Guideline for Management of Primary Headache in Adults

Summary
July 2012


These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate
health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making
1


This summary provides an evidence-based practical approach to assist primary
health care providers in the diagnosis and management of adult patients with a
long term history of headache. For more details, refer to Guideline for Primary
Care Management of Headache in Adults

Primary headache disorders are not due to another medical condition, and
include primarily migraine and tension-type headache. Cluster headache,
hemicrania continua, and new daily persistent headache are much rarer
primary headache types and will not be discussed further in this summary.
Secondary headache disorders are due to another medical disorder.

Practice Point
Rule out secondary headache when making a diagnosis of a primary
headache disorder.

Headache onset (thunderclap, association with head or neck trauma),
headache progression, duration of attacks, and days per month with
headache.
Pain location (unilateral, bilateral, associated neck pain).
Headache associated symptoms (nausea, vomiting, photophobia,
phonophobia).
Relationship of headache to possible precipitating factors (stress, posture,
cough, exertion, straining, neck movements, jaw pain, etc.).
Headache severity and effect of the headaches on work and family
activities.
Headache response and side effects to acute and preventive medications
tried in the past.
Presence of co-existent conditions that may influence treatment choice
(insomnia, depression, anxiety, hypertension, asthma, and history of heart
disease or stroke).



Headache in Adults
Summary



These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate
health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.
2


Practice Points
Neuroimaging is not indicated in patients with recurrent headache with
the clinical features of migraine, a normal neurological examination, and
no red flags.
Neuroimaging, sinus x-rays, cervical spine x-rays, and EEG are not
recommended for the routine assessment of the patient with headache.
History and physical / neurological examination is usually sufficient to
make a diagnosis of migraine or tension-type headache.

Migraine: If patients have at least two of: 1) nausea during the attack; 2) light
sensitivity during the attack; 3) some of the attacks interfere with their activities.

Practice Points
Migraine is by far the most common headache type in patients seeking
help for headache from physicians.
Migraine is historically under-diagnosed and under-treated. Many
patients with migraine are not diagnosed with migraine when they
consult a physician.
Migraine should be considered in patients with recurrent moderate or
severe headaches and a normal neurological examination.
Patients consulting for bilateral headaches which interfere with their
activities are likely to have migraine rather than tension-type headache
and may require migraine specific medication.
Consider a diagnosis of migraine in patients with a previous diagnosis of
recurring sinus headache.

Chronic migraine: If headache is present on 14 days a month or more, and
headaches meet migraine diagnostic criteria or are quickly aborted by migraine
specific medications (triptans or ergots) on 8 days a month or more. Consider
whether medication overuse is present in all patients with chronic migraine
(chronic migraine with medication overuse)


Headache in Adults
Summary



These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate
health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.
3


Practice Point
Medication overuse is considered present when patients with migraine or
tension-type headache use combination analgesics, opioids, or triptans on 10
or more days per month or acetaminophen or NSAIDs on 15 or more days a
month.
Episodic tension-type headache: If headache attacks are not
associated with nausea, and have at least two of the following: 1) bilateral
headache; 2) non-pulsating pain; 3) mild to moderate intensity; and 4)
headache is not worsened by activity.

Migraine management is complex and a comprehensive approach may be
needed. All of the following should be considered.
Training the patient in self-management: Self-management involves
patients partnering with the health professional and taking an active role in
management of their migraine. Patients may require some or all of the
following skills.
Self-monitoring to identify factors that influence their migraine.
Managing migraine triggers effectively.
Pacing activity to avoid triggering or exacerbating migraine.
Maintaining a lifestyle that does not worsen migraine.
Relaxation techniques.
Maintaining good sleep hygiene.
Stress management skills.
Cognitive restructuring to avoid catastrophic/negative thinking.
Communication skills to talk effectively about pain with family and
others.
Using acute and prophylactic medication appropriately.
Headache diaries: Encourage patients to keep a headache diary to monitor
headache frequency, intensity, triggering factors and medication use so that
treatment can be adjusted as needed. Refer to Headache Diary Sheets.


Headache in Adults
Summary



These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate
health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.
4


Practice Point
Comprehensive migraine therapy includes management of lifestyle factors
and triggers, acute and prophylactic medications, and migraine self-
management strategies.
Acute pharmacological therapy: NSAIDs (including ASA),
acetaminophen and triptans are the primary medications for acute migraine
treatment. A triptan should be used when NSAIDs are not effective. Patients
who do not respond well to one triptan may respond to another. Advise patients
to take their medications early in their migraine attack, where possible, to
improve effectiveness. For severe migraine attacks, consider providing an
additional rescue medication if the patients usual acute medication does not
work consistently with every attack. Refer to medication tables in Guideline for
Primary Care Management of Headache in Adults for drugs and dosages.

Practice Points
ASA, acetaminophen, NSAIDs, and triptans are the primary medications
for acute migraine treatment.
A triptan should be used when NSAIDs are not effective.
Opioid containing analgesics are not recommended for routine use for
migraine.
Butalbital-containing combination analgesics should be avoided.
Vast amounts of over-the-counter analgesics are taken for headache
disorders and treatment is often sub-optimal.

Prophylactic pharmacological therapy: Consider migraine
pharmacological prophylaxis when:
Recurrent migraine attacks are causing significant disability despite
optimal acute drug therapy.
The frequency of acute medication use is approaching levels that place
the patient at risk for medication overuse headache.



