Listen to CORE IM’s first 5 Pearls episode on Headaches!

Time Stamps

• 1:36 What are the indications for imaging for HA?
• 4:45 What is your approach to abortive therapy for migraines?
• 6:41 How do you diagnose medication overuse HA?
• 8:29 What is your approach to migraine prophylaxis?
• 10:42 What are some evidence based nonpharmacological therapies for migraines?

Show Notes

Pearl 1:

• Think about both patient characteristics and alarming headache qualities to determine if your patient’s headache requires imaging to look for secondary cause.
• Important patient characteristics are age and high-risk comorbities.
• Worrisome headache qualities include headache that awaken patient from sleep and constitutional symptoms.
• Remember that unless you’re looking for an acute bleed, MRI is the preferred imaging modality.

Pearl 2:

• NSAIDs are the first-line abortive therapy for both tension and migraine headaches.
• For moderate to severe migraines or when NSAIDs don’t work, triptans are useful abortive therapies.
• Don’t be scared to try multiple types of triptans if the first fails to help your patient.

Pearl 3:

• If you notice your patient’s headache changes from intermittent to a chronic, daily headache while using lots of abortive therapy medications, consider medication overuse headache.
• To avoid medical overuse headache, encourage your patient to limit triptans and NSAIDs to less than 2 times per week on average.

Pearl 4:

• If patients are getting migraines requiring abortive therapy more than 2x/week or have a medical overuse headache, think about adding migraine prophylaxis.
• Beta blockers like propranolol and anti-seizure meds like topiramate are the mainstay of migraine prophylaxis.

Pearl 5:

• There is strong evidence to support nonpharmacologic headache treatment, such as CBT, progressive muscle relaxation regular sleep and exercise!

Transcript

Pearl 1: Indications for Imaging

S: let’s jump into it Marty. The vast majority of headaches that a PCP is going to see are primary HAs. Of those, 70% will be tension type, 16% migraines and less than 1% will be the much rarer cluster HA.  That said, we should always look out for ‘red flags’

M: Yes Shreya. Red flags are clues that there might be a secondary headache going on here and we might need imaging. 

Think about concerning patient conditions and concerning headache features. Patient conditions that would make you think twice are serious medical conditions like cancer, HIV infection, seizures as well as pregnancy.  A new HA in previously healthy pt older than 50 is concerning for new mass lesions.

S: Yes I am definitely more cautious in patients with those demographics. But what are some headache features I should be looking out for?

M: Features of the headache include obvious things like constitutional symptoms, such as weight loss and fever, nausea/vomiting   or focal neurologic signs including papilledema (which I know, I know that can be difficult to evaluate during a non-dilated eye exam, but do your best to examine!) .  Always ask about patterns that may trigger headache like sex, coughing or exertion. HA that wakes the patient from sleep may indicate a mass. A changing headache is also a concerning headache and may warrant imaging.  

S: Yep, particularly if the changing feature is such that its the worst HA of their life or an acute thunderclap HA, in those scenarios you would be concerned for the possibility of an aneurysmal bleed.

M: Exactly, so to recap, you should watch out for key features while taking a history: a new HA in someone >50, a HA wakes them up from sleep, HA associated weight loss or fever, positional changes, occurring with sex or cough and immunocompromised status

S: And if there is a red flag sign …

M: Then don’t pass go! Go directly to imaging!

S: Of course, now how do I choose between CT vs MRI?

M: Fortunately, there is great expert guidance available.  The American Headache Society’s Choosing Wisely list outlined these.  Their first two recommendations discuss imaging. #1:Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine   #2 in their list is “Don’t perform CT imaging for headache when MRI is available, except in emergency settings”.  If you’re looking for blood or acute stroke CT is fine.

S: But I think in the majority of cases in primary care offices where the physician are ordering imaging for a patient w/ headache –  they are worried about mass lesions or vascular disease. Whats the imaging of choice then?

M:  CTs just aren’t sensitive enough for these conditions.   Also, saving the patient from unnecessary ionizing radiation should always be high on our priority list.   

S: Ok Marty, so we talked about red flag signs.. and the possible need for imaging, but in our approach to HAs, we should also always consider other  secondary causes of HA such as obstructive sleep apnea leading to morning HAs, sinusitis associated with frontal HAs, or did the pt have a trauma and the HA is a part a postconcussive syndrome. These are somethings you want to think of and rule out

Pearl 2: Abortive Treatment

M: Alright, we’ve ruled out any red flag signs or other secondary causes of HA; you determine it’s a migraine, then what?

