1. Headache By Dr. Andrew Gutwein

2. We all get ‘em! So why do patients come to the doctor? Severity Worried about brain tumor

3. Headache History Be mute! Its all pattern recognition.

4. Headache Physical examine the head look at and feel the scalp look at the fundi listen to the orbits with the stethoscope check the visual fields is their language normal can they tell a coherent story can they walk on a narrow base check the reflexes and the plantar response focus on the neurologic systems Not your internists general physical exam! It’s not about the lungs, heart, and abdomen!

5. Diagnostic Testing Only to prove a specific diagnosis (such as MRI for suspected MS or CT scan with contrast for suspected tumor) 99% of headache patients do not need imaging or blood tests of any kind. Consider the non-contrast CT if it is going to be the only way the patient will stop worrying (likely cost effective)

7. Headache Case #1a 34 y.o. W no PMH, c/o HA that are unilateral and throbbing. They happen once or twice a week and last for 7-8 hours. When they occur she feels a little nauseated and must go lie down for a while away from loud noises. They usually go away after she takes “Excedrin” OTC from her local pharmacy. Red wine occasionally causes a HA.

8. Headache Case #1b 34 y.o. W no PMH, c/o HA that are bilateral and dull and happen every two days and last for 3-5 hours. She also feels the pain in her neck. She keeps working during the HA but is less productive. Tylenol and “Excedrin” work sometimes to relieve the pain but not always.

9. Migraine Overview neurologic, not vascular vasoconstriction and vasodilation. It is the spreading depression/ depolarization of neurons across the cortex that results in a release of neurotransmitters which causes normal vascular pulsation to be felt as nociception. 18% of women and 6% of men are migraneurs Described as pulsating or pounding and unilateral but can be bilateral Frequently associated with neck pain – don’t be fooled! Cause

10. Migraine History photophobia/ phonophobia nausea/ vomiting disability (the patient must stop what they are doing and frequently they need to lie down in a quiet room) Timeline: Lasts 4 hours to 3 days Any hemicranial HA, any pulsating headache, and any neurologic phenomenon lasting over 20 minutes may also help clue you in on this diagnosis. 10% of migraine patients have aura and 50% of the time the aura is not followed by HA. When this happens it is called the dissociated migraine. 3 Keys to the history:

11. Migraine Cycle Migraneur life cycle: infantile colic childhood abdominal pain menstrual accompaniment motion sickness red wine headache benign sex headache ice cream headache worsening of headache with life stressors cerebrovascular disease transient global amnesia Depression, bipolar disorder, generalized anxiety disorder and social phobia are all more common in the migraneur.

12. Migraine - Mild 2/3 of patients with migraine headache have mild migraine and never come to complain to you about the headache. They self treat with: massage, relaxation techniques, avoiding light, going to bed, acetaminophen, low dose NSAIDs, or combination products like Excedrin Migraine which has aspirin, acetaminophen and caffeine in it. These medications work well for many people but be wary of using any of these (especially ones with caffeine) too frequently for too long. Treatment of mild to moderate Migraine:

13. Migraine - Triptans Triptans expensive (about $20-25 per dose for PO) but safe. Use as early in the headache as possible and beat the headache until it is gone or it will come back. When taken early pain free 50% at 2 hours, 85% at 4 hours. If you wait until the headache is moderate to severe you get only about half that response. If the headache continues for 1 hour after taking the triptan take another dose. Acute treatment of the moderate to severe Migraine:

14. Migraine - Triptans One can even prevent the HA when taken during the prodrome but do not take during an aura as it does not work. Avoid in pregnant patient - pregnancy category C Chest pain side effect that can occur is not myocardial (<1 in a million) Triptans can be used in a patient on an SSRI (serotonin syndrome is very rare) Triptans are not contraindicated in women on oral contraceptives with migraine with aura but you should advise smoking cessation as all these things add up to increased relative risk of CVA.

15. Migraine - Triptans All triptans are available PO but only a few have other routes. Injectable (expensive) – sumatriptan Intranasal (nasty aftertaste) – sumatriptan, zolmitriptan, rizatriptan Sublingual – zolmitriptan, rizatriptan Of the PO frovatriptan and naratriptan are slower to act - this may be good in the patient that has a slow growing headache and patients who get a rebound headache after using the more rapid acting triptans. Eletriptan and almotriptan are the other triptans.

16. Migraine - Triptans If the patient does not respond to one triptan, they will still have an 80% chance of responding to another. They can take 10mg of metoclopramide, wait 10 minutes, and then take the oral medication if there is severe nausea or vomiting. Otherwise use the sublingual route. Triptans are to be used no more than twice a week on average. Triptans are contraindicated in patients with CAD,CVA, PAD, and uncontrolled HTN.

