headaches in primary care steve cobb md residency program director esjh family medicine residency

Headaches in Headaches in Primary CarePrimary Care

Steve Cobb MD

Residency Program Director

ESJH Family Medicine Residency

Headaches in Headaches in Primary Care – ObjectivesPrimary Care – Objectives

Use IHS criteria to diagnose common primary headache syndromes.

Treat common primary headaches.Recognize symptoms and signs associated

with secondary and worrisome headaches

Why Us?Why Us?

Family Physicians and Internists– Headache is the second most common pain

complaint seen in primary care– 63% of migraineurs see their PCP alone for

care– 18M patients visit PCPs per year for HA– Over 1,000 visits to the OU FMC annually

Case 1Case 1

26 year old female presents with CC of headache x 6 months. Headaches occur everyday, are usually unilateral, but not always. They often improve with Midrin, but sometimes she misses work when it fails. Sometimes she is nauseated enough that she vomits. Physical exam, including vital signs, fundoscopic, and neurologic exams are normal today.

Strategy for Headache Strategy for Headache Evaluation and TreatmentEvaluation and Treatment

1. Ensure this is a benign primary Headache disorder.

2. Determine the type. 3. Determine treatment goals and prioritize and

communicate them clearly. 4. Arrange for periodic review and oversight. 5. Know when to refer and to whom.

Clinical Approach to Clinical Approach to Headache Headache

How many headache types are there?Headache history for each typePhysical ExamDifferential DiagnosisIndications for NeuroimagingClassification Treatment

HistoryHistory

Age of onsetFrequencyCharacterAura or prodromeNeurologic symptomsPrecipitating factorsPMHx/Meds/Trauma/Procedures

Migraine auraMigraine aura

Visual disturbances confined to one field– phosphenes, eg, sparks, flashes, geometric forms – scotoma, area of diminished vision moving across visual field– scintillating scotoma, flickering spectrum at margin of scotoma

Sensory: unilateral paresthesias and/or numbnessWeakness, or more commonly a sense of limb

heaviness: unilateralSpeech: dysphasia

Migraine Aura: Scintillating Scotoma

Reprinted with permission from Fisher CM. Late-life (migrainous) scintillating zigzags without headache: one person’s 27-year experience. Headache. 1999;39:391-397.

PhysicalPhysical

BP, fundoscopy, temporal and scalp area palpation

Neuro Exam

Indications for NeuroimagingIndications for Neuroimaging

Abnormal neurologic findings

Confusion, somnolence Post-traumatic An isolated severe

headache Abrupt onset, or onset

during exercise Pain severe enough to

disturb sleep

Age less than 5 years Onset in late life Family history of

aneurysm or polycystic kidney disease

Consistently localized head pain

Progressively worsening

““SNOOP”SNOOP” Systemic symptoms-fever, weight loss, stiff neck, rash

Secondary risk factors-HIV, cancer, coagulopathy

Neurologic symptoms or signs-confusion, change in alertness or LOC

Onset is sudden-abrupt or split second onset

Older age at onset-new or progressive headache, first at age>50

Previous Headache history-first/worst headache, different progressive type, change in clinical features



2. Determine the type. 3. Determine treatment goals and prioritize and

communicate them clearly. 4. Arrange for periodic review and oversight. 5. Know when to refer and to whom.

Make the diagnosisMake the diagnosis Pearls Pearls

Use a validated screening tool– ID Migraine TM

Listen (3 minute rule)Make a follow up appointment specifically

to discuss headache and do a careful neurologic exam

Headache diariesNeuro-imaging is seldom necessary

Make the Diagnosis Make the Diagnosis International Headache Society International Headache Society

ClassificationClassification Primary

– Migraine– Tension type– Cluster– “Miscellaneous

headache not associated with structural lesion”

Secondary– Increased (or decreased)

intracranial pressure– Vascular disorders

(Temporal arteritis)– Substance associated– Infection– Metabolic disorder– Trauma– Neuralgias– Associated with other

diseases of the cranium

Differential Diagnosis - PearlsDifferential Diagnosis - Pearls 90% of HA’s are Primary HA’s Life-threatening causes are rare Evaluate carefully for Secondary and life-

threatening HA’s– If exam is normal, then neuroimaging is usually normal– If history supports intracranial bleed and CT is normal, LP

Once you R/O Secondary HA….. Determine what type(s) of primary headache your

patient has.

