Transcript Headaches - University of Virginia

Headaches
Anne Mounsey M.D.
Dept. of Family Medicine
Univ. of Virginia School of Medicine
Objectives
• Learn how to distinguish life threatening
headaches from benign headaches.
• Learn management of migraine and chronic
tension headache.
Causes of headaches.
1. Traction or dilatation of intracranial or extracranial
arteries.
2. Traction of large extracranial veins
3. Compression, traction or inflammation of cranial
and spinal nerves
4. Spasm and trauma to cranial and cervical muscles.
5. Meningeal irritation and raised intracranial
pressure
6. Disturbance of intracerebral serotonergic
projections
Pathophysiology of pain
management in migraine
• Cortical spreading depression activates the
trigeminal and parasympathetic systems
which causes vasodilatation and release of
neuropeptides that cause inflammation.
• Serotonin 5 HT receptors modulate the
release of neurogenic peptides.
Acute onset headache
• Sufficient evidence from retrospective and
prospective studies to support the
association of an acute sudden onset
headache with a vascular event.
• Sudden onset headache is a red flag
Critical issues in the evaluation and management of patients
presenting to the emergency department with acute headache: Annals
of Emerg Med 2002 (1):39.
Life Threatening causes of acute headaches.
• Intracranial
hemorrhage
– Subdural hemorrhage
– Subarachnoid
hemorrhage.
• Meningitis
• Hypertensive
encephalopathy.
Subarachnoid hemorrhage:causes
• 80% of non traumatic hemorrhages from
ruptured saccular aneurysms.
• Other causes: AV malformations,
neoplasms, blood dyscrasias.
• Commonest ages 40-60 yrs.
Subarachnoid hemorrhage:risk
factors.
• Estimated that 5% of population have a berry
aneurysm.
• HTN
• Smoking and alcohol
• Sympathomimetic drugs
• Polycystic kidney disease
• Coarctation of the aorta
• Marfans syndrome
Subarachnoid hemorrhage:useful signs
and symptoms
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•
•
•
•
Sudden onset of worst headache of life.
Worse on exertion eg valsalva, exercise.
75% of patients have nausea and vomiting.
50% of patients have meningism.
25% of patients have neck stiffness.
Linn F et al: Prospective study of sentinel headache in aneurysmal
subarachnoid hemorrhage, Lancet 344:590, 1994.
Locksley HB: Report on the cooperative study of intracranial aneurysms
and subarachnoid hemorrhage, J Neurosurg 25:219, 1966.
Risk factors for SDH
• Age, alcohol, anticoagulation or antiplatelet treatment.
• May be minimal trauma such as coughing
• The signs and symptoms of brain
compression may not appear until up to 2
weeks after the trauma..
Subdural hemorrhage
• Dull, mild generalized head pain.
• Symptoms of chronic SDH may be subtle.
• Up to 50% have altered level of
consciousness
• Headache is worse at night and same side as
hematoma
• On exam patient may have unilateral
weakness and increased reflexes.
Hypertensive Encephalopathy
• Associated with high blood pressure,
nausea, vomiting and blurred vision
• Usually associated with blood pressures of
200/130.
• Headache diffuse and worse in the morning
and subsides during the day.
Meningitis:useful signs and
symptoms.
• The absence of fever, neck stiffness and altered
mental status in a patient with a headache virtually
eliminates the diagnosis of meningitis.
• In multiple studies the presence of neck stiffness
on examination has a pooled sensitivity of 70%.
• Does this adult patient have meningitis? Attia et al. JAMA
1999;281(2):175-181
Signs of Meningism.
• In a prospective study of young adult
patients Kernigs sign had a sensitivity of
9% and a specificity of 100%.
• Brudzinskis sign has not been evaluated
since the original report .
• Uchihara T, Tsukagoshi H. Headache 1991;31:167-171.
Can response to therapy aid
diagnosis?
• No meta-analyses or RCTS to support or refute
using response to therapy as an indicator of
underlying pathology.
• Case reports exist of patients whose headaches
have significantly improved with analgesia and
then subsequently died from an intracranial
hemorrhage.
• Bottom line: Level C recommendation that
response to therapy should not be used as the sole
diagnostic indicator of the etiology of the
headache.
Acute H/A: Factors in history associated
with abnormality on neuroimaging.
• Headache waking patient up.
• Headache worsening with valsalva
• Subjective sensory disturbance.
• Rapidly increasing headache.
However the absence of these does not rule
out positive findings on neuroimaging.
Annals of Emergency Medicine: Vol 39:1:Jan 2002.
Clinical Policy of the ACEP for management of
patients presenting with acute onset headache.
Level B recommendations:
• Patients with headache and abnormal neuro exam
should undergo an emergent non contrast CT.
• Patients presenting with an acute sudden onset
headache should be considered for an emergent
CT scan.
• HIV patients with a new headache should have
urgent neuroimaging
Clinical Policy of ACEP cont.
Level C recommendation:
• Patients over 50 with a new headache
should be considered for urgent
neuroimaging.
