Best Dx/Best Rx: Headache

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Headache

Randolph W. Evans, M.D
Joan and Sanford = I. Weill=20 Medical College of Cornell University and Methodist = Hospital

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition/Key=20 Clinical Features

Migraine=20

Recurrent unilateral or bilateral, pulsating, = mild to=20 severe headache, exacerbated by physical activity, often beginning in=20 frontotemporal or ocular regions=20
Pain in face, jaw, and neck are common=20
Pain usually accompanied by nausea, = photophobia, or=20 phonophobia=20
Visual aura in 20% of migraineurs=20
85% of migraineurs report triggers or = precipitating=20 factors

Tension-Type = Headache

Pressing or tightening in quality, mild to = moderate in=20 intensity, and bilateral in location=20
No worse with physical activity=20
Either phonophobia or photophobia, but not = both=20
Not accompanied by nausea or vomiting=20
Episodic; may last hours to days; if headache = occurs=20 > 15 days/mo, condition is chronic

Chronic Daily Headache

Subtypes=20

Transformed migraine: often from medication = abuse,=20 stress, anxiety, or depression=20
Chronic tension headache=20
Hemicrania continua: rare, associated with = ptosis,=20 lacrimation, nasal congestion; responds to indomethacin=20
New daily persistent headache =

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Differential = Diagnosis

Extensive: over 300 different types and = causes=20
For "first or worst" headaches, consider = possibility of=20 subarachnoid hemorrhage=20
For new-onset headache in persons > 50 yr, = consider=20 temporal arteritis as the cause

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Best=20 Tests

History and physical examination usually = sufficient for=20 diagnosis=20
CT and MRI rarely abnormal when neurologic = exam is=20 normal=20
Consider testing for the atypical patient or = the one=20 with red flags (e.g., abnormal neurologic exam, worst headache, = thunderclap=20 headache, onset in persons > 50 yr; change in attack frequency, = severity,=20 clinical features; headache not responding to treatment; new-onset = headache in=20 patients with history of cancer or HIV positive)=20
Blood tests generally not useful, except as = baseline=20 before beginning medications=20
Lumbar puncture may be helpful for diagnosis = of=20 meningitis, subarachnoid hemorrhage, carcinomatosis, pseudotumor = cerebri;=20 usually performed after doing CT or MRI

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Best=20 Therapy

Migraine=20

Treatment is more effective with any = medication when=20 given when headache is mild rather than moderate or severe=20

Over-the-Counter Medications =

Acetaminophen: efficacy rating (on a scale of = 0 to 4):=20 2+=20
- Dose: 750=961,000 mg
Aspirin: efficacy rating (on a scale of 0 to = 4):=20 2+=20
- Dose: 650 mg
Ibuprofen: efficacy rating (on a scale of 0 to = 4):=20 2+=20
- Dose: 400=96800 mg
Acetaminophen + aspirin + caffeine: efficacy = rating (on=20 a scale of 0 to 4): 3+=20
- Dose: 500 mg acetaminophen; 500 mg aspirin; = 130 mg=20 caffeine

