Transcript Headache - MEDtube

HEADACHE
Presentation
By Dr. Asha Rani Natarajan
23-July-2016
HEADACHE HISTORY
● Headache attacks
• How it begins
• Precipitating event, illness, injury
● Headache attack descriptions
• Frequency and patterns
• Location
• Time to peak intensity
• Duration
• Quality and intensity
• Warning symptoms and aura
• Associated symptoms and level of disability
• Triggers and aggravating or relieving factors
2
SYMPTOMS THAT SUGGEST A SERIOUS UNDERLYING DISORDER
• Sudden-onset headache
• First severe headache
• "Worst" headache ever
• Vomiting that precedes headache
• Subacute worsening over days or weeks
• Paininduced by bending,lifting, cough
• Pain that disturbs sleep or presents immediately upon awakening
• Abnormal neurologic examination
• Pain associated with local tenderness, e.g. region of temporal artery
3
WHEN A SCAN IS NOT RECOMMENDED FOR HEADACHE
• Patient with established history of episodic headache
• Current headache is consistent with previous headaches or is
consistent with different manifestation of a primary
headache.
•
Normal neurological exam
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COMMON CAUSES OF HEADACHE
Primary Headache
Secondary Headache
Type
%
Type
%
Migraine
16
Systemic Infection
63
Tension-Type
69
Head Injury
4
Cluster
0.1
Vascular Disorder
1
Stabbing
2
SAH
<1
Exertional
1
Brain Tumor
0.1
PRIMARY HEADACHE SYNDROME
Migraine
Tension Type
Headache + Associated Features
Featureless Headache
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1. MIGRAINE
Benign and recurring syndrome of headache associated with other symptoms of
neurological dysfunction
Symptom
Nausea
Photophobia
Lightheadedness
Scalp Tenderness
Vomiting
Visual Disturbances
Paresthesias
Vertigo
Photopsia
Alteration of consciousness
Diarrhea
Fortification Spectra
Syncope
Seizure
Confusional State
Patients Affected %
87
82
72
65
56
36
33
33
26
18
16
10
10
4
4
7
MIGRAINE – A MULTISYMPTOM COMPLEX
AURA
LANGUAGE SYMPTOMS
MOTOR
DYSFUNCTION
PATHOPHYSIOLOGICAL
MECHANISMS
YAWNING,
POLYURIA
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SIMPLIFIED DIAGNOSTIC CRITERIA FOR MIGRAINE
Repeated attacks of headache lasting 4-72 hours in patients with a normal
physical examination, no other reasonable cause for the headache and:
At Least 2 of the Following Features:
Plus at-least one of the Following
Features
Unilateral Pain
Nausea / Vomiting
Throbbing Pain
Photophobia and Phonophobia
Aggravation by movement
Moderate or severe Intensity
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MIGRAINOUS AURA
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CLASSIFICATION - MIGRAINE
● Migraine without aura
● Migraine with aura
 Migraine with typical aura
 Typical aura with headache
 Typical aura without headache
 Migraine with brainstem aura
Hemiplegic migraine
 Familial hemiplegic migraine (FHM)
FHM Type 1,Type 2, Type 3
 Sporadic hemiplegic migraine
Retinal migraine
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CHILDHOOD PERIODIC SYNDROME THAT ARE
COMMONLY PRECURSORS OF MIGRAINE
Abdominal
Migraine
Benign Paroxysmal
Vertigo
Cyclical Vomiting
Syndrome
Benign Paroxysmal
Torticollis
CHILDHOOD
PERIODIC
SYNDROME
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COMPLICATIONS OF MIGRAINE
Status
Persistent Aura
Migrainosus
(30 to 60 Minutes)
Without Infarction
(> 72 Hours)
Migraine Triggered
Seizures
Chronic Migraine
Complications
of Migraine
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EPIDEMIOLOGY
• Migraine accounts for 64% of severe
Headache in Females and 43% of Severe
Headache in Males
• Individuals >12 Years incidents increases with
age, reaching a peak at 30 – 40 Years
• F:M – 3.5:1 at 40 Years
FAMILY HISTORY
• Aprox 70% of the patients have a first degree
relative with a history of migraine
