Outpatient Headache

Lauren Waskowicz

Type

Presentation

First-line Treatment
Tension (most common) Mild-to-moderate visor-like pressure/tightness without significant photophobia, phonophobia, or nausea

Abortive: Acetaminophen

Preventative: TCAs, SNRIs
Migraine Unilateral, pulsating, moderate-tosevere pain, lasting 4-72hrs, worse with activity and improves with sleep. Associated with nausea, photophobia, phonophobia, ± aura

Abortive: NSAIDs, acetaminophen, triptans, CGRP antagonists

Preventative: Anti-depressants, anti-hypertensives, anti-seizures, CGRP antagonists
Cluster Severe (often extreme) unilateral peri-orbital/temporal stabbing pain, associated with lacrimation, rhinorrhea, sweating, swelling of face, and visual changes. Occurs in “clusters” with each individual episode lasting minutes-to-hours

Abortive: 100% FiO2 at 12L/min (for at least 15 mins), triptans, indomethacin

Preventative: Verapamil
Medication Overuse (Rebound) @15 days of the month with a preexisting headache disorder, overusing an abortive treatment, often presents as worsening headache despite increased intake of medication. Using an abortive agent >2-3x/week can cause. Seen with NSAIDs, APAP, caffeine-based medications (Excedrin, Fioricet), triptans, ergotamines, and opioids. Stop offending medication, typically via taper. Headache will worsen before it gets better (important to warn pt of this). Start concurrent daily prophylactic headache medication.

Evaluation

  • Assess for red flag symptoms (refer to “Headache: Inpt”)
  • If no red flag symptoms present, no need for further work-up
  • Assess lifestyle factors that can be contributing to headache: good sleep hygiene, routine meal schedules, regular exercise, water intake, and managing migraine triggers

Medication Overview 

  • Abortive
    • Triptans: Cannot be used more than 10 days/month. Avoid in pts with significant coronary artery disease, prior strokes, and prior MI. Associated with vasospasm.
    • CGRP antagonists: Newer options. Insurance typically requires failure of 2 abortive triptans prior to approval. Refer to Neurology Clinic for this.
  • Preventative
    • Amitriptyline: indicated for both migraine and tension-type. Helps with sleep and comorbid depression. Most common side effects (SE) = dry mouth, sedation
    • Topiramate: Can help with weight loss. Most common SE = sodas taste bad, sedation/cognitive effects, paresthesias. Avoid in patients with history of kidney stones.
    • Propranolol: useful for relative lack of interactions. Mild cardiac/blood pressure effects compared to other beta-blockers. Most common SE = drowsiness/insomnia, dizziness
    • Magnesium oxide: reduces headache frequency with almost no SE. Start 400mg daily, can go up to 800mg BID. Patients can increase their dose as tolerated. Most common SE = diarrhea
    • Riboflavin (vitamin B2): mild effect but essentially has no side effects. 400mg daily.
    • Gabapentin: can be useful if HAs have stabbing/electric quality. Main SE = sedation
    • Venlafaxine: useful for migraines with significant vestibular symptoms (dizziness). SE = hypertension/tachycardia.
    • Verapamil: can be used for migraine and cluster headaches. Can use ER formulation
    • Botox: can be administered every 3 months. Can be very effective, but pts generally will have had to fail multiple medications for insurance to approve. Refer to neuro resident clinic
    • CGRP receptor modulators (mostly injections) such as Rimegepant are newer options
Last updated on