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Managing Headache at Managing Headache at UW Health:UW Health:

Making a Tough Job EasierMaking a Tough Job Easier

Nathan J. Rudin, M.D.Nathan J. Rudin, M.D.Associate Professor, Orthopedics and RehabilitationAssociate Professor, Orthopedics and Rehabilitation

Medical Director, Pain Treatment and Research CenterMedical Director, Pain Treatment and Research CenterUW HealthUW Health

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Headache: A Worldwide ProblemHeadache: A Worldwide Problem

Up to 25% of American Up to 25% of American adults have a severe adults have a severe headache each yearheadache each year

Up to 4% have daily or Up to 4% have daily or near-daily headachenear-daily headache

Lifetime prevalence: Lifetime prevalence: 90% 90% or moreor more

Significant suffering Significant suffering and economic lossand economic loss

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Headache: A Local ProblemHeadache: A Local Problem

12201467 1413

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FY 2002 FY 2003 FY 2004

UW Emergency Dept Headache Visits

• Average visit length: 3.5 hours

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Barriers To SuccessBarriers To Success

Limited physician trainingLimited physician training Limited access to careLimited access to care Inappropriate or incomplete treatmentInappropriate or incomplete treatment Underestimation of morbidityUnderestimation of morbidity

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Ambulatory Care Innovation GrantAmbulatory Care Innovation Grant

Funding from UW Medical FoundationFunding from UW Medical Foundation Goal: Goal:

Improve pain care referral, triage and Improve pain care referral, triage and utilizationutilization across UW Health across UW Health

First step:First step: SurveySurvey physicians, nurses, and midlevel providers physicians, nurses, and midlevel providers

about their comfort with and use of pain about their comfort with and use of pain managementmanagement

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Staff Survey ResultsStaff Survey Results

Key areasKey areas Reduce emergency department utilization for non-Reduce emergency department utilization for non-

emergency pain careemergency pain care Improve pain education for staff at all levelsImprove pain education for staff at all levels Improve communication of pain-related Improve communication of pain-related

information across UW Healthinformation across UW Health Centralize pain referral and case triageCentralize pain referral and case triage Improve coordination of perioperative pain careImprove coordination of perioperative pain care

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Staff Survey ResultsStaff Survey Results

Key areasKey areas Reduce emergency department utilization for Reduce emergency department utilization for

non-emergency pain carenon-emergency pain care Improve pain education for staff at all levelsImprove pain education for staff at all levels Improve communication of pain-related Improve communication of pain-related

information across UW Healthinformation across UW Health Centralize pain referral and case triageCentralize pain referral and case triage Improve coordination of perioperative pain careImprove coordination of perioperative pain care

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Goals 2006 – 2007 Goals 2006 – 2007

Familiarize primary care and emergency room Familiarize primary care and emergency room providers with basic headache managementproviders with basic headache management

Educate patients Educate patients Standardize treatment protocols Standardize treatment protocols Standardize communication of headache care Standardize communication of headache care

plansplans Incorporate care plans, protocols and Incorporate care plans, protocols and

educational tools into EMReducational tools into EMR

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Provider ToolkitProvider Toolkit

Video on Headache Care Basics (DVD and Video on Headache Care Basics (DVD and online)online)

Introductory article on headacheIntroductory article on headache Headache diagnostic classificationHeadache diagnostic classification Madison citywide headache treatment Madison citywide headache treatment

guidelinesguidelines Headache treatment plan formHeadache treatment plan form Headache Clinic consult request formHeadache Clinic consult request form

downloadable from uconnect and uwhealth.org

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Headache Treatment GuidelinesHeadache Treatment Guidelines

Developed by panel of specialistsDeveloped by panel of specialists Provides a framework for headache treatment, Provides a framework for headache treatment,

particularly migraineparticularly migraine

uconnect: Clinical Guidelines / Pain Management Resources

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Headache Treatment PlanHeadache Treatment Plan

Outline patient’s individual treatment planOutline patient’s individual treatment plan One copy scanned into EMROne copy scanned into EMR Copy 2 – give to patientCopy 2 – give to patient

Standard Register #SR300078

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When To Call The Headache Clinic?When To Call The Headache Clinic?

