Event 2: Joe's Diagnosis and Treatmet

Joe's Co-Occurring Conditions

Joe’s history and clinical evaluation suggest multiple co-occurring conditions.

  • History of intermittent migraine headaches
  • Transformed migraine
  • Medication overuse headache
  • Myofascial neck pain

Medication Overuse Headache

Medication Overuse Headache (MOH) results from excessive use of analgesics

  • Secondary headache disorder
  • Analgesic use >2-3 days per month
  • Underlying diagnosis of migraine or tension-type headache
  • Preventive medications may be ineffective

Pharmacist's Role

Pharmacists play an important role in managing medication overuse headaches.

  • Often first to recognized MOH
  • Can work with healthcare team to develop tapering/monitoring plans
  • Can educate patients about proper use of analgesics and when to seek medical attention

Multipronged Treatment Plan

A multipronged treatment plan is the best approach to managing chronic headache pain.

  • Behavior modification
  • Discontinuation of analgesics
  • Preventive medications
  • Migraine-specific abortive medication

Treatment Plan

Dr. Bernstein explains to Joe various treatment options.

Preventive Medications

Preventive medications may be appropriate for some patients with frequent headache attacks.

Indications

  • Frequent attacks (1-2 per week)
  • Disability with attacks
  • Poor response to acute meds
  • Contraindications to abortive meds

Cautions

  • Co-existing medical conditions
  • Concurrent medications
  • Side effects
  • Contraindications

Pharmacological Treatments

There are several evidence-based pharmacological treatments for migraine headache.

Pharmacological Treatments for Migraine
Medication Adverse Effects Limitations

Beta-blockers

  • propranolol
  • timolol
Lethargy; depression; exercise intolerance depression; asthma; low blood pressure; Raynaud's syndrome

Anticonvulsants

  • topiramate
  • valproate

tingling; weight loss (topiramate)

weight gain; hair loss (valproate)

kidney stones (topiramate)

birth defects (valproate)

Antidepressants

  • venlafaxine
  • amitriptyline
  • nortriptyline
weight gain; sleepiness; dry mouth serotonin syndrome; increased risk for anticholinergic effects in older adults (amitriptyline, nortriptyline); QT interval prolongation (venlafaxine)

CGRP Antibodies

  • erenumab
  • fremanezumab
  • galcnezumab
constipation; muscle spasms or cramps hypersensitivity; high cost
Onabotulinum toxin A Spasticity; cervical dystonia; weakness; drooping forehead hypersensitiivty; myasthenia gravis; Only approved for chronic migraine

Start low and go slow evidence-based pharmacological treatments for migraine headache.

Medicinal Herbs and Vitamins

Various medicinal herbs and vitamins have been tried for migraine prevention.

  • Riboflavin
  • Magnesium Citrate
  • Coenzyme Q10

Abortive Medications for Treating Migraine Headaches

There are several types of abortive medications for treating migraine headaches.

Analgesics

  • diclofenac
  • ibuprofen
  • naproxen
  • acetaminophen

Indications

Mild to moderate headache intensity used 10-15 days month; preventative for menstrual pain.

Adverse Effects

Stomach upset, bleeding, kidney or liver damage.

Triptans

  • sumatriptan
  • rizatriptan
  • eletriptan
  • zolmitriptan
  • almotriptan
  • naratriptan
  • frovatriptan

Indications

Moderate to severe intensity.

Contraindications

Cardiovascular disease, cerebrovascular disease, uncontrolled hypertension.

Combination Drugs

  • sumatriptan + naproxen
  • aspirin + acetaminophen + caffeine (limit to 5 or fewer days/month)

Indications

Refractory headaches.

Adverse Effects

Stomach upset, bleeding, kidney or liver damage, medication overuse headache.

Dihydroergotamine

Indications

Refractory headaches.

Adverse Effects

Stomach upset, bleeding, kidney or liver damage.

Healthy Lifestyle

Maintaining a healthy lifestyle can help protect against headache vulnerability.

  • Sleep
  • Exercise
  • Meals and hydration
  • Stress reduction

Multimodal Approach

A multimodal approach should be introduced early in headache treatment.

Neck Pain

Joe’s physician recommends further evaluation of his neck pain.

Headache Diaries

Headache diaries can help guide treatment.

  • Frequency and severity of headaches over time
  • Triggers
  • Headache characteristics
  • Frequency of medication use
  • Exercise
  • Response to medication or therapy over time
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