Managing Headache at

UW Health:
Making a Tough Job Easier
Nathan J. Rudin, M.D.

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Associate Professor, Orthopedics and Rehabilitation

Medical Director, Pain Treatment and Research Center
UW Health

Headache: A Worldwide Problem

Up to 25% of American
adults have a severe
headache each year
Up to 4% have daily or
near-daily headache
Lifetime prevalence:
90% or more
Significant suffering
and economic loss

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Headache: A Local Problem

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Average visit length: 3.5 hours

Barriers To Success
Limited physician training
Limited access to care
Inappropriate or incomplete treatment

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Underestimation of morbidity

Ambulatory Care Innovation Grant

Funding

from UW Medical Foundation

Goal:
Improve pain care referral, triage and

utilization across UW Health

First step:
Survey physicians, nurses, and midlevel providers

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about their comfort with and use of pain

management

Staff Survey Results

Key

areas

department utilization for nonemergency pain care

Improve pain education for staff at all levels
Improve communication of pain-related
information across UW Health
Centralize pain referral and case triage
Improve coordination of perioperative pain care

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Reduce emergency

Staff Survey Results

Key

areas

Reduce emergency department utilization for

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non-emergency pain care

Improve pain education for staff at all levels
Improve communication of pain-related
information across UW Health
Centralize pain referral and case triage
Improve coordination of perioperative pain care

Goals 2006 2007

primary care and emergency room
providers with basic headache management
Educate patients
Standardize treatment protocols
Standardize communication of headache care
plans
Incorporate care plans, protocols and
educational tools into EMR

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Familiarize

Provider Toolkit
Video on Headache Care Basics (DVD and

downloadable
from uconnect
and uwhealth.org

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online)
Introductory article on headache
Headache diagnostic classification
Madison citywide headache treatment
guidelines
Headache treatment plan form
Headache Clinic consult request form

Headache Treatment Guidelines

panel of specialists
Provides a framework for headache treatment,
particularly migraine

uconnect: Clinical Guidelines / Pain Management Resources

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Developed by

Headache Treatment Plan

patients individual treatment plan
One copy scanned into EMR
Copy 2 give to patient

Standard
Register #SR300078

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Outline

When To Call The Headache Clinic?

headache
608-263-9550
Unclear diagnosis
Intensive and/or interdisciplinary treatment
needed

Register #SR300077

Consult
Form Standard

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Refractory

Patient Toolkit
Video on Headache Basics (DVD and online)
Introductory

letter
Headache Diary
Health Facts
Migraine; Medication Overuse Headache; Diet and

downloadable
from uconnect
and uwhealth.org

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Headache; Avoiding the ED

Headache Diary
Patient fills this

Standard
Register #SR300079

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out daily
Brings to clinic
visit
Lets you evaluate
headache pattern
and treatment
effects

Basic Principles
Rule out potentially

dangerous (secondary)

headache
Neoplasm, infection, hemorrhage, etc.

and physical
Diagnose headache type
Implement treatment
Monitor outcome

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Thorough history

Secondary Headache Disorders

<2% of headaches in primary

care offices

Head trauma
Vascular disease
Neoplasms
Substance abuse or withdrawal
Infection/Inflammation
Metabolic disorders

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others

Warning Signs
(thunderclap headache)
progressive or new daily persistent HA
age >50 or <5 years
HA associated with fever, rash, stiff neck
HA associated with abnormal mental status or
abnormal neuro exam

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first or worst HA

Warning Signs
HA associated with papilledema
new HA in patient with h/o malignancy,

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immunosuppression/HIV, pregnancy
awakening because of HA
HA with Valsalva or exertion

Primary Headache
Intrinsic dysfunction of the nervous system
Most patients presenting to PCP with headache

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have primary headache syndromes

Episodic headache: more common
Chronic headache: attacks occurring more
frequently than 15 days/month for more than 6
months

Diagnostic Steps
Rule out secondary

headache

Thorough history
Neurological and musculoskeletal examinations
Imaging, blood work and/or CSF analysis if

red flag(s) found

Diagnose headache type

comorbid illnesses

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Identify

Headache History
Area of head involved
Pain quality
Pain severity
Other symptoms (nausea, vomiting, light sensitivity)
Triggers
Timing (including perimenstrual)
Pre-headache warning symptoms (aura) for
example, visual changes