Refractory headacheRefractory headache Unclear diagnosisUnclear diagnosis Intensive and/or interdisciplinary treatment Intensive and/or interdisciplinary treatment

neededneeded

Consult Form – Standard Register #SR300077

608-263-9550608-263-9550

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Patient ToolkitPatient Toolkit

Video on Headache Basics (DVD and online)Video on Headache Basics (DVD and online) Introductory letterIntroductory letter Headache DiaryHeadache Diary Health FactsHealth Facts

Migraine; Medication Overuse Headache; Diet and Migraine; Medication Overuse Headache; Diet and Headache; Avoiding the EDHeadache; Avoiding the ED

downloadable from uconnect and uwhealth.org

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Headache DiaryHeadache Diary

Patient fills this Patient fills this out dailyout daily

Brings to clinic Brings to clinic visitvisit

Lets you evaluate Lets you evaluate headache pattern headache pattern and treatment and treatment effectseffects

Standard Register #SR300079

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Basic PrinciplesBasic Principles

Rule out potentially dangerous (secondary) Rule out potentially dangerous (secondary) headacheheadache Neoplasm, infection, hemorrhage, etc.Neoplasm, infection, hemorrhage, etc.

Thorough history and physicalThorough history and physical Diagnose headache typeDiagnose headache type Implement treatmentImplement treatment Monitor outcomeMonitor outcome

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Secondary Headache DisordersSecondary Headache Disorders

<2% of headaches in primary care offices<2% of headaches in primary care offices Head traumaHead trauma Vascular diseaseVascular disease NeoplasmsNeoplasms Substance abuse or withdrawalSubstance abuse or withdrawal Infection/InflammationInfection/Inflammation Metabolic disordersMetabolic disorders othersothers

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““Warning Signs”Warning Signs”

first or worst HA (“thunderclap headache”)first or worst HA (“thunderclap headache”) progressive or new daily persistent HAprogressive or new daily persistent HA age >50 or <5 yearsage >50 or <5 years HA associated with fever, rash, stiff neckHA associated with fever, rash, stiff neck HA associated with abnormal mental status or HA associated with abnormal mental status or

abnormal neuro examabnormal neuro exam

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““Warning Signs”Warning Signs”

HA associated with papilledemaHA associated with papilledema new HA in patient with h/o malignancy, new HA in patient with h/o malignancy,

immunosuppression/HIV, pregnancyimmunosuppression/HIV, pregnancy awakening because of HAawakening because of HA HA with Valsalva or exertionHA with Valsalva or exertion

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Primary HeadachePrimary Headache

Intrinsic dysfunction of the nervous systemIntrinsic dysfunction of the nervous system Most patients presenting to PCP with headache Most patients presenting to PCP with headache

have primary headache syndromeshave primary headache syndromes Episodic headache: more commonEpisodic headache: more common Chronic headache: attacks occurring more Chronic headache: attacks occurring more

frequently than 15 days/month for more than 6 frequently than 15 days/month for more than 6 monthsmonths

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Diagnostic StepsDiagnostic Steps

Rule out secondary headacheRule out secondary headacheThorough historyThorough historyNeurological and musculoskeletal Neurological and musculoskeletal

examinationsexaminationsImaging, blood work and/or CSF analysis if Imaging, blood work and/or CSF analysis if

“red flag(s)” found“red flag(s)” foundDiagnose headache typeDiagnose headache type Identify comorbid illnessesIdentify comorbid illnesses

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Headache HistoryHeadache History Area of head involvedArea of head involved Pain qualityPain quality Pain severityPain severity Other symptoms (nausea, vomiting, light sensitivity)Other symptoms (nausea, vomiting, light sensitivity) TriggersTriggers Timing (including perimenstrual)Timing (including perimenstrual) Pre-headache warning symptoms (“aura”) – for Pre-headache warning symptoms (“aura”) – for

example, visual changesexample, visual changes

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Migraine PathophysiologyMigraine Pathophysiology

