Migraine and Tension-Type Headache Management

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Questions and Answers

Which medication is considered a first-line agent for migraine prophylaxis?

Propranolol (correct)

Gabapentin

Verapamil

Amitriptyline

What is a key consideration when using Topiramate for migraine prophylaxis?

It has no side effects

It requires slow dose titration (correct)

It can be used without dose adjustments

It should be taken during meals

In which condition is the use of NSAIDs contraindicated during the last trimester of pregnancy?

Peptic ulcer disease

Gout

Migraine (correct)

Prior stroke

What is a common side effect associated with the use of tricyclic antidepressants for tension-type headaches?

Sedation Signup and view all the answers

Which calcium channel blocker is noted for its effectiveness in migraine prophylaxis but has complications like depression?

Flunarizine Signup and view all the answers

What is a key principle of acute headache treatment?

Start treatment as soon as possible. Signup and view all the answers

When should prophylaxis for tension-type headaches be considered?

When analgesics are used more than 15 days per month. Signup and view all the answers

Which treatment is NOT advised for tension-type headache due to dependency risks?

Acetaminophen with codeine Signup and view all the answers

What is the appropriate use of NSAIDs for tension-type headache?

Limit to no more than 15 days of use per month. Signup and view all the answers

What is a non-pharmacological treatment option mentioned for tension-type headaches?

Cognitive-behavioral therapy Signup and view all the answers

Which of the following options is the best initial action for a physician treating acute tension-type headache?

Initiate pharmacological treatment. Signup and view all the answers

What is the maximum recommended frequency for analgesic use to avoid medication overuse headache?

15 days per month Signup and view all the answers

What should be the approach for initiating prophylactic treatment?

Start with a low dose and gradually increase. Signup and view all the answers

Which pharmacological treatment is considered first-line for acute migraine management?

Acetaminophen Signup and view all the answers

What is a primary indication for using triptans?

When analgesics and NSAIDs are ineffective Signup and view all the answers

What is a recommended adjunctive medication to be used with NSAIDs for treating acute migraines?

Metoclopramide Signup and view all the answers

Which symptom is NOT listed as an adverse effect of triptans?

Shortness of breath Signup and view all the answers

What is the maximum recommended dosage of Ketorolac for acute migraine treatment?

120 mg/day Signup and view all the answers

Which of the following is a contraindication for the use of analgesics in acute migraine treatment?

Overuse of medications Signup and view all the answers

What is a contraindication for the use of triptans?

Ischemic heart disease Signup and view all the answers

How long should one wait after using a triptan before using another?

24 hours Signup and view all the answers

Which treatment is classified as a third-line option for acute migraine management?

Triptans + NSAIDs Signup and view all the answers

Which of the following is a relative contraindication to triptan use?

Pregnancy or breastfeeding Signup and view all the answers

What is a potential risk when triptans are co-administered with SSRIs and SNRIs?

Serotonin syndrome Signup and view all the answers

Which of the following is advised when using triptans to avoid medication overuse headache (MOH)?

Using them less than 10 days a month Signup and view all the answers

What common feature do all seven available triptans share?

They have demonstrated efficacy for migraines Signup and view all the answers

What is a primary focus of the classification of headache disorders?

Differentiating primary and secondary headaches Signup and view all the answers

Which of the following is considered a non-pharmacological management option for headaches?

Hydration therapy Signup and view all the answers

What does the SCHOLARE acronym help assess in headache evaluation?

Severity, characteristics, history, onset, location, associated symptoms, remedies, and exacerbating factors Signup and view all the answers

What is a key component of the diagnostic criteria for headache disorders?

Differentiation based on frequency and duration Signup and view all the answers

Which statement about the epidemiology of headache disorders is correct?

Headache disorders have a wide prevalence across various age groups. Signup and view all the answers

What is one of the essential characteristics of aura in migraine with aura?

Aura must consist of visual, sensory, and/or speech/language symptoms. Signup and view all the answers

In cluster headache, what is the maximum duration of a headache attack if untreated?

15-180 minutes Signup and view all the answers

In managing headache disorders, what role does a pharmacist play?

Monitoring medication adherence and effectiveness Signup and view all the answers

What is a common characteristic of medication overuse headache?

Is induced by withdrawal from pain relief medications Signup and view all the answers

Which of the following is NOT a characteristic of migraine with aura?

Aura symptoms include severe bilateral pain. Signup and view all the answers

Which factor is NOT typically considered a 'red flag' in headache assessment?

Mild headache without any other symptoms Signup and view all the answers

What percentage of chronic cluster headache cases experience no significant remission?

