Headache Disorders: Acute Management
In this article we present a series of actual patients who we think represent clinical scenarios that may routinely be encountered in the oupatient neurology setting with the aim of illustrating how to navigate special situations in acute headache disorder management. Names were changed to protect patient confidentiality. Key points are summarized after each clinical scenario.
Key Points of A Walking Contraindication
Diagnosis
Kelly was diagnosed with chronic migraine with aura with subsequent hemiplegic migraine.
Discussion
A woman, age 54, with a history of coronary vasospasm and chronic migraine, who was successfully treated in the past with onabotulinumtoxinA injections, reverted back to a pattern of chronic migraine. She also developed motor aura accompanying some of her migraine attacks. After a diagnostic evaluation, she had a trial of erenumab without significant improvement. In the context of coronary vasospasm and motor aura, she had a trial of lasmiditan, which was ineffective and not tolerated due to sedation. Subsequently, after fulfilling diagnostic criteria for chronic migraine she restarted treatment with onabotulinumtoxinA injections for preventive treatment. Rimegepant was then trialed as an acute treatment and found effective and tolerable.
In people with a reported history of vasospasm, vascular disease, coronary artery disease, stroke, or hemiplegic migraine (motor aura), triptans should be avoided.1
Lasmiditan is a highly selective 5-HT1F agonist without vasoconstrictive activity that can be used when there are contraindications to triptan use.2,3 Lasmiditan can cause sedation, making it important to advise patients to avoid driving motorized vehicles or operating machinery until 8 hours after taking lasmiditan. Because of possible drug-liking effects of lasmiditan, it is a Schedule V controlled substance.
Another acute treatment option to consider when triptan use is contraindicated are gepants, which are small molecule calcitonin gene-related peptide (CGRP) receptor antagonists that currently do not have any black box warnings or contraindications to use in vascular disease or hemiplegic migraine.4 Currently available gepants are ubrogepant and rimegepant, with mild self-limited nausea and somnolence as side effects and no reports of increased cardiovascular events to date.5
Key Points of My Friend the Cyclops
Diagnosis
Rachel was diagnosed with chronic migraine with aura and headache attributed to disorder of homoeostasis and treated for both while avoiding medication-overuse headache.
Discussion
A woman, age 35 with a history of migraine with aura, had progression to chronic migraine—likely related to periods of hyperthyroidism that resulted from treatment for papillary carcinoma of the thyroid. An initial trial of rizatriptan was neither effective nor tolerable, but naratriptan was able to be used effectively as an abortive therapy. Despite preventive management, migraine attacks continued to increase in frequency and medication-overuse headache was avoided through counseling and use of a transcutaneous supraorbital nerve stimulator.
Education before the implementation of an acture treatment regimen is important to help prevent the development of medication-overuse headache.6 Naratriptan can be an effective triptan when other triptans are not tolerated.7 Transcutaneous supraorbital nerve stimulators can be used on an acute basis to help to reduce analgesic use and can provide meaningful pain relief in chronic migraine.8 The implementation of an effective preventive regimen with onabotulinumtoxinA injections decreased the frequency and severity of headache attacks and helped mitigate potential for developing medication-overuse headache.
Key Points of Unexpected Pain While Expecting
Diagnosis
Ashley was diagnosed and treated for headache attributed to pre-eclampsia.
Discussion
A woman, age 27 in her 28th week of pregnancy and experiencing pre-eclampsia, presented with a 2-week history of headache. Without an antecedent history of migraine, she did not fulfill International Classification of Headache Disorders (ICHD)-3 diagnostic criteria for migraine without aura or status migrainosus. Her red-flag presentation of new-onset headache in pregnancy warranted a diagnostic work-up for dangerous causes of headache in pregnancy, including cerebral venous thrombosis and pituitary adenoma. Fortunately, none of these causes were found, and the diagnostic work up was unrevealing.9 Her headache course was without benefit from acetaminophen, sumatriptan, promethazine, or metoprolol. She ultimately found relief acutely with bilateral supraorbital and occipital nerve blocks and was able to use a transcutaneous supraorbital nerve stimulator to augment headache control.
Triptan use should generally be avoided during pregnancy, but with refractory migraine, sumatriptan can be considered on a limited basis.10 Treating early in the headache course typically improves the efficacy of acute medications, and the use of sumatriptan 2 weeks after headache onset partly explains the lack of efficacy in this case. Peripheral nerve blocks can be helpful in acute headache management and are an option during pregnancy when treatment options are limited.11
Key Points of Where There’s Smoke, There’s Fire
Diagnosis
Frank was diagnosed and treated for episodic cluster headache.
Discussion
A man, age 59 with a history of cigarette smoking, presents with usually right-sided cluster headaches occurring up to 2 to 3 times per day, sometimes for months at a time, but may be pain free for 3 to 4 months in between cycles. He initially found benefit from high-flow oxygen and a sumatriptan injectable as acute treatment strategies along with a reduction in the occurrence of cluster cycles with verapamil as a preventative. Oral steroids were not tolerated in the past and a right occipital nerve block was effective as a transitional therapy. Galcanezumab would have been a potential alternative if the occipital nerve block was not effective.
High-flow oxygen with a non-rebreather mask at a rate of 12 to 15 L/min is the first-line acute treatment for cluster headache.12 Oxygen tanks, however, can be difficult for patients to transport and have readily available at onset of an attack. It can also be difficult to obtain reimbursement from insurance companies for oxygen treatment of cluster headache. Subcutaneous sumatriptan and intranasal zolmitriptan are also effective for acute treatment of cluster headache; oral triptan formulations do not work quickly enough to be effective for cluster headache.13 A course of oral prednisone or suboccipital steroid injections are treatment options as a transitional therapy for cluster headache, and preventive treatments include verapamil and galcanezumab.14,15 A transitional therapy can be implemented early in the course of a cluster cycle to provide pain relief and decrease dependence on acute treatments while waiting for preventive treatments to take effect.
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