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Migraine Pathophysiology
Migraine is a

brain

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disorder
Brain becomes
hypersensitive and
overly responsive
to stimuli
The trigeminal
nerve appears to be
a key pathway

Migraine Cascade

Vasoactive substances
inflame vascular and
meningeal tissue,
activate trigeminal
axons

Perivascular release
of vasoactive
neuropeptides;
spreading neurogenic
inflammation

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The inflammatory
response spreads along
the trigeminovascular
system

Pain signals reach

trigeminal nucleus
caudalis and other
pain systems
Dorsal raphe nucleus
may modulate
migraine pain

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Migraine Cascade

Migraine
pain
Pulsating, throbbing, stabbing
Attacks: 4-72 hours
Unilateral in 60%
Up to 75% may have neck pain

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Episodic, progressive head

Migraine
female : male
6% of males, 18% of females, 4% of children
Family history + in 80-90%
Onset typically during adolescence or young
adulthood
Onset after age 40 possible

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3 : 1

Migraine Triggers
Hormonal fluctuations
Perimenstrual migraine very common

Weather changes
Diet, including missed meals

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Stress

Migraine Subtypes
Migraine with aura (20%)
Neurologic event precedes migraine

(usually by 30-60 minutes)

Visual, auditory, olfactory
disturbances
Migraine without aura
No aura or other warning symptoms

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Chronic migraine

Chronic Migraine
Starts as episodic migraine
Attacks occur at increasing frequency
Eventually

15+ attacks/month

medication overuse
Psych comorbidity common

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Frequent association with

Medication Overuse Headache

Persistent,

Ingredients: Succinic acid, fumaric acid,

dextrose and bioflavonoids

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recurring headache
in the setting of regular
analgesic use
Continues until medication is
stopped
Often responsible for
transformation of episodic
into chronic headache

Overuse Headache: Features

Short-acting analgesic use more than 2-3

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times/week
Headaches become predictable, more
frequent, even continuous
Medications no longer prevent headaches

Common Culprits
Analgesics, especially short- or intermediate-

acting
Opioids
NSAIDs including

acetaminophen
Combination analgesics
Caffeine
Triptans

OCPs, others

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Hormones:

Tension-Type Headache
Episodic or chronic; possible

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migraine variant
Episodic form affects up to 38%
of US adults annually
Less disability and morbidity
than migraine, so less seen by
MDs

Tension-Type Headache
Bandlike

frontal, temporoparietal
Referred (myofascial) pain from neck to
head
Neck structures may contribute to pain
(cervicogenic headache)

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Bilateral:

Cluster Headache
Rare disorder
M:F 3:1; genetic predisposition
Cycles/clusters lasting weeks to months
Repetitive headaches during a cluster
1-3 hours apiece; always unilateral
Focal facial and eye pain,

lacrimation,

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rhinorrhea
Often occur when sleeping or napping

Cluster Headache
leonine face,
furrowed and thickened skin with
prominent folds, a broad chin,
vertical forehead creases, and
nasal telangiectasias.
Typically tall and rugged-looking

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CH face:

Chronic Daily Headache

Chronic

migraine
Chronic tension-type headache
New daily, persistent headache
Generally poor prognosis

Hemicrania continua
Unilateral, persistent

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Some migraine features; head trauma in 20%

Treatment: Define Goals

Patients goals
Pain relief; medication; ? improved

function
Your goals
Pain relief or reduction; improved

function; appropriate medication use

congruence

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Bring goals into

Treatment Plan
Preventive therapy
Abortive therapy
Pre-emptive therapy
Short-term to

prevent anticipated headache

Urgent (rescue) therapy

or eliminate where possible

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Minimize

Non-Drug Treatment
Learn appropriate prevention and treatment
Avoid headache triggers:

foods, drugs, activities

Avoid frequent abortive treatment
Stop smoking
Normalize

sleeping and eating

Exercise
Relaxation and

biofeedback

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Psychotherapy

Rehabilitation
Treat postural dysfunction and

myofascial pain

Relaxation training
Physical therapy
Reduce spasm
Improve posture

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Reduce triggers/perpetuating factors

