Susan Hurst

Clinical Nurse Specialist in Headache

•Headache is one of the most common disorders of the nervous system

•It is estimated that 47% of the adult population (worldwide) have suffered at least one headache in the past year

•Headache disorders are associated with personal and societal burdens of pain, disability, damaged quality of life and financial cost

•Headache has been underestimated, under recognised and under-treated throughout the world (WHO)

Primary Headaches

Migraine

Cluster Headache

Tension type Headache

History taking and headache

• Description of Headache

• Associated Features (Aura, photophobia, phonophobia, nausea)

• Family History

• Current/Previous Medication (Dosage and duration)

• Lifestyle

Symptoms of Migraine

•Unilateral or bilateral

•Pulsating/throbbing

•Pain – moderate/severe

•Withdraw/lie down

•Nausea/vomiting

•Sensitivity-Light/sound

•Duration – 4-72 hrs

Four Stages of Migraine

Prodromal phase before the migraine

Aura phase

Attack phase

Postdromal phase after the migraine

What is medication overuse headache?

MOH is classified in the International Classification of Headache Disorders 3rd Edition (BETA version) section 8.2

Definition:

‘Headache occurring on 15 or more days per monthdeveloping as a consequence of regular overuse ofacute or symptomatic headache medication (on 10 ormore, or 15 or more days per month, depending on themedication) for more than 3 months. It usually, but notinvariably, resolves after the overuse is stopped

How does medication overuse headache occur?

• painkillers are taken more regularly to relieve headache and migraine

• rebound’ or ‘withdrawal’ headache develops on the days when painkillers are not taken

• More painkillers are then taken as the person assumes that this is another migraine or headache - this pattern develops into a vicious circle

• Headaches occur on a daily basis leading to the overuse of medication

Which medication can cause MOH?

Paracetamol or a combination of paracetamol and other drugs like codeine can cause medication overuse headache; e.g. Co-codamol, Kapake®, Solpadol®, Tylex®, Co-dydramol, Remedeine®

Opiates and Morphine salts; e.g. Oromorph®, MST®, Codeine phosphate, Dihydrocodeine, DF118®, Tramadol,

Combination Painkillers containing caffeine: e.g. Anadin Extra®

Triptans used for migraine; Almotriptan, Eletriptan, Naratriptan, Rizatriptan, Sumatriptan, Zolmitriptan and Frovatriptan

Anti Inflammatory Drugs for example Ibuprofen – may cause medication overuse headache, but are less likely to do so

How much is too much?

• Triptans – no more than 5-6 doses in month

• codeine based products – no more than 8 – 10 days in month

• Simple analgesia i.e. paracetamol, aspirin etc. - no more than 15 days in month

Management of MOH by the Clinical Nurse Specialist at RVI, Newcastle

• assist the patient to recognise and understand that the cause of frequent headaches may be the painkillers

• advise that headaches become worse for a while depending on the painkillers that were taken. This may cause feelings of sickness, anxiety and affect sleep patterns in the early stages of withdrawal

• advise that the most effective method is to stop taking painkillerscompletely for two months .

• provide ongoing support by offering a telephone support call during period of withdrawal and encourage the use of a headache diary

A study conducted on patients who underwent medication withdrawal within the headache clinic

0% 10% 20% 30% 40% 50% 60%

Less frequent

Not waking with headache

Less Severe

Shorter in duration

• 50% headache improved and was less frequent• 25% not waking with headache• 19% headache not as severe• 6% headache shorter in duration

0%

10%

20%

30%

40%

50%

60%

70%

Paracetemol Triptans Ibuprofen Codeine Naproxen

Analgesia overused in Medication Overuse Headache

Paracetemol 58%

Triptans 42%

Ibuprofen 25%

Codeine 22%

Naproxen 5%

Migraine ManagementAcute Treatment at Onset of Headache

•NSAID i.e. Ibuprofen 400mg

•Paracetamol 1g

•Soluble Aspirin 900mg

•Anti-emetic i.e. Metoclopramide

•Triptans i.e. Sumatriptan, Zolmitriptan, Rizatriptan, Frovatriptan

Migraine Management Prophylactic Treatment

•Anti-Convulsants - Topiramate, Gabapentin, Pregabalin

•Anti-depressants – Amitriptyline, Duloxetine, Pizotifen, Venlafaxine

•Beta-Blockers – Propranolol

•Botox Injections/Acupuncture

NICE recommendations for treatment of Chronic Migraine with Botox®

•Patients have tried three preventative medications

•Patients do not have Medication Overuse Headache

•Patients experience headache on more than 15 days per month – 8 days with migraine