– Emergent means done immediately
– Urgent means scan appointment is arranged
prior to discharge and included in disposition.
Annals of Emergency Medicine: Vol 39:1:Jan 2002.
Migraine: IHS criteria
5 attacks of
• Headache lasting 4-72 hours.
• Must be associated with nausea or vomiting or
photophobia and phonophobia
• Must have 2 of the following
1.
2.
3.
4.
Unilateral
Pulsating
Moderately severe.
Aggravated by physical activity
Sinus H/A vs. Migraine
Summit study.
Prospective multi center observational study of 2,991
patient with self diagnosed or physician diagnosed
sinus headache. Using the IHS migraine criteria
80% of them had migraine.
Schreiber CP, et al. Archives of Internal Medicine. In publication
Phases of migraine
• Premonition: eg hunger, energy surges,
irritability.
• Prodrome: aura.
• Headache phase
• Postdrome.
Migraine Treatment
Drug
Tylenol
NSAIDS
Triptans
Fiorinal
Midrin
Opiates
DHE
Steroids
Level of
Evidence
B
A
A
A
B
A
B
C
Triptans
• Meta-analysis of 53 studies showed all the oral
triptans are effective and well tolerated.
• Rizatriptan 10mg, eletriptan 80mg amd
almotriptan 12.5 mg were the most effective.
• 40-80% two hour headache response.
• Give as early as possible in migraine attack.
• Nasal spray or S/C injection may be more
effective.
Oral triptans in acute migraine:a meta-analysis of 53 trials. Ferrari MD. Lancet. 358
(9294):1668-75. 2001 Nov 17.
Percentage of patients with two hour headache response
for each treatment ((bars are 95% confidence interval of
the percentage)
NNT for headache response at 2 hours
Consider prevention when:
US Headache consortium guidelines.
• Interferes with patients daily routine.
• >2/week
• Acute medications ineffective or
contraindicated.
• Presence of uncommon migraine conditions
– Hemiplegic migraine
– Basilar migraine
– Migraine with prolonged aura.
Migraine Prevention
Drug
Valproate
Amitriptyline
Propranolol
Prozac
Riboflavin
Gabapentin
ACE
Aspirin
Clonidine
Verapamil
Evidence
A
A
A
B
B
B
B
B
B
B
Episodic Tension Type Headache.
IHS Criteria
• Tension type headaches < 15 per month.
• Lasts 30 mins to 7 days
• No nausea or vomiting
• No photophobia and phonophobia (1 ok)
• Headache has at least 2 of the following criteria:
a.
b.
c.
d.
pressing/tightening
Bilateral
Mild-moderate
Not aggravated by physical activity.
Causes of TTH
• Some evidence that like migraine caused by
serotonin imbalance but to a lesser extent
than migraine.
• This would indicate that similar treatments
would work.
Treatment of TTH
• Simple analgesia:ibuprofen is more
effective than acetaminophen.
• Combine analgesics with a sedating anithistamine eg diphenhydramine.
• Limit treatment to 2 days a week to prevent
rebound headaches.
Chronic Daily Headache
• Affects 4-5% of the population.
• Definiton: head pain for at least 4 hours for more
than 15 days/month.
• Often develops from an episodic headache
disorder either migraine or episodic tension type
headache
• Includes chronic tension type headache(CTTH)
and chronic daily migraine
Chronic Tension Type Headache.
• Develops from episodic tension type
headaches
• The most common form of CDH.
• Familial tendency.
• Medication rebound headache may be a
factor in the transformation of episodic
headache to CDH.
Chronic Tension Type Headache
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•
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•
Affect women more than men
Most common in middle age
Stress is often a trigger
Average duration is 4-13 hours.
Treatment of CTTH.
• Treating each headache increases the
frequency and severity of the headaches.
• Reserve medications for worse than usual
headache.
• Expert opinion: treat 2 headaches a week.
Prevention of CTTH
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•
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Tricyclic antidepressants.
Stress management
Tizanidine
SSRIs:prozac
Anticonvulsants:gabapentin and topiramate.
Acupuncture
Rebound Headaches. IHS
criteria.
•
Headache for 15 days/month with at least one of
the following characteristics and 2,3 and 4.
a.
b.
c.
•
•
•
Bilateral
Pressing/tight non pulsating quality
Mild/moderate intensity
Simple analgesic use >15 days a month for 3
months
Headache has increased during analgesic use
Headache resolves or reverts to previous pattern
within 2 months after discontinuation of
analgesia.
Rebound headaches
• Most significant factor in their development
is the lack of awareness by physicians and
patients. “Prevention better than cure”
• Triptans, all analgesics and ergotamines
have been associated with medication
rebound headaches.
Rebound headaches
• If patient is unable to tolerate abrupt
cessation of medication may need to titrate
down over 2 weeks.
• May need inpatient treatment to
successfully withdraw
• Various regimes including tizanidine, daily
triptans, steroids and parenteral DHE have
been used.