So I’m using the Curbsiders podcast episode list to review some primary care topics. I listen to the Curbsiders podcast to get started and then I review my past posts on the topic and review some other resources.
And regarding headache, be sure to review my post, Be Sure You Are Not Missing A Serious Nonmigraine Headache.
So today I’ve listened to the podcast #4: Are You Afraid of Patients with Migraines? An approach to diagnosis and management of chronic migraine headache from The Curbsiders MARCH 30, 2016
Here are the Take Home Points from the show notes:
- Take a simple approach to the diagnosis of chronic headache syndromes.
- If patient is “sick” with their headache, then call it a migraine.
- If patient is not nauseous or debilitated with their headache, then call it chronic tension type headache.
- One in 1,000 will have cluster headaches. Other causes are even more rare than that
- Rationale for preventive therapy: there are a number of drug classes to choose from and they more or less all cause 50% reduction in headache frequency for about two-thirds of patients. Therefore, tailor your therapy based on side effects and comorbid conditions.
- Stop thinking you need a Specialist. Primary Care Physicians can and should handle most headache cases.
- Don’t talk too much. Let the patient talk and DON’T interrupt them.
- Failure to start prophylaxis. Don’t be afraid. Know the side effects for each drug class and give patients at least a one month trial at therapeutic doses before calling treatment a failure.
Abortive Therapy [Link is to web page of above that contains detailed discussion of the topic. What follows below are just excerpts.]
Table 1. Abortive Medication Stratification by Headache Severity
Moderate Severe Extremely Severe NSAIDs Naratriptan DHE (IV) Isometheptene Rizatriptan Opioids Ergotamine Sumatriptan (SC,NS) Dopamine antagonists Naratriptan Zolmitriptan Rizatriptan Almotriptan Sumatriptan Frovatriptan Zolmitriptan Eletriptan Almotriptan DHE (NS/IM) Frovatriptan Ergotamine Eletriptan Dopamine antagonists Dopamine antagonists DHE=Dihydroergotamine; NSAIDs=nonsteroidal anti-inflammatory drugs
Acute treatment is most effective when given within 15 minutes of pain onset and when pain is mild. 
For more severe pain, 5-hydroxytryptamine–1 (5-HT1) agonists (triptans) and/or opioid analgesics are used, either alone or in combination with dopamine antagonists (eg, prochlorperazine [Compazine]). The use of abortive medications must be limited to 2-3 days a week to prevent development of a rebound headache phenomenon.
Intravenous metoclopramide is recognized as an effective therapy for acute migraine, but the optimal dosing has not been established.
The effectiveness and tolerability of triptans varies among patients. Lack of response or side effects experienced with one triptan does not predict the response to another.
The safety of triptans is well established, and the risk of de novo coronary vasospasm from triptan use is exceedingly rare. However, triptans should not be taken by patients with known or suspected coronary artery disease, as they may increase risk of myocardial ischemia, infarction, or other cardiac or cerebrovascular events.
The dose of rizatriptan must be reduced to 5 mg in patients taking propranolol. Sumatriptan, zolmitriptan, and rizatriptan are primarily metabolized by monoamine oxidase (MAO) and should be avoided in patients taking MAO-A inhibitors.
Patients with severe headaches need subcutaneous, intravenous, or oral formulations of an ergot alkaloid or triptan. Do not administer vasoconstrictors, such as ergots or triptans, to patients with known complicated migraine; treat their acute attacks with one of the other available agents, such as NSAIDs or prochlorperazine.
Treatment of nausea and vomiting
Antiemetics (eg, chlorperazine, promethazine) are used to treat the emesis associated with acute migraine attacks. Patients with severe nausea and vomiting at the onset of an attack may respond best to intravenous prochlorperazine. These patients may be dehydrated, and adequate hydration is necessary.
Antiemetics are commonly combined with diphenhydramine to minimize the risk of akathisia. This combination of drugs has been found to be superior to subcutaneous sumatriptan when given intravenously in emergency patients. 
For an outstanding brief but detailed ” how to” review of emergency department treatment of severe migraine headache please see the outstanding [and again brief] review, Emergency Department Management of Acute Headache from Management of Pain And Procedural Sedation, a free open source e-book by Reuben Strayer, Sergey Motov, & Lewis Nelson, eds.
Prophylactic Therapy [Link is to web page of above that contains detailed discussion of the topic. What follows below are just excerpts.]
The following may be considered indications for prophylactic migraine therapy:
Frequency of migraine attacks is greater than 2 per month
Duration of individual attacks is longer than 24 hours
The headaches cause major disruptions in the patient’s lifestyle, with significant disability that lasts 3 or more days
Abortive therapy fails or is overused
Symptomatic medications are contraindicated or ineffective
- Use of abortive medications more than twice a week
- Migraine variants such as hemiplegic migraine or rare headache attacks producing profound disruption or risk of permanent neurologic injury 
The goals of preventive therapy are as follows:
Reduce attack frequency, severity, and/or duration
Improve responsiveness to acute attacks
Currently, the major prophylactic medications for migraine work via one of the following mechanisms:
5-HT2 antagonism – Methysergide
Regulation of voltage-gated ion channels – Calcium channel blockers
Modulation of central neurotransmitters – Beta blockers, tricyclic antidepressants
- Enhancing gamma-aminobutyric acid-ergic (GABAergic) inhibition – Valproic acid, gabapentin
Most preventive medications have modest efficacies and have therapeutic gains of less than 50% when compared with placebo. The latency between initiation of therapy and onset of positive treatment response can be quite prolonged. Furthermore, the scientific basis for using most of these medications is wanting.
Table 2. Preventive Drugs For Migraine:
First line High efficacy Beta blockers
Low efficacy Verapamil Second line
MAOIs = monoamine oxidase inhibitors
[The preventive medicine used should be based on the patients comorbid conditions. See Table 3 on this web page.]
For any of these prophylactic agents, prophylaxis should not be considered a failure until it has been given at the maximum tolerable dose for at least 30 days. Some additional drug classes that are also used for migraine prevention include botulinum toxin and monoclonal antibodies that bind to the calcitonin gene-related peptide (CGRP) receptor*.
*See the article, Monoclonal Antibodies for Migraine Prevention: Progress, but Not a Panacea [PubMed Abstract]. JAMA. 2018 May 15;319(19):1985-1987. doi: 10.1001/jama.2018.4852.
Next [note to myself] review my post, Be Sure You Are Not Missing A Serious Nonmigraine Headache.
Headache Intake Questionnaire from Cleveland Clinic Canada
Migraine Headache Treatment & Management
Updated: Jan 30, 2018 from emedicine.medscape.com
My Posts on Headache
The Diagnosis Of Increased Intracranial Hypertension And Other Dangerous Headaches – My Review Posted on June 12, 2018