NR 565 Week 4
Chapter 35: Chronic Migraine and Cluster Headache
Chapter 29: Anxiety and Depression
Chapter 15: Drugs Affecting the Central Nervous System
Chapter 35: Chronic Migraine and Cluster Headache
Chronic daily headache headaches 15 or more days a month for longer than 3 months
Chronic daily headaches (CDH) can be divided into five subtypes:
o chronic tension-type headache
o chronic migraine
o hemicrania continua (Not in the study guide = not covered in depth)
rare disorder that responds completely to indomethacin and to nothing else.
Indomethacin (Indocin) 75 to 150 mg is given daily; doses up to 200 mg daily
may be needed. Referral to a neurologist is recommended.
o medication-overuse headache
o new daily persistent headache.
Use of drugs for acute headache treatment more than 9 days a month is associated with
increased risk of chronic daily headaches.
Medication-overuse is addressed later
Pathophysiology: Patho of CDH is often unclear and of mixed origin.
There is a clear difference between chronic migraine and hemicrania continua (Not in the
study guide = not covered).
The boundary between chronic tension-type headache and chronic migraine is less clear and
may require a neurology referral for treatment.
The term chronic migraine refers to CDH that starts as episodic migraine (less than 15 days a month)
that transforms into a chronic pattern of greater than 15 days a month of migraine headache
It was formerly called “transformed migraine.”
The initial migraines have the pathogenesis of migraine discussed earlier.
Chronic migraine is not well understood but is thought to be related to a combination of atypical pain
processing, cortical hyperexcitability, neurologic inflammation, and central sensitization.
Risk factors for chronic migraine include female gender, history of head or neck injury, life
stress, psychiatric disorders, and comorbid pain disorders
Goals of Treatment
The first goal of treatment for CDH is to break the pattern of daily headache. The patient is then
stabilized on prophylactic or preventive therapy.
,Rational Drug Selection
Chronic Migraine
In most patients with chronic migraine, the daily headache cycle can be broken by using repeated
doses of IV DHE (dihydroergotamine mesylate).
Approximately 70% to 80% of patients respond to DHE.
o The patient is given a test dose of 0.33 mL of DHE (1 mg/mL solution) with 5 mg of
metoclopramide or 10 mg of prochlorperazine (Compazine).
o Followed by 0.5 mL of DHE and one of the anti-nausea medications every 6 hours for 48
to 72 hours.
o This usually requires inpatient treatment.
o DHE is contraindicated in coronary and peripheral vascular disease.
Alternatives to DHE:
Chlorpromazine (Thorazine)
Prochlorperazine.
If the patient has medication-overuse headache due to misuse of analgesics, ergots, or combination
medications, the patient has to be detoxified (Discussed later)
Treatment of chronic migraine may require consultation with a neurologist.
Preventive pharmacotherapy can be started after the headache cycle is broken.
The patient usually responds to migraine-preventive medications such as propranolol,
divalproex, or a tricyclic antidepressant.
Amitriptyline is a good choice if the patient is also depressed.
The seizure medications topiramate or valproic acid may be used.
The patient is on preventive medication until the headache days are reduced by 50%, and then
an additional 3 to 4 weeks, for a total of 6 to 12 weeks.
The patient should also receive alternative therapy to treat CDH. Behavioral counseling, biofeedback
therapy, relaxation therapy, physical exercise, and acupuncture are all valid alternative therapies for
treatment of CDH.
Monitoring
Monitoring of patients with CDH who are on preventive therapy requires the patient to keep a diary of
headache and medication use.
Patients’ blood pressure should be monitored if they are on a beta blocker
Liver function monitored if on divalproex, as per migraine therapy monitoring.
Ongoing monitoring of headache is necessary because 31% may have recurrence of headache in
spite of preventive medication.
Outcome Evaluation
,Patients with CDH are difficult to treat. Treatment success is determined by how effective it has been
in breaking the cycle of daily headaches and how effective the preventive treatment is. The patient's
headache diary is key in the evaluation of the success of treatment.
Patient Education
Should include a discussion of information related to the overall treatment plan as well as that specific
to the drug therapy, reasons for taking the drug, drugs as part of the total treatment plan, and
adherence issues.