15-20% Signup and view all the answers

What triggers could precipitate a cluster headache attack?

Nitroglycerin and alcohol Signup and view all the answers

How many attacks must occur for a diagnosis of migraine with aura according to the criteria?

At least 2 attacks Signup and view all the answers

What demographic shows a higher prevalence of cluster headaches?

Predominantly males Signup and view all the answers

Which of the following disorders is cluster headache classified under?

Primary headache disorder Signup and view all the answers

Study Notes

Headache Disorders - Overview

Headache disorders are a common complaint, with pain in the head.
There is a classification of headache disorders based on primary and secondary causes.
Students will be able to describe the classification, epidemiology, assessment, and diagnostic criteria for headache disorders. They will also describe the management of headache disorders and the role of pharmacists in managing and monitoring them.

Objectives

Students will be able to describe headache classifications.
Students will be able to describe the epidemiology of headache disorders.
Students will be able to describe the assessment and diagnostic criteria for headache disorders.
Students will be able to describe the management of headache disorders.
Students will be able to discuss the pharmacist's role in managing and monitoring headache disorders.

Outline

Definition of headache disorders
Classification of headache disorders
- Primary headache disorders
  - Epidemiology
  - Classification
  - Onset
- Diagnostic Criteria
- Assessment
- Management
  - Non-pharmacological
  - Pharmacological
  - Medication overuse headache
  - Special populations
  - Monitoring

Required Reading

Sherif H Mahmoud (2019) Headache (Chapter 4). In: Mahmoud S. (eds) Patient Assessment in Clinical Pharmacy. Springer, Cham
https://link.springer.com/book/10.1007%2F978-3-030-11775-7

Scenario 1

Adam (47 M) presented to the pharmacy complaining of a headache.
Next steps include using the SCHOLARE tool, assessing pain intensity, onset (new or ongoing), medication changes, hydration, precipitating factors, comorbidities, and location (unilateral or bilateral). Red flags include intensity, frequency increase, and worst headache, in which case immediate referral to the ER is necessary.

Definition

"Pain in the head." Headache is a common complaint encountered by healthcare practitioners.

The International Classification of Headache Disorders (ICHD-III)

Primary Headaches
- Migraine
- Tension-type headache
- Trigeminal autonomic cephalalgias (cluster headaches)
- Other primary headaches
Painful cranial neuropathies, other facial pains, cranial neuralgias and central causes of facial pain, and other headaches
Secondary Headaches
- Headache as a symptom of organic disease
- Head and neck trauma
- Cranial or cervical vascular disorders
- Non-vascular intracranial disorders
- Substance or its withdrawal
- Infection
- Disorders of Homeostasis (e.g., hypotension, thyroid changes, hypertension)
- Facial pain due to disorders of the cranium, neck, nose, eyes, ears, sinuses, mouth or teeth
- Psychiatric disorders

Tension-Type Headache (TTH)

Epidemiology: Experienced by 90% of females and 70% of males in their lifetime.
Classification: Episodic infrequent (less than 1 attack/month), Episodic frequent (up to 14 attacks/month), and Chronic (15 or more days/month for 6 months).
Onset: May occur at any age but less common in those over 50. Can be triggered by stress, tension, smoking, fatigue, prolonged poor posture (e.g., excessive computer use).
Diagnostic Criteria: Episodes lasting 30 minutes to 7 days, at least two of the following characteristics: Bilateral location, pressing/tightening quality, mild/moderate intensity, not aggravated by routine physical activity, no nausea or vomiting (anorexia may occur), no more than one of photophobia or phonophobia. Not attributed to another disorder.

Migraine

Epidemiology: ~15-18% in females, 5-8% in males. ~3.5 million Canadians have experienced migraine. High family history relevance. Ranked by WHO as one of the top 20 conditions causing disability.
Classification: With aura (~25%) and Without aura (~75%).
Onset: Always below age 50.
Triggers: Stress, smoking, fatigue, altered sleep patterns, some medications, weather changes, menses, odors, and food triggers (cheese, wine, chocolate, MSG, hot dogs).
Aura: A sensory perception that precedes a migraine attack, involving flashing lights, geometric patterns, distorted vision or hearing sounds. Lasts 5–60 minutes.
Migraine without Aura Diagnostic Criteria: At least 5 attacks fulfilling criteria B-D. Headache lasting 4–72 hours (untreated or successfully treated). Headache has at least two of the following characteristics: Unilateral location; pulsating quality; moderate or severe pain intensity; aggravation by or causing avoidance of routine physical activity. During headache, at least one of the following: Nausea and/or vomiting; photophobia and/or phonophobia. Not attributed to another disorder.
Migraine with Aura Diagnostic Criteria: At least 2 attacks fulfilling criteria B-D. Aura consisting of visual, sensory, and/or speech symptoms; fully reversible, but no motor, brainstem, or retinal symptoms. At least 2 of the following: Aura symptom spread gradually over ≥5 minutes, two or more symptoms occur in succession; each symptom lasts 5-60 minutes; symptom is unilateral; aura is accompanied by or followed within 60 minutes by headache. Headache fulfills criteria B-D for migraine without aura. Not attributed to another disorder.