Common Primary HeadachesCommon Primary Headaches

MigraineTensionClusterChronic Daily Headache

Migraine - EpidemiologyMigraine - Epidemiology

25 – 30 Million sufferers in the U.S.One year prevalence

– Women – 18%– Men – 6%

Many Still Undiagnosed – 14.6MLipton et al Headache 2001;41:638-645.

– Women – 49%– Men – 59%

2

Migraine: Diagnostic Criteria

At least 5 attacks that include• Headache lasting 4 to 72 hours• At least 2 of the following:

— Unilateral location— Pulsating quality— Moderate to severe intensity (inhibits or prohibits

daily activity)— Aggravated by climbing stairs or similar activity

• At least 1 of the following:— Nausea and/or vomiting— Photophobia and/or phonophobia

• Not attributable to other causes

Headache Classification Committee of the InternationalHeadache Society. Cephalalgia. 1988.

2 of these

1 of these

Make The Make The DiagnosisDiagnosis

Migraine - PathophysiologyMigraine - Pathophysiology

– The Neurovascular Theory = Vasodilatation may be secondary to Neurogenic Inflammation

Trigeminal Nerve Activation Dural Blood Vessel Dilation AND Inflammation

– 5HT 1B1D Receptors - Where Triptans Work 1B Cranial Blood Vessel Constriction 1D Inhibits Neurogenic Inflammation

CGRP: calcitonin gene-related peptide

NK: neurokinin A

SP: substance P

CGRPNKSP

5-HT1F5-HT1D

5-HT1B

Blood vessel

Trigeminal nerve

MOA of triptans

CONSTRICTION

INHIBITION

Adapted from Goadsby et al. Neurol Clin. 1997.

Proposed Mechanism of Action

Central ActivationCentral Activation

Periaqueductal Grey AreaTrigeminal Nucleus CaudalisCranial nerve stimulated by abnormal

signaling centrally



2. Determine the type. 3. Determine treatment goals and prioritize

and communicate them clearly. 4. Arrange for periodic review and oversight. 5. Know when to refer and to whom.

Treatment GoalsTreatment Goals

Eliminate Pain and other associated symptoms

Preserve/Restore functionPrevention (reduce number and intensity of

headaches).

Migraine - TreatmentMigraine - Treatment

Non-pharmacologic effortsMedsTreat concomitant mood disordersFollow-up and re-evaluation

Migraine- Associated triggersMigraine- Associated triggers

-Menstruation, pregnancy, menopause-Hormonal contraceptives or hormone replacement therapy

-Intense or strenuous activity/exercise

-Sleeping too much/too little/jet lag

-Fasting/missing meals

-Bright or flickering lights

-Excessive or repetitive noises

Odors/fragrances/tobacco smoke

-Weather/seasonal changes

-High altitudes -Medications -Stress/stress letdown

Migraine Triggers - DietaryMigraine Triggers - Dietary

Probably: Monosodium

glutamate (MSG) (soy sauce, meat tenderizers, seasoned salt)

Alcoholic beverages (wine, beer, whiskey, etc.)

Possibly: Ripened cheeses (cheddar,

ernmenthaler, stilton, brie, camembert)

Sausage, bologna, salami, pepperoni, summer sausage, hot dogs, pizza

Herring (pickled or dried) Any food pickled, fermented,

or marinated Broad beans, lima beans,

fava beans, snow peas Caffeinated beverages (tea,

coffee, cola, etc.) Aspartame/phenylalanine-

containing foods or beverages

Non-pharmacologicNon-pharmacologic

Grade A Evidence– Relaxation Therapy– Thermal Biofeedback– Cognitive behavioral

therapy

Grade B Evidence– Behavioral therapy

with medication

Grade C Evidence– Hypnosis– Acupuncture– TENS Unit– Cervical spine

manipulation– Occlusal Adjustment– Hyperbaric O2

Pharmacologic Treatment Pharmacologic Treatment Episodic MigraineEpisodic Migraine

Prophylactic– Antiepileptics– Antidepressants– B-Blockers– CCB– NSAIDS– Serotonin Agonists– Vitamins and Herbs

Abortive– Specific

Triptans Ergots

– General Antiemetics NSAIDS Opioids Barbiturates Corticosteroids*

EvidenceEvidence

Prophylaxis– Level A

Depakote (Topamax) Sansert Propranolol

– Level B Tegretol Gabitrol Other B-blockers Verapamil Feverfew, B2, Mg

Abortive– Level A

Triptans Intra-nasal DHE

– Level B Exedrine in non-

disabling migraines Caffeine Corticosteroids in status

migranosis

Two Migraine Abortive Agents

Ergots• Acts on 5-HT1A, 1B, 1D,

1F, 2A and 2C receptors, also DA1 and DA2

• Relieves headache; can be taken during aura to abort attack

• Vomiting is a side effect of ergotamine (less with DHE)

