A Family Doctors Approach To "That Nagging Headache "

1. A Family DoctorsApproach To"That Nagging Headache" DR JANE MCDONALD

2. INTRODUCTION • Headache is one of the most frequent diseases seen in clinics by the primary care physician

4. TYPES OF HEADACHES

5. ANATOMY

6. Table 2. Comparison of key features distinguishing migraine, tension, and cluster headaches Migraine Tension Cluster Laterality Unilateral (60%) Bilateral Unilateral (exclusive) Intensity Moderate or severe Mild or moderate Severe Pain descriptor (variable) Pulsating (50%) Pressing or tightening Boring, piercing Physical activity Aggravation by physical activity Does not worsen with physical activity Restlessness or agitation during attack Associated symptoms Nausea and/or photophobia/ phonophobia No nausea, but may rarely have photophobia or phonophobia Ipsilateral symptoms; conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, eyelid edema Duration 4–72 hr Minutes to days 15- to 180-min cluster periods

7. 72.2% of all migraine sufferers went to their primary care physician • Migraine is the most common headache disorder seen by primary care physicians • One half go undetected

8. WHY? • Lack of appropriate screening tools • Constraints on physician time • Misdiagnosed as a sinus headache • Poor communication • More likely if female/upper income bracket vs. men/lower income bracket

9. COSTS Did you know… • In the USA, migraine and the associated disability cost employers 13 Billion annually

10. Posted: 21/January/2009 at 7:19am • "Canadians who have pursued post-secondary studies now owe the federal government $13 billion in loans, according to new figures from the Canadian Federation of Students." • "the $13-billion figure does not include $5 billion students owe to provinces, banks, credit companies and their parents." • http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20090121/student_loans_090121/20090121?hub=TopStories

11. Lorraine Sommerfeld

12. TENSION HEADACHES

13. TENSION HEADACHES • Mild to moderate pain • Bilateral • Steady • No autonomic symptoms • No nausea, vomiting • May have photophobia and phonophobia • Normally do not need to rest

14. QUESTION • Are tension headaches just mild migraines? • Both are worse with stress • Both get worse as day goes on • Both respond to the same medications • Usually there is no aura • It is believed that primary headaches exist in a spectrum from mild to severe

15. RED FLAG HEADACHES WARNING SIGNS “WORST HEADACHE OF THEIR LIFE” • Warning signs of possible disorder other than primary headache are: - Subacute and/or progressive headaches that worsen over time (months) - A new or different headache - Any headache of maximum severity at onset - Headache of new onset after age 50 - Persistent headache precipitated by a Valsalva maneuver - Evidence such as fever, hypertension, myalgias, weight loss or scalp tenderness suggesting a systemic disorder - Presence of neurological signs that may suggest a secondary cause - Seizures

16. Thunderclap Headache:Sudden and Serious Definition By Mayo Clinic staff Thunderclap headaches live up to their name, grabbing your attention like a boom of thunder. The pain of these sudden, severe headaches peaks within 60 seconds and usually fades over several hours. Some of these headaches, however, can last for more than a week. Thunderclap headaches are uncommon, but they can be a warning sign of potentially life-threatening conditions — usually having to do with bleeding in and around the brain. That's why it's so important to seek emergency medical attention if you experience a thunderclap headache

17. SNOOP Table 3. Indicators of possible secondary headache: SNOOP* • Systemic systems/signs (fever, myalgias, weight loss) • Systemic disease (malignancy, AIDS) • Neurologic symptoms or signs • Onset sudden (thunderclap headache) • Onset after age 40 yr • Pattern change —Progressive headache with loss of headache-free periods —Change in type of headache AIDS = acquired immunodeficiency syndrome. Adapted from Advances in the Study of Medicine.26 *  Mnemonic for systemic, neurologic, onset sudden, onset after 40, and pattern change.

18. MIGRAINES • Migraine-associated symptoms are often misdiagnosed as "sinus headache" by patients and health care providers. This has led to the under diagnosis and treatment of migraine. • Appropriate pharmacological or analgesic treatment of acute headache should generally not exceed more than two days per week on a regular basis. More treatment other than this may result in medication-overuse chronic daily headaches. • Disability from headaches is an important issue for migraineurs.

