#122 Headaches Advanced Class: Migraines, medication overuse, and more!

October 29, 2018 | By Paul Williams

We delve into advanced management of headaches, including novel therapies, migraines with aura, migraines in complicated patients, and headaches of short duration with Dr. Rebecca Burch, a headache medicine specialist at the John R. Graham Headache Center at Brigham and Women’s Hospital.

Credits

Written and produced by: Paul Williams MD

Edited by: Matthew Watto MD

Hosts: Paul Williams MD, Stuart Brigham MD, Matthew Watto MD

Guest: Rebecca Burch MD

Headache 201 Pearls

1. Migraines are characterized by duration 4-72 hours, photophobia and phonophobia, or nausea and vomiting, as well as unilaterality, at least moderate severity, and symptoms that impact daily activity.
2. Chronic migraine means at least 15 headache days per month; fewer headaches mean episodic migraines.
3. Migraines can transform from episodic to chronic and vice versa.  Risk factors that increase likelihood of chronification include tobacco use, obesity, depression, difficult sleep or apnea, stress, and low socioeconomic status.
4. Migraine with aura is defined by the presence of a neurologic event that precedes the headache.  This can include visual aura, retinal migraines (with unilateral vision symptoms), abdominal migraines, brainstem migraines, and hemiplegic migraine.
5. Magnesium 400-500 mg/day can be used for prevention or for acute treatment of migraine with aura.  Antiepileptic drugs also appear to be effective.
6. Migraine patients with depression and anxiety tend to have more frequent headaches.  It is probably safe to use triptans with SSRIs and SNRIs.  Venlafaxine can be considered for migraine prophylaxis.
7. OnabotolinumtoxinA is FDA approved for chronic migraine only.  The CGRP antagonists erenumab and fremanezumab are approved for episodic and chronic migraines, but use will be limited by insurance considerations.
8. Counsel patients on the importance of consistent, quality sleep and stress management with things like yoga or meditation.
9. The use of OCPs does increase the risk for stroke in patients with migraine with aura, but baseline risk of stroke is very low, so risks and benefits of use must be weighed accordingly.
10. Treatment of overuse headache involves ensuring that the patient is on preventive medication, and withdrawing the overused medication.  BUT, this is only helpful for about 50% of patients, and rebound headaches can also occur.
11. Acetaminophen and naproxen seem to be less likely to cause overuse headache.  Hydroxyzine and gabapentin can be considered in the acute setting.
12. Headaches of shorter duration with autonomic features suggest the trigeminal autonomic cephalgias, which include cluster headache, paroxysmal hemicrania, and the SUNA/SUNCT headaches.
13. Secondary headaches are due to a specific cause (e.g. infection, trauma, mass, bleeding, etc.). Clues might include precipitation by a specific activity, such as cough or sexual activity. MRI without contrast is generally a reasonable place to start.

In-Depth Show Notes

Migraines

Diagnosis of migraine

Migraines last between 4-72 hours, and must have associated phonophobia AND photophobia or nausea and vomiting.  There must also be unilaterality, pounding or throbbing quality, severity rated from moderate to severe, and worsening with activity or symptoms that cause avoidance of activity.

Migraine with aura

Aura is neurologic event that happens before the onset of headaches. 95% of auras are visual, but they can be sensory or motor as well.  Terminology is a little tricky. “Complicated migraine” is not a technical term. The term “complex” was formerly used to denote the presence of aura.  

Chronic versus episodic migraine

Frequency of headache matters, with more than 15 headache days a month constituting chronic migraines.  This is in contrast to episodic migraines, which are characterized by less than 15 headache days per month.  Note that in this instance, chronicity is function of frequency and not duration.

Chronic daily headache

Chronic daily headache is not recognized in international classification of headache disorders.  Specialists prefer to classify into primary headache type. When a patient has headaches that meet criteria for migraines, their less severe headaches may still be a milder form of migraine aka a “forme fruste”.  Migraines can transform from episodic to chronic (about 2.5% per year) or vice versa (slightly lower chance of this).

Risk factors for chronic migraine

Tobacco use, obesity, depression, difficult sleep or apnea, stress, and low socioeconomic status all increase the risk of chronification.  Transformation back can be improved by preventive management

Other flavors of migraine headache

Retinal migraines

Retinal migraines involve spreading cortical depression that occurs in the retina itself  that occur unilaterally (in the unilateral eye). These are fairly rare, The term “ophthalmic migraine” generally denotes visual aura.  

Abdominal migraines

Abdominal migraines are characterized by abdominal pain or vomiting as part of the headache syndrome.  These symptoms usually predominate over the headache. This is seen primarily in children and adolescents, although can manifest as cyclic abdominal pain and vomiting in adults.  

