Transcript WHAT A HEADACHE

WHAT A HEADACHE !/?
Paul Hart
Consultant Neurologist
Epsom +St Helier
AMW SGH
RMH
0208 296 3355
0208 725 4107
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Headaches
• Common
1 in 3 suffer a severe HA at some stage in life
Lifetime prevalence: M 90%; F 95%
Migraine M 6.5%; F 18.2% = 28 million in USA
112 million bed ridden days per year
$13 billion / year
WHO : Among the most disabling medical conditions
experienced worldwide
What causes pain ?
• Ray + Wolfe 1930s
Intracranial:
– Circle of Willis + 1st few cms of branches
– Meningeal (dural)arteries
– Large veins + dural venous sinuses
– Portions of dura near bv’s
Extracranial:
ECA + branches, scalp + neck muscles, skin +cut nerves,
cervical n’s + nerve roots, sinus mucosa, teeth.
(via V VII IX and X to CNS)
• Pain localisation
• Pain modulation
Headache Classification
• International Headache Society 2004
Primary Headaches
–1
–2
–3
–4
Migraine
Tension-type Headache
Cluster HA and other trigeminal autonomic
cephalalgias
Other primary headaches
• International Headache Society 2004
Secondary Headaches
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HA attributed to head + neck trauma
HA attributed to cranial or cervical vascular disorder
HA attributed to non-vascular intracranial disorder
HA attributed to a substance or its withdrawal
HA attributed to infection
HA attributed to disorder of homeostasis
HA or facial pain attributed to cranium, neck, eyes, nose,
sinuses, teeth, mouth or other facial or cranial structures
– 12 HA attributed to psychiatric disorders
– 13 Cranial neuralgias and central causes of facial pain
– 14 Other HA, cranial neuralgia, central or primary facial pain
Primary Headaches
1 - Migraine
• Hemikranios
• 200 AD
Aretaeus of Cappadocia
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90% Onset <40 years
F = 20% M = 6%
90% FHx
Unilateral
Throbbing
Mod-severe
Prodrome in 60%
Duration 4 – 72 hours
Worse with exercise
Anorexia N + V
Photo phono osmo – phobia
HA history: Current HA(s), Past HA(s), other…
HA behaviour
Migraine cont …
• Migraine without aura
– Prodrome
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(hrs – days)
Mood or energy change
Thirst
Yawning
Food craving
– Unilateral / bilateral pain
– Or lower half headache
– Postdrome
• Tired, listless, exacerbation of pain
• Frequency
• Inter + intrapatient variability - Catamenial
Migraine cont …
• Migraine with aura
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(15% of migraineurs)
Visual
Sensory
Motor
Language
Other focal cerebral or brainstem symptoms
Differential diagnosis
• Migraine equivalent / Acephalic migraine
– Usually past history of MwA
– Any age (usually>40)
Migraine cont …
• Basilar migraine
• Ophthalmoplegic migraine
• Complications of Migraine
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Hemiparesis
Facioplegic migraine
Field defect
Migraine + stroke
• O/E
• Investigations
Migraine cont …
• Genetics
– FHM 50% chromosome 19p13
CACNA1A
alpha 1 subunit of a brain specific VG
P/Q type Ca channel
(EA type 1)
chromosome 1q31
neuronal Ca channel alpha 1E subunit gene
• Pathophysiology
– Lashley 1941
– Leao 1944
Migraine cont …
• Treatment + Management
– Explain + reassure
– Trigger factors (diet stress tobacco drugs sleep)
– Pharmacotherapy
• Symptomatic
Frequency
Long duration
Dread of attack
• prophylactic
Severe neuro symptoms
Failed symptomatic Rx
Menstrual migraine
Migraine cont …
• Symptomatic treatment
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Take as early as possible (except sc sumatriptan)
Simple oral analgesics
+ caffeine
Metoclopramide
– Sleep etc..
Headache treatment centres
– Ergots DHE Isometheptene
– Triptans - selective agonists -
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Drug
Almotriptan
Eletriptan
Frovatriptan
Naratriptan
Rizatriptan
Sumatriptan
Zolmitriptan
Table 75-9. Oral serotonin (5-HT) agonists
Dose
Headache response (%)*
(mg)
1 hr
2 hr
4 hr
12.5
20.0
40.0
2.5
1.0
2.5
5.0
10.0
25
50
100
2.5
5.0
35
20
30
NA
19
21
30
37
NA
NA
NA
38
44
57
49
60
42
42
48
60
67-77
52
50
56
64
66
NA
NA
NA
61
51
67
NA
NA
68
70
75
75
77
Recurrence†
23%
30
22
10-25%
17-28%
30-35%
35-40%
31%
*Headache response is defined as a reduction in headache severity from moderate or severe
pain to mild or no pain.
