TOC  | Neurology

HEADACHE -                    See    Migraine   |  Headache Rx  (KP Intranet only)

REF: ACP Medicine Best DX/Best Rx 2006

Headache

Randolph W. Evans, M.D.
University of Texas at Houston Medical School

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition/Key Clinical Features

Migraine

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

Tension-Type Headache

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

Chronic Daily Headache

Subtypes

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

Differential Diagnosis

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

Best Tests

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

Best Therapy

Migraine

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

Over-the-Counter Medications

• Acetaminophen: efficacy rating (on a scale of 0 to 4): 3+
  • Dose: 750–1000 mg
• Aspirin: efficacy rating (on a scale of 0 to 4): 3+
  • Dose: 650 mg
• Ibuprofen: efficacy rating (on a scale of 0 to 4): 2+
  • Dose: 400–800 mg
• Acetaminophen + aspirin + caffeine: efficacy rating (on a scale of 0 to 4): 3+
  • Dose: 500 mg acetaminophen; 500 mg aspirin; 130 mg caffeine

Prescription Drugs

• Isometheptene mucate 65 mg + dichloralphenazone 100 mg + acetaminophen 325 mg: efficacy rating (on a scale of 0 to 4): 3+
  • Dose: 2 capsules at onset followed by 1 capsule q. 1 hour (max 5/24 hours)
• Butalbital 50 mg + aspirin 325 mg: efficacy rating (on a scale of 0 to 4): 3+; can lead to rebound headache and habituation.
  • Dose: 2 q. 4–6 hr
• Acetaminophen 325 mg + caffeine 40 mg + codeine 30 mg: efficacy rating (on a scale of 0 to 4): 3+; can lead to rebound headache and habituation
  • Dose: 2 capsules q. 4-6 hr
• Butorphanol nasal spray: efficacy rating (on a scale of 0 to 4): 3+; for patients who cannot keep oral drugs down or do not respond to other medications; can lead to rebound headache and habituation
  • Dose: 1 spray q. 4 hr p.r.n.
• Triptans: Contraindicated in patients with ischemic heart disease or those at risk for unrecognized coronary artery disease, peripheral vascular disease, cerebrovascular disease, and uncontrolled hypertension. Patients may respond differently to different triptans.
  • Almotriptan: efficacy rating (on a scale of 0 to 4): 4+
    • Dose: 1.25 mg
    • Cost/mo: $62/9 tabs
  • Eletriptan: efficacy rating (on a scale of 0 to 4): 4+
    • Dose: 20 mg and 40 mg
    • Cost/mo: $172/12 tabs
  • Frovatriptan: efficacy rating (on a scale of 0 to 4): 3+; minimal side effects and less recurrence
    • Dose: 2.5 mg
    • Cost/mo: $129/9 tabs
  • Naratriptan: efficacy rating (on a scale of 0 to 4): 3+; minimal side effects and less recurrence
    • Dose: 2.5 mg
    • Cost/mo: $168/9 tabs
  • Rizatriptan tab and MLT (orally dissolving wafer): efficacy rating (on a scale of 0 to 4): 4+
    • Dose: 10 mg
    • Cost/mo: $94/6 tabs or MLT
  • Sumatriptan: efficacy rating (on a scale of 0 to 4): 4+; use subcutaneous or intranasal for patients with nausea/vomiting; subcutaneous administration provides the fastest and highest efficacy of all the triptans
    • Dose: 25, 50, 100 mg tab; 20 mg nasal spray; 6 mg subcutaneous
    • Cost/mo: $153/9 tabs; $136/6 inhalers; $260/5 vials
  • Zolmitriptan: efficacy rating (on a scale of 0 to 4): 3+; minimal side effects and less recurrence
    • Dose: 2.5 mg and 5 mg
    • Cost/mo: $85/ 6 tabs or ZMTs (orally disintegrating tablet)

