronic tension type headache

4  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 You Make the Call: Case 2

5 Diagnosis? Audience Question 1.Cluster headache 2.Thunderclap migraine 3.Raeder’s Paratrigeminal headache 4.Aneurysmal headache 5.Temporal arteritis

6  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 You Make the Call: Case 3

7 Diagnosis? Audience Question 1.Occipital Neuralgia 2.Cervicocephalgia 3.Temporal arteritis 4.Post herpetic neuralgia

8 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

9 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

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

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

12 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: ; Colas R et al. (2004), Neurology 62:

13 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 et al. (1996), Neurology 47:

14 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: ; Bigal ME et al. (2002), Cephalalgia 22:

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

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

17 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): Individual Attacks at Home

18 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:

19 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 Silberstein SD (2000), Neurology 55(6):

20 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):

21 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 Aug 20;70(12):

22 Triptans List  Sumatriptan mg po/6 mg sq/5 mg nasal at HA onset, rpt 1 hr sq, 2 hr po/nasal  Zolmitriptan mg  Rizatriptan 10 mg SL  Eletriptan (Relpax ® ), frovatriptan (Frova ® ), almotriptan (Axert ® ), others Johnston MM, Rapoport AM. Triptans for the management of migraine. Drugs Aug 20;70(12):

23 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) mg bid  Lower toxicity than divalproex (Depakote ® ), no weight gain  Tricyclics antidepressants (D): nortriptyline (Pamelor ® ) mg  NSAID: naproxen sodium (Anaprox DS ® ) (C) (menstrual migraine mg bid x 10 days) Silberstein SD (2000), Neurology 55(6): First Line (Pregnancy Class)

24 Migraine Prophylaxis  Divalproex (Depakote ® ) (D) FDA  Gabapentin (Neurontin ® ) (C)  Baclofen (Lioresal ® ) (C)  “MigreLief” 1,2 $20 /60 pills  Riboflavin (Vitamin B 2 ) 400 mg/day (A)  Magnesium oxide 360 mg/day (B)  Feverfew 100 mg/day  Petadolex 1 tid (Butterbur extract) (A) Other Options 1 Pfaffenrath V, Wessely P, Meyer C, et al. Magnesium in the Prophylaxis of Migraine - A Double-Blind, Placebo-Controlled Study. Cephalalgia 1996;16: Schoenen 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

25 Transformed Migraine/Status Migrainosus  Unremitting headache > 72 hours fulfilling criteria for migraine  80% associated with medication overuse

26 Transformed Migraine/Status Migrainosus  Withdraw all medication  Raskin protocol: DHE IV 0.5 mg/metoclopramide (Reglan ® ) 10 mg IV q 8 hours for 3 days 1  Dexamethasone (Decadron-LA ® ) 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): Raskin NH (1986), Neurology 36(7): Treatment *FDA boxed warning 2/26/09 –Long-term or high-dose use of metoclopramide has been linked to tardive dyskinesia.

27 Complicated Migraine  Persistent neurologic residue of a migraine attack  Migraine with dramatic focal neurologic features (include ophthalmoplegic, hemiplegic, basilar migraine)

28 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 et al. (1996), Neurology 47:

29 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

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

31 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?

32 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:

33 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),

34 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.

35 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:

36 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

37 Cluster Headache  Uncommon (69/100,000)  Men:women 6:1  Headaches begin years of age (mean 30)  High incidence of smoking, Peptic Ulcer Disease (PUD)  Familial cases unusual

38 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

39 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 1 Russell D (1981), Cephalalgia 1:

40 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

41 Other Cluster Variants  Chronic paroxysmal hemicrania  Multiple short, severe HA occurring daily  Short episodes of cluster 1-2 minutes  Average 14 daily  SUNCT ( S hort-Lasting, U nilateral, N euralgiform headaches with C onjunctival injection and T earing)  attacks daily  Usually < 30 seconds  Responds to indomethacin

42 Cluster Headache: Treatment  Stop smoking  Prophylactic treatment of chronic cluster  Indomethacin (Indocin ® ) 75 mg SR, mg tid  Avoid over age 60  Lithium carbonate mg daily  Methysergide (Sansert ® ) 2-8 mg daily  Propranolol, Nifedipine (Procardia ® ), verapamil (Calan ® ) Silberstein SD (2000), Neurology 55(6):

43 Cluster Headache: Treatment (Cont.)  Abortive therapy  Rectal ergot for nocturnal attacks  100% oxygen  Sumatriptan injection  Prednisone or dexamethasone: burst and taper Silberstein SD (2000), Neurology 55(6):

44 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:

45 Medication Overuse Headache  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): ; Zwart JA (2003), Neurology 61:

46 Medication Overuse Headache  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 tid 1  May require hospitalization  Raskin protocol: DHE mg IV q 8 hours/ metoclopramide 10 mg for 3 days Treatment 1 Saper JR et al. (2002), Headache 42(6):

47 Steroids ineffective for MOH Neurology 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 ©

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

49 How often is “Sinus” Headache Really Migraine? Schreiber CP, et al. Arch Intern Med. 2004;164: Subject (%) Migraine with or w/o Aura (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

50 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):

51 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 po)  Dihydroergotamine mg nasal, IM, subq  Antiemetics: metoclopramide mg

52 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 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

53 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): ; Rapoport AM, Bigal ME (2005), Neurol Sci 26(suppl 2):S111-S120; Available at:

54 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

55 Worrisome HA Red Flags  S ystemic symptoms: fever, weight loss  N eurologic symptoms or signs: confusion, depressed alertness or consciousness  O nset: sudden, abrupt, split-second  O lder: new HA > 50 years old - temporal arteritis  P revious HA history: change in usual HA pattern - change in frequency, character, severity  S econdary risk factors: HIV, cancer “SNOOPS”

56 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

57 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

58 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

59 Questions from the Audience?

60 References 1.Dodick DW. Chronic Daily headache. NEJM 2006;354: Headache Classification Subcommittee of the International Headache Society (2004), Cephalalgia 24: Edlow JA. Diagnosis of subarachnoid hemorrhage in the emergency department. Emerg Med Clin North Am 2003;21: 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 Sep 26;55(6): Freitag FG. Acute treatment of migraine and the role of triptans. Curr Neurol Neursci Rep 2001;1: Silberstein SD, Liu D. Drug overuse and rebound headache. Curr Pain Headache Rep 2002;6: Snow V, et al. pharmacologic management of acute attacks of migraine and prevention of migraine headache.Ann Intern Med 2002;137: Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near- daily headaches: field trial of revised HIS criteria. Neurology 1996;47:


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