Understanding HeadachesUnderstanding Headaches

Grace Forde, M.DGrace Forde, M.D

Assistant Professor of Neurology Assistant Professor of Neurology

New York UniversityNew York University

Director of Neurological ServicesDirector of Neurological Services

North Shore Pain ServiceNorth Shore Pain Service

Migraine EpidemiologyMigraine Epidemiology

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Lipton RB, et al. Neurology. 2007; 68(5):343-349.National Headache Foundation. http://www.headaches.org/education/Headache_Topic_Sheets/Migraine. Accessed December 1, 2009.

Migraine PrevalenceMigraine Prevalence

Approximately 26 million patients with Approximately 26 million patients with migraine in the United States (migraine in the United States (>> age 18) age 18)

One in 4 households has at least 1 One in 4 households has at least 1 migraine sufferermigraine sufferer

Migraine Prevalence:Migraine Prevalence:Age and GenderAge and Gender

Lipton RB, et al. Neurology. 2007;68(5):343-349.

Migraine prevalence peaks in the 25-55 age range

Migraine Economic Impact, Migraine Economic Impact, Productivity, and Quality of LifeProductivity, and Quality of Life

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Economic Burden of Migraine in Economic Burden of Migraine in USUS

Lost productivity is the greatest contributor to migraine economic Lost productivity is the greatest contributor to migraine economic burden burden

Productivity losses cost US employers up to $13 billion annually Productivity losses cost US employers up to $13 billion annually

Direct costs of migraine per patient range from ~$500-$7000/yearDirect costs of migraine per patient range from ~$500-$7000/year

Total medical costs in households with at least 1 member with Total medical costs in households with at least 1 member with migraine are 70% higher than families without a member with migraine are 70% higher than families without a member with migrainemigraine

Hu XH et al. Arch Int Med. 1999;159(8):813-818.Hawkins K et al. J Occup Environ Med. 2007;49(4):368-374.Edmeads J and Mackell JA. Headache. 2002;42(6):501-509.Stewart WF et al. JAMA. 2003;290(18):2443-2454.Osterhaus JT et al. Pharmacoeconomics. 1992;2(1):67-76.

Etemad LR, et al. JMCP. 2005;11(2):137–44.Pesa J and Lage MJ. Headache. 2004;44(6):562–70.Lafata JE, et al. J Gen Intern Med. 2004;19(10):1005–12.Hawkins K, et al. Value Health. 2006;9:A85.Stang PE, et al. Am J Manag Care. 2004;10(5):313–20.

*N=200 Full-Time Employees

Timing and Impact of MigraineTiming and Impact of Migraine

Landy SH, et al. Poster presented at: 50th Annual American Headache Society Meeting, June 26-29, 2008; Boston, MA.

58% of Migraines Occurred During Typical Work Hours*

Impact of Migraine: ProductivityImpact of Migraine: Productivity

Landy SH, et al. Poster presented at: 50th Annual American Headache Society Meeting, June 26-29, 2008; Boston, MA.

*N=157 Full-time employees

Pro

du

ctiv

ity

Lev

els

74% of Patients With Migraine* Reported Productivity Levels Below 80%

Migraine Diagnosis Migraine Diagnosis and Treatmentand Treatment

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Migraine Is an Episodic Recurrent Headache Lasting 4-72 Hours with:

International Headache Society International Headache Society Criteria for MigraineCriteria for Migraine

+• unilateral pain• throbbing pain• pain worsened by

movement• moderate or severe pain

• nausea• vomiting• photophobia and

phonophobia

Any 2 of these pain qualities:

Any 1 of these associated symptoms:

Features such as osmophobia and posterior head and neck pain can also be present in a headache that meets IHS criteria for migraine.

Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. 2nd edition. Cephalalgia. 2004;24(suppl1):117-118,138.

Many Migraine Sufferers Remain Many Migraine Sufferers Remain UndiagnosedUndiagnosed

Diagnosed Migraine

56%

Undiagnosed Migraine

44%

Diamond S et al. Headache. 2007;47(3):355-363.

Patients with Recurrent Headache May Patients with Recurrent Headache May Meet Criteria for MigraineMeet Criteria for Migraine

87% of patients presenting to PCP with recurrent headache met IHS criteria for migraine

Migraine (n=237)

Other (n=3)1%Probable Migraine

(n=31)

Episodic Tension-type Headache (n=1)0.4%

Tepper SJ et al. Headache. 2004;44(9):856-864.

