Fariborz Khorvash
Associate Professor of
Neurology

 Why talk about headaches?

 Headaches are a common problem
 They are sometimes difficult to treat
 Can usually be treated well by internists
 Headache management is often not optimal
 Recent advances can translate into better treatment

 Chest pain approach
– Does this patient have a brain tumor?
 Episodic care
 Underdiagnosis of migraine headache
 Ineffective treatments are commonly used
– Acetaminophen, Butalbital/ASA/Caffeine
 Inappropriate use of analgesics

 Thunderclap headache
 New onset headache
 Headache with neurologic signs
 Headaches in pregnancy
 Headaches in elderly
 Progressing headaches
 Changes in frequenc or quality of headache

 Prepared to manage migraines 48%
 Prepared to manage MI, DKA, Asthma 95%

 What is a sinus headache?
 Many patients with migraines have sinus symptoms.
– Rhinorrhea, congestion, ocular symptoms occur in up to 46% of patients with migraines

 Study of 2991 patients with sinus headaches
– Self or physician diagnosed
– 88% met IHI criteria for migraine
 Patients reported
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Sinus pressure – 84%
Sinus pain – 82%
Nasal congestion – 64%
 Diagnosis of sinus headache should be reserved for those patients who meet diagnostic criteria for sinusitis.

 New onset headache
 Headache with neurologic sign
 Headache with seizure
 Headache with elevated ICP
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Patient request
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Intracranial pathology
Contiguous structures
Migraine
Cluster
Tension type
Chronic daily/Rebound

 Tumor
 Subarachnoid hemorrhage
 Meningitis
 Pseudotumor cerebri

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111 consecutive patients with primary or metastatic brain tumor
Classic early morning headache is uncommon
Primary symptom in only - 44%
Worse with bending over - 33%
Similar to TTH in 77%; migraine in 9%
Nausea and vomiting – 40%
Forsyth, Neurology, 1993

 Relatively solid recommendations
– Not indicated in patients with migraines and normal exam
– Indicated in patients with headache and abnormal exam

 Headache worsened by valsalva, exertion, sex
 Abrupt onset or awakens patient from sleep
 Change in established pattern
 New headache in patient >50
 Progressively worsening headache
 Comorbidities: HIV, cancer, immune suppression

 Sinuses?
 Eyes
 Ears
 TMJ
 Teeth
 Temporal artery
 Cervical spine

IHS criteria for migraine without aura
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Duration 4-72 hours
Two of the following characteristics
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Unilateral
Moderate – severe intensity
Pulsating
Aggravated by routine physical activity
Headache accompanied by one the following
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Nausea or vomiting
Photophobia or phonophobia
5 attacks
No other explanation

 Old theory: vasoconstriction triggers vasodilation
 Current concepts
– Originates as a neurologic event in the brain stem
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Trigeminal nerve ganglion is stimulated
Vasodilation occurs
Serotonin release contributes

 Acute
 Preventive
– Life style
– Pharmacologic

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Establish a diagnosis
Treat early
Use adequate doses
Tailor treatment to the severity of attack
Use migraine specific therapies
Use preventive strategies
Form a therapeutic alliance with the patient
Empower the patient
Avoid narcotics

 Mild - oral
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ASA 975 mg
Naproxen 500-1250 mg
Ibuprofen 800-2400 mg
Cataflam
Ergotamine 2 mg + caffeine 200 mg
Brufen/caffeine/codeine
 Mild with nausea
– Add metaclopramide 10 mg

 Severe
– Tryptans: oral, nasal, wafer, subQ
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DHE 1mg subQ, IV, nasal spray
Alternatives
 Ketorolac 60 mg IM
Adjuncts
 Promethazine
 Chlorpromazine (phenergan)
Narcotics

 Contraindications
– CAD
– CAD likely
 Side effects
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Chest and neck pressure
Dizziness
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Warmth, numbness, tingling, tightness, flushing
Nausea and vomiting

 Though sumatriptan may not be the most effective of the tryptans, it is available generically and should be the first choice.