Migraine is a Migraine is a brain brain disorderdisorder

Brain becomes Brain becomes hypersensitive and hypersensitive and overly responsive overly responsive to stimulito stimuli

The The trigeminal trigeminal nervenerve appears to be appears to be a key pathwaya key pathway

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Migraine CascadeMigraine Cascade

Vasoactive substances Vasoactive substances inflame vascular and inflame vascular and meningeal tissue, meningeal tissue, activate trigeminal activate trigeminal axonsaxons

Perivascular release Perivascular release of vasoactive of vasoactive neuropeptides; neuropeptides; spreading neurogenic spreading neurogenic inflammationinflammation

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Migraine CascadeMigraine Cascade

The inflammatory The inflammatory response spreads along response spreads along the trigeminovascular the trigeminovascular system system

Pain signals reach Pain signals reach trigeminal nucleus trigeminal nucleus caudalis and other caudalis and other pain systemspain systems

Dorsal raphe nucleus Dorsal raphe nucleus may modulate may modulate migraine painmigraine pain

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MigraineMigraine

Episodic, progressive head painEpisodic, progressive head pain Pulsating, throbbing, stabbingPulsating, throbbing, stabbing Attacks: 4-72 hoursAttacks: 4-72 hours Unilateral in 60%Unilateral in 60% Up to 75% may have neck painUp to 75% may have neck pain

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MigraineMigraine 3 : 1 3 : 1 female : malefemale : male 6% of males, 18% of females, 4% of children 6% of males, 18% of females, 4% of children Family history + in 80-90%Family history + in 80-90% Onset typically during adolescence or young Onset typically during adolescence or young

adulthoodadulthood Onset after age 40 possibleOnset after age 40 possible

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Migraine TriggersMigraine Triggers

Hormonal fluctuationsHormonal fluctuations Perimenstrual migraine very commonPerimenstrual migraine very common

Weather changesWeather changes Diet, including missed mealsDiet, including missed meals StressStress

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Migraine SubtypesMigraine Subtypes

Migraine with aura (20%)Migraine with aura (20%) Neurologic event precedes migraine Neurologic event precedes migraine

(usually by 30-60 minutes)(usually by 30-60 minutes) Visual, auditory, olfactory Visual, auditory, olfactory

disturbancesdisturbances Migraine without auraMigraine without aura

No aura or other warning symptomsNo aura or other warning symptoms Chronic migraineChronic migraine

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Chronic MigraineChronic Migraine

Starts as episodic migraineStarts as episodic migraine Attacks occur at increasing frequencyAttacks occur at increasing frequency

Eventually 15+ attacks/monthEventually 15+ attacks/month Frequent association with Frequent association with medication overusemedication overuse Psych comorbidity commonPsych comorbidity common

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Medication Overuse HeadacheMedication Overuse Headache

Persistent, recurring headache Persistent, recurring headache in the setting of regular in the setting of regular analgesic useanalgesic use

Continues until medication is Continues until medication is stoppedstopped

Often responsible for Often responsible for “transformation” of episodic “transformation” of episodic into chronic headacheinto chronic headache Ingredients: Succinic acid, fumaric acid,

dextrose and bioflavonoids

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Overuse Headache: FeaturesOveruse Headache: Features

Short-acting analgesic use more than 2-3 Short-acting analgesic use more than 2-3 times/weektimes/week

Headaches become predictable, more Headaches become predictable, more frequent, even continuousfrequent, even continuous

Medications no longer prevent headachesMedications no longer prevent headaches

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Common CulpritsCommon Culprits

Analgesics, especially short- or Analgesics, especially short- or intermediate-actingintermediate-actingOpioidsOpioidsNSAIDs including acetaminophenNSAIDs including acetaminophenCombination analgesicsCombination analgesicsCaffeineCaffeineTriptansTriptans