Headache in Adults
Summary



These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate
health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.
5


When prescribing a prophylactic medication:
1. Educate patients on the need to take the medication daily and according to
the prescribed frequency and dosage.
2. Ensure that patients have realistic expectations as to what the likely
benefits will be; that is:
a. Headache attacks will likely not be abolished completely.
b. A reduction in headache frequency of 50% is usually
considered worthwhile and successful.
c. It may take 4 to 8 weeks for significant benefit to occur.
d. If the prophylactic drug provides significant benefit in the first 2
months of therapy, this may increase further over several
additional months of therapy.
3. Evaluate the effectiveness of therapy through the use of patient diaries
that record headache frequency and drug use.
4. For most prophylactic drugs, initiate therapy with a low dose and increase
the dosage gradually to minimize side effects.
5. Increase the dose until the drug proves effective, until dose-limiting side
effects occur, or a target dose is reached.
6. Provide an adequate drug trial. Unless side effects mandate
discontinuation, continue the prophylactic drug for at least 6 to 8 weeks
after dose titration is completed.
7. Gradual discontinuation of the drug should be considered for many
patients after 6 to 12 months of successful therapy, but preventive
medications can be continued for much longer in some patients.

The most commonly used prophylactic drugs are the beta-blockers, the tricyclic
antidepressants, and topiramate, but many other drugs are also used, including
divalproex sodium, candesartan, pizotifen, flunarizine, and others.

OnabotulinumtoxinA is used for chronic migraine (migraine with headache on
15 days a month). Non-drug compounds which also have some prophylactic
value include butterbur, riboflavin, magnesium citrate, and co-enzyme Q10.
(Refer to medication tables in Guideline for Primary Care Management of
Headache in Adults for more detail on drugs and dosages). Selective serotonin
reuptake inhibitors are not recommended for migraine prophylaxis.


Headache in Adults
Summary



These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate
health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.
6


Practice Point
A substantial number of people who might benefit from prophylactic therapy
do not receive it.

Non-pharmacological therapies: Recommended therapies include
relaxation training, biofeedback, cognitive behavioural therapy, and
acupuncture.
Migraine Treatment in Pregnancy: Drugs for migraine should be
avoided during pregnancy where possible.
Acetaminophen 1000 mg and metoclopramide 10 mg can be used if
necessary.
If necessary, acetaminophen - codeine combination analgesics are an
option.
Ibuprofen 400 mg can be used but only during the second trimester of
pregnancy.
Sumatriptan should not be used routinely in pregnancy, but may be
considered for use when other medications have failed and the
benefits outweigh the risks.
Preventive drugs should be gradually discontinued prior to the commencement
of a planned pregnancy; or stopped as soon as possible during an unplanned
pregnancy. Obtain specialist advice if it is necessary to continue migraine
prophylaxis.
Menstrual Migraine: Acute pharmacological treatment is similar to non-
menstrual migraine. For patients with refractory menstrual migraine, consider
frovatriptan 2.5 mg twice a day starting 2 days before the anticipated onset of
the menstrually associated migraine attack and continuing for a total of 6 days.



Headache in Adults
Summary



These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate
health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.
7


Careful monitoring of acute medication use by both the patient and the
physician is important in the prevention of medication overuse headache.
Headache diaries should be used by patients with frequent migraine to monitor
acute medication use.

When medication overuse headache is suspected, the patient should also be
evaluated for:
Psychiatric comorbidities (depression and anxiety); these may need to
be considered in planning an overall treatment strategy.
Psychological and physical drug dependence.
Use of inappropriate coping strategies. Expanding the patients
repertoire of adaptive coping strategies may facilitate reduction of
medication use and ultimate improvement in headache.

Treatment plans for the patient with medication overuse headache should
include:
1. Patient education with regard to medication overuse headache.
Patients need to understand that:
a. Acute medication overuse can increase headache
frequency.
b. When medication overuse is stopped, headache may worsen
temporarily.
c. Many patients will experience a long-term reduction in
headache frequency after medication overuse is stopped.
d. Prophylactic medications may become more effective.
2. Formulation of a plan for cessation of medication overuse.
3. A strategy for the treatment of remaining severe headache attacks
with limitations on frequency of use (i.e. a triptan for patients with
analgesic overuse, DHE for patients with triptan overuse, etc.).
4. Patient follow-up and support.
5. Pharmacological prophylaxis with the prophylactic medication started
prior to or during medication withdrawal.



Headache in Adults
Summary



These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate
health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.
8


Stopping Medication Overuse: Withdrawal of the overused medication
should be attempted in all patients with suspected medication overuse
headache.
Abrupt withdrawal should be advised for patients with suspected
medication overuse headache caused by simple analgesics
(acetaminophen, NSAIDs) or triptans, although gradual withdrawal is
also an option.
Gradual withdrawal should be advised for patients with suspected
medication overuse headache caused by opioids and opioid-
containing analgesics.
Practice Point
Monitor for medication overuse

Many patients with tension-type headache do not require medication.
Reassurance, identification of trigger factors, adjusting lifestyle factors, and
stress management are often helpful. Use Headache Diary Sheets for
assessment and monitoring. Monitor for medication overuse.
Acute Pharmacological Therapy: Recommended medications include:
ibuprofen, aspirin, naproxen, diclofenac potassium, and acetaminophen.
Pharmacological Prophylaxis: Consider prophylaxis if tension-type
headaches are frequent. Efficacy of preventive medication is often limited and
treatment may be hampered by side effects. Drug of first choice is amitriptyline.
Non-pharmacological Therapy for Tension-type Headache:
Recommended therapy includes: cognitive behaviour therapy, biofeedback,
relaxation training, therapeutic exercise, and physical therapy.

Primary headache disorders present many treatment challenges. Refer to
Guideline for Primary Care Management of Headache in Adults for more
management details.




July 2012