11%

87%

Focusing on Migraine DiagnosisFocusing on Migraine Diagnosis

Opportunities for accurate diagnosis of migraine Opportunities for accurate diagnosis of migraine patients still exist:patients still exist:

– 80% of “sinus headache” patients met IHS criteria for 80% of “sinus headache” patients met IHS criteria for migrainemigraine

– 85% of “tension/stress” headache patients met IHS 85% of “tension/stress” headache patients met IHS criteria for migrainecriteria for migraine

Schreiber CP et al. Arch Intern Med. 2004;164(16):1769-1772.Kaniecki R et al. CMRO. 2006;22(8):1535-1544.

Adapted from Cady RK. Headache. 2008;48(9):1415-1416.Headache Classification Subcommittee of the International Headache Society. Cephalalgia. 2004;24(suppl 1):117-118. Cady RK. Diagnosis and treatment of migraine. Clinical Cornerstone. 1999;1(6):21-32.

Premonitory/

Prodrome

Aura

Mild Moderate to Severe

Postdrome

Time

Mig

rain

e In

ten

sity

Phases of a Migraine AttackPhases of a Migraine Attack

Migraine symptoms occurring

hours/days prior to headache

Migraine when headache is mild

Migraine when headache is moderate

to severe

Migraine symptoms occurring

hours/days after headache

resolution

Focal neurological symptoms preceding headache (<1 hour)

Symptoms :• Food cravings• Mood changes• Yawning• Fatigue

Symptoms:• Tiredness• Confusion• Lowered appetite• Stiff or sore muscles

Symptoms:• Same as mild but more intense

Symptoms:• Flashing lights or wavy lines• Numbness• Tingling in face• Disturbed senses

Symptoms:• Sensitivity to light• Sensitivity to sound• Nausea• Pain in the back of the head and neck

National Institutes of Health. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/headache/detail_headache.htm.Accessed December 7, 2009.

Pre-HA Post-HA

Headache

Treatment Phase

Possible Triggers of a Migraine Possible Triggers of a Migraine AttackAttack

Food and food additivesFood and food additives Bright lights/glareBright lights/glare Smells/odorsSmells/odors Dieting/hungerDieting/hunger Loud noises/soundsLoud noises/sounds Changes in altitude/Changes in altitude/

air travelair travel

StressStress Weather changesWeather changes CaffeineCaffeine Alcoholic beveragesAlcoholic beverages Changes in sleep habitsChanges in sleep habits Hormonal fluctuations/ Hormonal fluctuations/

menstrual cyclemenstrual cycle

Wober C et al. J Headache Pain. 2006;7(4):188-195.Friedman DI and De Ver Dye T. Headache. 2009;49(6):941-952.

Medication Options Available Medication Options Available for Migrainefor Migraine

Preventative MedicationsPreventative Medications May prevent or reduce the number May prevent or reduce the number

of migraine attacksof migraine attacks Typically taken on a daily basisTypically taken on a daily basis

– AntiepilepticsAntiepileptics

– AntidepressantsAntidepressants

– Beta blockersBeta blockers

– Calcium channel blockersCalcium channel blockers

Acute MedicationsAcute Medications May work quickly to relieve May work quickly to relieve

migraine pain and other symptomsmigraine pain and other symptoms Usually taken during a migraine Usually taken during a migraine

attackattack

– TriptansTriptans

– NSAIDsNSAIDs

– OpioidsOpioids

– Analgesics (Rx and OTC)Analgesics (Rx and OTC)

– Ergotamine/DHEErgotamine/DHE

– AntiemeticsAntiemetics

– NeurolepticsNeuroleptics

– CorticosteroidsCorticosteroids

Tepper SJ and Spears RC. Neurol Clin. 2009;27(2):417-427.Silberstein SD. Neurol Clin. 2009;27(2):429-443.

Differences in Patients with Differences in Patients with MigraineMigraine

Migraine patient’s brain is in a state of hyperexcitabilityMigraine patient’s brain is in a state of hyperexcitability– Reduced threshold for stimuliReduced threshold for stimuli– Everyday things can trigger a migraine attackEveryday things can trigger a migraine attack

Migraine patient’s gut is slowed Migraine patient’s gut is slowed – Gastric stasis is common and can delay tablet Gastric stasis is common and can delay tablet

absorptionabsorption– Conventional tablets rely on surface erosion and gastric Conventional tablets rely on surface erosion and gastric

motility for dissolution in the stomach, which must occur motility for dissolution in the stomach, which must occur before being absorbedbefore being absorbed

Hargreaves RJ and Shepheard SL. Can J Neurol Sci. 1999;26(suppl 3):S12-S19. Aurora S et al. Headache. 2006;46(1):57-63.