Hormones: OCPs, othersHormones: OCPs, others

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Tension-Type HeadacheTension-Type Headache

Episodic or chronic; possible Episodic or chronic; possible migraine variantmigraine variant

Episodic form affects up to Episodic form affects up to 38%38% of US adults annuallyof US adults annually

Less disability and morbidity Less disability and morbidity than migraine, so less seen by than migraine, so less seen by MDsMDs

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Tension-Type HeadacheTension-Type Headache

““Bandlike”Bandlike” Bilateral: frontal, temporoparietalBilateral: frontal, temporoparietal Referred (myofascial) pain from neck to Referred (myofascial) pain from neck to

headhead Neck structures may contribute to pain Neck structures may contribute to pain

(“cervicogenic headache”)(“cervicogenic headache”)

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Cluster HeadacheCluster Headache

Rare disorderRare disorder M:F 3:1; genetic predispositionM:F 3:1; genetic predisposition Cycles/clusters lasting weeks to monthsCycles/clusters lasting weeks to months Repetitive headaches during a clusterRepetitive headaches during a cluster

1-3 hours apiece; always unilateral1-3 hours apiece; always unilateralFocal facial and eye pain, lacrimation, Focal facial and eye pain, lacrimation,

rhinorrhearhinorrheaOften occur when sleeping or nappingOften occur when sleeping or napping

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Cluster HeadacheCluster Headache

““CH face”: leonine face, CH face”: leonine face, furrowed and thickened skin with furrowed and thickened skin with prominent folds, a broad chin, prominent folds, a broad chin, vertical forehead creases, and vertical forehead creases, and nasal telangiectasias.nasal telangiectasias.

Typically tall and rugged-lookingTypically tall and rugged-looking

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Chronic Daily HeadacheChronic Daily Headache

Chronic migraineChronic migraine Chronic tension-type headacheChronic tension-type headache New daily, persistent headacheNew daily, persistent headache

Generally poor prognosisGenerally poor prognosis Hemicrania continuaHemicrania continua

Unilateral, persistentUnilateral, persistent Some migraine features; head trauma in 20%Some migraine features; head trauma in 20%

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Treatment: Define GoalsTreatment: Define Goals

Patient’s goalsPatient’s goals Pain relief; medication; ? improved Pain relief; medication; ? improved

functionfunction Your goalsYour goals

Pain relief or reduction; improved Pain relief or reduction; improved function; appropriate medication usefunction; appropriate medication use

Bring goals into Bring goals into congruencecongruence

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Treatment PlanTreatment Plan

Preventive therapyPreventive therapyAbortive therapyAbortive therapyPre-emptive therapyPre-emptive therapy

Short-term to prevent anticipated headacheShort-term to prevent anticipated headacheUrgent (“rescue”) therapyUrgent (“rescue”) therapy

Minimize or eliminate where possibleMinimize or eliminate where possible

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Non-Drug TreatmentNon-Drug Treatment Learn appropriate prevention and treatmentLearn appropriate prevention and treatment

Avoid headache triggers: foods, drugs, activitiesAvoid headache triggers: foods, drugs, activities Avoid frequent abortive treatmentAvoid frequent abortive treatment

Stop smokingStop smoking Normalize sleeping and eatingNormalize sleeping and eating ExerciseExercise Relaxation and biofeedbackRelaxation and biofeedback PsychotherapyPsychotherapy

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RehabilitationRehabilitation

Treat postural dysfunction and myofascial painTreat postural dysfunction and myofascial pain Relaxation trainingRelaxation training Physical therapy Physical therapy

Reduce spasmReduce spasm Improve postureImprove posture Reduce triggers/perpetuating factors Reduce triggers/perpetuating factors

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Eliminate Overuse HeadacheEliminate Overuse Headache

Taper and stop offending agentsTaper and stop offending agents Severe headache invariably resultsSevere headache invariably results

Supportive treatment: hydration, antiemetics, anti-Supportive treatment: hydration, antiemetics, anti-withdrawal agents if neededwithdrawal agents if needed