†Recurrence of headache within 24 hours after initial headache response.
Note: Composite data from product information inserts and literature.
NA = not available.
Migraine cont …
Triptans
Table 75-8. Subcutaneous and intranasal serotonin (5-HT)
agonists
Headache response (%)*
Drug Dose (mg)
1 hr
2 hr
4 hr
Recurrence†
• Dihydroergotamine
s.c.
1
57
73
85
18
I.n.
2
46
47-61 56-70 14
• Sumatriptan
s.c.
6
70
75
83
35-40
I.n.
20
55
60
NA
35-40
• Zolmitriptan
I.n. 5
55
70
78
25
Headache response is defined as a reduction of headache severity from
moderate or severe pain to mild or no pain.
†Recurrence of headache within 24 hours after initial headache response.
NA = not available.
Migraine cont …
• Side effects + Contraindications
• Which triptan
– N+V: sc or in
– Headache peaks rapidly: Almo Riza Zolmi
– Benign but intolerable triptan SE’s:
Almo Nara Frova
– Recurrent HA after initial benefit:
Nara Frova DHE
– Combine with simple analgesia or antiemetic
Migraine cont …
• Prophylaxis
– Propranolol – effective in 55-93%
– Antidepressants - Amitriptyline
Imip Nortrip Desip
(SSRIs MAOIs)
– 5HT agents – Methysergide (cyproheptadine)
– Ca blockers - verapamil nimodipine flunarazine
– AEDs – valproate gabapentin topirimate
– Others – Mg, riboflavin, alternate day aspirin,
botox
Migraine cont …
• Hormones + migraine
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Menstrual migraine
Contraception
Pregnancy
Menopause
– IHS task-force evidence based
recommendations for the use of contraceptives
and HRT in migraineurs (Bousser 2000)
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Identify + evaluate risk factors
Diagnose migraine type (MwA MxA)
Stop smoking before starting COCs
Treat other risk factors (HT lipids)
Consider non-ethylestradiol methods
High dose COCs should be avoided esp if containing 1st
generation progestogens
Migraine symptoms that may necessitate further evaluation or
cessation:
• New persisting HA
• New onset of migraine aura
• Increased HA freq or intensity
• Development of prolonged or unusual aura
Primary Headaches
2 - Tension Type Headaches
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TTHA ------- Migraine
Generally bilateral
Tight band / pressure / bursting
No N, V, photo, phono, phobia
Rx
– Psychological
– Physical
– Pharmacological
Asp NSAIDs (avoid codeine)
Amitriptyline or….
Primary Headaches
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3 - Cluster Headaches and other Trigeminal
Autonomic Cephalalgias
Most painful
Most stereotyped
Most names
Most often misdiagnosed ?
10-50 times less common than migraine
Episodic: daily for days to months, respite for
weeks to years
Chronic (10 or 20): >1 year without a remission of
>2 weeks
Cluster cont…
• Clinical features
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M>F
Onset 20-30 (1-70)
Clusters 6-12 weeks; 1-3 per day
50% remit; 10% chronic
Onset – peaks over 5-10 min
Unilateral retro-orbital or temporal
Steady, boring, severe
Duration 45min – 2 hours (? 4 hours)
Behaviour during attack
Autonomic features
?? photo, phono, N (50%) + V (rare)
Offset gradual with possible exacerbations
Cluster cont…
• Investigations
– Imaging ?