The TriptansThe Triptans

SumatriptanSumatriptan ZolmatriptanZolmatriptan NaratriptanNaratriptan RizatriptanRizatriptan AlmotriptanAlmotriptan FrovatriptanFrovatriptan EletriptanEletriptan Sumatriptan and Naproxen sodiumSumatriptan and Naproxen sodium

Triptan Prescribing Information:Triptan Prescribing Information:Contraindications and Precautions for ALL Contraindications and Precautions for ALL

TriptansTriptans

Ischemic cardiac diseaseIschemic cardiac disease

Cerebrovascular diseaseCerebrovascular disease

Uncontrolled hypertensionUncontrolled hypertension

HypersensitivityHypersensitivity

Use within 24 hours of other 5-HTs/ergotsUse within 24 hours of other 5-HTs/ergots

Hemiplegic/basilar migraineHemiplegic/basilar migraine

History of risk factors for CADHistory of risk factors for CAD

SSRI precautionSSRI precaution

Case Scenario 2Case Scenario 2 29-year-old single woman, 29-year-old single woman,

sales clerk; history of 8-9 sales clerk; history of 8-9 migraines / month lasting migraines / month lasting for 12-14 hours, frequent for 12-14 hours, frequent recurrencerecurrence

HA associated with nausea and HA associated with nausea and sensitivity to light and soundsensitivity to light and sound

Currently taking an oral Currently taking an oral triptan tablettriptan tablet

Says that current treatment Says that current treatment takes too long to act and does takes too long to act and does not fully relieve headache painnot fully relieve headache pain

Looking for a way to Looking for a way to prevent attacksprevent attacks

Preventive Medication GroupsPreventive Medication Groups

AnticonvulsantsAnticonvulsants– valproate*valproate*– topiramate*topiramate*

AntidepressantsAntidepressants– TCAsTCAs– SSRIsSSRIs

β-adrenergic blockersβ-adrenergic blockers– propranolol*propranolol*– timolol*timolol*

Calcium channel Calcium channel antagonists antagonists

Serotonin antagonistsSerotonin antagonists OthersOthers

– Botulinum toxin A*Botulinum toxin A*– coenzyme Q10 coenzyme Q10 – NSAIDsNSAIDs– PetasitesPetasites

– RiboflavinRiboflavin– MagnesiumMagnesium

Silberstein SD. Lancet. 2004;363:381-391. SSRI = selective serotonin reuptake inhibitor TCA = tricyclic antidepressant

*Approved by FDA for this use.

Nonpharmacologic Therapies Nonpharmacologic Therapies Tested in Clinical TrialsTested in Clinical Trials

Behavioral TreatmentsBehavioral Treatments

Relaxation training*Relaxation training*

HypnotherapyHypnotherapy

Thermal biofeedback Thermal biofeedback training*training*

Electromyographic Electromyographic biofeedback therapy*biofeedback therapy*

Cognitive / behavioral Cognitive / behavioral management therapy*management therapy*

Physical TreatmentsPhysical Treatments

AcupunctureAcupuncture

Transcutaneous Transcutaneous electrical nerve electrical nerve stimulation (TENS)stimulation (TENS)

Occlusal adjustmentOcclusal adjustment

Cervical manipulationCervical manipulation*Proven effective in clinical trials

Adapted from US Headache Consortium Headache Guidelines. www.aan.neurology.org. 2000

Case Scenario #3Case Scenario #3

Sinus headache is the most common misdiagnosis

Migraine Is Often OverlookedMigraine Is Often Overlooked

Sinus pain caused by Sinus pain caused by inflammation induced inflammation induced allergens or by infection allergens or by infection occurs when exudate in occurs when exudate in inflamed, blocked sinuses inflamed, blocked sinuses exerts pressure that exerts pressure that stimulates local trigeminal stimulates local trigeminal nerve fibersnerve fibers

Chronic sinusitis is not Chronic sinusitis is not validated as a cause of validated as a cause of headache unless it headache unless it relapses into an acute relapses into an acute stagestage

Major factors – Purulence in nasal cavity on

exam

– Facial pain/pressure/congestion**

– Nasal obstruction/blockage/ discharge

– Fever (in acute only)

– Hyposmia/anosmia

** Facial pain/pressure alone does not constitute a suggestive history for rhinosinusitis in the absence of another major nasal symptom or sign. * American Academy of Otolaryngology-Head and Neck Surgery Lanza et al. Otolaryngol Head Neck Surg 1997.117(pt 2): S1-S7.