Eliminate Overuse Headache

Taper and stop offending agents
Severe headache invariably

results

Supportive

treatment: hydration, antiemetics, antiwithdrawal agents if needed

Initiate preventive therapy

as taper begins

Initiate nondrug therapies

Add abortive therapy

once withdrawal

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headache passes

Migraine: Preventive Treatment

Tricyclic antidepressants first-line
Amitripyline, doxepin if sleep is disturbed

Beta-blockers first-line
Atenolol, nadolol

channel blockers less effective

Verapamil most commonly

used

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Ca++

Migraine: Preventive Treatment

Anticonvulsants second-line; valuable
Valproate and topiramate are quite effective
Gabapentin best tolerated, ? effect
Lamotrigine, levetiracetam no good data as yet

help (anecdotal)
Psychotropic effects may be useful

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Pregabalin may

Migraine: Preventive Treatment

Ergots:

Rarely used for prevention

Side effects may

be problematic
Methysergide: fibrosis (use 6 months max)
MAOIs:

Can be very effective

Tyramine-free diet a must

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Numerous drug interactions

Migraine: Abortive Treatment

Simple and combined analgesics
APAP, NSAIDs, others

Mixed analgesics (barbiturate plus simple

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analgesics) avoid wherever possible

Ergot derivatives
Triptans
Opioids

Triptans
agonists
Reduce neurogenic inflammation
Most effective if used at onset of headache or
aura, though may be helpful at other phases
Used specifically for migraine
For nonresponders, try ergots (also act on NE,
DA, other receptors)

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Serotonin 5-HT1

Triptans
Generally

well tolerated
Contraindications:
Uncontrolled hypertension
CAD, PVD, cerebrovascular disease
Pregnancy
MAOIs
High-dose SSRIs, tramadol (rare interaction)

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Ergotamine or other triptan use within 24 hrs

Triptans
Short-acting
Sumatriptan, almotriptan, rizatriptan, zolmitriptan,

eletriptan
Longer half-lives
Naratriptan, frovatriptan

be needed to determine
the best triptan for a given patient

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Successive trials may

DHE
Nasal spray
Administer each nostril, may repeat in 15 minutes
Works best if taken early
Longer half-life than sumatriptan, though not as

reliable for some patients

Injection
1 mg can be given SQ or IM

3 mg/24 hours

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Max dose:

Other Agents
Antiemetics/Neuroleptics:

often combined

with abortive agents

Prochlorperazine, hydroxyzine, promethazine,

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metoclopramide
Chlorpromazine and other neuroleptics may be
effective alone

Drugs To Avoid
Butorphanol nasal spray
Very addictive and often poorly tolerated
Not suitable for chronic or frequent use

Meperidine
Neurotoxic metabolite, weak analgesic
There are almost always better choices

of any short-acting analgesic (opioids,

triptans, et al.)

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Overuse

Treating Cluster Headache

Acute:
Oxygen

inhalation 100% FM, or 7L NC

Triptans/ergots
Indomethacin
Chronic/Preventive:
Verapamil, lithium
Valproate, topiramate
Prednisone burst
Melatonin

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Ergots

Paroxysmal Hemicranias
Chronic and episodic

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varieties
Uniquely sensitive to
indomethacin!

Opioids
Headaches can sometimes get so bad that
doctors prescribe morphine or methadone.
Another way to look at this is that headaches
sometimes get so good that doctors
prescribe morphine or methadone.

The Onions Headache Relief Tips, 2002

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Opioids and Chronic Intractable

Headache
Saper et al.,

Neurology 2004; 62:1687-94

160 patients with intractable headache on

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scheduled opioids
Outcome variable: Reduction in headache
frequency x severity (Severe Headache Index)
74% failed to improve or were discharged for
clinical reasons
26% improved over 50%
Problem drug behavior occurred in half of patients

Cervicogenic Headache
Differentiate from migraine or other syndromes
Analgesics may

be tried as for migraine

Reserve triptans/ergots for refractory cases
Rebound often a significant issue
Therapy directed at neck may help
Facet blocks, trigger point injections, nerve

blocks,

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TENS, physical therapy

Other References
uConnect:

Clinical Guidelines: Pain

Management Guidelines
Adult and Pediatric Migraine Guidelines

Facts For You: search under Pain or

Headache
Kaniecki R. Headache assessment and
management. JAMA 289(11): 1430-1433,
2003.

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Health

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Thank
You!