S:  Then treat!  For abortive therapy, you either want to categorize the migraine as mild-mod or mod-severe. If its mild-mod, your 1st line options are: NSAIDs- naproxen vs. ibuprofen. I personally prefer naproxen because its longer lasting and which can be given every 12 hours vs. ibuprofen which is given every 6 to 8 hours

M: What about just acetaminophen?

S: In studies at least, acetaminophen alone is shown to NOT be an effective for acute migraines. So we typically do not use it to treat true migraines.

M: Good to know, what about patients that don’t respond to NSAIDS or those with mod-severe HA right off the bat?

S: then think about triptans. You want to be careful though because triptans do have vasoconstrictive properties. So be cautious starting it in pts with ischemic heart disease, stroke, uncontrolled HTN. But if the blood pressure is controlled, triptans can be given.  

Of all of the oral triptans, a meta-analysis found rizatriptan, eletriptan and almotriptan to be the 3 most effective so if those are on your hospital formulary, thats a win! In terms of the starting dose, some neurologist say they will even start at a full triptan dose because there have been studies to show that if patients try a lower dose, even if it is halved and don’t respond, then patients will often not comply with a higher dose.

M: humm.. Interesting.  But what if that full dose triptan I prescribed doesn’t work?

S: Luckily, treatment failure does not seem to be a class effect. Patients that didn’t respond to 1 triptan may respond to another. There are 7 triptan options. So switching triptans is very reasonable. I’ve had patients say that its life-saving when they do find the triptan that works for them.

Pearl 3: Overuse HA

M: While we are talking about benefits of abortive therapy, tell me about the flip-side of it, medication overuse HA

S: Right so, a medication-overuse HA is gonna happen in a patient with a pre-existing HA disorder who has been using abortive/acute meds in high, high frequency, such that the HA changes from episodic to CHRONIC and DAILY in nature. This is referred to as chronification.

M: Ok, so we should be looking for an increased frequency of HA AND high use abortive meds.

S: Yes, specifically if their episodic HA has changed to a chronic HA meaning 15 or more days per month.

M: So how much medication does it take to cause an overuse headache and all abortive medications the same?

S: Different meds can cause overuse headache with different frequencies of use.  For example, The American Migraine Prevalence and Prevention study demonstrated that  chronification of the HA is most likely to occur with 5 days of butalbital use per month – which is a component of fiorcet – also risk increased with more than 8 days of opioid use per month, greater than 10 days of triptans per month and 10-15 days of NSAIDS per month. For these reasons opioids and butalbital should be probably be avoided and acute migraine prescriptions  are best limited to 2 days per week.

M: Definitely be careful with fioricet or possibly avoid altogether!  It’s always tough giving medications for only 2 days per week because you don’t want your patients to be suffering! But we also dont want to be worsening the HA with overuse.  The way I approach it with my patients is to recommend limiting meds to 2x/week but if they have to take a third then maybe the following week try for just 1 day. But honestly, if you’re patient is using this much abortive therapy then maybe it’s time to start thinking about prophylaxis.

Pearl 4: Prophylaxis

S: Yaaaas! Perfect segway. So if your patient is experiencing effects of an  overuse HA from acute meds, the treatment is to stop the abortive therapy and start ppx. The other times ill start thinking of ppx is 1) if they have contraindications to the acute meds or 2) if despite managing triggers and appropriate use of the abortive meds, the pt says “hey doc im still having freq. HA” especially if 4 or more HAs a month OR “hey doc, I’m still having horrible migraine attacks that really interfere with their daily life, in these situations, you want to start OR add on migraine prevention meds

M: Right, sometimes patients with freq and severe HA require both abortive and preventive medications.  I start offering prophylaxis if the patient is experiencing HA more than 4x per month or the HAs are interfering with daily life.  Ok, there are tons of options for migraine ppx, how do I choose?

S: Yes a number to choose from, but in terms of trial data on prophylaxis, the ones with ESTABLISHED efficacy are Antiepileptics – divalproex and topiramate and B-blockers, particularly – metoprolol and propranolol. The ones with probable efficacy are amitriptyline, atenolol and ARBS such as candesartan. vs. meds such as Lisinopril and Ca Ch blockers are possibly effective

M: alright so reach for antiepileptics like topiramate and valproate or b-blockers like metoprolol and propranolol.  And isn’t there a great side-effect from topiramate? Topiramate is a weight-loss drug at the doses you would use for HA ppx!

S: haha, yes! And it’s important to note when starting migraine ppx to educate patients on what defines success. Neurologists consider it a success if the migraine freq. or # of days of migraines is reduced by 50% in 3 months.