Patient education information specific to treating CDH should focus on the following principles:
1. Education about the nature of the disorder, particularly that it is biological in origin, with
neurochemical changes producing the headache.
2. Overuse of analgesics, leading to medication-overuse headache, must be emphasized.
3. The influence of stress, anxiety, depression, and inability to relax should be discussed, and the
patient encouraged to use nonpharmacological therapies to decrease headache.
CLUSTER HEADACHES: characterized by intense pain lasting for 15 minutes to 2 hours.
Occur in “clusters” of several weeks or months, with the headache subsiding for months at a
time, often to recur.
The patient can experience one to three attacks a day, usually at the same time of day. They
occur most frequently at night, awakening the patient from sleep.
Men are affected more than women, with onset in their late twenties.
The pain of a cluster headache is unique in that it occurs behind or around one eye, with
tearing, conjunctival injection, and drooping of the eyelid common symptoms.
There may be nasal congestion, facial flushing, and sweating. The pain is so severe that the
patient is unable to lie down or sit still, often pacing the floor in pain.
Pathophysiology
No clear etiology for cluster headaches.
They are most likely a neuronal disorder originating in the hypothalamus.
The clockwork-like timing of cluster headaches suggests that the circadian pacemaker or
biological “clock” is dysfunctional.
Goals of Treatment
Relieving the pain of an acute cluster headache and decreasing the length of time of the cluster are the
goals of cluster headache management.
Rational Drug Therapy
Most patients with cluster headaches require acute and preventive therapy.
The acute attacks are severe and last only a short time-intervention must be fast-acting. The patient
usually requires both acute and preventive medications to manage the headache.
, Acute Therapy
Oxygen therapy administered via a 100% nonrebreather mask for 15 to 30 minutes often
provides immediate relief of cluster headache.
Sumatriptan, administered SC, or intranasal sumatriptan or zolmitriptan may provide relief of
acute cluster headaches
Intranasal lidocaine is thought to be effective in treating cluster headache.
o The patient lies supine, hyperextends the head at 45 degrees, and rotates it 30 degrees
to the side of the headache.
o The lidocaine nasal solution is then dripped into the nostril on the affected side over 30
seconds.
o The onset is approximately 5 minutes.
Ergotamine derivatives are also effective for acute cluster headaches.
o Sublingual 2 mg tablets are administered at the beginning of the cluster headache.
o Ergotamine suppositories or DHE intranasally or IM may also be used
o Ergotamine may also be administered in a 2 mg dose given before bed if nocturnal
attacks occur frequently.
Preventive Therapy
Verapamil can prevent cluster headaches in some patients.
Calcium channel blockers are thought to prevent cluster headache by inhibiting vasospasm
of the cerebral arteries.
Cluster headaches appear to need dosing in the high range to achieve headache reduction.
Divalproex can be effective in preventing cluster headaches. The dosing is the same as for
migraine prophylaxis
Lithium appears to have some effect on cluster headaches in some patients, and a trial of
lithium is warranted if the patient does not respond to other preventive medications.
o The dose for cluster headache prevention is 300 mg daily to a maximum of 300 mg 3
times a day.
o The patient needs careful monitoring for adverse effects, including electrocardiogram
(ECG), electrolytes, thyroid function, creatinine, and CBC studies.
Nonpharmacological therapies include avoidance of all alcohol during the clustering of headaches
because alcohol often precipitates a headache.
Patients often are able to drink alcohol between headache clusters without adverse effects.
Tobacco, stress, anger, and vigorous physical activity should be avoided.
The patient needs to maintain a normal sleep pattern, if possible.
Cluster headaches do not appear to respond to self-care measures such as massage and relaxation.
Monitoring
Cluster headaches can be severely disabling, and the intense pain and loss of sleep can
significantly affect the patient's quality of life.
The health-care provider needs to monitor the patient for suicidal thoughts during the
headache.
The headache diary helps to monitor the effectiveness of acute and preventive medications.
A patient treated with lithium requires careful monitoring of ECG and chemistries throughout
treatment.
