HEADACHE TOOLS HANDOUT

DIAGNOSIS : International Headache Society Criteria (u sed loosely)

PRIMARY HEADACHE: No other pathological cause
  Tend to be paroxysmal, episodic, and nonprogressive with recovery in between
  Positive family history, especially for migraine

MIGRAINE: Five similar attacks lasting 4 – 72 hours with the following:
   2 of 4 :                       1 of 2 :
   Unilateral                     Photo and Phonophobia
   Throbbing                    Nausea / Vomiting
   Mod / Severe       
   Worsens with activity
   Note 5 stages: Prodrome, Aura, Pain/HA, Resolution, Postdrome

CLUSTER: Flurries of daily headaches for 2 – 8 weeks with the following features:
   Unilateral / periorbital                         And > 1 of these ipsilateral autonomic features:
   Non-throbbing                                   Miosis                   Ptosis
   Severe / excruciating                          Lacrimation           Conjuctival erythema
   Clockwork periodicity                       Rhinorrhea             Congestion

TENSION-TYPE: Five similar attacks lasting up to 7 days with the following tendencies:
   Bilateral
   Nonthrobbing
   Moderate severity
   Does not interfere with daily activities

CHRONIC DAILY HEADACHE
   Often arises from a background of episodic migraine
   Overly frequent analgesic use is often contributory

SECONDARY HEADACHE:
   ACUTE                                                             CHRONIC
   First / Worst headache of my life                         Insidious onset but never fully recovering
   Sudden “thunderclap” onset                                Side-locked / stereotypical location
   Meningismus                                                       Progressively worsening
   History of trauma                                                Weight loss

BOTH
   Evidence of focal neurologic, behavioral or cognitive deficit
   Evidence of systemic illness (fever)
   Papilledema

TREATMENT OF HEADACHE

NONPHARMACOLOGIC

EDUCATION

Migraine pathophysiology :
Genetically hypersensitive nervous system ( à not weakness of character) prone to episodic “overload” ( à triggers)   leading to reversible impairment of neuronal function ( à prodrome, aura, and other associated symptoms) and inflammation of meninges and cranial vessels ( à pain) via the trigeminal nerve through neurotransmitters (such as serotonin)
 
Cluster pathophysiology :
Less well known. Now there is evidence of genetic link
Hypothalamic association explains periodicity ( à relaxation, sleep)
Trigeminal / sphenopalatine association explains pain, autonomic features
 
Tension-type headache pathophysiology :
Also not as well known. Decreased ability to release nerve-firing in certain tests of muscular activity. Clinically  the episodic variety is not usually significant.
 
Chronic Daily Headache
Discuss “rebound” as a function of brain's “pain control mechanism” becoming dependent on exogenous  analgesics, having to “relearn” how to control pain. Meanwhile, withdrawal headache occurs. “You have to get    sick first to get better”. Scientific explanation: downregulation of neurotransmitter (opiate and other) receptors   takes time to upregulate / normalize.
 
 **Important to remember this is the case for many (perhaps ~50%) but not all. For the rest, pathophysiology is unclear why  the brain loses the ability to modulate sensory input and it becomes painful.
 

  STRESS MANAGEMENT
  Biofeedback and Autogenics
  Cognitive psychotherapy

  LIFESTYLE CHANGES
  Avoidance of triggers
  Diet, exercise, sleep hygiene

  PHYSICAL MEASURES
  Physical therapy, chiropractic, massage, ice
  Acupuncture, others


ACUTE PHARMACOLOGIC TREATMENT

Early intervention is key to best efficacy due to hypersensitization once headache begins.
All (except maybe DHE-45) can cause rebound if overused for long period of time.

Selective 5HT1 agonists (triptans):                       sumatriptan:  Imitrex tabs, nasal spray , SQ injection
                                                                                              rizatriptan:    Maxalt tabs and MLT wafer
Act at trigeminal 5HT1 D and                              zolmitriptan:  Zomig tabs, nasal spray, ZMT wafer
meningeal vessel 5HT1 B receptor                       naratriptan:   Amerge tabs
sites to trigeminal nerve firing,                               almotriptan:  Axert tabs
inflammatory peptide release, and                         eletriptan:     Relpax tabs
vasoconstrict meningeal vessels.                            frovatriptan : Frova tabs
  
Nonselective 5HT1 agonists
             Ergotamine: Ergomar (SL), Cafergot, Bellergal (tabs)
             Dihydroergotamine: DHE-45 (IV, IM, SQ), Migranal (NS)

Combination drugs : barbiturate + sympathomimetic + mild analgesic +/- codeine
              Fiorinal (Fioricet, Esgic) = butalbital, caffeine, aspirin (acetaminophen)
              Midrin = phenelzone, isometheptene mucate, acetaminophen
              Phrenilin = decaffeinated Fioricet (butalbital + acetaminophen)

Others : NSAID's both by Rx and OTC
             Muscle relaxants mostly helpful for tension-type or neck pain
             (note: Toradol + Norflex IV useful in ER for nonspecific HA)
             Antiemetics PO help n/v, given IV may abort migraine, cluster
             Opiates – all sorts. Can provide humane rescue from pain, use infrequently
             Sedative hypnotics or benzodiazepines: promote sleep, lower anxiety (infreq)
  
Cluster headache : will respond to triptans (NS, inj), ergots; less well to opiates
             100% oxygen
              intranasal lidocaine (sphenopalatine block )

Status migrainosus :
              IV DHE-45, Reglan, Droperidol, Depacon, Thorazine, steroids, +/- analgesics
              IV propofol (administered by anesthesiology)

PREVENTIVE PHARMACOTHERAPY “ Neuromodulators ”

Most probably work by “calming down” a hypersensitive nervous system via various mechanisms,
including stabilization of nerve cell membranes, ionic channels, or increasing inhibitory neurotransmitter receptor function. Often, lower doses are used than for it's original purpose. (*denotes FDA approved for this indication)


Antidepressants :
             tricyclics: amitriptyline, nortriptyline
             phenelzine ( Nardil ) – used more by headache specialists than psych these days
             all others can be used especially if comorbid depression may exist

Anticonvulsants :
             * Depakote ER, Topamax, Neurontin most used. All others can be tried.
             Neurontin, Tegretol, +/- Dilantin for trigeminal neuralgia

Antihypertensives :
             Beta-blockers: *Inderal, Corgard, *Blocadren, +/- Lopressor and others
             Calcium channel blockers: Verapamil, +/- Norvasc
            Alpha-agonists: Clonidine

Serotonin 5HT 2 antagonists :
            * Sansert (methysergide), Methergine
            Periactin ( cyproheptadine )

Antipsychotics:
             Newer group: Seroquel, Risperdol, Zyprexa, Geodon
             Combinations: Triavil

Others : NSAID's (naproxen, indomethacin, Cox-2 inhibitors)
              Zanaflex (selective a 2 agonist)
              Baclofen
              Lithium, especially for cluster headache

Hormonal manipulation for menstrual migraine
              Adding estrogen during the menstrual week
              Continuous use of OCP's to prevent menstruation
              Chemical menopause