A 25-year-old woman presents to your clinic complaining of a bifrontal headache that started this morning. She describes the pain as throbbing and 8/10 in severity. She is complaining of photophobia and nausea. She has had similar headaches in the past, lasting a few hours to all day. She is unable to work during these headaches and prefers a dark, quiet room (as do we all). The physical examination, including neurological examination, is unremarkable.
Question 18.4.1 Which of the following statements is most accurate?
A) She likely does not have migraine headaches because her headache is bilateral
B) She likely does not have migraine headaches because they most commonly present in the fourth to fifth decade of life
C) She likely does not have migraine headaches because they rarely occur in the morning
D) She likely has migraine headaches
Answer 18.4.1 The correct answer is "D." She likely has migraine headaches. Migraine headaches may vary considerably in severity, time of day, and characteristics. The International Headache Society (IHS) has a useful classification system with criteria for the diagnosis of migraine headaches (Table 18-4). "B" is incorrect because migraine headaches typically present in the first three decades of life. Attacks typically last less than 1 day although they may occasionally last longer. Migraine headaches are typically moderate to severe in intensity, may occur at any time during the day, and occur with or without aura. Most migraine headaches are unilateral, preceded by aura, and accompanied by nausea and vomiting. They are more prevalent among women, with a 1-year prevalence rate of approximately 18% in women, 6% in men, and 4% in children. Family history is important as 80% of patients with migraine headache have a first-degree relative with migraines.
TABLE 18-4CRITERIA FOR THE DIAGNOSIS OF MIGRAINE WITHOUT AURA ||Download (.pdf) TABLE 18-4 CRITERIA FOR THE DIAGNOSIS OF MIGRAINE WITHOUT AURA
|At least five attacks fulfilling the following criteria: |
Headache lasting 4–72 hours (untreated or unsuccessfully treated)
Headache has at least two of the following characteristics:
Moderate or severe intensity (inhibits or prohibits daily activities)
Aggravation by walking stairs or similar routine physical activity
During headache at least one of the following:
Nausea and/or vomiting
Photophobia and phonophobia
No evidence of organic disease
Migraine headaches were formerly classified as classic type (migraine with aura) and common type (migraine without aura). Typical auras develop over several minutes and last for less than 60 minutes. Auras may involve visual, language, sensory, or motor deficits. The visual auras are by far the most common and may appear as photopsias (flashes of light), scotomas (blind spots), or complex shapes that build or move across the visual field. The IHS criteria for migraine with aura are listed in Table 18–5.
TABLE 18-5CRITERIA FOR THE DIAGNOSIS OF MIGRAINE WITH AURA ||Download (.pdf) TABLE 18-5 CRITERIA FOR THE DIAGNOSIS OF MIGRAINE WITH AURA
At least two migraines (see Table 18-4) fulfilling at least three of the following characteristics:
One or more fully reversible auraa symptoms indicating brain dysfunction
At least one aura symptom develops gradually over 5 minutes (or longer) or two or more symptoms occur in succession
No single aura symptom lasts more than 60 minutes
Headache begins during aura or within 60 minutes of the end of the aura
History, physical, and appropriate diagnostic tests exclude a secondary cause
Remember that the IHS criteria are research tools. Patients may have a migraine and not meet all of the criteria noted by the IHS. While patients with a certain type of migraine headache will ideally meet all criteria, it is not necessary to meet all criteria to make a clinical diagnosis of migraine headache.
You have decided to treat this woman's migraine headache.
Question 18.4.2 Which medication would be LEAST appropriate for acute management of her headache?
B) Intranasal sumatriptan
C) IV meperidine (Demerol)
Answer 18.4.2 The correct answer is "C." The least appropriate treatment from the above list would be Demerol (meperidine). The long-term use of opiates for rescue therapy has not been found to improve the quality of life in patients with migraines. Oral NSAIDs ("A"), including aspirin and combination analgesics containing caffeine, are a first-line choice for mild-to-moderate migraine attacks or severe attacks that have been NSAID responsive in the past. "B," the "migraine-specific" treatments, commonly called the "triptans" (e.g., sumatriptan, zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan, and frovatriptan—wow, talk about "me too" drugs …), are effective and relatively safe for the acute treatment of migraine headaches. Triptans are an appropriate initial treatment choice in patients with moderate-to-severe migraines who have no contraindications to their use (see below). Alternative vasoconstrictive agents, including DHE nasal spray (dihydroergotamine, "D"), can provide a safe and effective treatment of acute migraine attacks. DHE can be administered IV as well. Vasoconstrictive side effects, including the risk of coronary artery spasm, should specifically be discussed with patients prior to initiation of therapy.
