SOAP. – Migraine Headache – SỔ TAY LÂM SÀNG

Cheryl A. Glass

Definition

A.Migraine headaches are a common medical complaint responsible for a significant disability and loss of quality of life (QOL). The economic impact involves loss of workdays, school, social interaction, and productivity while at work (presenteeism). Migraines are ranked the third highest cause of disability worldwide in both males and females under 50 year of age.

B.Migraines have two major types, migraine without aura and migraine with aura:

1.Migraine without aura is a clinical syndrome characterized by headache with specific features and associated symptoms:

a.Recurrent headache disorder manifesting in attacks lasting 4 to 72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity, and association with nausea and/or photophobia and phonophobia.

2.Migraine with aura is primarily characterized by the transient focal neurological symptoms that usually precede or sometimes accompany the headache. Some patients also experience a prodromal phase, occurring hours or days before the headache, and/or a postdromal phase following headache resolution. Prodromal and postdromal symptoms include hyperactivity, hypoactivity, depression, cravings for particular foods, repetitive yawning, fatigue, and neck stiffness and/or pain.

C.There are multiple subtypes of migraines described by the International Headache Society (IHS) by type and diagnostic criteria.

D.Migraine headaches have been associated with increased risk of cerebral ischemia and an increased risk of cardiac ischemia.

E.Migraine and epilepsy are prototypical examples of paroxysmal brain disorders. Although migraine-like headaches are quite frequently seen in the epileptic postictal period, sometimes a seizure occurs during or following a migraine attack. This phenomenon, sometimes referred to as ‘migralepsy’, is a rare event.

Incidence

A.Headaches are one of the most common medical complaints. The exact incidence of migraines is unknown because patients self-treat, are underdiagnosed, and are commonly misdiagnosed.

B.It is estimated that more than 30 million people have one or more migraine headaches per year.

C.Gender: 64% of severe headaches occur in women and 43% of severe headaches in males. Approximately 75% of all persons who experience migraines are women.

D.Ethnicity: The prevalence of migraines is lowest among African Americans and Asian Americans.

E.Onset of migraines after age 50 is rare.

F.Migraines and ischemic strokes reportedly occur in 1.4 to 3.3 per 100,000 and account for 0.8% of total strokes.

G.Migraineurs, especially those with migraine with aura, have a higher incidence of adverse cardiovascular profiles.

Pathogenesis

A.Migraines have broad sensory processing dysfunction, with a prominent perception of pain in the dense somatosensory innervation of intracranial vessels. Current pathophysiologic concepts of migraine and migraine aura include a possible dysfunction of neuromodulatory structures in the brainstem and cortical spreading depression (CSD). Different receptors, including calcitonin gene-related peptide (CGRP), transient receptor potential cation channel subfamily V member (TrpVI [also known as the capsaicin receptor]), and glutamate receptors, are currently being targeted for migraine therapeutics.

Predisposing Factors

A.Family history of migraines.

B.Chronic use of over-the-counter (OTC) analgesics (rebound).

C.Posthead trauma.

D.Food, odor, light, sound, sleep, weather changes, hormonal changes, and stress triggers.

E.Menstruation.

F.Obesity.

G.Daily habitual snoring is a modest risk factor.

H.Estrogen use.

Common Complaints

A.Unilateral headache.

B.Frontotemporal area.

C.Photophobia, or sensitivity to light.

D.Phonophobia, or sensitivity to sound.

E.Osmophobia, or hypersensitivity/aversion to odors.

F.Nausea with/without vomiting.

G.Prodrome phase: Fatigue, reduced concentration, agitation, craving, irritability, depression, frequent yawning, or hyperexcitability hours to days before the onset of aura and headache.

Other Signs and Symptoms

A.Muscle tension and neck pain.

B.Cutaneous allodynia (pain from stimulus to normal skin or scalp).

C.Sinus congestion.

D.Prodrome phase can last 25 hours accompanied by fatigue and a hangover headache.

Subjective Data

A.Use the acronym PQRST for subjective information:

P: Provocation, or worsening of factors stimulating headaches.