Prescription=20 Drugs=20

Isometheptene mucate 65 mg + = dichloralphenazone 100 mg +=20 acetaminophen 325 mg: efficacy rating (on a scale of 0 to 4): = 3+=20
- Dose: 2 capsules at onset followed by 1 = capsule q. 1=20 hr (max 5/24 hr)
Butalbital 50 mg + aspirin 325 mg: efficacy = rating (on a=20 scale of 0 to 4): 3+=20
- Can lead to rebound headache and = habituation=20
- Dose: 2 capsules q. 4=966 hr =
Acetaminophen 325 mg + caffeine 40 mg + = codeine 30 mg:=20 efficacy rating (on a scale of 0 to 4): 3+=20
- Can lead to rebound headache and = habituation=20
- Dose: 2 capsules q. 4-6 hr
Butorphanol nasal spray: efficacy rating (on a = scale of=20 0 to 4): 3+. For patients who cannot keep oral drugs down or do not = respond to=20 other medications=20
- Can lead to rebound headache and = habituation=20
- Dose: 1 spray q. 4 hr p.r.n. =
Triptans: Contraindicated in patients with = ischemic=20 heart disease or those at risk for unrecognized coronary artery = disease,=20 peripheral vascular disease, cerebrovascular disease, and uncontrolled = hypertension. Patients may respond differently to different = triptans.=20
- Almotriptan: efficacy rating (on a scale of = 0 to 4):=20 4+=20
  - Dose: 12.5 mg=20
  - Cost/mo: $62/9 tabs
- Eletriptan: efficacy rating (on a scale of 0 = to 4):=20 4+=20
  - Dose: 20 mg or 40 mg=20
  - Cost/mo: $172/12 tabs
- Frovatriptan: efficacy rating (on a scale of = 0 to 4):=20 3+=20
  - Minimal side effects and less = recurrence=20
  - Dose: 2.5 mg=20
  - Cost/mo: $129/9 tabs
- Naratriptan: efficacy rating (on a scale of = 0 to 4):=20 3+=20
  - Minimal side effects and less = recurrence=20
  - Dose: 2.5 mg=20
  - Cost/mo: $168/nine tabs
- Rizatriptan tab and MLT (orally dissolving = wafer):=20 efficacy rating (on a scale of 0 to 4): 4+=20
  - Dose: 10 mg=20
  - Cost/mo: $94/6 tabs or MLT =
- Sumatriptan: efficacy rating (on a scale of = 0 to 4):=20 3+; 4+ for subcutaneous or intranasal for patients with = nausea/vomiting;=20 subcutaneous administration provides the fastest and highest = efficacy of all=20 the triptans=20
  - Dose: 25, 50, 100 mg tab; 20 mg nasal = spray; 6 mg=20 S.C.=20
  - Cost/mo: $153/9 tabs; $136/6 nasal = inhalers; $260/5=20 vials for S.C. injection
- Zolmitriptan: tab and ZMT (orally = disintegrating=20 tablet) and nasal spray; efficacy rating (on a scale of 0 to 4): = 3+=20
  - Minimal side effects and less recurrence =
  - Dose: 2.5 mg or 5 mg tab or ZMT and 5 mg = nasal spray=20
  - Cost/mo: $85/6 tabs or ZMT; $39/5 mg nasal = spray=20
Dihydroergotamine nasal spray: efficacy rating = (on a=20 scale of 0 to 4): 3=964+=20
- Minimal side effects and low recurrence = rate; cannot=20 be given within 24 hr of a triptan=20
- Ergot derivative; contraindicated in the=20 following:=20
  - Ischemic heart disease=20
  - Peripheral arterial disease=20
  - Severe hepatic or renal disease=20
  - Pregnancy=20
  - Patients taking protease inhibitors or = macrolide=20 antibiotics
- Dose: 0.5 mg in each nostril; may repeat = once after 15=20 min=20
- Cost/mo: $213/8 ampules =

Intractable Migraine and Migraine=20 Status=20

I.V. fluids and electrolytes may be needed for = intractable vomiting

Parenteral=20 Agents=20

Sumatriptan: efficacy rating (on a scale of = 0 to 4):=20 4+=20
- Dose: 6 mg S.C.
Dihydroergotamine: efficacy rating (on a = scale of 0 to=20 4): 4+=20
- May cause nausea (combine with = antiemetic); do not=20 use within 24 hr of a triptan=20
- Dose: 0.5=961 mg by slow I.V. =
Prochlorperazine: efficacy rating (on a = scale of 0 to=20 4): 4+=20
- Dose: 5=9610 mg I.V.
Ketorolac: efficacy rating (on a scale of 0 = to 4):=20 4+=20
- May cause nausea (combine with antiemetic; = do not=20 use within 24 hr of a triptan=20
- Dose: 30=9660 mg I.M.
Corticosteroids: efficacy rating (on a scale = of 0 to=20 4): 3+=20
- May help to break migraine status=20
- Prednisone=20
- Dose: single or rapidly tapering dose, = starting at=20 80 mg/day
Dexamethasone=20
- Dose: 6 mg p.o. or I.V.
Meperidine: efficacy rating (on a scale of 0 = to 4):=20 3+=20
- May be combined with promethazine=20
- Dose: 50=96100 mg
Valproate sodium: efficacy rating (on a = scale of 0 to=20 4): 4+=20
- Dose: 500 mg diluted in 50 ml saline I.V. = over 5=9610=20 min q. 8 hr
Droperidol: efficacy rating (on a scale of 0 = to 4):=20 4+=20
- Rare risk of torsade de pointes=20
- Dose: 2.5 mg I.M. or I.V.=20

Migraine = Prevention=20

Consider daily preventive medication for the=20 following:=20
- Headaches significantly interfere with daily = routine=20
- Acute medications are contraindicated, = ineffective,=20 overused, or not tolerated=20
- Migraines occur ≥ 2 times/wk=20
- The cost is significantly less than that of = acute=20 treatment
Principles of preventive treatment=20
- Start with low dose and increase = slowly=20
- Give each drug a 2- to 3-mo trial=20
- Discontinue or taper drugs that may be = causing rebound=20 headache=20
- Patient should keep a record of = headaches=20

