Chronic Headache UpdateNov 8, 2019

Spokane Pain ConferenceDavid R. Greeley, MD, FAAN

Northwest Neurological, PLLC

Principal Investigator for TEVA for Phase II study for post-traumatic headacheotherwise

• not employed by any pharmaceutical company for headache or pain• not on any speaking bureaus or advisory boards• no patents, no royalties, no stock or options• no industry-sponsored grants for headache

Chronic Headache —what’s usually most helpful

to me?

History?

Exam?

Lab work?

CT or MRI?

EEG?

History — which part?

Place?

Quality?

Radiation?

Severity?

Associated symptoms?

History— which part?

Place — most syndromes can be unilateral or bilateral, front or back

Quality —‘throbbing’

Radiation — tough to describe

Severity — “10/10” is most common answer

Associated symptoms — almost everyone says they get nausea and light-sensitivity

History— timing

I want to know about the first headaches as much if not more than the most recent

Onset, Duration and Frequency

History— behavior

Continue to work?

Go to sleep?

What medication do they take, when do they take it and how many do they take in a month?

What are they like in between headaches?

History

Past Medical History

Past Psychiatric History

Family History

Social History

The Cycle of Chronic Pain

chronic pain

depressionpoor sleep

Nature and Nurture

Common family history of:

- chronic pain

- chronic headache

- psychiatric concerns

- abuse

Learned behavior on medication use/abuse

Adverse Childhood Experiences

common mistakes in managing chronic pain

Blaming the patient

“non-compliant”

"smokes, overweight, depressed…”

“chronic pain patient”

Unwilling to consider another diagnosis

Not all headaches are migraines!

https://ichd-3.org

Primary (57 categories, ‘only’ 15 migraine)

Secondary (200+ categories)

Neuropathies, Facial Pains… (37+ categories)

Primary Headaches

Migraine (19 categories)

Tension-type headache (9)

Trigeminal Autonomic Cephalagias (14)

Other (15)

What’s the diagnosis?

Unilateral headache

Pulsating

Recurring

Moderate to Severe

Nausea

Light-sensitivity

Triptan helps

Medication-overuse?

Unilateral headache

Pulsating

Recurring

Moderate to Severe

Nausea

Light-sensitivity

Triptan helps — prescribed 10-30 per month!

near-daily headache for months

Medication-overuse headache

The most common cause of near-daily headache in the US

>15 days per month

>15 analgesics, triptans or opioids per month

Ask what they take for acute pain (incl OTC)

Ask how many they take in a month

occipital neuralgia ?

Unilateral headache

Pulsating

Recurring

Moderate to Severe

Nausea

Light-sensitivity

Triptan helps

tenderness over the occipital nerve

migraine?

Unilateral headache

Pulsating

Recurring

Moderate to Severe

Nausea

Light-sensitivity

Triptan helps

untreated lasts 4-72 hours

migraines — brief but common and disabling

36,000,000 people have migraine

- more than asthma and diabetes combined

- 7th most common disease in the world

4,000,000 have > 15 migraines per month

#1 WHO disability rank when severe

A Multifactorial Treatment Approach

- Education

- Exercise

- Sleep

- Physical modalities

- Psychiatric management

- Avoidance of ER’s and Urgent Care

- Dietary changes

- Medication

Exercise

- regular, not excessive

- simple, cheap and enjoyable

- Yoga, T’ai Chi, water aerobics...

Sleep Hygiene

- sleep consolidation

- avoidance of stimulants

- regular and consistent behavior

- light box

- overnight oximetry

- Wearables: Oura, Ebb, Vielight, Bellabee

- Rx: Belsomra®

Physical Modalities

- physical therapy

- chiropractic

- massage / myofascial release

- acupuncture

- craniosacral therapy

- Rolfing / Structural Integration

Psychological / Behavioral

- Counseling / Support

- Biofeedback / Meditation

- Rx therapy

- NeuroStar TMS

- FDA approved for depression

- being used in chronic pain

NeuroStar TMS

Dietary Changes

- hydration -- “half your weight in oz/d”

- eating “healthy foods”

- supplements as necessary

- ? allergies -- IgG from US Biotek

- elimination diets

- “gluten-free”

- Naturopathic medicine

Acute Pain Meds <9 days a month

- NSAIDs and OTC products

- triptans

- butalbital/caffeine/APAP

- opioids

- steroid tapers

- trigger point injections

Migraine Prevention —headaches >3 days/month

FDA-approved devices

Non-prescription agents

Prescription oral agents

Prescription injectables

FDA-approved Devices for Migraine

Cefaly® — headband ‘Trigeminal TENS’ unit

sTMS Mini®

GammaCore® — vagal nerve stimulator

Nerivia Migra® — peripheral stim device Bluetooth connected to a smartphone

Non-prescription Agents for Migraine

- Migrelief® (riboflavin400mg/d, magnesium sulfate 360mg/d, feverfew 100mg/d)

- Petadolex® (butterbur 150mg/d)

- Gliacin® (boswellia serrata 100-300mg tid

- Zira Nourished Mind® (butterbur, CoQ10, alpha lipoic acid, magnesium, green tea, milk thistle, 5-methyltetrahydrofolate, Vit B1, B2, B3, B6, B12, D3, E)

Non-prescription Agents for Migraine

- magnesium citrate 300mL/d

- magnesium oxide 400mg/d

- turmeric/curcumin

- CoQ10 — 100mg tid

Anti-epileptic Meds

- topiramate (Topamax®)

- divalproex (Depakote®)

- lamotrigine (Lamictal®)

- gabapentin (Neurontin®)

- pregabalin (Lyrica®)

Tricyclic Antidepressants

- amitriptyline

- imipramine

- nortriptyline

- despiramine

Beta Blockers

- propranolol

- timolol

- atenolol

- metoprolol

- nadolol

Botox® in Migraine

strabismus —> blepharospasm —> other dystonias

—> hemifacial spasm

—> facial wrinkles

—> migraine

spasticity —> hyperhidrosis

—> esophageal dysmotility

—> bladder dysfunction

Botox® in Migraine

FDA-approved protocol

80+% reduction in headache

31 injections x5 units every 10-12 weeks:

- 7: corrugator, procerus, frontalis- 8: temporalis- 6: occipitalis- 4: paracervical- 6: trapezius

Calcitonin Gene-Related Peptide

Member of the calcitonin family

α and β forms

37 amino acids

derived from cell bodies of spinal cord motor neurons — helps with regeneration

derived from dorsal root ganglia — linked to transmission of pain

derived from trigeminal ganglion — involved in migraine

involved in cardiovascular homeostasis

CGRP in Migraine

Meningeal nociceptors from the trigeminal ganglion release CGRP

CGRP binds to CGRP receptors on meningeal vessels

potent neurogenic vasodilator

Triptans block CGRP

acutely

Botox prevents release of CGRP by cleavage of SNAP-25 protein

monoclonal antibodies block CGRP after monthly infusion

anti-CGRP antibodies

Aimovig® : erenumab-aooe

Ajovy® : fremanezumab-vfrm

Emgality® : galcanezumab-gnlm

eptinezumab

anti-CGRP antibodies

Aimovig® : erenumab-aooe

Ajovy® : fremanezumab-vfrm

Emgality® : galcanezumab-gnlm

eptinezumab

Research

Post-Traumatic Headache

Phase 2, Multicenter, Placebo-controlled

Fremanezumab (Ajovy®)

Chronic Headaches

QUESTIONS?

David R. Greeley, MD, FAAN

Northwest Neurological, PLLC

509-747-5615

nwn@me.com

www.nwn4me.com