Botox® Injection sites for Chronic Migraine

0%5%10%15%20%25%30%35%40%45%50%

Series1

67 patients (90.5%) reported that their headache had improved after receiving their first

cycle of Botox® and only 7 patients (9.5%) reported that there had been no

improvement in their headache after their first cycle of Botox®

0%

5%

10%

15%

20%

25%

30%

35%

40%

24hrs orless

1-7 days 1-2 weeks 2-4 weeks 1 month ormore

Series1

Onset of action following first cycle of Botox®

0% 20% 40% 60% 80%

Shorter in Duration

Reduction in Severity

No change in Duration orSeverity

Series1

Change in severity and duration of headache following first cycle of Botox®

The majority of patients who were experiencing headache described that the pattern of

their headache had changed. 45 patients (60%) reported that their headache was

shorter in duration with 51 patients (69%) reporting that their headache had changed

from severe to mild-moderate intensity.

Improvement in qualityof life - 62 patients

No Improvement inquality of life - 12patients

Improvement in quality of life following first cycle of Botox®

When our patients were asked if they had experienced an improvement in their well- being

and quality of life, 62 patients (84%) reported that their quality of life had improved since

receiving Botox® with only 12 patients (16%) who did not think that their quality of life had

improved

Patient comments following Botox:-

'generally happier and pain free, not as scared to try new things in fear of having a

headache‘

'working full-time, enjoying family life, all round great improvement‘

'been able to do a lot more instead of being in bed bad with migraine‘

'better outlook, more positive, light at the end of the tunnel‘

'do not spend as much time in bed‘

'I have been able to go out a lot more, also not as many days off work‘

'more sociable now, enjoying life more, can look forward to life more‘

'less tired, more engaged with my children'

'having Botox has given me my life back, its’ actually given me a life that I never

thought was possible'

CGRP Drugs – Recent Research Trials

Calcitonin Gene-Related Peptide Antagonists

• 4 drugs which have completed clinical trials, 3 have licences

• Early indicators are minimal side effects – effective in

reducing headache – migraine days

• Awaiting NICE Approval (In consultation phase)

Lifestyle and Headache

Diet

Hydration

Sleep

Stress and Anxiety

Exercise

Alcohol/Smoking

Diet and Hydration

• Well Balanced Diet

• Introduction of breakfast and supper

• Eat regularly avoiding periods of hunger

• Avoid foods that are identified as triggers•• Drink Water (at least 2 litres a day)

• Avoid caffeinated drinks – tea, coffee

• Avoid fizzy pops eg Coke, Dr. Peppers, Energy drinks (hidden caffeine)

Sleep Hygiene

• Regular sleep pattern – waking and retiring

• Well ventilated bedroom

• Avoid using computer/i pad/games/i phone within an hour of retiring

• Unwind before going to bed i.e. listening to music, reading, warm bath

• Eat supper i.e. snack with warm milk

• Use relaxation techniques/cognitive therapy if restless during the night

Stress and Anxiety

• Stress can increase incidence of headache

• Manage stress appropriately, seek help!

• Prioritise problems and tasks

• Incorporate ‘me’ time into daily life

• Utilise relaxation techniques e.g. massage, reflexology, meditation

• Avoid negative coping mechanisms i.e. alcohol, smoking, recreational drugs

Exercise

• Increase in BMI can impact on headache

• Regular exercise at least three times a week can improve incidence of headache

• Exercise can be a form of stress management

• Production of endorphins can provide a ‘feel good factor’

• Exercise can be an effective diversional therapy for headache sufferers

Any Questions?