19. MIGRAINES • All patients should be considered for prophylactic therapy. • Migraines occurring in association with menses and not responsive to standard cyclic prophylaxis may respond to hormonal prophylaxis with the use of estradiol patches or estrogen-containing contraceptives. • Women who have migraines with aura should avoid use of estrogen-containing contraceptives. Headaches occurring during perimenopause or after menopause may respond to hormonal therapy. • Most prophylactic medications should be started in a low dose and titrated to a therapeutic dose to minimize side effects and maintained at target dose for 8-12 weeks to obtain maximum efficacy Diagnosis and Treatment of Headache Eighth Edition/January 2007

21. What do Family Doctors Do? Detailed History Functional disabilities at work, school, housework or leisure activities during the past three months Assessment of the headache characteristics requires determination of the following: Temporal profile: • Time from onset to peak • Usual time of onset (season, month, menstrual cycle, week, hour of day) • Frequency and duration • Stable or changing over past six months and lifetime

22. LOOK FOR Autonomic features: • Nasal stuffiness • Rhinorrhea • Tearing • Eyelid ptosis or edema

23. Ask Questions About Descriptive Characteristics: pulsatile, throbbing, pressing, sharp, etc. Location: uni- or bilateral, changing sides Severity 1/10 Precipitating features and factors that aggravate and/or relieve the headache History of other medical problems Pharmacological and non-pharmacological treatments that are effective or ineffective Aura (present in approximately 15% of migraine patients)

24. AURA Reversible Visual symptoms (flickering lights, spots, lines and or loss of vision Sensory symptoms “pins and needles” Dysphasic speech disturbance Homonymous visual symptoms (Pertaining to the corresponding vertical halves of the visual fields of both eyes.) Gradually develops over more than 5 minutes but last less than 60 minutes

25. TRIGGERS • Strong odors, perfumes, bright light or loud noises • Changes in weather or altitude • Being really tired, stressed or depressed or the let-down after an intense or stressful event • Changes in sleeping patterns or sleeping time, especially sleeping late or sleeping less or longer than usual • Missing meals or fasting • Menstrual periods, birth control pills or hormones for some women • Medications including analgesics

26. TRIGGER FOODS • Aged, canned, cured or processed meat, including bologna, game, ham, herring, hot dogs, pepperoni and sausage. • Meat tenderizer • Aged cheese • Monosodium glutamate (MSG) • Alcoholic beverages, especially red wine • Nuts and peanut butter • Aspartame • Onions, except small amounts for flavoring • Avocados • Papaya • Beans, including pole, broad, lima, Italian, navy, pinto and garbanzo beans • Passion fruit • Brewer's yeast, including fresh yeast coffee cake, donuts and sourdough bread • Pea pods

27. TRIGGER FOODS • Caffeine in excess • Pickled, preserved or marinated foods, such as olives and pickles, and some snack foods • Canned soup or bouillon cubes • Raisins • Caffeine-containing foods and drinks • Red plums • Chocolate, cocoa and carob • Sauerkraut • Cultured dairy products, such as buttermilk and sour cream • Seasoned salt • Figs • Snow peas • Lentils • Soy sauce

28. TREATMENT OF MIGRAINE

29. PATHOPHYSIOLOGY “INFLAMMATORY SOUP” Can be started by triggers. • Inflames the meninges (causes throbbing) • Activates the parasympathetic system • Sends signals to the trigeminal nucleus and cortex • Signal mediated by neural receptors • Serotonin is depleted and the receptor gates open causing inflammation • Goal:Fool the receptor sites and reduce inflammation and stop the “soup”

30. TRIPTANS • Designer serotonin compounds that fool the receptor and shut it of NSAIDS reduce the inflammation

31. TRIPTANS • Tablets • Melt • Nasal Spray • Subcutaneous • Short and Long Acting • As stated earlier, teaching points for the migraine patient must stress the earliest use of headache medicine in an attack to prevent central sensitization. Treating headache early is the best prognosticator of success.

33. Case Study • 60 year old female • Severe Headache • Unilateral • Distribution of the Trigeminal (5th nerve) • Thought it was “sinus’ • No fever, chills, nasal discharge • No nausea or vomiting • Hurts to touch • Went to ER • No help with codeine or NSAIDS

34. Diagnosis“Tic Douloureux” NEURALGIA

35. NEURALGIASevere headache “knife like” Treatment Tegretol Gabapentin

36. Lewis Carroll “Alice In Wonderland “ syndrome The patient complains of distortions of objects. Objects appear too big or too small.

