Welcome to the program!

Calgary Headache Assessment & Management Program (CHAMP)

EDUCATION SESSION

Why is this Session Mandatory?

• Provide headache management information and orientation to the Champ program

• Opportunity to hear from other people living with headaches and to ask questions

• 12-14 month wait to see the Champ neurologist

Session Outline

• Introduction to the program • Headache Diagnosis

• Medical treatment of headaches

• Behavioral Approaches for headache management

• CHAMP program components • Questions and discussion

Calgary Headache Assessment &

Management Program (CHAMP)

Who we are…

a multi-disciplinary team of neurologists, nurses, occupational therapists, a psychologist and a kinesiologist working with you toward optimal

Neurologist

• Specialist expertise in headache diagnosis and overall headache

management.

- Medical treatment options and behavioral strategies.

Nurse

Nursing interventions provided in the clinic and over the phone:

• Medication teaching and counselling

Occupational Therapist

Help you to achieve functional goals and to resume roles and activities that may have been disrupted by your headaches

Psychologist

Short term counselling to address

psychological issues that may affect headache condition.

• mood/anxiety problems • relationship stress

• adjustment to physical or mental health conditions.

Kinesiologist

Practical education for:

• safe approaches to exercise and activities. • exercise as a pain

management tool.

CHAMP Research Team

Conduct studies to gain more information that may help us to provide better headache

management in the future.

Additional CHAMP Resources

Within CHAMP, patients also have access to: • Registered Dietician

• Physical Therapist • Psychiatrist

*Referral required

Self-Management Approach

A Multi-Faceted Approach

What is Successful

Headache Management?

• Reduced frequency, intensity, and/or duration of headache

• Improved day-to-day function despite headaches

• Quality of life improvement/satisfaction • Sense of control over headaches

Headache: Diagnosis and Use of

Medications

Calgary Headache Assessment and Management Program (CHAMP)

Medical Section Outline

• How are headaches diagnosed? • Where does the pain come from?

• Acute medications to relieve headache attacks.

• Preventative medications to reduce headache frequency.

• Medication overuse headache.

Making a Diagnosis:

• You are asked to tell your headache story • Headache diaries can be very helpful.

• The doctor will examine you.

Headache Diagnosis

The first decision: Are the headaches:

Secondary Headaches?

or

Secondary Headaches: Headaches from an Identifiable Cause Examples: 1. Head/neck injury 2. Medication Overuse 3. Caffeine withdrawal 4. Alcohol Induced 5. Meningitis 6. Brain tumor 7. Brain Hemorrhage 8. Neuralgias 9. Others

Primary Headache: Headaches with no

other Underlying Cause

Examples:

1. Migraine with or without aura

2. Tension-type headache

3. Cluster headache

4. others

Chronic Migraine and Chronic

Tension-Type Headache

• Chronic migraine: migraine with headache on more than 14 days a month

• Chronic tension-type headache: tension-type headache on more than 14 days a month.

• Some people may have migraine on some

How do we diagnose primary

headaches?

• Migraine without aura • At least 5 attacks, 4-72 hrs • 2 of:

– One-sided

– Moderate-severe – Throbbing

– Worse with routine activity • 1 of:

– Nausea/vomiting

– Light and sound sensitivity • No other cause

• Tension-Type Headache

• At least 10 attacks, 30 min-7 days

• 2 of:

- Mild-moderate intensity - Bilateral

- Tight, non-throbbing, band-like headache

- No worsening with activity • Both of:

- No nausea or vomiting

- No more than one of light or sound sensitivity

What is an aura?

• Nervous system symptoms that come on slowly before a migraine and last less than 1 hour

• Occur in 1/3 of migraine patients

– Vision changes

– Numbness/Pins and needles – Speech problems

– Less commonly, weakness, dizziness

Cortical Spreading Depression

and Migraine Aura

25 Lauritzen M. Trends Neurosci 1987;10:8-13

What Causes the Pain in a Migraine

Attack?