Q: Quality of pain, severity of pain.

R: Region of headache.

S: Strength of pain; evaluate pain on a scale of 0 to 10.

T: Time, including onset, frequency, and duration of headaches.

B.Assess whether the patient has migraine headaches frequently. Is this the first or worst headache ever experienced by the patient?

C.If recurrent headaches exist, note frequency and patterns of similar headaches.

D.Note whether the patient has ever identified potential triggers of recurring headaches such as menstruation, diet, stressors, and odors (i.e., perfumes and cigarette smoke).

E.Identify the location of the pain, along with radiation if present.

F.Describe the type of pain: Throbbing, constant, or burning.

G.Assess the presence of associated symptoms: Nausea or vomiting, photophobia, and noise sensitivity.

H.Determine whether the patient experiences any neurologic symptoms and/or prodromal symptoms prior to headache.

I.Review the methods used in the past to abort and/or prevent headaches and the results.

J.Inquire about past diagnostic evaluations for headaches.

K.Note a family history of headaches.

L.List current medications, including OTC medications and herbal products.

M.Review the patient’s medical history for head trauma, infection, allergies, presence of a ventriculoperitoneal (VP) shunt, or other neurologic diagnoses.

Physical Examination

Physical exam may be normal unless the patient presents with a headache.

A.Check blood pressure (BP), pulse, and respirations (temperature if meningeal signs are present).

B.Inspect:

1.Observe overall appearance for the presence of discomfort, photosensitivity (use of sunglasses indoors), and level of consciousness (LOC).

2.Examine the eyes; perform funduscopic exam.

3.Inspect the ears, nose, and throat.

C.Auscultate:

1.Listen for bruit at neck, eyes, and head for clinical signs of atrioventricular (AV) malformation.

D.Palpate:

1.Palpate the head, eyes, ears, temporomandibular joint (TMJ), sinus cavities, temporal, and neck arteries.

2.Palpate cervical vertebrae, cervical muscles, and shoulder regions. Identify potential trigger areas: Occipital nerves leave halfway between the middle of the neck at the back of the neck and lateral to this area. When palpating this trigger area, pain may be reproduced with palpation.

3.Examine the spine and neck muscles.

4.Assess the cervical range of motion (ROM).

E.Perform neurologic exam:

1.Extraocular muscles (EOM).

2.Pupil response.

3.Getting up from a seated position without any support.

4.Walking on tiptoes and heels.

5.Tandem gait.

6.Romberg test.

7.Symmetry on motor, sensory, deep tendon reflexes (DTRs), and coordination tests.

Diagnostic Tests

A.Neuroimaging, MRI and CT, are based on patient history and physical examination:

1.Adults with stable headaches, a normal examination, and absence of seizures do not require neuroimaging.

2.An emergent noncontrast CT should be obtained in an emergency setting when the patient complains of the worst headache ever or when focal neurologic findings, nuchal rigidity, or altered mental status exist.

3.The presence of personality changes, depression, and a migraine may indicate a temporal lobe tumor.

4.The presence of orbital bruit requires neuroimaging.

5.Neuroimaging is recommended for adults with onset of headache after age 40.

6.Onset of headache with exertion, cough, or sexual activity should be considered for neuroimaging.

B.A lumbar puncture (LP) may be indicated with altered mental status or focal findings.

C.Order sinus films to rule out sinusitis or a lesion.

D.Laboratory tests are not required for most patients with typical symptoms and a negative physical examination.

1.Drug screen may be indicated.

2.Complete metabolic panel (CMP).

3.Complete blood count (CBC).

4.Thyroid-stimulating hormone (TSH).

5.Sedimentation rate.

Differential Diagnoses

A.Migraine:

1.Migraine with aura.

2.Migraine without aura.

B.Other types of headaches:

1.Medication overuse headache (MOH).

2.Common headache.

3.Cluster headache.

4.Combination headache.

5.Chronic daily headache.

6.Tension headache.

7.Hypnic headaches (geriatrics).

C.Sinusitis.

D.Space-occupying lesion: Subacute and progressive pain, new onset for adults older than 40 years.