Hemiplegic migraine

Hemiplegic migraine must have exam-confirmed motor weakness, as well as other aura (including dysphasia).  Generally, triptans are avoided in the management of hemiplegic migraine.

Brainstem migraines

Brainstem migraines can present with diplopia, vertigo, dysphagia, disorders of consciousness– it is uncertain if these truly originate in the brainstem.

Pathophysiology of migraines

This is an area of active research.  Migraines were previously thought to be a primarily vascular problem, but they are now thought to be more likely due to neuronal hypersensitivity.  This is evidenced by the fact that vasodilation is not required for migraines, and vasoconstriction may not help them. Migraine medications seem to generally work by reducing provoked cortical spreading depression.   For instance, triptans seem to act by preventing release of nociceptive neurotransmitters from peripheral pain neurons to deeper pain structures. Of note, one of the neurotransmitters involved is CGRP, which is a novel therapeutic target in the treatment of migraines.

Special considerations for migraine

Mood Disorders

Migraine patients with depression and anxiety tend to have headaches more frequently, and the headaches are often tied into the patient’s anxiety.  Patients with anxiety may treat prematurely which can precipitate overuse headache. Migraine and depression/anxiety seem to have a bidirectional relationship. You probably CAN safely use triptans with SSRI and SNRI medications, as there is no documented evidence of serotonin toxicity in patients who have been co-prescribed.  Venlafaxine has level B evidence for migraine prophylaxis.

Migraines and OCPs

Original studies of migraine with aura, oral contraceptive pills (OCP), and stroke risk looked at combined OCPs with high doses of ethinyl estradiol.  Presence of aura doubles risk of stroke, and high dose estrogen doubles risk again, so historically estrogen therapy has been avoided in patients with migraine with aura (the progesterone component does not appear to confer risk).  However, pregnancy also increases risk for stroke. The baseline risk for stroke is very low in this population, so risks and benefits must be weighed when considering hormonal contraception.

Migraine Treatment

Migraine with aura tends to respond to same treatments as migraine without aura.  Magnesium 400-500 mg/day seems to be useful to prevent or for acute treatment of migraine with aura.  Antiepileptic drugs may be useful for migraine with aura as well, especially lamotrigine. Calcium channel blockers may also be helpful.  

Acute and chronic therapy

Check out The Curbsiders episode #4 for Migraines 101 with in-depth discussion of acute treatment and prevention

Migraine cocktails

Migraine “cocktails” (e.g. metoclopramide or promethazine with diphenhydramine plus ketorolac) are often used in the acute setting, but migraine specific therapy may be more helpful.  Subcutaneous triptans can be tried, and you could also consider dihydroergotamine before considering an agent such as opioid analgesia.

Newer migraine therapies

OnabotolinumtoxinA is FDA approved for chronic migraine only, and there is no evidence for benefit in episodic migraine.  This may be considered for patients who have failed multiple oral medications. The CGRP antagonists erenumab and fremanezumab are approved for episodic and chronic migraines, although insurance coverage will be a limiting factor.  These have not been compared to other agents in head to head trials, but seem to be equivalent in efficacy.  

Nonpharmacologic management

High quality sleep is maybe the most important behavioral consideration in prevention of migraines.  Counsel patients on getting enough sleep, and going to bed and waking up at consistent times. Also consider stress management such as yoga and meditation.  Being sedentary can lead to chronification, so encourage exercise, if tolerated. Encourage healthy eating choices, and avoid foods that appear to trigger migraines.  There are no proven specific diet programs to reduce migraines.

Setting goals in migraine therapy

Expectation management is critical at the onset of treatment.  A 50% reduction of headache days constitutes a success, although it is reasonable to try to do even better.  The goal is an increase in the overall quality of life, so functionality is important as well (e.g a reduction in work days lost).

Medication overuse headache

Medication overuse headache defined as intake of greater than 15 days a month of naproxen or acetaminophen.  Use of butalbital, triptans, ergots, or opiates for more than 10 days a month for headache also constitute overuse headache.

Some controversy exists, but the headache community generally believe that overuse headaches exist.  Most medications that are overused can cause other issues as well. Only 50% of patients who have overuse see improvement once the overused medication is stopped, and it is hard to predict who will benefit.

Medication withdrawal

Start by ensuring patient is on chronic treatment, although Europeans tend to favor withdrawal as primary strategy.  Withdraw slowly, and use shared decision making; or, try abrupt discontinuation. Rebound headaches can be treated with steroid taper or occipital nerve blocks.  Note that there is the risk of seizure with abrupt withdrawal of butalbital.

