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