• Migraine in inherited disorders – MELAS,
CADASIL, Genetic Vasculopathies
DISABILITY
ASSESSMENT
• Simple questionnaire like MIDAS (Migraine
Disability Assessment Score) cab be used to
quantify the disability and for follow-up
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MIGRAINE TRIGGERS
• Stress
• Excessive or insufficient Sleep
• Medications (OCP, Vasodilators)
• Strong Odors(Perfumes, Cologne)
• Hormonal Changes (Pregnancy and Menstruation)
• Weather Changes
• Foods containing Tyramine (Cheese, Yoghurt, Banana)
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WORK UP
• Migraine is a clinical Diagnosis
• Diagnostic Investigations are performed to rule out any structural and
metabolic causes of headache
• Visual Field Testing should be performed in patients with persistent visual
phenomenon
MANAGEMENT
• Acute Attack
• Preventive
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ACUTE ATTACK MANAGEMENT
1. Simple Analgesics : Acetaminophen, Aspirin, Caffeine
2. NSAIDs: Naproxin,Ibuprofien
3. Tryptans (Serotonin 1B/1D receptor agonist)
a. Drug of Choice for patients with moderate to severe migraine
b. Routes- Oral,Nasal,SC
c. Drugs- Sumatriptan – 50 to 100mg tablet at onset, May repeat after 2
Hours (max 200 mg/D)
* Rizatriptan and Eletriptan – Most Efficaious
* Others – Naratriptan,Almotriptan,Zolmitriptan
d. Not be used > 3 days weekly to avoid medication over-use headache
4. Ergot alkaloids (Non Selective 5HT1 agonists): Ergotamine
5. Dopamine Antagonists: Cholrpromozine, Metachlopramide, Prochlorparazine
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PREVENTIVE TREATMENT
When to consider ?
1. Frequency of Migraine > 2/Month
2. Duration of individual attack longer than 24 Hrs
3. Major disruption in lifestyle
4. Migraine variants such as Hemiplegic migraine
Pharmaco Therapy
1. PIZOTIFEN
2. BETABLOCKER: Propranolol
3. Tricyclics: Amitriptyline, Nortriptyline
4. Anticonvulsants: Topiramate, Valproate, Gabapentin
5. Serotonergic Drugs: Methysergide, Flunarizine
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2. Tension-type headache
● Infrequent episodic tension-type headache
● Frequent episodic tension-type headache
● Chronic tension-type headache
3.Trigeminal autonomic cephalalgias
● Cluster headache
 Episodic cluster headache
 Chronic cluster headache
● Paroxysmal hemicrania
 Episodic paroxysmal hemicrania
 Chronic paroxysmal hemicrania
● Short-Iasting unilateral neuralgiform headache attacks
 Short-Iasting unilateral neuralgiform headache attacks with conjunctival
injection and tearing (SUNCT)
 Short- Iasting unilateral neuralgiform headache attacks with cranial
autonomic symptoms (SUNA)
● Hemicrania continua
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MIGRAINE HEADACHE
TENSION HEADACHE
CLUSTER HEADACHE
Characteristics of pain
Deep throbbing and pulsating
pain
Dull and pressure-like pain in the
head or tight band on the head
and/or around the neck.
Stabbing pain
Gender predominance
More common in women
More common in females
More common in men
Sensitivity to light or sound
Typical
Rare
Rare
Location of pain
Pulsating pain in temporal region
and around the eye usually
Unilateral
The pain is typically generalized,
with areas of more intense pain
in the scalp, forehead, temples or
the back of the neck. Usually
bilateral.
pain located near the eye on
affected side. Usually unilateral.
Severity of pain
Ranging from moderate to quite
severe
Mild to moderate in severity
Very severe
Time of onset
Long; headache gradually peaks
in around 4-24 hours
Pain develops gradually,
fluctuates in severity and then
can remain for several days
Short; headaches peak within 45
minutes
Triggers
Bright lights, loud noises, changes
in sleep patterns, exposure to
smoke, skipping meals etc.
Stress
