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.
| Medication | Adverse Effects | Limitations |
|---|---|---|
|
Beta-blockers
|
Lethargy; depression; exercise intolerance | depression; asthma; low blood pressure; Raynaud's syndrome |
|
Anticonvulsants
|
tingling; weight loss (topiramate) weight gain; hair loss (valproate) |
kidney stones (topiramate) birth defects (valproate) |
|
Antidepressants
|
weight gain; sleepiness; dry mouth | serotonin syndrome; increased risk for anticholinergic effects in older adults (amitriptyline, nortriptyline); QT interval prolongation (venlafaxine) |
|
CGRP Antibodies
|
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
