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Integrative Medicine Rakel > Ch 13: Headache > Flashcards

Ch 13: Headache Flashcards

1
Q

What is the most common form of pain experienced by Americans?

A

Headache

Over 95% of population experiences it at some point

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2
Q

What is the most common type of headache?

What is the most likely headache type to present in clinic?

A

While tension type headaches are the most common…

migraines are the most likely to present in clinic.

Good to note : Over time, most patients with one type of headache will have cross-over symptoms of another type

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3
Q

What are the most common triggers for migraine

A
  • Stress (80%)
  • Hormones
  • Skipped meals
  • Weather
  • Sleep disturbacnes
  • Perfume/odor (44%)

Other triggers: neck pain, lights, alcohol, smoke sleeping late, heat, food, exercise

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4
Q

What are the most common comorbidities found in migraine disorder?

A
  • Insomnia
  • Depression
  • Anxiety
  • Gastric ulcer/ GI bleed
  • PAD
  • Angina

Others: allergies, epilepsy, arthritis, stroke/TIA, RA, asthma, Vit D deficiency

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5
Q

Most common food triggers for migraine?

A
  • Alcohol
  • Caffeine
  • MSG
  • aspartame
  • cocoa
  • cheese / dairy
  • sulfate and nitrate containing foods (aged & processed meats and cheese, dried fruits)
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6
Q

Most frequently used CAM types for headache

A
  1. Manipulative therapy
  2. dietary supplements
  3. acupuncture
  4. mind-body therapies
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7
Q

What 3 questions / signs have 93% PPV in diagnosing migraine

A
  1. Has a headache limited your activities for a day or more in the last 3 months?
  2. Are you nauseated or sick to your stomach when you have a headache?
  3. Does light bother you when you have a headache?
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8
Q

SNOOP4

A

A Mnemonic to rule out emergent secondary causes of HA

S = systemic symptoms (fever, myalgia, weight loss) –> cancer, infxn
N = neuro sx –> stoke, lesion
O = older age (> 50 yrs old ) at onset –> TA, glaucoma, mass
O = onset thunderclap –> bleed
P = papillodema –> elevated ICP
P = positional –> intracranial hypotension
P = precipitated by valsalva or exertion –> elevated ICP
P = progressive or pattern change –> any secondary cause

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9
Q

Pathophysiology of Migraine

A

Tigerring of trigeminal (sensory), parasympathetic, and sympathetic nerve fibers

 PLUS

Release of **vasoactive neuropeptides **(like CGRP, serotonin, substance P, NO-synthase, VIP, neuropeptide Y, acethylcholine, NE, and orexin)

 LEADING TO

vasodilation
sterile inflammation
cortical spreading / propogation of aberrant electrical signaling

 EXTENDING TO

brainstem, cortex, dura, and other cranial structures such as the vagal nerve

 LEADING TO

neuro sx, autonomic sx, GI sx

CGRP = calcitonin gene-related peptide

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10
Q

Beta Blockers

A

Propranolol, timolol

Consider: HTN

Caution: renal or hepatic impairment, chronic fatigue, POTS

as a preventative

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11
Q

Anticonvulsants

A

Divalproate, topiramate

Consider: epilepsy, obesity (topiramate)

Caution: hepatic impairment, concomitant alcohol use, depression

as a preventative

Valproic acid is not FDA approved but likely also efficacious.

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12
Q

Calcitonin gene-related peptide (CGRP) inhibitors

A

Erenumab
Galcanezumab
Fremanezumab
Eptinezumab

Consider: previous failed preventatives

Caution: history of constipation, hypertension, injection hypersensitivity

a preventative

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13
Q

OnabotulinumtoxinA

A

Consider: chronic migraine, failed preventatives

Caution: history of muscle weakness, injection sensitivity

as a preventative

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14
Q

Antihypertensives, Not FDA approved, for migraine

A

CCB, ACE inhibitors, ARBs

probably efficacious

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15
Q

ANtidepressants, Not FDA approved, for migraine

A

TCAs, SSRI, SNRI
Amitryptiline, fluoxetine, venlafaxine

Consider: sleep disruption, depression, anxiety, amplified pain syndromes
Caution: fatigue. Polypharmacy because of cytochrome P450 pathway and caution regarding serotonin syndrome if using triptans,
Selected: renal and hepatic impairment; alcohol use

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16
Q

Memantine

A

Consider: chronic migraine. Not FDA approved but likely efficacious.
Cognitive dysfunction, amplified pain syndromes
Caution: can initially worsen headache; dizziness

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17
Q

First line abortive meds for all headache types

A

NSAIDs
APAP
Caffeine

18
Q

most common abortive Rx for migraine

A

Triptans.
5-HT1 receptor agonists

19
Q

Other abortive meds for migraines

A
  • Calcitonin gene-related peptide receptor antagonists or gepants (e.g., ubrogepant, rimegepant)
  • 5-HT1F receptor agonists or ditans (e.g., lasmiditan) have been released and will likely expand in the near future.
  • Older agents, including ergotamine derivatives (e.g., DHE), can be helpful in selected cases and
  • opioids (e.g., butorphanol) have been historically used but are typically avoided because of risk and lack of specific targeting of migraine pathological features.

All acute medications have risk of contributing to rebound headache as well as medication overuse headache, which affects up to 50% of patients with chronic headache

20
Q

Exercise dichotomy in migraines

A
  • Exercise can be a trigger but can also decrease migraine intensity, frequency, duration, and improve QOL

Graded aerobic exercise program. Emphasize proper nutrition and hydration. Exercise in a therapeutic setting. Can work even in POTs or comorbid dysautonomia.

Yoga also beneficial. And HIIT too - but caution when progressing.