Initiate preventive therapy as taper beginsInitiate preventive therapy as taper begins Initiate nondrug therapiesInitiate nondrug therapies Add abortive therapy once withdrawal Add abortive therapy once withdrawal

headache passesheadache passes

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Migraine: Preventive TreatmentMigraine: Preventive Treatment

Tricyclic antidepressants – first-lineTricyclic antidepressants – first-line Amitripyline, doxepin if sleep is disturbedAmitripyline, doxepin if sleep is disturbed

Beta-blockers – first-lineBeta-blockers – first-line Atenolol, nadololAtenolol, nadolol

Ca++ channel blockers – less effectiveCa++ channel blockers – less effective Verapamil most commonly usedVerapamil most commonly used

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Migraine: Preventive TreatmentMigraine: Preventive Treatment

Anticonvulsants – second-line; valuableAnticonvulsants – second-line; valuable Valproate and topiramate are quite effectiveValproate and topiramate are quite effective Gabapentin – best tolerated, ? effectGabapentin – best tolerated, ? effect Lamotrigine, levetiracetam – no good data as yetLamotrigine, levetiracetam – no good data as yet Pregabalin – may help (anecdotal) Pregabalin – may help (anecdotal) Psychotropic effects may be usefulPsychotropic effects may be useful

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Migraine: Preventive TreatmentMigraine: Preventive Treatment

Ergots: Rarely used for preventionErgots: Rarely used for prevention Side effects may be problematicSide effects may be problematic Methysergide: fibrosis (use 6 months max)Methysergide: fibrosis (use 6 months max)

MAOIs: Can be very effectiveMAOIs: Can be very effective Tyramine-free diet a mustTyramine-free diet a must Numerous drug interactionsNumerous drug interactions

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Migraine: Abortive TreatmentMigraine: Abortive Treatment

Simple and combined analgesicsSimple and combined analgesics APAP, NSAIDs, othersAPAP, NSAIDs, others

Mixed analgesics (barbiturate plus simple Mixed analgesics (barbiturate plus simple analgesics) – avoid wherever possibleanalgesics) – avoid wherever possible

Ergot derivativesErgot derivatives TriptansTriptans OpioidsOpioids

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TriptansTriptans

Serotonin 5-HTSerotonin 5-HT11 agonists agonists Reduce neurogenic inflammationReduce neurogenic inflammation Most effective if used at Most effective if used at onset of headache or onset of headache or

aura, aura, though may be helpful at other phases though may be helpful at other phases Used specifically for migraineUsed specifically for migraine For nonresponders, try ergots (also act on NE, For nonresponders, try ergots (also act on NE,

DA, other receptors)DA, other receptors)

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TriptansTriptans

Generally well toleratedGenerally well tolerated Contraindications:Contraindications:

Uncontrolled hypertensionUncontrolled hypertension CAD, PVD, cerebrovascular diseaseCAD, PVD, cerebrovascular disease PregnancyPregnancy MAOIsMAOIs High-dose SSRIs, tramadol (rare interaction)High-dose SSRIs, tramadol (rare interaction) Ergotamine or other triptan use within 24 hrsErgotamine or other triptan use within 24 hrs

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TriptansTriptans

Short-actingShort-acting Sumatriptan, almotriptan, rizatriptan, zolmitriptan, Sumatriptan, almotriptan, rizatriptan, zolmitriptan,

eletriptaneletriptan Longer half-livesLonger half-lives

Naratriptan, frovatriptanNaratriptan, frovatriptan Successive trials may be needed to determine Successive trials may be needed to determine

the best triptan for a given patientthe best triptan for a given patient

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DHEDHE

Nasal sprayNasal spray Administer each nostril, may repeat in 15 minutesAdminister each nostril, may repeat in 15 minutes Works best if taken earlyWorks best if taken early Longer half-life than sumatriptan, though not as Longer half-life than sumatriptan, though not as

reliable for some patientsreliable for some patients InjectionInjection

1 mg can be given SQ or IM1 mg can be given SQ or IM Max dose: 3 mg/24 hoursMax dose: 3 mg/24 hours