Headache:Headache: A Minor Criteria in AAO-HNS Sinusitis A Minor Criteria in AAO-HNS Sinusitis

Minor factors – Headache

– Fever (chronic)

– Halitosis

– Fatigue

– Dental pain

– Cough

– Ear pain/pressure/fullness

Headache is a minor factor in the diagnosis of rhinosinusitis, according to AAO-HNS*

0 20 40 60 80 100

Vomiting

Itchy Nose

Aura

Watery Eyes

Rhinorrhea

Phonophobia/Photophobia

Nasal Congestion

Nausea

Sinus Pain

Worsened by Activity

Sinus Pressure

Pulsatile

Moderate/Severe Pain

Sinus Features May Hide the Presence of Sinus Features May Hide the Presence of MigraineMigraine

Headache Symptoms at Screen Among IHS Diagnosed Migraineurs

% of Subjects

IHS Migraine Symptom Criteria

Sinus Like Features

96%

84%

87%

84%

82%

70%

65%

57%

42%

38%

28%

27%

23%

n=2257

Schreiber et al. Poster Presented at: American Headache Society Meeting; June 21-23, 2002: Seattle, WA.Data on file, GlaxoSmithKline.

Why do so many Why do so many Americans think they Americans think they have have Sinus Sinus Headache? Headache? In his 1988 review, “Sinus Headache: A Neurologist’s Viewpoint,” Couch writes:

In my experience and in that of others, “sinus headache,” as reported by patients, is a popular conception that is often erroneous. Patients reason that, since the sinuses are close to the eyes (as depicted in advertisements in popular magazines), headaches located in the frontal, supraorbital, or infraorbital region are sinus headaches… [These] headaches frequently are associated with some gastrointestinal symptomatology, photophobia, and phonophobia, and may have some visual or neurologic symptoms. In short, these “sinus headaches” are usually migraine headaches, most often of the common migraine type.

Couch, J. Seminars in Neurology. 1988;8(4):298-302.

Cady et al. Headache Free. 1993;36-38.

Migraine Is Often Overlooked Migraine Is Often Overlooked (cont’d)(cont’d)

Tension headache is another common Tension headache is another common misdiagnosismisdiagnosis

Symptoms includeSymptoms include– Dull steady ache Dull steady ache – Physical activity does not worsen painPhysical activity does not worsen pain– Nausea, photo/phonophobia Nausea, photo/phonophobia

are not usually presentare not usually present– Vomiting never presentVomiting never present– Patients have likely tried OTCs and failedPatients have likely tried OTCs and failed

Migraine Pain Can Be Felt in Peripheral Migraine Pain Can Be Felt in Peripheral Locations Such as the NeckLocations Such as the Neck

In Kaniecki’s study of 144 patients with In Kaniecki’s study of 144 patients with migrainemigraine

Kaniecki et al. Poster presented at: 10th IHC; June 29-July 2, 2001; New York, NY.

75%reported neck pain with their migraine

– 75% reported neck 75% reported neck pain pain with their migrainewith their migraine

– 43% described neck 43% described neck pain as bilateral and pain as bilateral and 57% as unilateral57% as unilateral

– 69% described the 69% described the neck neck pain as “tightness” and pain as “tightness” and

17% as stiffness”17% as stiffness”

Activation of the TNC May Result in Activation of the TNC May Result in Referred Pain that Could be Perceived Referred Pain that Could be Perceived Anywhere along the Trigeminocervical Anywhere along the Trigeminocervical

NetworkNetwork

Activation of the TNC May Result in Activation of the TNC May Result in Referred Pain that Could be Perceived Referred Pain that Could be Perceived Anywhere along the Trigeminocervical Anywhere along the Trigeminocervical

NetworkNetwork

Case Scenario 5Case Scenario 5 26-year-old man, computer programmer, 26-year-old man, computer programmer,

married with 2 childrenmarried with 2 children Has severe, stabbing Has severe, stabbing

pain behind his right eyepain behind his right eye Headaches are Headaches are

accompanied by accompanied by lacrimation and nasal lacrimation and nasal congestioncongestion

Pain lasts 30 to Pain lasts 30 to 45 minutes; attacks 45 minutes; attacks occur daily for several occur daily for several weeks, then stop for weeks, then stop for months at a timemonths at a time

Treatment of Hypnic HeadachTreatment of Hypnic Headach Lithium Carbonate Lithium Carbonate

(200-600mg)(200-600mg) IndomethacinIndomethacin Verapamil (160my Verapamil (160my

QHS)QHS) MethysergideMethysergide Caffeine (60mg)Caffeine (60mg) LamotrigeneLamotrigene

TRIGEMINAL NEURALGIATRIGEMINAL NEURALGIA