21
Q

Stepwise Approach to dietary management for headaches

A
  1. Increase awareness: dietary hx, log.
  2. Reduce triggers: regular meals, hydrate, reduce food triggers. Eliminations.
  3. Foundational dietary recs: antiinflammatory. HEI. Low glycemic index.
  4. Specialized dietary recs: keto, vegan, low fat, low histamine. Hard to maintain.
  5. Foundational supplements: Mg, CoQ10, Riboflavin, B vitamins, Vit D, Omega 3
  6. Specialized supplements: herbs and other nonvitamin supplements

Give the intervention at least 3 months before re-evaluation.
HEI = healthy eating index
Herbs are great way to match one therap with a complex clinical scenario (IE ginger for pt with OA, headaches, complicated by NSAID-gastritis or nausea)

22
Q

Magnesium

A

DOSAGE: Adult: ≥2–600mg.
Pediatric: 9mg/kg
- serum and CSF levels in migraine more likely to be deficient
- Deficiency increases risk of migraines
- influences absorption of other nutrients such as Vit D

  • GI tolerability can be an issue; many common forms available (oxide, sulfate)
  • Consider chelated formulation (glycinate) and split dosing with food or dosing at bedtime
  • May improve depression, myalgia, sleep
23
Q

CoQ10

Ubiquinone

A

Lower levels in migraine patients

Dose: 100-300 mg

  • Consider ubiquinol formulation (activated form), especially with higher comorbidities since they may have heightened oxidative stress
  • may benefit fatigue, FMS
  • generally well tolerated
24
Q

Vitamin D3

A

Dose: >1000 IU (Dose to increase blood levels to 40ng/ml)
Levels found to be lower in patients with migraine
May work synergistically with magnesium and pharmacotherapy (enhances response of meds especially in pts who are deficient)

25
Q

Riboflavin

A

Vitamin B2
50-400mg
* An antioxidant that modulates flavoenzymes in mitochondrial respiratory chain
* inconsistent results in kids (maybe due to large variability in dosages), many positive results in adults

strong yellow Urinary discoloration
mild-mod GI symptoms

26
Q

B Vitamins:
B12, B9 (Folate), B6

A

B12: 400mcg-2mg
B9 Folate: 400mcg-2mg
Vit B6: 25-50mg

  • Target elevated homocysteine;
  • consider methylated forms
  • Vitamin B6 confirm P5P form
  • People with MTHFR are more prone to migraine with Aura
27
Q

Alpha Lipoic Acid

A

600 mg

Reduces oxidative stress

28
Q

Omega 3

A

Dosage: 1-3+ grams

Background diet is key, especially reducing inflammatory foods and excess omega-6s. Adjunctive benefit with pharmacotherapy
Trials of supplementation have mixed results
Beneficial when added to conventional preventatives

29
Q

Ginger

A

Dosage: 0.5-2 grams

Helpful for nausea; comorbid gastropathy and inflammatory conditions
Abortive for acute migraines

30
Q

Melatonin

A

3-10mg at bedtime

Caution: vivid dreams; daytime drowsiness. Rotate off periodically

May be helpful in amplified pain syndromes (like fibromyalgia and temporomandiubla disorder) and cluster headache, as well as migraine. May improve IBS and NSAID-gastropathy

31
Q

Probiotics

A

Consider with comorbid IBS; look for research based formulations

32
Q

Butterbur

A

Dosage:
Adults 150
Pediatrics 100mg
Antiinflammatory and mast cell stabilization (was used for allergies)
Use only pyrrolizidine alkaloid (PA) free forms (e.g., Petadolex) as these are potentially hepatotoxic and were found in several US formulations; avoid with history of liver dysfunction; monitor liver function and consider rotation off periodically

33
Q

Enzogenol

A

1000-1200 mg/day
Monterey pine bark extract
Consider in TBI and cognitive dysfunction or post-concussive headache

34
Q

Boswellia

A

350-1000 mg
Contains pentacyclic triterpene acids (antiiinflamnatoryl; inhibit 5-lioxygenase)
Prelim evidence in cluster headaches
May be helpful with asthma and arthritis comorbidities

35
Q

Feverfew

A

Dosage: Varies typically 50–150mg dried leaf; 2.08–18.75mg of a CO2 extract

Mixed results based on formulation and product potency; may cause aphthous ulcers and withdrawal syndrome if abrputly stopped. COntraindicated in pregnancy

36
Q

Iron

A

Helpful in menstrual migraine compounded by iron deficiency

May help comorbid depression and anxiety

37
Q

Mind-body with good evidence

A
  1. Biofeedback: tension type and migraine. Improved efficacy of meds.
  2. Mindfulness Meditation: specifically MBSR. Canaactually change cognitive networks. Continuing a home practice has ongoing benefit.
  3. Others: CBT, relaxation (PMR), diaphragmatic breathing, guided imagery, hypnosis. Apps are good

Mind-body generally one of the most researched areas of therapy for migraine.
The benefit seems to be related to complying with a home practice.

38
Q

Biomechanical Techniques with good evidence

A
  • Manual therapy
  • spinal manipulation - can work through endocannabinoid modulation
  • ELectrical stimulation (like TENS). Transcutaneous vagal or trigeminal, transcutaneous magnetic, remote electrical neuromodulation (REN)
39
Q

Is acupuncture beneficial for acute headache treatment or as a preventative?

A

BOTH!

The most recent reviews on acupuncture noted that it is better than placebo, at least as effective as other preventives, and potentially superior to current pharmacotherapy. In addition, recent trials of manual, electrical, and auricular acupuncture demonstrated that they may be effective in preventing migraine.

40
Q

Energy-based therapies with some benefit in headache

A

Healing touch

Homeopathy

Note that some patients with headaches have significant hx trauma and/or sensitivity

Integrative Medicine Rakel (16 decks)

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