What is the recommended headache abortive therapy in a patient with a history of Cerebrovascular Accident (CVA)?

Headache Abortive Therapy in Patients with History of CVA

For patients with a history of cerebrovascular accident (CVA), non-steroidal anti-inflammatory drugs (NSAIDs) and triptans should be avoided due to increased risk of recurrent stroke, making acetaminophen (1000 mg) the safest first-line abortive therapy for headaches. 1, 2

Treatment Algorithm Based on Headache Type

For Tension-Type Headaches:

1. First-line: Acetaminophen 1000 mg

   • Demonstrated efficacy for tension-type headaches 2, 3
   • Safest option for patients with cerebrovascular disease
   • Can be repeated every 6 hours as needed (maximum 4000 mg/day)

2. Second-line (if acetaminophen ineffective):

   • Combination of acetaminophen with caffeine 1
   • Avoid aspirin and NSAIDs due to bleeding risk in CVA patients 1

For Migraine Headaches:

1. First-line: Acetaminophen 1000 mg 1

   • While less effective than migraine-specific medications, it offers the safest profile

2. Second-line options:

   • Acetaminophen-caffeine combinations 1
   • Anti-emetics (metoclopramide, prochlorperazine) for associated nausea 1
   • Greater occipital nerve block (if severe and refractory) 1

3. Avoid in CVA patients:

   • Triptans (contraindicated due to vasoconstrictive properties)
   • Ergotamine derivatives (contraindicated due to vasoconstrictive properties)
   • NSAIDs including aspirin (increased bleeding risk) 1
   • Lasmiditan (has driving restrictions and adverse effect profile) 1

Special Considerations for CVA Patients

Medication Contraindications:

• Triptans: All triptans (sumatriptan, rizatriptan, etc.) are contraindicated due to their vasoconstrictive effects, which may increase stroke risk 1
• NSAIDs and Aspirin: May increase bleeding risk in patients with cerebrovascular disease 1
• Ergotamine derivatives: Contraindicated due to vasoconstrictive properties

Adjunctive Measures:

• Non-pharmacological approaches: rest in dark, quiet room
• Adequate hydration
• Stress management techniques
• Sleep hygiene optimization

Monitoring and Follow-up

• Monitor frequency of headaches and medication use
• Evaluate for medication overuse headache if using analgesics more than twice weekly 2
• Consider preventive therapy if headaches occur more than twice weekly 1
• Assess for new neurological symptoms that might indicate recurrent stroke rather than headache

Important Caveats

• Avoid opioids due to risk of dependency and medication overuse headache 1
• If headaches have atypical features or are accompanied by new neurological symptoms, consider neuroimaging to rule out recurrent CVA 1
• The combination of acetaminophen with caffeine may be more effective than acetaminophen alone but use caffeine with caution in patients with hypertension

By following this algorithm, clinicians can provide effective headache relief while minimizing the risk of recurrent cerebrovascular events in patients with a history of CVA.