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Headache and orofacial pain - Management (3.7.19 - 3.7.27)

Updated: May 6, 2022



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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