Disabling headaches? You just need a plan

Clinical pearls for frontline PCPs

A 45-year-old woman makes an appointment because she is “just so sick of these headaches.”

The medical assistant (MA) checks her in and gets the following history: She has had a long history of disabling headaches since her mid-teens. Her headaches have waxed and waned over the years, often getting worse when she sleeps poorly and when she is under a great deal of stress. She has been pregnant twice and recalls that these were actually the best times of her adult life in terms of her headache. Her headaches are nearly always one-sided and are associated with nausea and even vomiting on some occasions.

Philip A. Bain

During a bad headache, she has had to miss school and work and retreat to a dark room. Over the past 3 to 6 months, her headache pattern has progressed to the point where she now has a headache on a daily or nearly daily basis. She works as a third-grade teacher and has already used her allotted sick days for the semester. She is worried that she might lose her job if she misses any more work. Her medications include propranolol 20 mg twice daily, topiramate 25 mg nightly, and venlafaxine 75 mg daily for depression. She takes rizatriptan daily as needed, but her insurance company limits her to only nine tablets per month, and in the past 3 months, she has run out within the first 2 weeks of the month. She has been taking an over-the-counter pain reliever containing aspirin, acetaminophen and caffeine when she runs out of her rizatriptan. She has had to take more of this combination in the past 6 weeks, to the point where if she doesn’t take it, she gets a bad headache. She now takes four to six per day. She went to Mexico over Christmas break and bought 50 extra rizatriptan tablets, but she has run out of these as well.

The MA tells the physician, “Doc, this lady is miserable. She has a long history of bad headaches, and they have become much more frequent and much more severe in the past 3 to 4 months. Her previous physician just retired, and she needs help.”

The physician enters the exam room and asks the patient to tell him about her headache history. She reiterates the story that she told the MA. Her headaches started around the time that she began menstruating and for the first few years correlated very strongly with her periods. In her mid-twenties, during her first pregnancy, the early portion of the first trimester was pretty rough, but then her headaches almost completely resolved for the rest of her pregnancy. She breastfed her infant, and her headaches returned after her delivery but were generally pretty tolerable. Once she stopped breastfeeding, however, her headaches came roaring back, similar to what she noted before becoming pregnant. A similar pattern occurred with her second pregnancy.

On physical exam, her vital signs are normal. The physician conducts a SHEENT exam — skin, head, eyes, ears, nose and throat. Fundoscopy shows an excellent view of her optic disc margins, which are sharp. Her retinal vessels look normal. Her scalp is diffusely tender. Her heart and lung exams are normal. Her neurologic exam is entirely normal.

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The physician diagnoses chronic migraine with medication overuse headaches (MOH). He explains the pathophysiology of MOH and chronic migraine. He continues the propranolol, topiramate and venlafaxine at the previous dosages. He asks her to stop the aspirin-acetaminophen-caffeine combination and limit the rizatriptan to no more than 2 days per week. He recommends that she use OTC naproxen as the first-line agent for pain. He discusses adding erenumab — sold under the brand name Aimovig (Amgen) — at 70 mg subcutaneously every month. She asks about botulinum toxin, and the physician says that this is a possibility for her chronic migraine, but that he prefers to start with a calcitonin gene-related peptide (CGRP) antagonist. He also asks her to start riboflavin (vitamin B2) 400 mg daily and magnesium oxide 400 mg daily. He warns her that vitamin B2 might cause her urine to turn bright (“highlighter like”) yellow. She asks about what type of “migraine diet” she should adopt, and the physician explains that current practice is to pay attention to what specific foods and drinks were closely associated with her headaches and to avoid those items. A general “migraine diet” is not thought to be very helpful. She tells him that she has already cut out red wine and avocados, since those two things always seem to bring on her headaches. She wonders if she should have a repeat MRI of her brain, as she had one about a year ago that was normal except for multiple small microvascular changes. Because of the classic presentation, normal neurologic and fundoscopic exams and MRI within the past year, the physician opts to hold off on a repeat MRI.