37. You Are In Good Company! Migrainuer and Post-Impressionest Dutch Painter Vincent Van Gogh's 'Self Portrait With Straw Hat'

38. Celebrities and historical figures with Migraine disease include • President, and architect of the Declaration of Independence Thomas Jefferson • The great painters Vincent Van Gogh, • George Seurat (after which is named the Seurat effect, a current medical term often used to describe the visual phenomena of scintillating aura aka scotoma) • Claude Monet; great authors Virginia Woolfe, Cervantes (best known as the author of the classic, 'Don Quixote‘ • Lewis Carroll who's Migraines are said to have influenced his gifts of literature still so popular today • Leaders such as Julius Caesar, Napoleon, Ulysses S. Grant, Robert E. Lee, Mary Todd Lincoln • Scholars such as psychoanalyst Sigmund Freud, • Friedrich Nietzsche, the great German philosopher and poet who kept his enemy Migraine closer • Icon Elvis Presley, the King of Rock & Roll who struggled with the king of all 'headaches.'

39. Treatment of Migraine • 5-HT-1 agonists (triptans) intervention during the mild phase of headache; contraindicated with coronary heart disease (4)[A] • Triptans recommended if 1st-line therapy fails or pattern of migraine is severe (4)[A]: • Oral tablets more effective in early phase • Sumatriptan (Imitrex): 6-mg self-administered injection with efficacy of 70–85%. If initial injection fails to relieve migraine after 1 hour, do not repeat injection. 20-mg, or 25-mg, 50-mg, and 100-mg tablets with efficacy of 65%. If headache returns, may repeat, nasal spray, or oral tablets. • Zolmitriptan (Zomig, Zomig-ZMT): 2.5-mg tablet at onset of migraine; 5-mg tablet available; efficacy ~65% • Naratriptan (Amerge): 2.5 mg initially, 1-mg tablet available (both oral); slower to act than other triptans, but fewer adverse effects • Source: 5minute Clinical Consult.2009

40. Treatment of Migraine • Rizatriptan (Maxalt): Tablet and orally disintegrating tablet—initial dose 10 mg; efficacy similar to other triptans; reduce dose to 5 mg if patient using propanolol • Almotriptan: Oral tablets (6.25 or 12.5 mg); efficacy similar to other triptans • Frovatriptan (Frova): 2.5 mg at onset; up to 3 oral doses in 24-hour period • Eletriptan (Relpax): Oral tablets (20 mg and 40 mg); similar efficacy to other triptans; avoid eletriptan within 72 hours of ketoconazole, itraconazole, nefazodone, troleandomycin, or clarithromycin. Reference: 5 Minute Clinical Consult 2009

41. Treatment of Migraine:Continued • Contraindications: • Avoid 5-HT-1 agonists (triptans) in coronary heart disease, peripheral vascular disease, uncontrolled hypertension, and complex migraine (e.g., basilar or hemiplegic migraine). • 5-HT-1 agonists should not be used within 24 hrs of an ergot derivative or other triptans. • Selective 5-HT-1 agonists (triptans) are pregnancy category C. Ergotamines are pregnancy category X. • Avoid NSAIDs if danger of gastric erosion or renal or hepatic disease. • Avoid narcotics or butalbital in addiction-prone patients and patients with frequent migraines. • Avoid vasoconstrictors in uncontrolled hypertension, coronary heart disease, and peripheral vascular disease. • Avoid sumatriptan, zolmitriptan, and rizatriptan within 2 weeks of MAOI usage. • Source: 5minute Clinical Consult.2009