Drugs for Migraine=20 Prevention=20

Beta blockers: side effects=97hypotension, = tiredness,=20 depression=20
- Propranolol: efficacy rating (on a scale of = 0 to 4):=20 4+=20
  - Dose: 40=96120 mg b.i.d.=20
  - Cost/mo: $8
- Long-acting propranolol=20
  - Dose: 60=96160 mg/day=20
  - Cost/mo: $39
- Metoprolol: efficacy rating (on a scale of 0 = to 4):=20 4+=20
  - Dose: 50=96200 mg/day=20
  - Cost/mo: $39
- Atenolol: efficacy rating (on a scale of 0 = to 4):=20 4+=20
  - Dose: 50=96100 mg/day=20
  - Cost/mo: $4
- Timolol: efficacy rating (on a scale of 0 to = 4):=20 4+=20
  - Dose: 10=9630 mg/day=20
  - Cost/mo: $8
- Nadolol: efficacy rating (on a scale of 0 to = 4):=20 4+=20
  - Dose: 40=96160 mg/day=20
  - Cost/mo: $13
Antidepressants=20
- Amitriptyline: efficacy rating (on a scale = of 0 to 4):=20 4+=20
  - Anticholinergic side effects, weight = gain=20
  - Dose: 25=96150 mg h.s.=20
  - Cost/mo: $8
- Nortriptyline: efficacy rating (on a scale = of 0 to 4):=20 4+=20
  - Anticholinergic side effects, weight = gain=20
  - Dose: 25=96150 mg/day=20
  - Cost/mo: $10
- Venlafaxine: efficacy rating (on a scale of = 0 to 4):=20 4+ (anecdotal, not well studied)=20
  - Fewer side effects than tricyclics;=20 weight-neutral=20
  - Dose: 75=96150 mg XR/day=20
  - Cost/mo: $39
Anticonvulsants=20
- Divalproex sodium: efficacy rating (on a = scale of 0 to=20 4): 4+=20
  - Nausea, tremor, weight gain, alopecia, = fetal=20 anomalies=20
  - Dose: 500=961,000 mg/day=20
  - Cost/mo: $20
- Topiramate: efficacy rating (on a scale of 0 = to 4):=20 4+=20
  - Weight loss, paresthesias, cognitive = effects, kidney=20 stones (about 1%)
  - Dose: 50=96300 mg h.s. (100 mg h.s. usual = effective=20 dose); start at 25 mg h.s. and increase by 25 mg/week=20
  - Cost/mo: $123
- Gabapentin: efficacy rating (on a scale of 0 = to 4):=20 2+=20
  - Dizziness, tiredness, drowsiness=20
  - Dose: 300=96800 mg t.i.d.=20
  - Cost/mo: $111 =

Tension Headache=20

Drugs for Tension Headache=20

Acetaminophen: efficacy rating (on a scale of = 0 to 4):=20 3+=20
- Dose: 500 mg
Aspirin: efficacy rating (on a scale of 0 to = 4):=20 4+=20
- Dose: 500=96650 mg
Ibuprofen: efficacy rating (on a scale of 0 to = 4):=20 4+=20
- Dose: 400=96800 mg
Acetaminophen + aspirin + caffeine: efficacy = rating (on=20 a scale of 0 to 4): 4+=20
- Dose: 1=962 tablets q. 4 hr =
Isometheptene mucate: efficacy rating (on a = scale of 0=20 to 4): 3+=20
- Dose: 2 capsules at onset followed by 1 = capsule q. 1=20 hr (max 5/24 hr)
Butalbital 50 mg combination drugs: efficacy = rating (on=20 a scale of 0 to 4): 3+=20
- Can lead to rebound headache and = habituation=20
- Dose: 1=962 q. 4 hr
Muscle relaxants=20
- Baclofen: Nonhabituating=20
  - Dose: 5=9610 mg t.i.d., p.r.n. =
- Tizanidine: nonhabituating; monitor liver = function for=20 elevated transaminase=20
  - Dose: 2=964 mg t.i.d.=20

Prevention of = Tension=20 Headache=20

Tricyclic antidepressants may be more = effective than=20 SSRIs

Chronic Daily = Headache=20

Behavioral psychotherapy=20
Physical therapy for myofascial = symptoms=20
Trigger-point injection or occipital nerve = block may=20 help in some cases=20
Preventive and symptomatic medications same as = for=20 migraine and tension headaches

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Best References

Evans RW, et al: Headache 46:160, 2006 [PMID=20 16412164]

Headache Classification Subcommittee of the = International=20 Headache Society: Cephalalgia 24(suppl 1):1, 2004 [PMID = 14979299]

Silberstein SD: Lancet 363:381, 2004 [PMID=20 15070571]

June=20 2006