Triptans• 5-HT1D and 1B receptor

agonists

• Relieves headache & associated symptoms

• May produce “triptan sensations” as side effects, eg, tightness in the chest and jaw

Triptans vs Analgesics:Triptans vs Analgesics:2-Hour Pain Free Response2-Hour Pain Free Response

0

10

20

30

40

50

60

70

80

Mild Moderate

Non-Triptan

Triptan

% of Attacks

25

73

10

48

Cady et al Clin Ther. 2000;22:1035-1048.

How do Triptans Work?

Selective 5-Hydroxytryptamine 1B/1Receptor Agonist (5-HT 1B/1D)

Two Theories Activation of 5HT1 receptors on cranial blood vessels

leads to vasoconstriction Activation of 5HT1 receptors on sensory nerve endings

in the trigeminal system results in inhibition of pro-inflammatory neuropeptide release

Triptan Treatment Pearls

• Acute Treatment (Abortive) for Patients with Diagnosed Migraine with and without Aura

• Do Not Use as Diagnostic Agent

• 18 years of age?

• Do not use Triptans and Ergotamines/DHE within 24 hours of each other.

• Triptans with Propanolol– Ergots + Propanolol = risk of severe vasoconstriction– Frovatriptan + Propanolol = hypotension/AV Block

Comparative TriptansAbortive Therapy – Selective 5-HT 1B/1D receptor agonists

Tmax Triptan Dose Formulations

2.5h Sumatriptan 25/50/100 (Imitrex) – 1991 T/SC/IN

2h Zolmitriptan 2.5/5 (Zomig) - 1997 T/DT

2.5h Rizatriptan 5/10 (Maxalt) T/DT

1-3h Naratriptan 2.5 (Amerge) T

1.5-3.8h Almotriptan 6.25/12.5 (Axert) T

2-4h Frovatriptan 2.5 (Frova) T

1-2h Eletriptan 20/40 (Relpax) T

Tepper SJ Headache. 2001;85:959-970

Stratified TherapyStratified Therapy

Behavior Modification (Avoid triggers)Preventive PharmacotherapyEarly treatment with specific therapy

– Ergotamine/DHE– Triptan

Rescue Medication– Anti-emetics– Analgesics

20

Efficacy of Eletriptan: Comprehensive Relief at 2 Hours

Relief of Photophobia, %

Headache response, %

Relief of Nausea, %

Relief of Phonophobia, %

Pain-free response, %

Placebo

0

20

40

60

4030

80

2010

40

60

80

80

40

60

80

Adapted from Mathew et al. Headache. 2003.

Sumatriptan was blinded using encapsulation. Encapsulated sumatriptan was bioequivalent to commercial tablets.

60

20 20

2040

*P<.001 vs placebo.

21




Relief of Nausea, %



Placebo

0

20

40

60

4030

80

2010

40

60

80

80

40

60

80



60*

*

*

* *

*P<.001 vs placebo. †P<.05 vs sumatriptan.

Sumatriptan 100 mg

20 20

2040

22




Relief of Nausea, %



Placebo

0

20

40

60

4030

80

2010

40

60

80

80

40

60

80



60

*†

*†

*†*†

*†

*

*

*

* *

*P<.001 vs placebo. †P<.05 vs sumatriptan.

Sumatriptan 100 mgEletriptan 40 mg

20 20

2040

Triptans• Prophylaxis• Cluster HA• Hemiplegic or Basilar Migraine• Pts with Known or Suspected Ischemic Heart Disease• Pts with Neurovascular Syndromes – CVA /TIA• Pts with ASPVD• Pts with Uncontrolled HTN• Pts with Severe Hepatic Impairment• Pts who have used another 5-HT1 agonist /DHE/Methysergide

within 24 hrs• With meds that are potent CYP3A4 Inhibitors• Pregnancy Category C

EpisodicTension-type EpisodicTension-type headacheheadache

A. At least 10 previous headache episodes fulfilling criteria B through D; number of days with such headaches: less than 180 per year or 15 per month

