Headache Disorders: Acute Management

History and Clinical Presentation

Kelly is age 54 with a history of coronary vasospasm and renal artery stenosis as well as a history of migraine with aura since age 10 years. With her aura, she has what looks like a flash from a camera starting on her right side and migrating across her visual field over approximately 1 hour. After the aura, a headache begins within 30 minutes that is throbbing in nature and accompanied by nausea, photophobia, phonophobia, and worsening with exertion.

Treatment

At her first evaluation in our clinic, Kelly noted that she had already trialed propanolol and verapamil with limited success and was having more than 15 headache days per month. She began treatment with onabotulinumtoxinA injections using a protocol for chronic migraine, and her attack frequency decreased to 1 to 3 migraine attacks per year. After 2 years of infrequent migraine attacks, Kelly elected to discontinue onabotulinumtoxinA injections. For a subsequent 2 years, her migraine attacks continued to be infrequent (1 to 3 times per year) and she used promethazine as acute treatment as needed.

Subsequent Clinical Presentation

Recently, however, Kelly’s migraine with visual aura attacks changed in character. She has a new left retro-orbital headache and began having episodic right-sided hemiparesis lasting 30 minutes to 1 week associated with a migraine attack. The change in character of migraine attacks was accompanied by an increase to weekly attack frequency in which migraine attacks would last 4 days.

Diagnostic Studies

Because of Kelly’s new episodes of hemiparesis, a brain MRI with and without contrast was obtained. Findings were normal without any evidence of restricted diffusion.

Later Treatment

Kelly started a 3-month trial of erenumab 70 mg once a month via subcutaneous injection that was not effective at improving migraine attack frequency or severity, and so she restarted periodic onabotulinumtoxinA injections after having experienced over 15 headache days per month over a 3-month period. With reimplementation of onabotulinumtoxinA injections, Kelly’s migraine attack frequency was reduced to 6 headache days per month, only 2 of which were severe. Kelly was prescribed lasmiditan 100 mg once daily as needed but found she could not tolerate it because of sedation. As an alternative, rimegepant 75 mg once daily as needed was prescribed. Kelly reports achieving adequate pain relief when she uses rimegepant to treat severe migraine attacks acutely with no adverse events.

History and Clinical Presentation

Rachel is age 35 and has a history of headache attacks during her menstrual cycle that started in her teenage years. After a car accident 2 years ago, a mass was found incidentally while clearing her cervical spine following neck trauma. The mass was diagnosed as papillary carcinoma of her thyroid, and she underwent surgical resection. Rachel then required thyroid hormone supplementation and titration of levothyroxine was a slow process with periods of symptomatic hyperthyroidism. Over the course of 2 years, her headache attacks gradually increased, leading to referral to our clinic. Rachel’s headache was unilateral and throbbing as well as accompanied by photophobia, phonophobia, and a preference for rest. Occasionally, she would have central visual loss for about 30 minutes coinciding with the start of head pain.

Treatment

Initially, treatment with rizatriptan 10 mg as needed provided only short-term pain relief with frequent migraine attack recurrence, and there were side effects of some somnolence. Rachel switched to treatment with naratriptan, 2.5 mg as needed, which provided more sustained pain relief without sedation. She also began treatment with amitriptyline, titrated up to 50 mg per night, which decreased the frequency and severity of her headache attacks and improved her sleep. Despite the addition of the preventive treatment, however, the headache attacks continued to gradually increase to more than 15 headache days per month. As a result, Rachel was no longer able to take nara-triptan with every headache attack.

Rachel’s boyfriend gave her a supraorbital transcutaneous stimulator that she calls her “Cyclops.” She has found it helpful on an as-needed basis for 60 minutes. The “Cyclops” provides pain relief while using the device that is sustained for several hours afterward. Rachel uses it in isolation for mild attacks and combines it with naratriptan when an attack is severe.

After a trial of a second preventive medication, Rachel started treatment with onabotulinumtoxinA injections when she fulfilled diagnostic criteria for chronic migraine. Her headache attack improved to once per week of mild-to-moderate severity.

History and Clinical Presentation

Ashley is age 27 and in her 28th week of pregnancy and experiencing pre-eclampsia treated with bedrest. She came to the headache clinic with a 2-week history of a constant throbbing headache and a preference for rest and dark quiet areas. Her headache did not respond to acetaminophen or a metoclopramide. For preventive treatment, she was taking metoprolol which was also being used to treat postural orthostatic tachycardia syndrome (POTS). After review with her obstetrician, oral sumatriptan and promethazine had been tried on a limited basis for 2 days without relief.

Diagnostic Evaluations

Ashley’s physical examination was normal, and she had no evidence of papilledema. She was admitted to the hospital for evaluation and head MRI, including MR angiography (MRA) and venography (MRV), and there were no concerning findings. Hypertension was adequately treated with metoprolol, and laboratory evaluation for hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome was negative.

Treatment

Intravenous infusion with fluids, steroids, and metoclopramide was without benefit. Ashley had bilateral supraorbital nerve blocks and occipital nerve blocks with lidocaine and ropivacaine. Her headache improved after this treatment from a 10 of 10 in severity to a 2 of 10. She was discharged from the hospital and continued being seen as an outpatient for headache disorder management. A transcutaneous supraorbital nerve stimulator was prescribed for acute treatment of headache attacks as needed.

History and Clinical Presentation

Frank is age 59 with a 25-pack-year cigarette smoking habit and a 10-year history of a headache disorder. He has episodes of headache 2 to 3 times a year and notices that alcohol will trigger a headache attack when he is in one of these periods. Frank’s headache typically involves the right temple, although on 2 to 3 occasions the headache has occurred on the left. At the start, his headache attacks feel like a toothache that then develops into a stabbing sensation over the right temporal region. His headache attacks are accompanied by redness in the eye along with tearing and nasal congestion. Frank feels anxious during his headache attacks, which last approximately 45 minutes and occur 2 to 3 times a day.

Treatment

Treatment with oxygen usually resolves Frank’s headache in 2 to 4 minutes. More severe headache attacks include mild nausea and phonophobia; these resolve within 15 minutes of treatment with a 6 mg subcutaneous sumatriptan injection. Oral steroids have not been tolerable for Frank because of insomnia as an adverse event. With the addition of verapamil, which was titrated up to 240 mg twice daily, his headache cycles were reduced to once every 2 years.

Subsequent Presentation

Frank returned to the clinic after a month-long episode of headache attacks.

Subsequent Treatment

Frank had treatment with a right occipital steroid and local anesthetic injection with anticipatory recommendations to consider monthly galcanezumab injections if the steroid injection was not effective. Just before this procedure, he noticed a headache attack beginning, but it was aborted with the suboccipital injection. Frank’s headache attacks improved after the suboccipital injection, and he did not start galcanezumab.

Subsequent Treatment

Frank had treatment with a right occipital steroid and local anesthetic injection with anticipatory recommendations to consider monthly galcanezumab injections if the steroid injection was not effective. Just before this procedure, he noticed a headache attack beginning, but it was aborted with the suboccipital injection. Frank’s headache attacks improved after the suboccipital nerve block, and he did not start galcanezumab.