Outcome Evaluation
Chapter 35: Chronic Migraine and Cluster Headache
Chapter 29: Anxiety and Depression
Chapter 15: Drugs Affecting the Central Nervous System
Chapter 35: Chronic Migraine and Cluster Headache
Chronic daily headache headaches 15 or more days a month for longer than 3 months
Chronic daily headaches (CDH) can be divided into five subtypes:
o chronic tension-type headache
o chronic migraine
o hemicrania continua (Not in the study guide = not covered in depth)
rare disorder that responds completely to indomethacin and to nothing else.
Indomethacin (Indocin) 75 to 150 mg is given daily; doses up to 200 mg daily
may be needed. Referral to a neurologist is recommended.
o medication-overuse headache
o new daily persistent headache.
Use of drugs for acute headache treatment more than 9 days a month is associated with
increased risk of chronic daily headaches.
Medication-overuse is addressed later
Pathophysiology: Patho of CDH is often unclear and of mixed origin.
There is a clear difference between chronic migraine and hemicrania continua (Not in the
study guide = not covered).
The boundary between chronic tension-type headache and chronic migraine is less clear and
may require a neurology referral for treatment.
The term chronic migraine refers to CDH that starts as episodic migraine (less than 15 days a month)
that transforms into a chronic pattern of greater than 15 days a month of migraine headache
It was formerly called “transformed migraine.”
The initial migraines have the pathogenesis of migraine discussed earlier.
Chronic migraine is not well understood but is thought to be related to a combination of atypical pain
processing, cortical hyperexcitability, neurologic inflammation, and central sensitization.
Risk factors for chronic migraine include female gender, history of head or neck injury, life
stress, psychiatric disorders, and comorbid pain disorders
Goals of Treatment
The first goal of treatment for CDH is to break the pattern of daily headache. The patient is then
stabilized on prophylactic or preventive therapy.
,Rational Drug Selection
Chronic Migraine
In most patients with chronic migraine, the daily headache cycle can be broken by using repeated
doses of IV DHE (dihydroergotamine mesylate).
Approximately 70% to 80% of patients respond to DHE.
o The patient is given a test dose of 0.33 mL of DHE (1 mg/mL solution) with 5 mg of
metoclopramide or 10 mg of prochlorperazine (Compazine).
o Followed by 0.5 mL of DHE and one of the anti-nausea medications every 6 hours for 48
to 72 hours.
o This usually requires inpatient treatment.
o DHE is contraindicated in coronary and peripheral vascular disease.
Alternatives to DHE:
Chlorpromazine (Thorazine)
Prochlorperazine.
If the patient has medication-overuse headache due to misuse of analgesics, ergots, or combination
medications, the patient has to be detoxified (Discussed later)
Treatment of chronic migraine may require consultation with a neurologist.
Preventive pharmacotherapy can be started after the headache cycle is broken.
The patient usually responds to migraine-preventive medications such as propranolol,
divalproex, or a tricyclic antidepressant.
Amitriptyline is a good choice if the patient is also depressed.
The seizure medications topiramate or valproic acid may be used.
The patient is on preventive medication until the headache days are reduced by 50%, and then
an additional 3 to 4 weeks, for a total of 6 to 12 weeks.
The patient should also receive alternative therapy to treat CDH. Behavioral counseling, biofeedback
therapy, relaxation therapy, physical exercise, and acupuncture are all valid alternative therapies for
treatment of CDH.
Monitoring
Monitoring of patients with CDH who are on preventive therapy requires the patient to keep a diary of
headache and medication use.
Patients’ blood pressure should be monitored if they are on a beta blocker
Liver function monitored if on divalproex, as per migraine therapy monitoring.
Ongoing monitoring of headache is necessary because 31% may have recurrence of headache in
spite of preventive medication.
Outcome Evaluation
,Patients with CDH are difficult to treat. Treatment success is determined by how effective it has been
in breaking the cycle of daily headaches and how effective the preventive treatment is. The patient's
headache diary is key in the evaluation of the success of treatment.
Patient Education
Should include a discussion of information related to the overall treatment plan as well as that specific
to the drug therapy, reasons for taking the drug, drugs as part of the total treatment plan, and
adherence issues.