M: Good to know! It is so important to set expectations for the patient.  (we should try) Our goal is usually to decrease sx by half if they stick with it for at least 2-3 months

Pearl 5:  Nonpharmacologic treatment

S:  So Marty, I had this patient who told me all about her long struggle with HAs and I go to tell her the plan, she stops me and says she not interested im not interested in adding anymore pills! And I’m like, ‘don’t you want something for these terrible HA you spent 30 minutes telling me about??!! so what do I do in the situation where a patient is really suffering but doesn’t want any medications

M: Oh no!  We have all been there. A great plan only works if the patient agrees, but good for her, there are tons of great options that have been studied and shown efficacy.

S: id love to hear about it. I definitely didn’t feel as confident in my treatment plan without the meds I’ve known to work

M: There was a great review published in Continuum, the official review article journal of the American Academy of Neurology, that describes non-pharmacological treatment options.  We’ll list the paper in the show notes. Three great options are cognitive behavioral therapy, biofeedback and progressive muscle relaxation therapy. They are all level A evidence based preventive treatments.

S: Tell me more about them!

M:  Progressive relaxation, is a technique that teaches you how to relax muscles with purposeful systematic tension followed by relaxation.  This alternation between tension and relaxation has been shown in prospective studies to reduce the frequency of migraines. Patient can find apps out there to help guide this. Many people will remember that CBT (cognitive-behavioral therapy) is a type of psychotherapy that helps patients modify destructive patterns of thinking and behavior.  Randomized trials demonstrate the efficacy of CBT alone or in combination with the previously mentioned nonpharmacologic strategies

S: But what about my underserved patients who do not have access to CBT or my grandpa that can’t use apps?

M: Aerobic exercise – A large observational study demonstrated that low physical activity was associated with higher prevalence of migraines than those who exercise more.  A follow-up experiment showed that 40 mins of indoor cycling 3x/week was equally as effective at migraine prophylaxis than topiramate and relaxation techniques. And Sleep! – a regular sleep schedule is crucial to prevent migraines!

S: That is so empowering to hear.  now that I know there is good evidence behind.   I’m definitely gonna more confident in the future talking about exercise, relaxation for migraines

..Let’s review the key points from our discussion of headaches.

Take aways

M: Think about both patient characteristics and headache qualities to determine if your patient’s headache requires imaging to look for secondary cause.  Important patient characteristics are age and comorbities. Worrisome headache qualities are HA that awaken patient from sleep and a changing headache. Remember that unless you’re looking for a bleed, MRI is the preferred imaging modality.

S: NSAIDs are the first-line abortive therapy for both tension and migraine HAs.   When NSAIDs don’t work triptans are useful abortive therapies. Remember to start with full-dose and don’t be scared to try multiple types of triptans if the first fails to help your patient.

M: Be alert for medication overuse headache, especially if you notice your patient’s headache changes from intermittent to a chronic, daily headache while using lots of abortive therapy medications.  To avoid this encourage your patient to limit triptans and NSAIDs to less than 2 times per week on average.

S: That’s right, and if they’re still getting HAs requiring abortive therapy more than 2x/week then it’s probably time to start offering prophylaxis.  Beta blockers like propranolol and anti-seizure meds like topiramate are the mainstay of migraine prophylaxis.

M: And finally, other than medication prophylaxis there is good data to support nonpharmacologic HA prophylaxis like CBT, progressive muscle relaxation, biofeedback, regular sleep and exercise!  

S: So true that the simplest solution are sometimes the best

References:

• Loder, Elizabeth, et al. “Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question.” Headache: The Journal of Head and Face Pain 53.10 (2013): 1651-1659.
• Health Quality Ontario. Neuroimaging for the evaluation of chronic headaches: An evidence-based analysis. Ont Health Technol Assess Ser. 2010;10:1- 57.
• Detsky, Michael E., et al. “Does this patient with headache have a migraine or need neuroimaging?.” Jama 296.10 (2006): 1274-1283.
• Gilmore, Benjamin, and Magdalena Michael. “Treatment of acute migraine headache.” Am Fam Physician 83.3 (2011): 271-280.
• Munksgaard SB, Jensen RH. “Medication overuse headache.” Headache. 2014: 807-22.
• Pringsheim, Tamara, et al. “Canadian Headache Society guideline for migraine prophylaxis.” Can J Neurol Sci 39.2 Suppl 2 (2012): S1-59.
• Mauskop, Alexander. “Nonmedication, alternative, and complementary treatments for migraine.” CONTINUUM: Lifelong Learning in Neurology 18.4, Headache (2012): 796-806.
• Silberstein, S. D., et al. “Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society.” Neurology 78.17 (2012): 1337-1345.