Migraine Treatment

• Basics

– Lifestyle issues – Specific triggers

• Treatment for individual headache attacks (acute therapy)

– Non-medication – Medications

• Preventing headache attacks - Preventative medications

Choosing Acute Migraine Medications

Mild Attacks:

– ASA, Acetaminophen (Tylenol), Ibuprofen (Advil)

Moderate:

– NSAIDS (Ibuprofen, Naproxen, Diclofenac, Others) – Ergots, Triptans

Severe Attacks:

Treating Acute Migraine Attacks

• Treat early in the attack if you can • Avoid too frequent use

• NSAIDS and Triptans can be taken together • Codeine-containing medications are not

recommended for routine use

The Triptans: Medications Designed

Specifically for Migraine

Medication Tablet Wafer Nasal Spray Injection

Imitrex x x x Zomig x x x Amerge x Maxalt x x Relpax x Axert x Frova x 31

Tension-Type Headaches

• Attacks are often not severe, so not all attacks require medication.

• For individual attacks, NSAIDS (Ibuprofen, Naproxen, etc) are best.

Preventive Medication

• Consider a daily preventive if:

– you have significant disability despite the use of acute treatments.

– you need to use acute medications so frequently that you are at risk for medication-induced

headache.

– Preventive medications need to be taken every day

Reduction in Monthly Migraine Frequency

withTopiramate

Migraine preventative medications

• Certain blood pressure medications

• propranolol (other bets blockers), verapamil, candesarten

• Certain antidepressants

• Amitriptyline, nortriptyline, venlafaxine • Certain anti-seizure medications

• Divalproex sodium, Topiramate, gabapentin • Certain vitamins, minerals, herbs

• Riboflavin, magnesium, butterbur (Petadolex), coenzyme Q10

• Others

– Sandomigran, flunarazine ,

Preventive Medications for Other

Headache Types

Tension-type headache:

• Amitriptyline, Nortriptyline, Venlafaxine Cluster headache:

• Verapamil, Lithium

Post-traumatic headaches:

• Depends on the headache type

Can medications taken for headache

cause more headache?

For acute medications, the answer is YES!

How much is too much?

• Triptans, opioids, DHE, ergotamine

(e.g. migranal, imitrex, codeine, demerol, 222s, Tylenol#3)

– 10 or more days/month for more than 3 mo.

• NSAIDs (ibuprofen, naproxen, diclofenac, etc), ASA, acetaminophen

39

40 One Year After

Treating Medication Overuse

• Patient Education

• Stop medication overuse

• Provide a good acute medication • Start a preventative medication

Key Messages

• Understand your headaches and diagnosis. • Become skillful in using acute medications. • Use preventative medications if necessary. • Avoid medication overuse.

• Use diaries if necessary to monitor headaches and medication use.

Opportunity To Enter Clinical Trials

Medication Overuse Study - 3 month study

• For chronic migraine sufferers (more than 14 days of headache per month)

• Using pain medications on more than 14 days per month

Exercise Study - 6 month study

• For migraine sufferers ages 18-50 with less than 25 headache days per month

• For those interested in an exercise program that are not currently exercising regularly

*If interested, please sign up during the break *30 days of diaries are needed to assess eligibility

For more information go to

Behavioural Approach in Headache

Treatment

“…interventions intended to change the

behaviour of a headache sufferer with the

goal of reducing symptoms, improving

functional status, or improving health related quality of life.”

Why Consider Behavioural Strategies?

• The individual prefers a non-drug approach.

• Effective medications cannot be taken or don’t work. • The patient is pregnant, has plans to become

pregnant or is nursing.

• There is excessive use of acute medication.

• Significant life stress or deficient stress-coping skills are present.

Main Behavioural Strategies

 Identify and Manage Triggers

 Lifestyle Adjustments

 Relaxation Practice

Behavioral Strategy #1:

Identify and Manage Triggers

• Determine your personal headache triggers (Headache diaries can help)

• Avoid/minimize the triggers you can control • Develop a coping plan for times when you

Headache Triggers: CHALLENGES

• triggers can vary from one

headache attack to the next

• identified triggers vary

among individuals

• triggers may affect the

brain chemistry quickly or slowly

Migraine Trigger Threshold Theory

Migraine Trigger Threshold Theory

Migraine Trigger Threshold Theory

The objective of headache trigger management is to keep your trigger level below your threshold.

