Successful Management of the Difficult Headache Patient

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Success with the Difficult HA Patient
Charles Yanofsky, MD Susquehanna Health
Systems www.Susqneuro.com
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Conquering Headache
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Headaches

• We have a better understanding of the physiology
  of Headache than ever
• Larger Armamentarium
• Better Medicines
• Better Diagnostic Tools (MRI)
• More rational treatment of Comorbidities
• More treatments for chronic pain

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Our Armamentarium expands
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Migraine Pathophysiology
Goadsby NEJM 346 257-70,2002
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Mechanisms for treatment
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TRIPTANSTREATMENT CHOICES

• Almotriptan
• Tablet (6.25, 12.5 mg)

• Frovatriptan
• Tablet (2.5 mg)

• Zolmitriptan
• Tablet (2.5, 5 mg)
• Nasal spray (5 mg)

• Naratriptan
• Tablet (1, 2.5 mg)

• Are there differences between the triptans?
• If one triptan fails, will another triptan work?

• Rizatriptan
• Tablet (5, 10 mg)

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Pick a Triptan

• Relpax (elitriptan) is more reliably absorbed
• Rapid Onset and medium halflife
• Lipophilic Gut and BBB
• For Perimenstrual migraines prophylaxis Frova
  (frovatriptan) has a super long half life with
  slow onset
• Parenteral choices Zomig, Imitrex NS or imitrex
  sq
• Some patients respond to second triptan

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Relpax (Eletriptan) Advantages

• Favorable pain free, 1 and 2 hour efficacy vs.
  Sumatriptan
• Longer half life, quick absorption
• Peak 1.5-2 hrs, T1/24 hrs, 50 oral absorption
• Cerebro (vs. Cardio) Selective
• Avid binder to relevant receptors

Eletriptan (Relpax)
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Pharmacokinetic parameters for eletriptan and
sumatriptan
Intersubject variability 37 60 Oral
bioavailability 50 14
Renal clearance 10 20 Metabolic
pathway P450 MAO4
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Then Why do we Fail?

• Misdiagnosis
• Poor Choices for Therapy
• Failure to treat psychiatric factors
• Failure to treat co-morbidities
• Ignoring headache prevention

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Why we fail (and what to do about it)

• Misdiagnosis exclusion, inclusion
• Unrealistic expectations
• Chronic Daily headache and rebound
• Logic and Persistence
• Ignoring psychological factors
• Missing Red Flags

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Misdiagnosis

• Migraine underdiagnosed
• Cause of headache until proved otherwise
• TTH
• Sinus Headache
• Failure of typography Cluster, SUNCT, CIH
• Failure to assess psychosocial milieu
• Eating disturbance
• Ennui dissatisfaction with life
• Failure to diagnose more serious condition
  (RARE!!)
• SAH
• Pseudotumor and tumor
• Schaltenbrandts low pressure headache

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Sinus Headache and Tension Headaches are almost
always migraine headachesTension headache
pharmacologically is Migraine
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Therapy

• The first triptan in your drug cabinet?
• Ignoring prophylaxis
• Pharmacologic
• Non-Pharmacologic
• Treat Comorbidities
• Depression, anxiety
• Sleep disorder

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Prevention

• Tailor to patient
• May reduce frequency of HA 30-50
• Topamax, Zonegran, Depakote, Keppra
• Trazodone, Nortriptylene sleep, depr
• Inderal, verapamil HTN, Cluster (verap)
• Habits

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Prevention

• Migraine-Tension Spectrum
• Pharmacologically these are migraines
• Tension Headache less responsive to prns
• Chronic Daily Headache
• Clusters or Chronic Intermittent Hemicrania?

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Changing Meds

• Most preventives reqr 1-2 month trial
• Long lists of meds
• Inadequate trial
• Inadequate dosage
• I want relief now!!
• 2 headache (for PRNs), 2 month (for prophylaxis)
  rule

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Inadequate trials

• Pick a medication
• Good track record Type IA evidence
• Treat comorbidities
• Sleep disturbance
• Depression
• Hypertension
• Use it long enough for reasonable trial
• 2 months No medicine works immediately
• Headache calendar
• Give patient an out for breakthru headache

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Expectations

• Two thirds of patients will have a 50 reduction
  of headaches
• Migraine is a Chronic Disease
• No Preventive therapy will eliminate all
  headaches
• Patients should expect breakthrough headache
• Give patient some means of escape
• You cant kill every headache with medicine
• Rules of the game have to be explained

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Chronic Daily Headache

• Transformed Migraine (morphed Migraine)
• Analgesic Rebound
• New Chronic Daily Headache
• Chronic Tension Type Headache

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Morphed Migraine

• Conversion from headache attacks to chronic
  headache.
• Paroxysmal headache becomes chronic headache
• Patients describe multiple headache types
• All of them are migraine variants
• Migraine natural history
• Asthma becomes COPD
• RR MS becomes secondary progressive MS

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Chronic Daily Headache

• Exclude Serious Causes (red flags)
• Exclude psychiatric causes
• Prophylax not prn

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WORRISOME HEADACHE RED FLAGSSNOOP
Systemic symptoms (fever, weight loss) or
Secondary risk factors (HIV, systemic cancer)
Neurologic symptoms or abnormal signs
(confusion, impaired alertness, or consciousness)
Onset sudden, abrupt, or split-second
Older new onset and progressive headache,
especially in middle-age gt50 (giant cell
arteritis)
Previous headache history first headache or
different (change in attack frequency, severity,
or clinical features)
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Headache Red Flags

• First or worst headache
• Significant change from previous headache pattern
• New onset headache in middle age or later
• New progressive headache lasting for days
• Precipitation by cough, sneeze, bending down
• Systemic symptoms fever, myalgia, malaise, wt
  loss, scalp tenderness, jaw claudication
• Focal symptoms or altered sensorium, seizures
• Pryce-Phillips et al, 1997

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Children red flags

• AM headache
• Vomiting without nausea
• Papilledema
• Focal signs or ataxia
• Consider tumor or pseudotumor

Picasso
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SENSITIVITY OF CT SCAN IN SUBARACHNOID HEMORRHAGE
(SAH)
van Gijn J, van Dongen KJ. Neuroradiology.
1982. Kassell NF et al. J Neurosurg. 1990.
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LUMBAR PUNCTURE
Thunderclap headache with negative CT head
Subacute progressive headache
Headache associated with fever, confusion,
meningism, or seizures
High or low CSF pressure suspected (even if
papilledema is absent)
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Comorbidities
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Headache Crisis

• Rule out serious Cause
• DHE Reglan i.v.
• Toradol i.v. Reglan
• Depacon i.v. 1000 mg.
• Decadron
• Morphine infusion
• Consider outpatient Actiq-saves trip to ER
• Dependence

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Botox from imigraine.net
From Todd Troost, MD
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Fini