• Treatment + Management
– Acute symptomatic
• Oxygen, Imigran, DHE, Zolmitriptan, i.n. lidocaine
– Transitional prophylaxis
• Steroids, Ergotamine, DHE, (triamcinalone, Mpred),
ipsilateral occipital n block
– Maintenance prophylaxis
• Verapamil, Methysergide, Lithium
Indomethacin-Responsive Headache syndromes
• Prompt, absolute, and often permanent response to
Indomethacin
• May be confused with cluster
– But shorter duration + higher frequency
• Paroxysmal hemicrania
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Episodic (2w-5m, remissions 1-36m)
Chronic
Age 10-30 F:M 2:1
Daily attacks (5/day) of severe short lived (20
min) unilateral pain (orbital temporal)
– At least 1 autonomic feature
Cluster cont…
• Hemicrania continua
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Continuous unilateral hemicrania or focal area
Moderate intensity
Onset 28 (5-67)
F:M 2:1
Autonomic features more subtle
• Indomethacin
SUNCT
• 15-120 seconds
• In or around eye
• May be triggered
• 1 per day – 30 per hour
• V ophth (cf TN)
• Rx: CZP LTG Gaba Top
Primary stabbing HA
• Patients with M, Cluster, TTHA etc
Other types of headache + facial pain
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CO2 CO
Hypoxia
Hypoglycemia
HT
Phaeochromocytoma
(Pre) eclampsia
Primary Headaches
4 - Other Primary Headaches
• Cough Headache
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Secs – mins
M:F 4:1 Age 55 (19-77)
Suboccipital/occipital/bilateral
Underlying structural abnormality in 50%
Rx Indomethacin
• Exertional Headache
– Bilateral throbbing HA precipitated by sustained
physical exercise
– Non explosive
– 5 min – 24 hours
– Benign or symptomatic
– Cardiac cephalalgia
Primary Headaches
4 - Other Primary Headaches …cont…
• Headache associated with sexual activity
– usually benign
– gradual onset or sudden onset (?SAH)
– or post orgasm with postural component
resembling low csf state
– M>F
– Rarely recurs
– Rx Indomethacin, propranolol, diltiazem
Secondary Headaches
7 - HA attributed to non-vascular, non-infectious
intracranial disorders
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High CSF pressure
Low CSF pressure
Non-infectious inflammatory disorders
Intracranial neoplasms
Chiari malformations
Seizure + headache
• Mass lesions
– 50% of patients with brain tumours have
headache
– Primary complaint in 1/3 (17%)
– Pain depends upon
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Location of lesion
Rate of growth
Affect on CSF flow
Cerebral oedema
Features of raised ICP
am>pm; N+V; worse with cough sneeze + strain
• Warning signs of a non-benign HA
(Purdy 2001 Med Clin North Amer)
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Subacute + progressive
New onset in those >40 years
Change in headache pattern
N or V in non migraine headache
Nocturnal headache
Awakening headache
Precipitation or worsening with valsalva
Confusion
Seizures
Weakness
Abnormal neurological examination
• Intraventricular tumours
– Rare but can present dramatically
• Colloid cyst
• Intraventricular meningioma
• Choroid plexus papilloma
– CASE
• Colloid cyst
– Sudden severe HA
– May be precipitated or relieved by change in
posture or precipitated by valsalva
– Usually slowly enlarging HC resulting in a
generalised constant HA with episodes of
catastrophic increase in headache.
– N+V
– Possibly LOC
NB most cough or exertional headaches are
benign
Abnormalities of CSF Circulation
• Obstruction of CSF pathways
– Colloid cyst, Dandy-walker cyst, Arnold-Chiari
– SAH, meningitis, venous occlusion
• Low CSF pressure
• Idiopathic Intracranial Hypertension
Secondary Headaches
9 - HA attributed to infection
• Meningitis
– Acute
– Chronic
• TB
• Fungal
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Meningoencephalitis
Sinusitis
Mastoiditis
Epidural / intraparenchymal abscess
Skull osteomyelitis
Secondary Headaches
6 - HA attributed to cranial or cervical vascular
disorders
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Aneurysms, AVMs, and thunderclap headache
Parenchymal haemorrhage
Cerebral ischaemia
Dissection
Giant cell arteritis
• Table 75-3. Symptoms of giant cell arteritis n=166
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Symptom
(%)
Headache
72
PMR
58
Malaise, fatigue
56
Jaw claudication
40
Fever
35
Cough
17
Neuropathy
14
Sore throat, dysphagia11
Amaurosis fugax
10
Permanent vis loss
8
Claudication of limbs 8
TIA/stroke
7
Neuro-otology
7
Scintillating scotoma 5
Tongue claudication
4
Depression
3
Diplopia
2
Tongue numbness
2
Myelopathy
0.6
initial symptom (%)
33
25
20
4
11
8
0
2
2
3
0
0
0
0
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0.6
0
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0
Secondary Headaches
11 - HA caused by disorders of…..
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Eyes
Nose
TMJ
Other dental disorders
Cervical spine
• Other facial + cranial structures
Headaches: Top Tips
• An accurate diagnosis of the headache
syndrome is essential
• It’s all in the history
• Investigations – atypical features or
secondary headache
• Treatment rules - multimodal; adequate
trials of adequate doses; improve not cure