Intractable Migraine and Migraine Status

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

Parenteral Agents

• • Sumatriptan: efficacy rating (on a scale of 0 to 4): 4+
    • Dose: 6 mg s.c.
  • Dihydroergotamine: efficacy rating (on a scale of 0 to 4): 4+; may cause nausea (combine with antiemetic; do not use within 24 hr of administering triptans
    • Dose: 0.5–1 mg by slow I.V.
  • Prochlorperazine: efficacy rating (on a scale of 0 to 4): 4+
    • Dose: 5–10 mg I.V.
  • Ketorolac: efficacy rating (on a scale of 0 to 4): 4+; may cause nausea (combine with antiemetic; do not use within 24 hr of administering triptans
    • Dose: 30–60 mg I.M.
  • Corticosteroids: efficacy rating (on a scale of 0 to 4): 3+; may help to break migraine status
    • Prednisone
      • Dose: single or rapidly tapering dose, starting at 80 mg/day
    • Dexamethasone
    • Dose: 6 mg p.o. or I.V.
  • Meperidine: efficacy rating (on a scale of 0 to 4): 3+; may be combined with promethazine
    • Dose: 50–100 mg
  • Valproate sodium: efficacy rating (on a scale of 0 to 4): 4+
    • Dose: 500 mg diluted in 50 ml saline I.V. over 5–10 min q. 8 hr
  • Droperidol: efficacy rating (on a scale of 0 to 4): 4+; rare risk of torsade de pointes
    • Dose: 2.5 mg I.M. or I.V.
  • Magnesium sulfate: efficacy rating (on a scale of 0 to 4): 2+
    • Dose: 1 g I.V. over 15 min

Migraine Prevention

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

Drugs for migraine prevention

• Beta blockers: side effects—hypotension, tiredness, depression
  • Propranolol: efficacy rating (on a scale of 0 to 4): 4+
    • Dose: 40–120 mg b.i.d.
    • Cost/mo: $8
  • Long-acting propranolol
    • Dose: 60–160 mg/day
    • Cost/mo: $39
  • Metoprolol: efficacy rating (on a scale of 0 to 4): 4+
    • Dose: 50–200 mg/day
    • Cost/mo: $39
  • Atenolol: efficacy rating (on a scale of 0 to 4): 4+
    • Dose: 50–100 mg/day
    • Cost/mo: $4
  • Timolol: efficacy rating (on a scale of 0 to 4): 4+
    • Dose: 10–30 mg/day
    • Cost/mo: $8
  • Nadolol: efficacy rating (on a scale of 0 to 4): 4+
    • Dose: 40–160 mg/day
    • Cost/mo: $13
• Antidepressants
  • Amitriptyline: efficacy rating (on a scale of 0 to 4): 4+; anticholinergic side effects, weight gain
    • Dose: 25–150 mg h.s.
    • Cost/mo: $8
  • Nortriptyline: efficacy rating (on a scale of 0 to 4): 4+; anticholinergic side effects, weight gain
    • Dose: 25–150 mg/day
    • Cost/mo: $10
  • Venlafaxine: efficacy rating (on a scale of 0 to 4): 4+ (anecdotal, not well studied); fewer side effects than tricyclics; weight-neutral
    • Dose: 75–150 mg XR
    • Cost/mo: $39
• Anticonvulsants
  • Divalproex sodium: efficacy rating (on a scale of 0 to 4): 4+; nausea, tremor, weight gain, alopecia, fetal anomalies
    • Dose: 500–1,000 mg/day
    • Cost/mo: $16
  • Topiramate: efficacy rating (on a scale of 0 to 4): 4+; weight loss, paresthesias, cognitive effects, kidney stones (about 1%); start at 25 mg h.s. and increase by 25 mg/week
    • Dose: 50–300 mg h.s. (100 mg hs usual effective dose)
  • Gabapentin: efficacy rating (on a scale of 0 to 4): 2+; dizziness, tiredness, drowsiness
    • Dose: 300–800 mg t.i.d.
    • Cost/mo: $111

     

Tension Headache

Drugs for Tension Headache

• Acetaminophen: efficacy rating (on a scale of 0 to 4): 3+
  • Dose: 500 mg
• Aspirin: efficacy rating (on a scale of 0 to 4): 4+
  • Dose: 500–650 mg
• Ibuprofen: efficacy rating (on a scale of 0 to 4): 4+
  • Dose: 400–800 mg
• Acetaminophen + aspirin + caffeine: efficacy rating (on a scale of 0 to 4): 4+
  • Dose:
  • Cost/mo:
• Isometheptene mucate: efficacy rating (on a scale of 0 to 4): 3+
  • Dose: 2 capsules at onset followed by 1 capsule q. 1 hr (max 5/24 hr)
• Butalbital 50 mg combination drugs: efficacy rating (on a scale of 0 to 4): 3+; can lead to rebound headache and habituation
  • Dose:
• Muscle relaxants:
  • Baclofen: Nonhabituating
    • Dose: 5–10 mg t.i.d., p.r.n.
  • Tizanidine: nonhabituating; monitor liver function for elevated transaminase
    • Dose: 2–4 mg t.i.d.

Prevention of Tension Headache

• Tricyclic antidepressants may be more effective than SSRIs

Chronic Daily Headache

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

Best References

Bahra, et al: Neurology 58:354, 2002

Codispoti, et al: Headache 41:665, 2001

Freitag, et al: Headache 41:391, 2001

Lipton, et al: JAMA 2284:2599, 2000

Smith: Headache 42:175, 2002

July 2004