Migraine and Tension-Type Headache Management

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.

Suggested Readings

• Multiple articles for headache disorders, clinical management, and emerging treatments, for primary and secondary headache disorders.