Cluster Headache

Epidemiology: The most severe primary headache disorder; relatively rare (0.1% incidence). More predominant in males (4:1 to 12:1 ratio compared to females).
Classification: Episodic (80-85% of cases; remission between attacks) and Chronic (15-20% of cases; no significant remission).
Onset: Occurs at any age, with the most common onset between 20-40 years. Can be triggered by nitroglycerin, phosphodiesterase-5 inhibitors, alcohol and strong smells.
Diagnostic Criteria: At least 5 attacks fulfilling criteria B-D. Severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15-180 minutes. Headache is accompanied by at least one of the following: Ipsilateral conjunctival injection and/or lacrimation; ipsilateral nasal congestion and/or rhinorrhea; ipsilateral eyelid edema; ipsilateral forehead and facial sweating; ipsilateral miosis and/or ptosis; a sense of restlessness or agitation. Attacks occur with a frequency of 1 every other day to 8 per day; not attributed to another disorder.

Assessment of Headache

Medical History: Collect headache history (SCHOLAR or SCHOLAR-E), headache diary, age of onset, frequency, duration, severity, location, associated symptoms, and precipitating, aggravating, and relieving factors. Determine red flags.
Physical Examination: Normal physical examination expected, otherwise complete investigation (e.g., CT scan, lumbar puncture, lab tests) is necessary.
Dental Examination: Examine for dental pain and bruxism.
Laboratory & Imaging: Appropriate tests and imaging based on the assessment.

Red Flags

Onset: Age >50 or <5 years
Severe and abrupt onset ("thunderclap headache")
Increased frequency or severity
Significant change in pattern (atypical) New signs like stiff neck, reduced consciousness, fever, or sick appearance. New onset headache in pregnancy = eclampsia/pre-eclampsia

Management

Non-pharmacological Treatment:
- Patient education
- Patient reassurance
- Avoid triggers (stress, certain foods, poor sleep habits, smoking)
- Ice packs, adequate sleep, dark, quiet room.
- Informal psychotherapy, Biofeedback, relaxation therapy, Cognitive-behavioral therapy, Acupuncture
Pharmacological Treatment:
- General Principles for Acute Headache Treatment: Start quickly, minimum effective dose, titrate, consider severity and symptoms, check medical history, and consider patient preference.
- General Principles for Prophylaxis: Frequent attacks, severe disabling attacks, short-lived attacks (especially cluster headache), initiate low and go slow, use long-acting meds, taper if attack-free for 6-12 months.
- Treatment of Tension-Type Headache: analgesics (NSAIDs, ASA, naproxen, caffeine combinations). Limit analgesic use to no more than 15 days/month to avoid medication overuse headache (MOH).
- Treatment of Migraine: First-line- NSAIDs, Acetaminophen, ASA. Second line- Triptans. Third line- Triptans + NSAIDs, Gepants & Ditans. Fourth line- Ergot Derivatives. Analgesic use should be limited to no more than 15 days/month to avoid medication overuse headache (MOH).
- Treatment of Cluster Headache: Abortive therapy (oxygen, sumatriptan SC/nasal, zolmitriptan), Prophylaxis (verapamil), and Surgical intervention (for refractory cluster headache: nerve radio frequency ablation, neurostimulation).
Specific Considerations for Special Populations: Pregnant women, those who are lactating, those with other medical conditions (e.g., pre-existing conditions). Avoid certain drugs (e.g., during pregnancy). Use caution when co-administering certain medications that could increase the risk of serotonin syndrome.

Monitoring

Advise patients to keep a headache calendar, tracking headache severity, frequency, associated symptoms, adverse reactions, efficacy of agents, and record use of headache medications.

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Description

Test your knowledge on migraine and tension-type headache treatments with this quiz. Explore first-line medications, considerations for their use, and non-pharmacological options. This quiz also examines the contraindications and guidelines for acute headache management.