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Headache:: A Practical Summary For Primary Care Providers
Headache:: A Practical Summary For Primary Care Providers
Prevalence:
Women 25% (lifetime)
Men 8% (lifetime)
28 million persons have migraine each year in the U.S.
Highest from 25-50 years of age
Genetics
About 70% of migraineurs have a positive family history in a first-
degree relative
Unknown mode of transmission
Strange (Scary) Facts
Time
15% of patients
Episode of focal
neurologic changes
Develop over 5 to 15
minutes & last up to 60
minutes
Visual, weakness,
numbness, confusion
Headache
Depression
Drowsiness
Cognitive changes
Memory loss
Difficulty with concentration
Treatment philosophy
Avoid triggers!
Maintain regular sleep schedule
Maintain regular meal schedule
Low tyramine
Limit caffeine
Avoid nitrates/nitrites/MSG
Limit chocolate
Reduce stress
Adequate water intake
Treatment Options
Two Treatment Approaches
• Acute therapy
Work quickly to relieve migraine pain and other
symptoms
Are taken only at migraine onset
• Preventative therapy
Prevent or reduce the number of migraine attacks
Are taken on a daily basis
Migraine Abortives
NSAIDs
Triptans
Acetaminophen/Butalbital/Caffeine
OTC migraine preparations “Excedrin Migraine”
DHE
Acute Treatment
NSAIDS
Inhibit prostaglandin formation, thus reducing inflammation
Naproxen
Ibuprofen
ASA
COX2 inhibitors
Acute Treatment
Triptans
Selective 5-HT1B/1D agonists
Block actions of 5-HT such as dilation of cranial arteries/AV anastomoses, neurogenic dural
plasma extravasation
Use early!
More effective in mild/moderate pain
Caution about rebound
Acute Treatment
Triptans:
Almotriptan (Axert)
Eletriptan (Relpax)
Frovatriptan (Frova)
Naratriptan (Amerge)
Rizatriptan (Maxalt)
Sumatriptan (Imitrex)
Zolmitriptan (Zomig)
Acute Treatment
Triptans
Relative contraindication:
Complicated migraine
CAD, CVD, PVD
Smoker + oral contraception
Severe HTN
Acute Treatment
Ergotamine tartrate
Available for over 50 years
Vasoconstrictors
Oral, SL, IV, PR
Caution about rebound, dependence
Contraindicated:
CVD
CAD
PVD
Severe HTN
Sepsis
CKD
Hepatic disease
Pregnancy
Acute Treatment
OTC agents
Cautious of rebound!
Opioids and butalbital are NOT considered appropriate abortive agents except in
cases of last resort. [US Headache Consortium]
Status Migrainosus
Seizure Medications
Topiramate, valproate, gabapentin, zonisamide
Blood Pressure Medications
Beta Blockers: propranalol, nadolol
Ca+ Channel Blockers: verapamil
Antidepressants
Tricyclics: amitriptyline, nortriptyline
Combos: venlafaxine
Botulinum Toxin
No aggravation by walking up
stairs or similar routine physical
activity
Acute
NSAIDs
Acetaminophen
Muscle relaxers ?
Chronic
TCA
Physical Therapy
OMT
Occipital Nerve Block
Cluster Headache
Cluster Headache: Diagnostic Criteria
At Least 5 Attacks Fulfilling the Criteria Below
Frequency Description of Headache Associated Symptoms
of attacks:
1 every All of the Following: AND One of the Following
other day Severe Present on the Pain Side:
to 8 per
day Unilateral orbital, Conjunctival Miosis
supraorbital, and/or injection
Ptosis
temporal location
Lacrimation
AND Lasts 15 to
Eyelid edema
Rhinorrhea
180 minutes
(untreated) Nasal congestion