42. Treatment  of Cluster Migraines • Prophylactic therapy: If attacks significantly interfere with lifestyle or are not adequately controlled by appropriate acute interventions (6) • Propranolol (Inderal): 80–320 mg per day (6)[A] • Atenolol (Tenormin): 50–100 mg per day (6)[B] • Nadolol (Corgard): 40–80 mg per day (6)[B] • Timolol (Blocadren): 10–20 mg per day (6)[A] • Metoprolol (Lopressor): 100–450 mg per day (6)[B] • Amitriptyline (Elavil): 10–150 mg per day (6)[A] • Nortriptyline (Pamelor): 10–150 mg per day (6)[C] • Valproic acid (Depakene) or divalproex (Depakote): 250–1,500 mg per day (6)[A] • Verapamil (Calan): 80–120 mg per day (6)[B] • Topiramate: 100–200 mg per day (6)[A] • Cyproheptadine (Periactin): 4–16 mg per day (6)[C] • Source: 5minute Clinical Consult.2009

43. Treatment  of Cluster Migraines: Continued • General Measures  • During cluster periods: Avoidance of alcohol, bright lights and glare, and excessive emotion and stress, as these may precipitate attacks  • Treament of Cluster Migraine cont • Avoidance of narcotic analgesics, especially oral preparations • Avoidance of tobacco (high predilection for tobacco use in this population); may make patient more refractory to therapy Diet • During cluster phase, alcohol, even in small amounts, frequently precipitates attacks. • Rarely, specific foods may trigger attacks. Activity • Pain is of such severity that some patients consider suicide during attacks. Caution patient to avoid self-injury during bouts of excruciating pain. • Vigorous physical activity at 1st symptom may abort attack in some patients. • Compression of ipsilateral carotid or temporal artery may reduce pain in some patients. Exercise caution in recommending carotid massage in a patient at risk for occult carotid disease. • Source: 5minute Clinical Consult.2009

44. Treatment  of Cluster Migraines: Continued Medication (Drugs) • First-Line • General information: • Prophylactic therapy is paramount. • Avoid pain therapy, especially narcotic analgesics, for acute attacks. • Assess cardiovascular risk before instituting a vasoactive drug such as ergotamine or sumatriptan. • For acute attacks: • Oxygen 100% at least 7–10 L for 10–15 minutes, administered through a tight-fitting face mask with patient in sitting position and breathing at normal respiratory rate   • Source: 5minute Clinical Consult.2009

45. Treatment  of Cluster Migraines: Continued • Sumatriptan (Imitrex): 6 mg SC, maximum 12 mg/24 hours with at least 1 hour between injections (2)[A] (Sumatriptan 4 mg SC may be effective and allow additional daily dose) • Dihydroergotamine mesylate (DHE 45): 1 mg IM or IV; may teach SC self-administration • Prophylaxis (to shorten cluster period or prevent expected attacks): • Verapamil up to 80 mg PO q.i.d., spaced evenly through waking hours (3)[B] • Lithium carbonate (Eskalith): 300 mg b.i.d.–q.i.d. • Ergotamine timed to be at peak serum level during anticipated attack (e.g., 2 mg rectal or 1–2 mg PO 2 hours before); especially useful in preventing nocturnal attacks • Prednisone: Various schedules (e.g., 60–80 mg PO for 7 days followed by rapid tapering over 6 days or 40 mg/d for 5 days tapered over 3 weeks). This therapy is initiated during the use of a long-term agent such as verapamil or lithium. • Other agents with small or inconclusive studies include sodium valproate, clonidine, zolmitriptan NS, eletriptan, and topirimate • Source: 5minute Clinical Consult.2009

46. SUMMARY • Headache is a common disorder, which is seen throughout primary medical clinics in Canada. Each practioner needs to develop an approach to this difficult and potentially fatal disease in order that patients are treated in a timely, yet compassionate manner.  Guidelines, algorithms and tools have been developed to aid in the interaction between the physician and patient. • It will however always require exceptional communication skills, patience and understanding of the effects that headache has on someone’s life, in order to reduce the burden of this disease on the individual and society. 

47. REFERENCES 1. ICSI:Health Care Guidelines,2007.p1-73. 2. Elrington,Giles,Commentary: Controversies in SIGN guidelines on diagnosing and managing headache in adults.BMJ 2008;337:a2445.  3. Gladstein,Jack:Headache,Medical Clinics of North America,volume90,issue2 (March 2006). 4. Sadovsky,R.,Dodick,D.W:Identifying migraine in primary care settings, The  American Journal of Medicine vol 118,issue suppl, ( March 2005). 5. 5 Minute Clinical Consult, 2009.