She returns 8 weeks later and reports that her headache days were reduced by about 25%, and that her headaches seem to respond better to the rizatriptan. Whereas previously the rizatriptan helped about one out of every four or five times that she took it, it now works about three or four times out of five. She is thankful that he prescribed ondansetron for nausea, which she says has been effective. He slowly increases her topiramate dose to 50 mg nightly over 2 weeks.

She returns to the office in about 3 months and reports that her headache pattern clearly was better than when she first came to see the physician. Headache days now are on average 3 days per week. Her scalp sensitivity has noticeably improved compared with when she first met the physician. Her school absences also decrease significantly, and she has not had to miss school at all for the past 6 weeks. The physician recommends that she slowly taper down and off of the topiramate over the next month.

Lessons learned

1. Migraine is very common, affecting about 6% of men, 18% of women and 12% of all adults. These percentages are remarkably similar country to country. It generally is a condition affecting younger adults. If someone aged 50 years or older presents with new-onset headaches, other causes like giant cell arteritis and tumors (primary and secondary) should be considered.
2. Primary headaches (those not caused by a specific abnormality) include migraine, tension type and cluster headaches. Secondary headaches (those caused by another specific condition) should be considered when evaluating chronic headaches. A handy mnemonic is SNOOPS 10 (see Table). If headaches are classic for migraine, fundoscopic exam shows normal disc margins and vessels, and if the neurologic exam is normal, imaging with CT or MRI may not be needed.
3. While migraine headaches are very common, a history of having migraine headaches should not bias the practitioner to avoid considering other types of headaches.
4. The pathophysiology of migraines has evolved over the past few decades. It is no longer considered to be a primary vascular abnormality but rather is thought to involve a complex interplay between brain peptides, like CGRP, and other substances, abnormal nerve signaling and blood vessel changes. Some of the newer effective medications block the CGRP receptors.
5. Symptoms include throbbing headaches that are often (but not always) one-sided, nausea and vomiting, and light and sound sensitivity. Untreated, they generally last 4 to 72 hours and, by definition, are disabling.
6. Diagnosis is made by history and physical exam. There often is a strong family history of migraine. If one parent has a history of migraine, there is a 50% chance of the child having migraine. If both parents have a migraine history, there is about a 75% chance that the child will have migraines. One helpful tool is ID Migraine — a three-question screening tool developed by Pfizer that asks about nausea, light sensitivity and disability. It has a sensitivity of about 81% and a specificity of about 75%.
7. Treatment of migraine includes nondrug approaches like getting adequate sleep, avoiding dehydration, not skipping meals and avoiding specific foods and drinks that consistently correlate with development of a migraine. A broad general “migraine diet” is no longer thought to be necessary. It is important to prescribe an antinausea medication like ondansetron, metoclopramide or prochlorperazine if nausea is a significant issue. NSAIDs like aspirin, ibuprofen and naproxen can be very helpful as a first-line agent, especially if taken early in the course of a migraine headache. Triptans like sumatriptan and others have a long track record of safety and efficacy and are now generic and less costly. The newer oral CGRP antagonists, while about as effective as triptans, are not considered first line because of cost. They can be prescribed if triptans are ineffective, contraindicated or poorly tolerated.
8. Preventive medications for migraine can be considered if the patient suffers more than 4 headache days per month or if the migraine symptoms are very severe. First-line preventive agents include beta blockers, low-dose tricyclic antidepressants and antiseizure medications like valproic acid and topiramate. Newer CGRP antagonists — usually given once monthly via injection — have been shown to be effective in reducing the number and severity of migraine headaches.
9. MOH is a common cause of frequent headaches. When short-acting pain medications (even OTC medications) are taken more than 2 days per week on average for 4 to 6 weeks or more, a headache-medication-wearing-off cycle an occur. Medications that commonly cause MOH include barbiturate-containing medications and opioids. Triptans and caffeine-containing medications can also cause MOH. NSAIDs can cause MOH but are less likely to do so.
10. Caring for patients with headaches can be one of the more satisfying parts of a primary care practice. Most patients do not need to be referred to a neurologist or headache specialist unless they are not responding to usual evidenced-based medications for headaches. Armed with a good management strategy, most patients with migraine can have good success in treating their headaches.

Editor’s note: For more information on headaches, including presentation, diagnosis and treatment options, visit this Healio Clinical Guidance module on the subject .

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