Reduce your trigger load (minimize/avoid exposure) Raise your threshold

Trigger Categories

• Other (hormonal changes, high blood pressure)

Some Common Triggers

• *Stress/Let down

• Anxiety/worry and depression

• Overexertion

• Caffeine, alcohol

• MSG, Aspartame, Nitrates

• Odors/fumes

• Weather (e.g. Chinooks)

• Hormones (e.g. menstrual cycle)

Behavioural Strategy #2:

Lifestyle Adjustments

This involves adjustments in the areas of: • hydration and nutrition

• caffeine intake

• sleep routine and habits • exercise and posture

Lifestyle Adjustments

• eat at regular intervals (every 3-4 hours)

• glycemic index – avoid foods high in simple carbohydrates (sugars), especially eaten alone

• drink 2-2.5 litres of fluid per day

• limit caffeine intake to 1 cup per day (6-8 oz.); consider stopping caffeine use completely

Lifestyle Adjustments

• Maintain a consistent sleep-wake schedule daily

• make regular physical activity part of your routine

• learn about stretching and strengthening exercises to support good postural habits

• practice a relaxation strategy daily (e.g. diaphragmatic breathing, meditation)

Headache Behavioural Strategy #3:

Relaxation

•Relaxation can be used to help prevent headaches or stop headaches in their early stages.

•Relaxation practice can:

•counteract the stress response •manage negative emotions,

•enhance sleep

Relaxation Research

• Regular use of relaxation techniques is

associated with less frequent and less intense headaches for most individuals with migraine and tension headaches.

– Progressive Muscle Relaxation – Diaphragmatic Breathing

– Visualization/Imagery – Meditation

The Physical Stress Response

• When someone perceives they are under stress, their body reacts with the stress response (fight or flight):

-Increased heart rate -Release of hormones (Adrenalin) -Shallow breathing -Muscle Tension

Behavioural Strategy #4:

Cognitive Behavioural Therapy (Self Talk)

 Negative/Unhelpful thoughts and behaviour can generate stress and stress-related headaches

 A coping style of self-talk can help reduce stress and negative emotions

 The person is less vulnerable to stress-related headache

Depression and Anxiety in Headaches

- Depression and anxiety occur with greater frequency in people with recurrent headaches than in the

general population

- A recent Canadian survey (Molgat & Patten 2005) demonstrated the prevalence of major depression:

-7.4% of the general population;

-7.8% of individuals with chronic medical conditions -17.6% of individuals with migraine

Mental Health Resources

Crisis Management:

• The Distress Centre: 266-HELP (4357) • Your local hospital emergency room

Non-Crisis Support:

How confident are you that better

headache management is within

your control?

Calgary Headache Assessment & Management Program (CHAMP)

• Located at 2 sites:

1) South Health Campus

4448 Front Street S.E. (5th Floor) Phone (403) 956-3443

2) Richmond Road Diagnostic and Treatment Center 1820 Richmond Road S.W.

Phone (403) 956-3443

CHAMP Behavioral Programs

• Lifestyle Assessment – individual appointment • Workshops/Lectures – small group format

(max 10 participants) Workshops and Lectures are offered at

Lifestyle Assessments

• Focuses on key health domains (sleep habits,

hydration/nutrition, exercise and posture, and stress)

• Guidance given for lifestyle adjustments in these domains that can improve headache management

• Identify/clarify your goals for headache management

• Identify program workshops that may help you work towards your goals

Self Management Workshop

• An opportunity to learn and practice coping skills for headache management, including:

– Relaxation techniques – Stress Management – Pacing

– Self-talk strategies

• A supportive group environment

• Increase your confidence in your ability to have control over your headaches

Bodyworks Workshop

 Postural Awareness and Adjustments  Stretching and Strengthening Exercises

Sleep Lecture

A single session (1.5 hours)

 Exploring the relationship between sleep and headache

 Addressing strategies to promote improved sleep Behavioral Changes

Relaxation Workshop

• Focus is primarily on relaxation skills • Stress management is also addressed

• For those who prefer a self-study format • 8-week program: 3 clinic sessions,

Lecture Series

• Three 2-hour sessions, each with a different topic:

– Nutrition and Headache

– Headache Medications and Medication Use – Coping with Headaches at Work (includes

workstation ergonomics)

Headache Days / Month (N = 85)**

*P< 0.001 **CHAMP self management groups, headache days by patient report at baseline and 3 months post self management.

CHAMP Website

www.albertahealthservices.ca/3672.asp

• Workshop & Lecture Schedule

• Program Overview

• Headache Diaries and Instructions

WHAT’S NEXT?

• Participate in a Lifestyle Assessment

• Enroll in Champ Workshops and Lectures

• Participate in a Champ Clinical Trial (study)

• Assessment with a CHAMP neurologist in 12-14