Nitroglycerin, Hydrocarbons and
Alcohol
Prodromal Aura before
headache
Present
Absent
Absent
Nausea or vomiting
Common
Rare
Rare
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TREATMENT
TENSION TYPE
CLUSTER TYPE
Simple Analegisics: Actaminophen,Aspirin or
NSAIDs
Oxygen Inhalation Therapy
Behavioral Approaches including relaxation
Sumatriptan: Injection or Nasal Spray
Chronic TTH: Amitriptyline
Preventive Management:
Verapamil,Lithium,Methysergide
___
Deep Brain or Occipital Nerve stimulation
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CATEGORIZATION
PAROXYSMAL HEMICRANIA
SUNCT
Gender
F=M
F~M
Pain
• Type
• Severity
• Site
Unilateral:
Throbbing,Boring,Stabbing
• Excruciating
• Orbit, Temple
Unilateral:
Burning,Stabbing,Sharp
• Severe to excruciative
• Periorbital
Frequency
> 5 attacks/D
At least 20 attacks/D
Duration
2 -30 Mins
5 - 240 Seconds
Autonomic Features
• Lacrimination &
Conjuctival Injection
Present
Prominent  If absent Then it
is SUNA
Cutaneous Triggers
No
Yes
Indomethacin Effect
Yes
No
Abortive Treatment
No Effective Treatment
Lidocaine (IV)
Prophylactic Treatment
Indomethacin
Lamotrigine, Topirimate,
Gabapentin
* SUNCT: Short lasting unilateral neuralgiform headache attacks with conjunctival injection & tearing
* SUNA: Short lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms
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CHRONIC DAILY HEADACHE
Headache on 15 Days or more per month
• Medication Overuse Headache :
- Due to Over use of Analgesic medication or using preventive
medication along with analgesics
- Can be avoided by reducing the medication by 10% every one to
two weeks
• New Daily Persistent Headache (NDPH):
- Present on most of the days and patient typically recall the exact
day and circumstance of the onset of headache
1. Primary NDPH:
a. Migrainous Type – Same as Preventive Therapy for migraine
a. Featureless Type – Most Refractory to treatment
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2. Secondary NDPH:
Low CSF Volume Headache
Raised CSF Pressure Headache
M.C.C –CSF Leak Following LP
M.C.C-SOL, Pseudo Tumor Cerebri
Patient Feels Better on reclining
Worsens on reclining
Worsens during day
Improves as day progress
Treatment – Bed Rest , Blood Patch
Initially Acetozolamide if ineffective
topiramite
3. Post Traumatic Headache
Developed headache following injury to the head or an infectious episode like viral
meningitis or parasitic infection or after SAH
Treatment – Management is emperical. TCA and anticonvulsants can be added
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4. OTHER PRIMARY HEADACHE DISORDERS
● Primary cough headache
● Primary exercise headache
● Primary headache associated with sexual activity
● Primary thunderclap headache
● Cold-stimulus headache

Headache attributed to external application of a cold stimulus

Headache attributed to ingestion or inhalation of a cold stimulus
● External-pressure headache

External-compression headache

External-traction headache
● Primary stabbing headache
● Nummular headache
● Hypnic headache
● New daily persistent headache (NDPH)
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SECONDARY HEADCHES
1. MENANGITIS : Suggested if acute and severe headache with stiff neck and fever
2. INTRACRANIAL HEMORRHAGE:
- A Ruptured aneurysm, AV malformation or intra parenchymal hemorrhage
- Suggested if acute and severe headache with stiff neck but without fever
3. BRAIN TUMOURS: Rule out pitutory Adenoma or any cerebral metastasis
4. TEMPORAL ARTERITIS: Most Common in elderly patients with age of onset 70 years
Suggested if Jaw Clawdication, fever, weight loss and malaise are present
5. GLAUCOMA: Prostating Headache with severe eye pain associated with nausea &
vomiting
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