Headache & Migraine - Approach

Warning/Danger signs for headache
# worse headache of my life
# new headache in patient with cancer
# fever
# HIV
# headache that spreads down lower neck (think meningeal irritation)
# change in mental status
# rapid onset with exercise (think carotid dissection or intracranial hemorrhage)
# focal neurological symptoms, other than typical aura

Types of headaches and treatment options
Cluster Headaches are one of the most debilitating types of headaches. The treatment is similar to that of acute migraine. You can use triptans (injection) and high flow oxygen 7-10L/min via FM for 10 minutes. Then to try to arrest the cluster ( because they can occur several times in one day and over a 3-6 week period) give daily high dose oral corticosteroids for 2-4 weeks, then taper of 2-4 weeks to suppress the cluster period. Calcium channel blockers and anticonvulsants have also been used.

Tension Headaches are the most prevalent type of headache syndrome. They are often a squeezing
sensation or pressure around the head. They can have light or sound sensitivity, similar to migraines, but no nausea. The last minutes to days and the pain is typically constant. Anti-inflammatory drugs or muscle relaxants work well.

Medication overuse headaches usually present when or soon after awakening. Using medications sometimes decreases the intensity of their headaches but it won't completely remit. You should suspect this or be aware of at risk patients if they use medications >=2days/week for headache. Try to get patients off analgesic medications. Make sure they don't have headache from some other cause- e.g. sleep disorder, mass lesion, infection, inflammatory disorder, or cervical pathology.

Migraines affect 10% of the general population. About 60-70% have prodrome, which occurs up to 24 hours before migraine. Symptoms of prodrome can be food craving, depression, fatigue, hypomania, dizziness etc. About 15-20% of patients have aura within one hour of migraine, and these are neurologic abnormalities such as visual loss, hallucinations, numbness/tingling, confusion and weakness. Migraines in patients older than 50 may have late development of migraine, visual disturbance or other neuro deficits.

Migraine treatment:
#Ergot derivatives (non-selective 5HTR agonists) are the preferred tx for status migraines. You should give antiemetics and antihistamines first. This is category X for pregnant women.
#Most of us are more familiar with triptans, selective 5HTR agonists. These are contraindicated in coronary disease. Side effects include chest discomfort, flushing, nausea, dizziness etc. Both bind to the trigeminal nerve endings and blood vessels, stabilizing them and decreasing inflammatory substance release.
#If mild symptoms you can use nonspecific therapy such as ASA, tylenol, caffeine combo pills with ASA or tylenol, NSAIDS.
#Consider preventive if they have >=5 migraines/month or >=2 migraines/wk

Pearls:

# Earlier treatment of migraines increases success of the treatment.

# Triptans are not effective in migraine with aura unless the aura has finished

# Response to triptans is not class effect

# Give oral dopamine antagonists like reglan for increased absorption and to help with nausea both from migraine and other meds you are giving.

(Katharine Cheung MD, 9/24/10)