17. Migraine Other Treatments Other acute treatment options: Ergotamines – not used almost at all because of toxicity Steroids PO for 2-3 days (prednisone 20mg, no taper needed) Fioricet or Fiorinal and other medications that have caffeine or narcotics are ok for migraine headaches, but on a limited basis

19. Migraine Prophylaxis If the patient is having headaches more frequently than twice a week they likely need prophylaxis. If the patient is having headaches less than twice a week but it interferes significantly you can still consider prophylaxis. Who needs prophylaxis against migraines headaches?

20. Migraine Prophylaxis Chronic prophylaxis against moderate to severe Migraine: 1.Tricyclic Antidepressants 2.Beta-blockers 3.Anti-seizure Medications Candesartan/Lisinopril – some evidence CCB – weak evidence

21. Migraine Prophylaxis TCAs: amitriptyline, imipramine, nortriptyline, desipramine They work well but can have anticholinergic side effects Listed them in order of most to least anticholinergic side effects The first three should be taken before bed as they can be sedating and desipramine should be taken in the morning Start at 10-25mg depending on whether they are elderly and titrate up if needed to max 150mg Check EKG for QT before starting TCAs are a good first/second line choice for men and women.

22. Migraine Prophylaxis Beta Blockers: propranolol or nadolol Use non-selective as they cross the blood brain barrier and can work on the brain. Propranolol or nadolol are excellent but side effects can include impotence, fatigue, and depression. Start low and titrate up. These are a good first/second line in women.

23. Migraine Prophylaxis Anti-seizure medications: valproic acid, topiramate Valproic acid 250-500mg BID with food works very well but side effects include hair loss and weight gain and it is contraindicated in pregnancy. Topiramate 25mg BID titrated to 100mg BID as needed is now starting to be used for this indication as well. Topiramate can cause mental slowing and paresthesias. These are good first/second line choices for men.

24. Headache Case #1a 34 y.o. W no PMH, c/o HA that are unilateral and throbbing. They happen once or twice a week and last for 7-8 hours. When they occur she feels a little nauseated and must go lie down for a while away from loud noises. They usually go away after she takes “Excedrin” OTC from her local pharmacy. Red wine occasionally causes a HA.

25. Headache Case #1b 34 y.o. W no PMH, c/o HA that are bilateral and dull and happen every two days and last for 3-5 hours. She also feels the pain in her neck. She keeps working during the HA but is less productive. Tylenol and “Excedrin” work sometimes to relieve the pain but not always.

27. Headache Case #2 37 y/o M Program Director of an Internal Medicine Residency gets daily HA. These HAs frequently occur in the afternoon after hearing multiple complaints from housestaff all day. They are bilateral temporal and he can continue working right through them. They are sometimes relieved with tylenol.

28. Tension Type Overview This type of headache is frequently described as neck discomfort, or band like pain around the head but can be only front, back or top of the head. This is not caused by actual muscle tension (found on testing) but is really psychogenic headache. Any muscle tension is usually a secondary phenomenon. Cause:

29. Tension Type Treatment The real cause is stress. Find out what kind of stress is going on in their life and see if you can find a way to help them alleviate the stress. The answer is not the pills. Patients can use acetaminophen or NSAIDs PRN but the real answer is stress reduction. They can do this any way then want.

30. Headache Case #3 37 y/o M Program Director of an Internal Medicine Residency gets almost daily HA. These HAs frequently occur in the morning. They are bilateral temporal and he can continue working right through them. They are sometimes relieved with drinking his large mug of tea.

31. Chronic Daily Headache (CDH) Cause: Taking medications for their headache! People think the pills help the headache - the pills cause the headache. These are people that may have started out with tension type or migraine headaches but now have almost daily headaches, frequently the whole day long. This is really rebound headache. CDH can be caused by any analgesic taken too frequently. It is worse in drugs with caffeine added (Fioricet, Excedrin).

32. Chronic Daily Headache Treatment You should withdraw all meds (except barbiturates, opioids and benzodiazepines which need tapering). You can use clonidine to avoid opioid withdrawal, phenobarbital to avoid butalbital (found in Fioricet/ Fiorinal) withdrawal. If you have to, NSAIDs and antiemetics or even triptans can be used while withdrawing everything else. 8 of 10 respond eventually Last ditch treatment is one month of steroids: 20-100mg prednisone x2 weeks then taper for 2 weeks

34. Differential Diagnosis About 99% of all headaches seen in the internists office fall into these three categories: Migraine Tension Type CDH (Chronic Daily Headache)

35. Fin