E.Temporal arteritis: New onset progressive headache for adults older than 50 years.

F.Carotid dissection: Sudden headache with neck pain radiating to the face, ear, or eye.

G.TMJ syndrome.

H.Meningitis.

I.Brain abscess.

J.Encephalitis.

K.Idiopathic intracranial hypertension (HTN).

Plan

A.General interventions: There are four main approaches to migraine therapy:

1.Nonpharmacologic interventions:

a.Adjust habits to maintain a routine pattern of sleeping. This is especially important to maintain on weekends and vacations.

b.Do not skip breakfast. Eat regular meals with one or two snacks.

c.Avoid food triggers identified by the patient’s migraine diary.

d.Encourage drinking no more than two caffeinated beverages a day.

e.Hydration is important.

f.Encourage at least 30 minutes of exercise 3 to 7 days a week.

g.Cold compresses.

2.Behavioral interventions:

a.Use relaxation techniques such as yoga, deep breathing, meditation, and guided imagery.

b.Biofeedback is an adjunct to relaxation training.

c.Cognitive behavioral therapy (CBT).

d.Psychiatric therapy.

3.Complementary and alternative interventions:

a.Acupuncture.

b.Nutraceuticals, including magnesium and coenzyme Q10.

c.Vitamins: Riboflavin (B2).

d.Herbal (nonregulated by the Food and Drug Administration [FDA]), including feverfew, Petasites (purified extract of butterbur root extract), and MIG-99 (extract of Tanacetum parthenium [feverfew]).

e.Physical therapy.

f.Hypnosis.

g.Cerena Transcranial Magnetic Stimulator (Cerena TMS) is used to relieve pain caused by migraine headache with aura for patients 18 years and older. Users hold the device with both hands to the back of the head and press a button to release a pulse of magnetic energy that stimulates the occipital cortex. The recommended daily usage of the device is not to exceed one treatment in 24 hours.

h.In January 2018, the FDA approved a vagus nerve stimulator (VNS) for the treatment of migraine pain in adults. The handheld, noninvasive device was previously approved for treating episodic cluster headache pain. The prescription-only device is placed over the vagus nerve in the neck and releases a mild electrical stimulation to the nerve’s afferent fibers.

i.Chiropractic manipulation and occlusal adjustment are also noted in the literature.

B. See Section III: Patient Teaching Guide Migraines:

1.Encourage the patient to keep a headache diary; an example of a migraine diary is at www.webmd.com/migraines-headaches/guide/headache-diary.

a.Examples of food triggers are aspartame, saccharin, red wine, alcohol, chocolate, aged cheese, oranges, tomatoes, avocado, nuts, onions, tyramine, phenylethylamine, monosodium glutamate (MSG), and nitrates as well as nitrites found in hot dogs, luncheon meat, and sausage.

b.Examples of odor triggers are tobacco smoke, perfumes, and strong odors.

c.Examples of visual triggers include strobe lights, bright lights/sunlight, fluorescent lights, and glare.

d.Other triggers are medications, barometric weather changes, too much/too little sleep, and high altitude.

C.The 2014 AHA/ASA guidelines for the prevention of strokes in women state that because of the increased stroke risk seen in women with migraine headaches with aura, and smoking, it is reasonable to strongly recommend smoking cessation.

D.Pharmaceutical therapy (see Table 23.3).

The choice of drug therapy prophylactic agents depends on the patient’s comorbid conditions such as cardiac, respiratory, psychiatric, sleep, and gastrointestinal (GI) disorders:

1.Abortive medications:

a.Selective serotonin receptor (5-hydroxytryptamine–1, or 5-HT1) agonists (triptans):

i.Sumatriptan (Imitrex, Sumavel DosePro, Alsuma, Sumavel, Zembrace).

ii.Sumatriptan and naproxen (Treximet).

iii.Sumatriptan intranasal (Imitrex Intranasal, Onzetra Xsail).

iv.Sumatriptan transdermal (Zecuity).

v.Naratriptan (Amerge).

vi.Zolmitriptan (Zomig, Zomig-ZMT).

