Next, I would like to talk about some factors that are important on the transformation of episodic to chronic headache and ways to prevent the progression. These are the risk factors that have been identified. As important for the transformation from episodic to chronic migraine. Once again, transformation is about 2.5% per year and you can see that some of these are modifiable and some of these are non-modifiable. Studies have shown that when you modi, you address and modify some of these factors there's a reduction in both headache frequency, or they call it the headache index, which is a combination of frequency, severity and intensity. And it does prevent progression and it does improve remission. So they are very important to address. So how do we address some of these things? Well, I'm going to talk a little bit about medication overuse as I move forward as it's very important to address people and their pattern of medication use. So there's a huge risk factor for transformation to chronic headaches. And I'll go into it in a little bit more detail on how to exactly address that. You know caffeine, is used by over 80% of the world population. Very common. Probably, the most common mood altering drug used in the world. As you can see here, once you start using too much caffeine, it sets the tone for more frequent headaches and you can even think about it in yourself. If you drink too much coffee, you feel more tense. you, th, everybody tries to titrate that, I should say. Alright, you want to, if you're feeling tired, you have a little caffeine to kind of, get your energy back. You want to. Right to that nice middle ground where you feel energized. You're focused. You can get a lot of work done. But if you get too much caffeine, you might feel a little bit tense. And of course, how does that come out in terms of your body? Well, your shoulders get tighter. You clench your jaw a little bit more. And of course if you're that type A pattern, where you're drinking a lot of coffee to to work 16, 18 hour days. Then, you can see where it would be a big trigger or contributing factor pro, progression. I think everybody recognizes how stressful life events can contribute to headache And to dysregulation of one system, you don't get enough sleep, you, you tend to miss meals, and all those factors are important in, in to the genesis of headaches. Clearly, strategies dealing with stress management and relaxation are important for. Addressing those issues. In the last ten to 15 years the area of dental sleep medicine, and Sleep Apnea, and just sleep disorders in general have been highlighted by advances in those fields. Clearly snoring and sleep apnea and issues with insomnia are all important into the transformation of headaches, and need to be addressed in that population. As I've mentioned before, depression, anxiety, whether it be from a different cause, or refra, or reactive to the headache itself; needs to be addressed. Allodynia is a term used by neurologists, and pain specialists to, signify a specific condition where normal stimulus that would not be sensitive or painful is now either sensitive or painful, and otherwise experience like if you've had a sunburn, touch the skin where you've been burned. That area is a little bit hypersensitive and it's painful to touch, that would be an example of. Allodynia well it turns out in the head and neck region that people develop sensitivity to their skin, sensitivity to, to deeper palpitation into the muscle. We call that pericranium tenderness and the allodynia is a risk factor for transformation to more frequent headaches. The best treatment that for allodynia is to address the factors that are contributing to it such as clenching, or muscle dysfunction is very important. And coming up with a good strategy to prevent headaches or treat the headache when it occurs also helps reduce. The allodynia. We talk about attack frequency; it kind of makes sense. People that have more frequent headaches tend to progress more rapidly to chronic headache. And so if a person is having a, a headache, you know, one headache once every six months, that is not a huge risk factor for progression to daily headaches. But as Pamela, the person I spoke about before I was having more frequent headaches, then we need to come up with a plan to address that pattern to prevent progression. Obesity is now a clearly identified as a risk factor for progression of episodic. To a chronic headache, there's a number of different approaches to address that emerging epidemic. I include in this list muscle dysfunction because I do a lot of work with muscle dysfunction. Although it's not traditionally been recognized in the neurological community. As a factor for episodic to, to chronic transformation. But it is clearly recognized in the literature, in the TMD literature, as a major factor for progression from episodic to chronic headaches. So we can go back to the, to Pamela and she returns now three months later with two concerns. Her first concern is that her headaches are becoming worse, more frequent, and that now she's having a mild headache four days a week and a severe headache four times per month. So, now she has kind of crossed that threshold from an episodic headache disorder to a chronic headache disorder. Her diagnoses are still the same. She has a chronic. She has migraine headaches with a menstrual component. There's a component of tension type headache, but now she has a diagnosis of chronic daily headaches. Now we look at her medication use. She use, increased her medication to her over the counter medication to 14 days a month, and her Triptan use to eight days per month. The next slide is a busy slide that talks about the. Risk factor for medication overuse and the transformation of headaches. And you don't even need to read, be able to read the ordinants of the, the graphs to understand the importance of this, of this slide. What I can show you here is that there are three different medication categories. Opiate medication, barbituates, nonsteroidal anti-inflammatory medications, and triptans. And you can see under each of these medications there's when people use 0 to four, five to nine, and over ten medications per month, and what happens to the frequency of their headache over time. And you can see when people are overusing medications the, there is a gradual progression to more frequent headaches. Barbiturates are particularly known for this pattern. Opiates and triptons are less so. Interesting about non-steroidal or anti inflammatory medications or over the counter medications, they actually are very product, protective in low doses, but also can lead to old medication overuse headaches if overused. So how do we come about a strategy for managing people that are beginning to have more frequent headaches? And it involves a combination of treatments that involves both medications, behavioral treatments, and other factors, health-psych treatments to address this transformation. We come up with this slide slow shows. You have three rough areas. We want to come up with a medication that addresses their acute headache, so that they can feel confident that if they get a headache they will have a strategy to manage it. We also come up with medications that can prevent headaches, and then we come