Adding oral metoclopramide to aspirin or NSAIDs will improve their rate of success. Part of the nausea and vomiting from migraines (and the reason that oral medications often do not work) is from gastric paresis. Metoclopramide overcomes this problem and treats nausea as well. Our favorite drug to treat headaches with is prochlorpemazine, 10 mg IV or 25 mg PR. This works for both migraine and tension-type headaches. See Table 18-6 for a list of migraine headache treatments.
TABLE 18-6U.S. HEADACHE CONSORTIUM GUIDELINES FOR TREATMENT OF HEADACHE ||Download (.pdf) TABLE 18-6 U.S. HEADACHE CONSORTIUM GUIDELINES FOR TREATMENT OF HEADACHE
Question 18.4.3 Which of the following statements is correct?
A) If a patient does not respond to sumatriptan, there is no point in trying another triptan because the patient will not respond
B) DHE and sumatriptan may be safely used within the same 24-hour time period
C) Sumatriptan use is contraindicated in patients with known coronary artery disease, regardless of age
D) Flushing, sweating, and paresthesias after a dose of sumatriptan is an indication of a severe reaction and continued use of this medication is contraindicated
Answer 18.4.3 The correct answer is "C." The triptans should not be used in patients with known coronary disease. Patients who do not respond to one triptan may respond to other triptans, and a trial of other triptans is appropriate. Also, a patient may respond initially to a triptan but not respond on other occasions. Each triptan has a maximum recommended dose, and a good rule of thumb is that the initial dose may be repeated once in a 24-hour period of time. However, avoid the use of DHE within 24 hours after a triptan has been given due to increased vasoconstriction and the possibility of vasospasm.
Question 18.4.4 Contraindications to the use of "triptans" include all of the following EXCEPT:
B) Uncontrolled hypertension
C) Use of an MAO inhibitor within the last 2 weeks
D) Use of an ergot preparation within the last 24 hours
Answer 18.4.4 The correct answer is "A." Lung cancer is not a contraindication to the use of triptans. In addition to "B" to "D," caution should be used in patients with history of stroke, known cardiac risk factors, and impaired liver function.
Common reactions to triptans include jaw tightness, flushing, anxiety, dizziness, and sweating. These are uncomfortable but not dangerous. Serious reactions to triptans include coronary vasospasm, anaphylaxis, or hypertensive crisis in patients with known CAD, hypersensitivity to triptans, or uncontrolled hypertension. See Table 18-6 for acute treatment of migraine headaches.
Consider dexamethasone as an adjunct therapy in severe headache. A single dose of dexamethasone 10 mg PO, IV, or IM after abortive therapy in the ED may prevent headache recurrence in patients who have had a headache for more than 24 hours (NNT 9).
Your patient has decided to take ibuprofen for her headaches. This medication seemed to be effective at first, but she notes for the last several weeks that she is taking two to three doses of ibuprofen per day without significant headache relief. She has had a dull bilateral headache that is moderate in severity for the last 2 weeks. The medication dulls the headache but it comes right back. She has no personal or family history of coronary artery disease.
Question 18.4.5 Which of the following statements is correct?
A) She likely has a tension headache and should increase her frequency of ibuprofen and continue to take it on a daily basis
B) She likely has a medication-overuse headache in addition to chronic migraine headache (status migrainous) and should taper and then discontinue ibuprofen
C) A medication such as sumatriptan used on a daily basis does not increase the risk of rebound headache
D) She likely does not have medication-overuse headache because opiates are the only medications that increase the risk of these headaches
Answer 18.4.5 The correct answer is "B." See below for a detailed explanation.
Question 18.4.6 Which of the following medications taken on a frequent basis is LEAST likely to cause medication-overuse or rebound headache?
E) All of the above are equally likely to cause rebound headache
Answer 18.4.6 The correct answer is "D." Frequent use of opiates, acetaminophen, NSAIDs, ergotamine, triptans, and any other analgesics may put a patient at risk for medication-overuse or rebound headache. Although analgesic rebound headache characteristics can vary significantly, the patient typically reports a pattern of headache that decreases modestly in severity with the use of their analgesic of choice, and then in 2 to 4 hours (depending on the medication), the headache returns to its previous severity or worsens further. Failure to repeat analgesic use results in a withdrawal headache (similar to the caffeine withdrawal headaches physicians often experience when they miss their morning coffee). In the case of triptans, the headache may not worsen for many hours or even until the next day, but a cycle of regular use of the medication is still established. At this time, no clear consensus on the duration of therapy necessary to produce analgesic rebound is reported. As a general rule, it is best to limit the use of analgesic medications to no more than 2- to 3-headache days per week. In addition, limit the patient's analgesic use to no more than 2 to 3 weeks per month. Patient education is the most important part of therapy in treating analgesic rebound or medication-overuse headaches.