vii.Rizatriptan (Maxalt, Maxalt-MLT).

viii.Almotriptan (Axert).

ix.Frovatriptan (Frova).

x.Eletriptan (Relpax).

b.Ergot alkaloids:

i.Ergatomine tartrate (Ergomar).

ii.Dihydroergotamine (DHE-45, Migranal).

c.Analgesics:

i.Acetaminophen.

ii.Aspirin-Free Anacin Extra Strength.

d.Nonsteroidal anti-inflammatory drugs (NSAIDs):

i.Aspirin (Bayer, Bufferin, Ecotrin, Ascriptin).

ii.Ketorolac intranasal (Sprix).

iii.Ibuprofen (Motrin, Advil, NeoProfen, Caldolor).

iv.Naproxen (Naprosyn, Anaprox, Aleve, Midol Extended Relief ).

v.Ketoprofen (Active-Ketoprofen, Ketophene RapidPaq).

e.Combination products:

i.Excedrin (acetaminophen, aspirin, caffeine).

ii.Codeine/acetaminophen (Tylenol #3, Tylenol #4).

iii.Isometheptene, dichloraphenazone, and acetaminophen (Midrin, Epidrin).

iv.Butalbital, aspirin, and caffeine (Fiorinal).

v.Butalbital, acetaminophen, and caffeine (Fioricet).

f.Antiemetics:

i.Promethazine (Phenergan).

ii.Prochlorperazine (Compro, Compazine).

g.Opioids (not first-line treatment—prescribe sparingly to patients who do not respond to routine abortive treatment):

i.Morphine [Drug of Choice] (Arymo ER, Astramorph, DepoDur, MS Contin, Duramorph, Avinza, Infumorph, Kadian, MorphaBond).

ii.Oxycodone (OxyContin, Roxicodone, Oxecta, Oxaydo, Xtampza ER).

iii.Meperidine (Demerol).

iv.Hydromorphone (Dilaudid, Dilaudid-HR, Exalgo).

h.Antipsychotic

i.Chlorpromazine (Thorazine).

2.Prophylactic medications:

a.Antiepileptic drugs (AEDs):

i.Valproic acid (Depakote, Depacon, Depakene, Stavzor).

ii.Topiramate (Topamax, Qudexy XR, Topiragen, Trokendi XR).

b.Beta-blockers beta-1 selective (not a first-line agent):

i.Propranolol (Inderal, Inderal LA, Hemangeol,InnoPran XL).

ii.Timolol (Apo-Timol, Nu-Timolol, Teva-Timolol).

c.Tricyclic antidepressants (TCAs):

i.Amitriptyline (Elavil).

ii.Nortriptyline (Pamelor).

iii.Doxepin (Silenor).

iv.Protriptyline (Vivactil).

d.Calcium channel blockers:

i.Verapamil (Calan, Isoptin SR, Verelan).

e.Selective serotonin reuptake inhibitors (SSRIs).

i.Paroxetine (Paxil, Paxil CR, Pexeva, Brisdelle).

ii.Fluoxetine (Prozac, Prozac Weekly, Sarafem).

iii.Sertraline (Zoloft).

f.NSAIDs (as previously noted).

g.Serotonin antagonists.

h.Botulinum toxin

i.CGRP inhibitors—erenumab (Aimovig).

3.Patients should be counseled to take medications as prescribed. When patients overuse various analgesics for headaches, paroxysmal migraines can convert into chronic daily headaches. Acute overuse of symptomatic medication is considered one of the most important risk factors for migraine progression. MOH can occur with any analgesic, including acetaminophen or NSAIDs, such as ibuprofen, naproxen, and aspirin.

4.Opioid or butalbital-containing medication should not be prescribed as first-line treatment for recurrent headache disorders. Analgesics like butalbital and narcotics are associated with rebound headaches. Increasing the use of combination preparations may fail to provide pain relief and may worsen headache symptoms.

5.NSAIDs are generally used as abortive therapy in mild to moderately severe migraine headaches. However, these agents, especially ketorolac, may also be effective for severe headaches.