up with what I call preventative treatments where we start addressing contributing factors, and addressing triggers. That that that will reduce the transformation or actually lead to a remission in the headaches. What about acute medications? And specifically for migraine headache, we talk about there are non-specific medications that a kin, are used. Often to treat headaches. This non-specific medications can be helpful in people with tension-type headaches. I did not add and I would add muscle relaxants to this category for people with tension-type headaches. And then there are very much what we call migraine specific medications. Here's Ergotamine or Dihydroergotamine. Or the Triptan medications that really only work for treating the migraine headache or the people that have migranous headaches. And they're very effective. From the what is the evidence medicine from the American Academy of Neurology that recommends for migraine prevention. This kind of divides these medications into two categories either, that have either level one or level two evidence of their effectiveness. And they're in categories. And you can see that the anticonvulsants. Beta blockers and the triptans from migraine related menstrual related migraine have level A evidence. And, in level B, these medications often are actually very affective but they're older medications. And were not subject to the rigorous randomized, double-blind, placebo controlled trials that are, are currently the standard of care, the gold standard today that require them to actually become lev, have level a evidence. Stars that the medications that have stars by them are FDA approved. What about for the prevention or pharmacotherapy of people that now have chronic daily headaches. So we've gone beyond kind of the episodic migraine. What about people that have chronic daily headache. And you can see from this list that there's a large overlap of the medications that are, have been used for treating episodic migraine. But primarily in the category of antidepressant and anticonvulsants. One medication anabotoxin A has been shown to be effective and is the only FDA approved medication for the treatment of chronic migraine. In 2000 the US Headache Consortium. A published guidelines for the non-pharmacological treatment of headache. And once again, grade A evidence and grade B evidence. And you can see that there's a number of non-pharmacological treatments. Including relaxation training, thermal, and myogenic biofeedback. In cognitive behavioral therapy and there's grade B evidence of behavioral treatments combined with drug treatment. This was a meta analysis of 35 different studies. And, what was interesting, you, kind of looked at all this, the non-pharmological treatments actually equal the pharmacological treatments. And that roughly 30 to 50% of improvement in the headache index was found in both types of treatment. Since the 2000 headache conception guidelines, there's been some additional. Studies that are important to include in our thinking about the management of people with headaches. The first one I'd like to cover is the management of chronic tension type headaches, where there's a comparison between behavioral treatments and medications. This was a study published in 2001 that looked at 200 adults in a randomized controlled trial. Patients were invo, divided into four groups. The groups were tri-cyclic antidepressant, one was a tri-cyclic antidepressant plus stress management, one placebo. And the other was placebo plus stress management. And as you can see that the group with, received both medications or stress management did about the same. They had about a 35 to 38% improvement in their headaches. But if they received both treatments, both medication plus stress management. There was actually a 64%. Improvement of, in their headaches. The one caveat is people that were given medications tended to improve quicker than people that were given behavioral therapy. This was extended to migraine where they looked at beta blocker typical medication for effective medication for prevention of episodic migraine headaches versus behavioral treatments. Again this was a large randomized controlled trial. 230 patients. And again they divided people into four groups. Medication versus behavioral, there's a placebo control arm, and then the group of people that receive both medications and behavioral treatment and, basically, in outcome all four groups improved. But it was really only the beta blocker, plus the behavioral treatment that actually did better after they optimize acute care. So once again, there's a another very important study showing that when you combine both behavioral treatments with medication you get a better outcome than if you do either one by themselves. So what are the take home points that I want to talk about with medications. Overuse of acute pain medication leads to more headaches. We call that medication overuse headache. People can get away with very short episodic periods where they overuse medications. So let's say they have a bad week. And they over use medications for one week, it doesn't really matter that's not going to by itself lead to chronification of, of headache. But if they get in to a pattern where they're over using medications week after week after week, they're in trouble, and things need to be done to address that. Medications approximately equal the outcome of behavioral treatments where you get about a 30 to 50% improvement. Medications tend to work faster, while behavior treatments tended to take longer but tended to last longer. And if you combine the medications with med behavioral treatments you get the best outcome, and the best possibility of having a greater than 50% improvement in your headaches. So let's see how we could combine these together. And this is a slide by Dr. Caddy, about the use of medications in treatments for acute headache and this is for acute migraine and you can see that there's a, kind of program phase before the headache begins, then the aura. And the headache and the postdrome. And you can see that you can use different medications at different times. And in different formulations as it turns out. And, biofeedback and behavioral treatments tend to be most effective with done before a person has the acute headache, and so that would be you do, be doing your relaxation, or, and, and behavioral treatments before. So for example in that with a person that has a headache that builds over the course of the day, you have them step back from their work, change their posture, loosen up their neck and shoulders, stretch out, relax their jaw. And so you'd address the stress, the tension, the fatigue before actually a person even would experience a headache. Once the headache comes on, we tend to go with medications that will address the physiology of the headache. If it's a migraine, it would, be it might be a a triptan or an over-the-counter medication. Once headaches become more severe, you see that these more specific migraine specific medications are needed in a case there when all others fails, a rescue medication will help bring things down quicker and help a person to recover period, sometimes we add a non-surantine primetary drug. After the headache to prevent it from coming back. [BLANK_AUDIO]