B. Headaches lasting from 30 minutes to 7 days

C. At least two of the following pain characteristics:

1. Pressing or tightening (nonpulsating) quality

2. Mild to moderate intensity (nonprohibitive)

3. Bilateral location 4. No aggravation from walking stairs

or similar routine activities

D. Both of the following: 1. No nausea or vomiting

2. Photophobia and phonophobia absent, or

only one is present

Treatment –Tension type Treatment –Tension type headacheheadache

Acute headaches may respond to aspirin, acetaminophen, or combinations with caffeine; NSAIDs; isometheptene combinations; butalbital combinations; and muscle relaxants.

a. Overuse may lead to rebound headaches.

b. Frequent butalbital use can also result in dependency

Frequent headache may require preventive medications

a. Tricyclic medications are generally more effective than SSRIs

b. Other migraine preventatives (see chapter migraine) may be helpful especially when tension-type and migraine are both present

Cluster headacheCluster headacheSevere unilateral orbital, supraorbital

and/or temporal pain, lasting 15-180 min.Headache accompanied by at least 1 of

the following signs ipsilateral with the pain: - Conjunctival injection - Miosis- Lacrimation - Ptosis- Nasal congestion - Eyelid edema- Forehead/facial sweating - Rhinorrhea

Attack frequency: q.o.d. to 8 per day.International Headache Society Diagnostic Criteria. Cephalalgia 1988; 8(suppl 7)

Typical Temporal Patterns in Cluster Headache: Typical Temporal Patterns in Cluster Headache: Individual AttacksIndividual Attacks

Typical Seasonal Patterns in Episodic Cluster Headache (IHS 3.1.2)1997

Day Time90 Minute Attack in Late Evening

Night TimeTwo Attacks Disturbing Sleep

1998

1999

2000

Episodic Cluster Headache Episodic Cluster Headache Evolving to Chronic Cluster (IHS 3.1.3.2)Evolving to Chronic Cluster (IHS 3.1.3.2)

Chronic Cluster Headache Unremitting from Onset (IHS 3.1.3.1)

Note: Attacks for more than 1 year with remission lasting less than 14 days

Note: Attacks daily or almost daily for more than one year

1998

1999

2000

1999

2000

Treatment - ClusterTreatment - Cluster

Acute– O2– Injectable triptans– Injectable ergotamines

Preventive– Steroids– Verapamil– AED’s

Chronic Daily HeadacheChronic Daily Headache

1. Headache 15 or more days per month

2. Includes different headache types

CDH – Transformed migraineCDH – Transformed migraine

Transformed migraine (chronic migraine) with or without medication overuse

1. Previous history of intermittent migraine usually by age 20-30

2. In 80%, gradual transformation from episodic to CDH which may be associated with analgesic overuse and psychological factors (depression, anxiety, abnormal personality profile, and home or work stress).

3. In 20%, sudden transformation which may be triggered by head or neck trauma, flulike illness, aseptic meningitis, and operations, and medical illnesses.

4. Migraine characteristics to a significant degree intermittently or

continuously

CDH –Hemicrania ContinuaCDH –Hemicrania Continua

Hemicrania continua with or without medication overuse

1. Rare entity with constant, unilateral pain of variable intensity.

2. Painful exacerbations associated with ptosis, lacrimation, and nasal stuffiness.

3. Responds dramatically to indomethacin.

Chronic Daily HeadacheChronic Daily Headache

Taper medications which may be causing rebound

a. The headaches may get worse before improving which may not occur before three to six weeks

b. For outpatients, headaches may lessen with the transitional use of a tapering dose of prednisone (60 mg for 2 days, 40 mg for 2 days, and 20 mg for 2 days) for 6 days or the combination of tizanidine and a long-acting NSAID

Inpatient Detox may be required

a. Fluids

b. Steroids

c. Reglan

d. DHE-45

e. Phenobarbitol

Medicines Associated with Medicines Associated with “Rebound” Headache“Rebound” Headache

AcetaminophenCaffergotOpioidsButalbitalTriptansMidrinNSAIDS

ReferralReferral

Wayne Wasemiller, M.D.– 302-2661

OU Neurology– Marc Lenarts, M.D.– Jim Couch, M.D.

Call 271-3635 ext 0 Call chief resident on call

Case 1Case 1

26 year old female presents with CC of headache x 6 months. Headaches occur everyday, are usually unilateral, but not always. They often improve with Midrin, but sometimes she misses work when it fails. Sometimes she is nauseated enough that she vomits. Physical exam, including vital signs, fundoscopic, and neurologic exams are normal today.

headaches in primary care steve cobb md residency program director esjh family medicine residency

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