NSAIDs are also used as prophylactic agents, but they are associated with a higher risk of adverse effects, particularly gastropathy or nephropathy, than when they are used as abortive medications.

6.Triptans are used as abortive medications for moderately severe to severe migraine headaches. Triptans should be used cautiously in patients with cardiovascular comorbidities. Drug interactions occur with potent CYP450 3A4 inhibitors (e.g., ketoconazole, itraconazole, nefazodone, troleandomycin, clarithromycin, ritonavir, nelfinavir), which may increase toxicity, and with concurrent administration of ergot-containing drugs, which may increase vasospastic reactions.

7.Use ergot derivatives selectively. These medications are not to be used on a long-term basis or more than three times per week. There is an associated risk of strokes when using these medications due to the vasoconstrictive mechanisms on peripheral and cranial blood vessels

8.Ergots and triptans should not be given within 14 days of an monoamine oxidase (MAO) inhibitor.

9.Calcium channel blockers are particularly useful in patients with comorbid hypertension and in those with contraindications to beta-blockers, such as asthma and Raynaud disease. Calcium channel blockers may have particular advantage in patients with prolonged aura, basilar-type migraine, or hemiplegic migraine. Verapamil is frequently the first choice for prophylactic therapy because of ease of use and a favorable side-effect profile.

10.Beta-blockers are approved for migraine prophylaxis but are not considered a first-line therapy; however, they must be used with caution for patients with comorbidities such as asthma, depression, diabetes, and thyroid disease. Compared with other antihypertensive medications, beta-blockers pose a higher risk of cardiovascular events.

11.Antiemetic agents are used to treat migraine and the emesis associated with acute attacks. Drugs in this category are commonly combined with diphenhydramine to minimize the risk of akathisia.

12.Topiramate is indicated for migraine headache prophylaxis in adults and adolescents aged 12 years or older. Topiramate should not be prescribed or should be discontinued for a history of kidney stones.

13.As a rule, dopamine antagonists are avoided in patients with traumatic brain injury.

14.Onabotulinumotoxin A (Botox) is Food and Drug Administaration (FDA) approved for chronic migraines in adults who are 18 years or over with headaches 15 or more days a month lasting 4 hours or more each day. Safety and effectiveness have not been established for the prophylaxis of episodic migraine (14 headache days for fewer per month).

15.In 2018 the FDA-approved new injectable drugs to prevent migraine treatment that work by blocking the activity of calcitonin gene-related peptide (CGRP):

a.Erenumab (Aimovig).

b.Fremanezumab (Ajovy).

c.Galcanezumab (Emgality).

16.Dihydroergotamine mesylate (Migranal) is not to be used for patients during pregnancy or with heart disease, or for use with ischemic or vasospastic circulatory disease.

Follow-Up

A.See the patient in 2 weeks to evaluate how therapies have worked.

B.Evaluate the patient’s headache diary to assist him or her in identifying headache triggers or patterns, such as prior to menstruation. Utilize the information documented in the diary as a tool for reevaluating the need for other tests and consultations.

C.Monitor liver enzymes and CBC periodically with anti-seizure medication prophylaxis.

Consultation/Referral

A.Consult a physician if headaches are caused by acute problems other than migraine and/or tension headaches.

B.If medications do not help with headaches, refer the patient to a neurologist.

Emergent Issues/Instructions

Send the patient to the ED for any neurologic, life-threatening signs.

Individual Considerations

A.Pregnancy: Many medications are contraindicated in pregnancy.

B.Geriatrics:

1.Headaches decrease after age 50. Headache onset after age 50 is associated with epilepsy, essential tremor, ischemic stroke, mood disorders, asthma, and patent foramen ovale.

2.Consider imaging studies for elderly patients that present with unusual headaches.

3.Consider chronic subdural hematomas (SDHs) with patients who have frequent falls; perform CT scan or MRI for evaluation. Elderly patients may not exhibit any symptoms other than a headache.

4.Consider all contraindications when prescribing medications; many elderly patients have cardiovascular disease, which is contraindicated with ergot derivatives.