Outpatient Headache

Outpatient Headache

Background

Type

Presentation

First line meds

Tension type (most common)

Generally bilateral, pressure/tightness, mild/moderate pain, no significant photophobia/phonophobia, nausea

Acetaminophen, TCA’s, SNRI’s, anticonvulsants

Migraine

Unilateral/pulsating, moderate/severe pain, lasting 4-72hr, associated nausea, photophobia or phonophobia; ± aura, worse with physical activity, often improves with sleep

Acute: triptans
 

Preventive: TCAs, propranolol, topiramate, VPA

Cluster

Severe, often extreme unilateral orbital/supra-orbital/temporal pain, often with lacrimation, rhinorrhea, sweating/swelling of face, visual change

Acute: 100% FiO2 at 12L/min for at least 15 mins, triptans


Preventive: verapamil; some data for  nightly melatonin to regulate circadian rhythms

Medication Overuse

HA at least ½ the days of the month, w/medication intake at least ½ the days of the month; often presents as worsening HA despite increased intake of medication. Often seen with meds that include caffeine (excedrine, fioricet)

Acute: 100% FiO2 at 12L/min for at least 15 mins, triptans

 

Preventive: Verapamil

*STOP offending medication, typically via taper. HA will worsen before it gets better (can be alleviated with naproxen taper and/or steroid dose pack)

 

Medication Overview:

  • Abortive
    • Sumatriptan or rizatriptan are generally first choices. Cannot be used more than 10 days/month. Avoid in pts with hypertension/CAD
  • Preventative – generally start low and increase dose every few weeks
    • Amitriptyline: indicated for both migraine and tension-type. Helps with sleep and comorbid depression. Most common side effects (SE) = dry mouth, sedation
    • Topiramate: has the best evidence among migraine meds. Can theoretically help with weight loss. Most common SE = sodas taste bad, sedation
    • Propranolol: useful for relative lack of interactions. Mild cardiac/blood pressure effects compared to other beta-blockers. Most common SE = drowsiness
    • Magnesium oxide: reduces headache frequency with almost no SE. Start 400mg daily, can go up to 800mg BID. Patients can increase dose until they get diarrhea.
    • Riboflavin (vitamin B2): mild effect but effectively has no side effects. 400mg daily.
    • Gabapentin: can be useful if HAs have stabbing/electric quality. Main SE = sedation
    • Venlafaxine: useful for migraines with significant vestibular symptoms (dizziness)
      •  
      • Major SE = insomnia, hypertension/tachycardia
    • Verapamil: can be used for migraine and cluster headaches. Can use ER formulation
    • Botox: can be administered every 3 months. Can be very effective, but pts generally will have had to fail multiple medications for insurance to approve
    • CGRP receptor modulators (mostly injections) such as Rimegepant are newer options