HEADACHE LECTURE

Headache Eval: Red flags for secondary causes (SNOOP4)

 Systemic signs/symptoms: fever, blood work abnormal, wt loss, cancer hx
 Neuro exam abnormal
 Age of Onset < 5 yo or > 50 yo
 Acute Onset
 Pattern change/progressive
 Valsalva Precipitation
 Positional/postural
 Papilledema

Testing for 2ndary causes

 Imaging: MRI > CT except acute hemorrhage
o Suspect infxn or mass lesion  order WOW contrast
o Suspect vascular cause  vessel imaging
 LP
o Get opening pressure!
 Labs: CBC, ESR, CRP

Headache Dx: Migraine without Aura

 At least 5 attacks fulfilling criteria
 HA lacks 4-72 hrs (untreated or unscessfully treated)
 Has at least 2 of the following:
o Unilateral
o Pulsating
o Mod-severe pain
o Aggravation by or causing avoidance of routing physical activity (ex:
walking or climbing stairs)
 During HA at least 1 of the following
o N/V
o Photophobia and phonophobia

Headache Dx: Migraine without aura

 Atleast 2 attacks fulfilling criteria
 One or more of the following reversible aura symptoms
o Visual
o Sensory
o Speech/language
o Motor
o Brainstem
o Retinal
 At least 3 of the following
 o At least 1 aura spreads gradually over 5 mins
o 2 or more aura symptoms in succession
o each individual aura lasts 5-60 mins
o at least 1 aura symptom is unilateral
o at least 1 aura symptom is positive
o the aura is accompanied or following within 60 mins by headache

Headache Dx: Phases of migraine attack

 Prodrome (few hrs to days)
o MC is fatigue
o Then problems w/ concentration
o Then yawning, irritability, depression
 Aura (5-60 mins)
 Migraine attack (4-72 hrs)
 Postdrome (24-48 hr)

Treatment: Acute
 Non-specific
o Acetylsalicyclic acid
o Tylenol, advil, aleve
o Diclofenac
o RISK FOR REBOUND  don’t use more than 14 days per month
 Triptans
o Almotriptan
o Eletriptan
o Frovatriptan
o Naratroptan
o Rizatriptan *sometimes insurance covered
o Sumatriptan (oral, nasal subq) **most often covered by insurance
o Zolmitriptan (oral, nasal) *sometimes insurance covered
o Only use about 9x/month
 Combination – Sumatriptan + Naproxen
 No triptans: Hx of MI, uncontrolled BP (>160), Hx of stroke  triptans cause
vasoconstriction
 Opioids/Barbituates are last resort  can covert to chronic migraine, response
decreases over time, can increase migraines due to up-regulation of CGRP
receptors  don’t use more than 1x week
 Make a stratified plan for diff levels of intensity - mild, mod-severe, rescue tx

Headache: Preventative
 Lifestyle mod (hydration, sleeping, skipping meals, exercise)
 Avoid triggers
 Consider adding preventative meds if
 o 3+ HA per month causing functional impairment that don’t always respond
to acute tx
o > 6-8 HA per month
o contraindications to acute treatments
o severe presentation (hemiplegia)
o at risk of developing medication overuse

Headache Tx: Preventative

 anti-HTN
o metoprolol, propranolol, timolol, nadolol, atenolol
 anti-seizure meds
o topiramate
o Depakote
 Anti-depressant
o Amitriptyline
o Venlafaxine
 Nutra-ceuticals
o Magnesium citrate
o Riboflavin
o Feverfew
 Botulinum toxin injections (for chronic migraine only)
 Calcitonin-gene-related peptide inhibitors (CGRP)
o Erenumab
o Galcanezumab
o Fremanezumab

Hx of CGRP
 CGRP = potent dilator located in trigeminal system