Patient education information specific to treating CDH should focus on the following principles:
1. Education about the nature of the disorder, particularly that it is biological in origin, with
neurochemical changes producing the headache.
2. Overuse of analgesics, leading to medication-overuse headache, must be emphasized.
3. The influence of stress, anxiety, depression, and inability to relax should be discussed, and the
patient encouraged to use nonpharmacological therapies to decrease headache.
CLUSTER HEADACHES: characterized by intense pain lasting for 15 minutes to 2 hours.
Occur in “clusters” of several weeks or months, with the headache subsiding for months at a
time, often to recur.
The patient can experience one to three attacks a day, usually at the same time of day. They
occur most frequently at night, awakening the patient from sleep.
Men are affected more than women, with onset in their late twenties.
The pain of a cluster headache is unique in that it occurs behind or around one eye, with
tearing, conjunctival injection, and drooping of the eyelid common symptoms.
There may be nasal congestion, facial flushing, and sweating. The pain is so severe that the
patient is unable to lie down or sit still, often pacing the floor in pain.
Pathophysiology
No clear etiology for cluster headaches.
They are most likely a neuronal disorder originating in the hypothalamus.
The clockwork-like timing of cluster headaches suggests that the circadian pacemaker or
biological “clock” is dysfunctional.
Goals of Treatment
Relieving the pain of an acute cluster headache and decreasing the length of time of the cluster are the
goals of cluster headache management.
Rational Drug Therapy
Most patients with cluster headaches require acute and preventive therapy.
The acute attacks are severe and last only a short time-intervention must be fast-acting. The patient
usually requires both acute and preventive medications to manage the headache.
, Acute Therapy
Oxygen therapy administered via a 100% nonrebreather mask for 15 to 30 minutes often
provides immediate relief of cluster headache.
Sumatriptan, administered SC, or intranasal sumatriptan or zolmitriptan may provide relief of
acute cluster headaches
Intranasal lidocaine is thought to be effective in treating cluster headache.
o The patient lies supine, hyperextends the head at 45 degrees, and rotates it 30 degrees
to the side of the headache.
o The lidocaine nasal solution is then dripped into the nostril on the affected side over 30
seconds.
o The onset is approximately 5 minutes.
Ergotamine derivatives are also effective for acute cluster headaches.
o Sublingual 2 mg tablets are administered at the beginning of the cluster headache.
o Ergotamine suppositories or DHE intranasally or IM may also be used
o Ergotamine may also be administered in a 2 mg dose given before bed if nocturnal
attacks occur frequently.
Preventive Therapy
Verapamil can prevent cluster headaches in some patients.
Calcium channel blockers are thought to prevent cluster headache by inhibiting vasospasm
of the cerebral arteries.
Cluster headaches appear to need dosing in the high range to achieve headache reduction.
Divalproex can be effective in preventing cluster headaches. The dosing is the same as for
migraine prophylaxis
Lithium appears to have some effect on cluster headaches in some patients, and a trial of
lithium is warranted if the patient does not respond to other preventive medications.
o The dose for cluster headache prevention is 300 mg daily to a maximum of 300 mg 3
times a day.
o The patient needs careful monitoring for adverse effects, including electrocardiogram
(ECG), electrolytes, thyroid function, creatinine, and CBC studies.
Nonpharmacological therapies include avoidance of all alcohol during the clustering of headaches
because alcohol often precipitates a headache.
Patients often are able to drink alcohol between headache clusters without adverse effects.
Tobacco, stress, anger, and vigorous physical activity should be avoided.
The patient needs to maintain a normal sleep pattern, if possible.
Cluster headaches do not appear to respond to self-care measures such as massage and relaxation.
Monitoring
Cluster headaches can be severely disabling, and the intense pain and loss of sleep can
significantly affect the patient's quality of life.
The health-care provider needs to monitor the patient for suicidal thoughts during the
headache.
The headache diary helps to monitor the effectiveness of acute and preventive medications.
A patient treated with lithium requires careful monitoring of ECG and chemistries throughout
treatment.
Outcome Evaluation