 Not more effective
 Not specific for underlying pathophysiology
 Sedating
 Positive reinforcement?
 Potential for abuse
 Public health crisis

 Amitriptyline 25-150 mg
 Propranolol 80-240 mg
 Divalproex sodium 500-1500 mg
 Sodium valproate 800-1500 mg
 Venlafaxine 75-150 mg
 Fluoxetine 20-40 mg??????
 Dysport

 All are 70% effective
 Reduce frequency and severity of attacks
 Response cannot be predicted
 Dose adjustments necessary
 Calcium channel blockers less effective
 Decision process

 Establish and maintain routines
– Sleep
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Meals
Exercise
 Dietary triggers
– Caffeine, chocolate, alcohol, aged cheeses, monosodium glutamate

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Effective
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Relaxation training
Cognitive behavioral therapy
Ineffective
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Acupuncture
Hypnosis
Manipulation
TENS
Hyperbaric oxygen

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Observations from the Physicians’ Health Study
– 22,071 doctors randomized to 325 mg of ASA or control
 Treatment group: 6% experienced migraine after randomization
 Control group: 7.4% experienced migraine
 Treatment effect: 20%
Buring, JAMA, 1990

“A healthy robust man of middle age was suffering from troublesome pain which came on every day at the same hour at the same spot above the orbit of the left eye: after a short time the left eye began to redden, and to overflow with tears; then he felt as if his eye was slowly forced out of its orbit with so much pain, that he nearly went mad. After a few hours all these evils ceased, and nothing in the eye appeared at all changed.”
Textbook 1745

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Unilateral – 100%
Restlessness – 93%
Retroorbital – 92%, (temporal – 70%)
Lacrimation – 91%
Conjuctival injections – 77%
Nasal congestion/rhinorrhea – 75%
Ptosis/eyelid swelling – 74%
Phonophobia/phophobia – 50%

 Duration: 8 weeks
 Bouts per year: 1
 Maximum attacks per day: 4
 Attack duration: 15-180 min
 Nocturnal: 73%

 Acute
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Subcut tryptans
 74% effective within 15 min
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Nasal may be effective
Zolmitriptan 10 mg po – 60% response within 30 min
Oxygen

 Prophylactic – a small trial involving 30 patients
– Verapamil 120 tid
 80% of patients responded
– 40% at the end of one week
 Attacks per day after one week
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Verapamil - .6
Placebo
– 1.6
Leone, Neurology, 2000

 Other effective therapy
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Prednisone
 Bridge to verapamil
 Tapered over 3 week
Lithium
– Sodium valproate
– Methysergide

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Duration 30 min – 7 days
Two of the following characteristics
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Pressing or tightening ( not pulsatile)
Mild to moderate intensity (nonprohibitive)
Bilateral
– No aggravations from walking stairs
Both of the following
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No nausea or vomiting
Photophobia and phonophobia absent (or only one present)
10 previous attacks

 Acute headaches
– Minor analgesics
 Chronic tension type headaches
– Same diagnostic criteria
– Occur 15 days per month

 Amitriptyline vs stress management vs combination
– 409 patients recruited from primary care practices and randomized to one of 4 treatment groups
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Amitriptyline – 48
Stress management – 38
Amitriptyline and stress management – 45
Placebo – 38
Holroyd, JAMA, 2001

 Results: All three treatment groups effective
– Mean headache index score
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Days of at least moderate pain
Analgesic medication use
Headache disability
Amitriptyline produced results more quickly.
Combination treatment (AM+SM) produced greater than 50% reduction in HA severity in 2/3 of patients

 Identify and eliminate triggers
 Amitriptyline
 Symptomatic treatment with NSAID
 Avoid overuse
 Stress management

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¾ of patients with chronic daily headaches overuse analgesics
 Transformed migraines
– Past history of discrete migraines

 Butalbital/aspirin/acetomenophen/caffeine
 Codeine, propoxyphene, oxycodone, hydrocodone
 Aspirin, acetomenophen
 NSAID
 Nasal decongestants and antihistamines
 Ergotamine
 Tryptans

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Make a diagnosis
Establish and maintain a relationship
Inform the patients
Stop symptomatic treatment
Start prophylaxis – amitriptyline
Steroid taper (ranitidine 300 bid)
Recognize and treat the underlying headache disorder
Guard against overuse

 Most patients will stop symptomatic treatment
 Steroids seem to reduce withdrawal symptoms
 60-70% of patients improve
 Improvement occurs over 6 months
 30% of patients relapse

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How do we diagnose migraine headaches?
How should we treat migraines?
What causes migraines?
Who needs a CT scan?
How do we recognize cluster headaches?
How do we diagnose tension type headaches?
Does anything work for chronic daily headaches?