Dr Burch notes that acetaminophen and NSAIDs seem to have lower risk of precipitating medication overuse headaches.  Metoclopramide and hydroxyzine can be used acutely, and do not seem to cause overuse headaches.  Gabapentin is an off-label choice as well.

Headaches of shorter duration

These are different than migraines by definition.  Autonomic features (lacrimation, rhinorrhea, conjunctival injection) suggest trigeminal autonomic cephalgias (TAC).  All headaches in this category are unilateral and there is often a stabbing quality to the pain, which is usually ocular in location.  TACs are differentiated by duration and frequency.

Cluster headaches

Cluster headaches last 15 minutes to 3 hours and can happen from once every other day to up to 8 times a day.  Cluster headaches often respond to verapamil.

Paroxysmal hemicrania

The headaches of paroxysmal hemicrania last from seconds to minutes, and occur multiple times a day–these respond well to indomethacin.  

SUNA and SUNCT

Short unilateral neuralgiaform headache with autonomic features (SUNA) or conjunctival injection or tearing (SUNCT) are characterized by short-lasting, needle-like pains that occur many times a day.  These tend to respond well to lamotrigine.

Primary versus Secondary headaches

Secondary headaches may be provoked by specific activities, such as cough, exercise, or sexual activity.  Also consider trigeminal neuralgia, which does not have autonomic features.

When evaluating for primary headaches, secondary headaches must be ruled out; a primary headache cannot be diagnosed without confirmatory imaging.  Secondary headaches are caused by things like increased intracranial pressure due to increased CSF production or malignancy. Headaches associated with increased intracranial hypertension tend to be worse with maneuvers that increase intracranial pressure, such as Valsalva, straining, coughing, lifting, sneezing, and bending over.  These are classically worse when supine, especially in the early morning. Conversely, headaches associated with intracranial hypotension, such as those seen following lumbar puncture, are improved when supine and worse when standing or sitting upright.

Imaging

An MRI without contrast is a reasonable place to start–this allows a better look at the cerebellum and brainstem and avoids the cumulative radiation conferred by repeat head CTs often done for chronic headache patients.  Contrast can be used if there is suspicion for malignancy or low CSF pressure. Vascular imaging should be used in the setting of thunderclap headache.

Goals and Learning Objectives

Goal

Listeners will define, classify, diagnose and treat various types of headaches including migraines, medication overuse, and headaches of short duration.

Learning objectives

After listening to this episode listeners will…

1. Define and classify migraine headaches
2. Discuss management of migraine headaches, including novel and nonpharmacologic management
3. Explain the characteristics and management of medication overuse headaches
4. Categorize the headaches of shorter duration
5. Differentiate primary and secondary headaches
6. Order the appropriate imaging study for patients with headache

Disclosures

Dr Burch reports no relevant financial disclosures. The Curbsiders report not relevant financial disclosures.

Time Stamps

• 00:00 Disclaimer, intro and guest bio
• 03:28 Guest one-liner, movie and podcast recommendations, favorite failure and picks of the week from The Curbsiders
• 10:38 Clinical case of migraines; diagnosis and classification
• 14:12 Does medication overuse headache exist?
• 16:16 Chronic daily headache; Conversion from episodic to chronic and vice versa
• 21:43 Approaches to medication overuse headache
• 25:54 Case 2: migraine with aura and other types of migraine (retinal, hemiplegic, etc.)
• 32:09 Pathophysiology of migraine; how triptans work; How should aura effect management?
• 38:44 Migraine cocktails
• 41:15 Comorbid mood disorders; Use of psych meds and triptans
• 45:08 Migraines and oral contraceptives
• 48:42 Botulinum toxin and new CGRP therapies
• 53:36 What does success look like in migraine therapy?
• 55:32 Nonpharmacologic management
• 60:45 Case 3: headaches of short duration
• 66:36 Headache red flags; Imaging for headaches; pathophysiology of high and low pressure headaches
• 72:00 Idiopathic intracranial hypertension
• 75:25 Take home points
• 77:00 Outro

Links from the show

Picks of the week:

1. Curbsiders episode #4: Are You Afraid of Patients with Migraines? An approach to diagnosis and management of chronic migraine headache
2. The Chapo Guide to Revolution: A Manifesto Against Logic, Facts, and Reason
3. Marvel’s Spiderman (video game)
4. More Perfect (podcast)
5. The Peter Attia Drive (podcast)
6. TENS unit
7. Tom Clancy’s Jack Ryan (streaming on Amazon Prime)
8. Tramadont article by David Juurlink on the hazards of tramadol
9. American Headache Society website
10. American Migraine Foundation website