Outpatient Headache¶
| Type | Presentation | First line meds |
|---|---|---|
| Tension type (most common) | Generally bilateral, pressure/tightness, mild/moderate pain, no significant photophobia, phonophobia, or nausea | Acetaminophen, TCAs, SNRIs |
| Migraine | Unilateral, pulsating, moderate-to-severe pain, lasts 4-72hr, worse with activity and improves with sleep Associated with nausea, photophobia or phonophobia ± Aura |
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 changes | Acute: 100% FiO2 at 12L/min for at least 15 mins, triptans, Indomethacin |
| 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 (Excedrin, fioricet) | \*STOP offending medication, typically via taper. HA will worsen before it gets better, start concurrent daily prophylactic headache medication |
Medication Overview:¶
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Abortive
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Triptans (e.g. sumatriptan or rizatriptan)
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Cannot be used more than 10 days/month
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Avoid in pts with hypertension/CAD
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Preventative
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Amitriptyline: indicated for both migraine and tension-type. Helps with sleep and comorbid depression. Most common side effects (SE) = dry mouth, sedation
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Topiramate: has the best evidence among migraine meds. Can theoretically help with weight loss. Most common SE = sodas taste bad, sedation, parasthesias
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Propranolol: useful for relative lack of interactions. Mild cardiac/blood pressure effects compared to other beta-blockers. Most common SE = drowsiness
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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.
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Riboflavin (vitamin B2): mild effect but effectively has no side effects. 400mg daily.
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Gabapentin: can be useful if HAs have stabbing/electric quality. Main SE = sedation
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Venlafaxine: useful for migraines with significant vestibular symptoms (dizziness). SE = hypertension/tachycardia.
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Verapamil: can be used for migraine and cluster headaches. Can use ER formulation
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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 refer to neuro resident clinic
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CGRP receptor modulators (mostly injections) such as Rimegepant are newer options
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