Treatment of rebound headaches consists of discontinuing the medication. Several approaches have been tried to reduce headaches after the analgesic has been withdrawn. These include IV or oral steroids, long-acting NSAIDs (naproxen), and elective admission, and therapy with IV DHE (dihydroergotamine) or Thorazine (chlorpromazine). These should be combined with a prophylactic medication such as amitriptyline (or other tricyclic) used on a daily basis. Patients can also take hydroxyzine and prochlorperazine when they have a breakthrough headache at home; these medications do not cause rebound headaches.
Question 18.4.7 Which of the following medications would be the LEAST appropriate for the preventative treatment of your patient's migraine headaches?
Answer 18.4.7 The correct answer is "D." Clonazepam is not used as a preventive treatment for migraine headaches. Keep in mind the common side effects of these medications and the appropriateness in your specific patient. For example, valproate would be a bad choice for many patients secondary to weight gain or teratogenicity. Propranolol may cause hypotension. Amitriptyline may cause cardiac arrhythmia in certain patients, while constipation and urinary retention are relatively common in elderly patients. Topiramate (Topamax) may actually cause weight loss, and impaired cognition is common.
A number of medications are useful in the prevention of migraine headaches.
Medications that have been found to have medium-to-high efficacy, good strength of evidence, and mild-to-moderate side effects include amitriptyline, divalproex sodium, and propranolol/timolol, topiramate
Medications of lower efficacy include atenolol/metoprolol/nadolol, nimodipine/verapamil, aspirin/naproxen/ketoprofen, fluoxetine, ACE inhibitors, gabapentin, feverfew, magnesium, and vitamin B2
Antidepressants such as fluvoxamine, paroxetine, nortriptyline, sertraline, trazodone, and venlafaxine have also been found to be clinically efficacious based on consensus and clinical experience, but no randomized controlled trials have been done to establish their efficacy
Combination products such as butalbital/caffeine/acetaminophen/codeine (e.g., Fiorinal with codeine) have no role in the treatment of migraine or other headaches. Addiction, abuse, and diversion are potential issues with these drugs.
Question 18.4.8 Which one of the following medications is rated Class B or better in pregnancy?
A) Phenergan (promethazine)
Answer 18.4.8 The correct answer is "E." Headache treatment in pregnancy remains a difficult problem. Although numerous medications are available for headache treatment, their safety in pregnancy has not been established. Amitriptyline and valproic acid are class D in pregnancy. Other commonly used tricyclics include imipramine (Class C) and nortriptyline (Class D); venlafaxine is Class C. Promethazine, prochlorperazine, codeine, hydrocodone, and meperidine are all Class C. Ergotamine (DHE 45) is Class X. The triptan class of medications, including sumatriptan, remains Class C, though pregnancy registries, retrospective, and observational studies suggest that sumatriptan is safe.
Question 18.4.9 In which of the following patients is neuroimaging LEAST likely to be useful?
A) A 30-year-old woman with a headache typical of a migraine
B) A 23-year-old woman with a history of migraine headaches that is very concerned because her current headache of 1-week duration is more severe than her typical migraine headaches. She has been unable to sleep or concentrate at work because of her "headache anxiety."
C) A 60-year-old man with new headache, worse in the morning and of 6 weeks duration
D) A 40-year-old man with a headache and right arm weakness
Answer 18.4.9 The correct answer is "A." According to the U.S. Headache Consortium, neuroimaging is not typically recommended in migraine patients with a normal neurologic examination. Imaging may be considered in patients who are disabled by their fear of serious pathology or if the provider is suspicious about underlying pathology. Factors that may lead one to consider neuroimaging include a nonacute, atypical headache or unexplained abnormal neurologic examination.
Not all unilateral headaches are migraines. Think of occipital neuralgia, temporal arteritis, jolts and jabs (icepick) headache, temporalis muscle overuse/TMJ syndrome, chronic paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome, and cluster headaches, among others. We can't cover all of these in our limited space. We are trying our hardest, captain.
Objectives: Did you learn to…
Recognize and diagnose migraine headaches?
Initiate appropriate acute therapy for migraine headaches?
Identify contraindications and adverse reactions of the triptan medications?
Recognize and treat analgesic-related headaches?
Identify appropriate preventive therapy for chronic headaches?