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Other AgentsOther Agents

Antiemetics/Neuroleptics: often combined Antiemetics/Neuroleptics: often combined with abortive agentswith abortive agents Prochlorperazine, hydroxyzine, promethazine, Prochlorperazine, hydroxyzine, promethazine,

metoclopramidemetoclopramide Chlorpromazine and other neuroleptics may be Chlorpromazine and other neuroleptics may be

effective aloneeffective alone

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Drugs To AvoidDrugs To Avoid

Butorphanol nasal sprayButorphanol nasal spray Very addictive and often poorly toleratedVery addictive and often poorly tolerated Not suitable for chronic or frequent useNot suitable for chronic or frequent use

MeperidineMeperidine Neurotoxic metabolite, weak analgesicNeurotoxic metabolite, weak analgesic There are almost always better choicesThere are almost always better choices

Overuse of Overuse of anyany short-acting analgesic (opioids, short-acting analgesic (opioids, triptans, triptans, et alet al.).)

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Treating Cluster HeadacheTreating Cluster Headache

Acute: Acute: Oxygen inhalation 100% FM, or 7L NCOxygen inhalation 100% FM, or 7L NC Triptans/ergotsTriptans/ergots IndomethacinIndomethacin

Chronic/Preventive:Chronic/Preventive: Verapamil, lithiumVerapamil, lithium Valproate, topiramateValproate, topiramate Prednisone burstPrednisone burst MelatoninMelatonin ErgotsErgots

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Paroxysmal HemicraniasParoxysmal Hemicranias

Chronic and episodic Chronic and episodic varietiesvarieties

Uniquely sensitive to Uniquely sensitive to indomethacin!indomethacin!

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OpioidsOpioids

““Headaches can sometimes get so bad that Headaches can sometimes get so bad that doctors prescribe morphine or methadone. doctors prescribe morphine or methadone.

Another way to look at this is that headaches Another way to look at this is that headaches sometimes get so good that doctors sometimes get so good that doctors prescribe morphine or methadone.”prescribe morphine or methadone.”

The Onion’sThe Onion’s Headache Relief Tips, 2002 Headache Relief Tips, 2002

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Opioids and Chronic Intractable Opioids and Chronic Intractable HeadacheHeadache Saper et al., Saper et al., NeurologyNeurology 2004; 62:1687-94 2004; 62:1687-94

160 patients with intractable headache on 160 patients with intractable headache on scheduled opioidsscheduled opioids

Outcome variable: Reduction in headache Outcome variable: Reduction in headache frequency x severity (Severe Headache Index)frequency x severity (Severe Headache Index)

74% failed to improve or were discharged for 74% failed to improve or were discharged for clinical reasonsclinical reasons

26% improved over 50%26% improved over 50% Problem drug behavior occurred in half of patientsProblem drug behavior occurred in half of patients

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Cervicogenic HeadacheCervicogenic Headache

Differentiate from migraine or other Differentiate from migraine or other syndromessyndromes

Analgesics may be tried as for migraineAnalgesics may be tried as for migraine Reserve triptans/ergots for refractory casesReserve triptans/ergots for refractory cases Rebound often a significant issueRebound often a significant issue Therapy directed at neck may helpTherapy directed at neck may help

Facet blocks, trigger point injections, nerve blocks, Facet blocks, trigger point injections, nerve blocks, TENS, physical therapyTENS, physical therapy

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Other ReferencesOther References

uConnect: Clinical Guidelines: Pain uConnect: Clinical Guidelines: Pain Management GuidelinesManagement Guidelines Adult and Pediatric Migraine GuidelinesAdult and Pediatric Migraine Guidelines

Health Facts For You: search under Health Facts For You: search under Pain Pain or or HeadacheHeadache

Kaniecki R. Headache assessment and Kaniecki R. Headache assessment and management. management. JAMAJAMA 289(11): 1430-1433, 289(11): 1430-1433, 2003.2003.

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Thank Thank You!You!