Headaches

Migraine headaches:

  • Preventative:
    • Start Propranolol 40mg PO bid (start at 80mg/day and go up to 160mg/day)
      • Propranolol is better than Metoprolol for preventing migraine headaches because Propranolol crosses the blood brain barrier better and has some alpha receptor action (?), which facilitates it dilating cranial vessels.
    • Start Riboflavin (Vitamin B2) 400mg PO qd.
    • Start Magnessium 400mg PO qd
    • Amitriptyline 25mg PO every bedtime or Nortriptyline 10mg PO qd
      • Amitriptyline 25mg tabs: Take ½ tab each night or 2 weeks, 1 full tablet each night for 2 weeks, and 2 tabs each night then on.
    • Butterbur: a natural product found at Health Fair grocery store used to prevent migraine headaches.
    • Midrin: combination of 1) Acetaminophen (pain reliever), 2) Dichloralphenazone (mild sedative), and 3) Isometheptene (vasoconstrictor: narrows cerebral blood vessels; helpful especially if headache is due to dilation of cerebral vessels)
    • Fioricet: Butalbital/Acetaminophen/Caffeine
    • Topiramate 100mg PO bid
      • Start (1st week): 25mg PO q bedtime
      • 2nd week: 25mg PO bid
      • 3rd week: 25mg qAM and 50mg qPM
      • 4th week and on: 50mg PO bid
  • Abort/rescue migraines: Sumatriptan 50mg PO PRN onset of migraine aura and may repeat within 2 hours X 1 time only or Rizatriptan benzoate 5 mg PO PRN (take at onset of headache)
  • Determine if triggers can be identified: Avoid triggers.
    1. Have patient pay attention to possible triggers for migraine headaches: stress, lack of sleep, changes in diet, menstruation
    2. If pt gets get more migraines around her period. Consider taking an OTC NSAID (Ibuprofen, Aspirin, Diclofenac, Naproxen, etc.) the week prior to the start of menstruation to help mitigate the more severe migraine headaches. If regular cycle, can pre-treat week before with NSAIDs
    3. Headaches may be rebound medication induced (pain meds that are taken daily).
      1. Encouraged to slowly taper down her Ibuprofen and Tylenol use as overuse of these medication can exacerbate daily headaches.

Headache, Tension-type:

  • Ketorolac Tromethamine (potent NSAID) 30mg/ml IM injection solution: Inject 30mg IM X1 dose
  • Naproxen 250mg 1 tab PO q6-8hr PRN.

Headache, Cluster-type:

  • Patients should avoid triggers such as alcohol, smoking, and shift work.
  • 100% oxygen 6 to 12 L per minute for 15 minutes via face mask is the treatment of choice for acute CH.
  • Intranasal zolmitriptan and SC sumatriptan are both effective for acute CH.
  • Corticosteroids (Prednsone) in a dose of 100 mg per day for 5 days, then tapering down, are recommended during acute attacks based on limited clinical trial data.
    1. Recommend that the patient watch their diet as Prednisone causes weight gain.
  • Verapamil 240 to 480 mg per day is recommended as the first-line therapy for maintenance, although authors of a systematic review rated intranasal civamide (100 mcg daily) or suboccipital steroid injections for prevention and verapamil (360 mg), lithium (900 mg), and melatonin (10 mg).

Other headaches:

Paroxysmal hemicrania is a rare form of headache that usually begins in adulthood. Patients experience severe throbbing, claw-like, or boring pain usually on one side of the face; in, around, or behind the eye; and occasionally reaching to the back of the neck.

Raeder paratrigeminal syndrome (ie, paratrigeminal neuralgia) is characterized by severe, unilateral facial pain and headache in the distribution of the ophthalmic division of the trigeminal nerve in combination with ipsilateral oculosympathetic palsy or Horner syndrome.

Work up:

MRI of the orbits is ordered to be added to the already scheduled MRI of the head if possible.

The patient is prescribed Indomethacin 50mg PO bid.

Labs ordered today include ESR and CRP.

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