3.7.19 Discuss the evidence base for non-drug interventions in primary and secondary headache syndromes
The Quick Summary:
Mindfulness and exercise (generally) can be helpful. CBT for affect on life. Maybe dietary modifications may help. Maybe massage.
Principles of management: Take into account
Evidence of efficacy
Benefits and risks of treatments
Patients beliefs and desires
Principles of management: In general
Drug treatment no > than 2 days per week - otherwise the risk of MOH
Acute treatment to resolve
Prophylactic to reduce frequency and severity
Education and lifestyle management is crucial
CBT
Systematic review gave mixed results (2015)
Shown to help with mood and not the disability of pain intensity scales
Relaxation
Not shown in a systematic review to have major positive effects on intensity or disability
Mindfulness
Evidence of benefit for pain reduction 2018 meta-analysis
Sleep hygiene
Too few studies. Maybe some benefit. Unclear.
Exercise
Aerobic exercise has been shown to reduce migraine attacks (RCT)
Physical therapies evidence remains unclear
Diet
Ketogenic diet, low calorie, low fat and low glycemic diets have been shown in case series to reduce daily headaches
Massage
Small RCTs show some benefits
Possibly greater benefit in tension-type headaches
Acupuncture
Acupuncture has been shown in Cochrane review to be at least equivalent to prophylactic medication for migraine
3.7.20 Discuss the evidence base for pharmacological treatment of acute migraine: (UpToDate 2021)
(Remember episodic migraine is < 15 days per month and chronic migraine is > 15 days per month)
The quick summary:
Paracetamol NNT = 12 (to pain free - cochrane) for significant reduction in headache intensity
Aspirin - NNT = 6 (to pain free - cochrane) for significant reduction in headache intensity
Antiemetics - Metoclopramide should be used in conjunction to help reduce pain and nausea
Triptans - Sumatriptan 50-100mg - Subcut NNT = 2.5, Oral NNT = 6 (remember GI absorbed so won't work if they are vomiting) (but small cardiovascuar risk)
Simple analgesics
Paracetamol reduces headache from moderate/severe to none in 2 hours in 1 in 5. 1 in 10 for placebo
Non-steroidal anti-inflammatory drugs
Level A evidence of benefit for migraine attacks
Single-dose of 1000mg of aspirin is very helpful
From Mod/severe to non by two hours in 1 in 4 people vs 1 in 10 with placebo.
Antiemetics
Addition often helps reduce nausea and vomiting and NNT is 4 for a significant reduction in pain in migraine
Triptans
RCTs and systematic reviews have shown triptans to be beneficial.
May be better given earlier in the treatment
Use with NSAIDs may be more efficacious than either alone - systematic review 2016
Ergotomines
Binds to 5Ht 1b/d receptors (same as triptans)
RCTs are a bit more unclear regarding efficacy/benefit than triptans
CGRP
Meta-analyses in 2021 suggest better than placebo acute migraine treatment with rimegepant [UPDATE: Hepatotoxicity - withdrawn] . More trials are needed
Opioids
Should not be used as first line therapy. High risk of return to ED with a repeat headache within 7 days of first visit
They are not as effective as migraine-specific medications
Risk of developing MOH and chronic migraine
Nerve blocks
Case series showed benefit for occipital nerve blocks
Possible benefit also for sphenopalatine blocks
Reference:
Chaplin, S. (2018). SIGN on the pharmacological management of migraine. Prescriber, 29(8), 27-31.
3.7.21 Discuss the evidence base for pharmacological prophylaxis in migraine
The quick summary:
1st = Propranolol 80 - 160 mg daily
2nd = Topiramate 50 - 100 mg daily
3rd = Amitriptyline 25 - 100 mg daily
- Botox if chronic migraine sufferer and other things are not working
Beta-blockers
RCTs show benefit for migraine prevention (50% of patients will have 50% reduction)
And for Ag2 blockers (candesartan)
CCBs
Evidence is weaker and conflicting that CCBs and ACE are effective but still possible
Sodium valproate
Better than placebo in systematic reviews
TCA
Effective in 4 trials - However not recommended by NICE guidelines
Topiramate
Better than placebo
Several systematic reviews and meta analyses
Pizotifen
Little clinical trials of efficacy. NICE found minimal benefit.
CGRP
Monoclonal antibodies directed against the CGRP receptor or ligand - erenumab
Modestly effective for migraine prevention in placebo-controlled trials.
3.7.22 Discuss the evidence base for and the role of botulinum toxin in the management of chronic migraine
Several randomised control trials have found no consistent statistically significant benefit. It is not generally recommended for episodic migraine.
PREEMPT 1 and PREEMPT 2 = Botox A - decreased in frequency of headaches relative to baseline EXCEPT for acute pain medication intake. There was a large placebo response in these trials.
Reference: UpToDate (Sept 2021)
3.7.23 Discuss the role of occipital nerve stimulation in the management of refractory migraine
There is evidence of positive benefit with a reasonably large effect size but there are few RCTs and small numbers to draw evidence-based conclusions.
3.7.24 Discuss the treatment options available in the management of medication-overuse headache
Education for the patient on the mechanism and diagnosis - there is some evidence of benefit
Preventative therapy - Topiramate or botox could be considered
Management of withdrawal symptoms - Anxiety, sleep problems and autonomic symptoms - often lasting 2-7 days. Steroids were not shown to help in RCTs.
Reference: Diener, H.-C., Holle, D., Solbach, K., & Gaul, C. (2016). Medication-overuse headache: risk factors, pathophysiology and management. Nature Reviews. Neurology, 12(10), 575–583. https://doi.org/10.1038/nrneurol.2016.124
3.7.25 Discuss the evidence base for pharmacological treatment of trigeminal neuralgia with: (ref: UpToDate 2021)
Carbamazepine
Best studied for Classic TN - shown to be effective in systematic reviews NNT < 2
100-200 mg twice daily to maintainence 600-800 mg
Oxcarbazepine - Better tolerability than carbamazepine. Suggested both are equally effective.
Gabapentin
Shown to be possibly effective and fewer side effects than carbamazepine in 2016 meta-analysis - but studies were poor
Clonazepam
Not listed in UpToDate
Baclofen
Limited evidence suggests a possible benefit
3.7.26 Discuss the efficacy and complications of surgical options for trigeminal neuralgia: (Ref: UpToDate 2021)
Microvascular decompression
Up to 90% reduction in pain however this reduced with time to 75% at 5 years
Mortality 0.2%
Hearing loss in up to 10% of patients however
Radiofrequency ablation
Similar efficacy to microvascular decompression however possibly mire complications with dysaesthesia in 12 %
Balloon compression
As above - same studies
Radiosurgery / Gamma Knife
Lag time of 1 month for onset of relief
Possibly less efficacious than RF or microvascular decompression
Worsening facial sensory impairment in 9-37%
3.7.27 Discuss the evidence base behind the treatments for TMJ disease including but not limited to:
CBT
Physical therapies
Dental splints
TMJ irrigation
TMJ surgery
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