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WHAT A HEADACHE !/?

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WHAT A HEADACHE !/? Paul Hart Consultant Neurologist Epsom +St Helier 0208 296 3355 (M Tu Th) AMW SGH 0208 725 4107 (Wed Fri) RMH ... – PowerPoint PPT presentation

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Title: WHAT A HEADACHE !/?


1
WHAT A HEADACHE !/?
  • Paul Hart
  • Consultant Neurologist
  • Epsom St Helier 0208 296 3355 (M Tu Th)
  • AMW SGH 0208 725 4107 (Wed Fri)
  • RMH

2
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

3
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 bvs
  • Extracranial
  • ECA branches, scalp neck muscles, skin cut
    nerves, cervical ns nerve roots, sinus
    mucosa, teeth.
  • (via V VII IX and X to CNS)

4
  • Pain localisation
  • Pain modulation

5
Headache Classification
  • International Headache Society 2004
  • Primary Headaches
  • 1 Migraine
  • 2 Tension-type Headache
  • 3 Cluster HA and other trigeminal autonomic
    cephalalgias
  • 4 Other primary headaches

6
  • International Headache Society 2004
  • Secondary Headaches
  • 5 HA attributed to head neck trauma
  • 6 HA attributed to cranial or cervical vascular
    disorder
  • 7 HA attributed to non-vascular intracranial
    disorder
  • 8 HA attributed to a substance or its withdrawal
  • 9 HA attributed to infection
  • 10 HA attributed to disorder of homeostasis
  • 11 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

7
Primary Headaches 1 - Migraine
  • Hemikranios
  • 200 AD Aretaeus of Cappadocia
  • 90 Onset lt40 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

8
Migraine cont
  • Migraine without aura
  • Prodrome (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

9
Migraine cont
  • Migraine with aura
  • (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 (usuallygt40)

10
Migraine cont
  • Basilar migraine
  • Ophthalmoplegic migraine
  • Complications of Migraine
  • Hemiparesis
  • Facioplegic migraine
  • Field defect
  • Migraine stroke
  • O/E
  • Investigations

11
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

12
Migraine cont
  • Treatment Management
  • Explain reassure
  • Trigger factors (diet stress tobacco drugs sleep)
  • Pharmacotherapy
  • Symptomatic
  • prophylactic

Frequency Long duration Dread of attack Severe
neuro symptoms Failed symptomatic Rx Menstrual
migraine
13
Migraine cont
  • Symptomatic treatment
  • Take as early as possible (except sc sumatriptan)
  • Simple oral analgesics
  • caffeine
  • Metoclopramide
  • Sleep etc.. Headache treatment centres
  • Ergots DHE Isometheptene
  • Triptans - selective agonists -

14
  • Table 75-9. Oral serotonin (5-HT) agonists
  • Drug Dose Headache response () Recurrence
  • (mg) 1 hr 2 hr 4 hr
  • Almotriptan 12.5 35 57 NA 23
  • Eletriptan 20.0 20 49 NA 30
  •   40.0 30 60 NA 22
  • Frovatriptan 2.5 NA 42 61 10-25
  • Naratriptan 1.0 19 42 51 17-28
  •   2.5 21 48 67
  •  Rizatriptan 5.0 30 60 NA 30-35
  •   10.0 37 67-77 NA
  •  Sumatriptan 25 NA 52 68 35-40
  •   50 NA 50 70
  •   100 NA 56 75
  •  Zolmitriptan 2.5 38 64 75 31
  •   5.0 44 66 77
  •  

15
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.

16
Migraine cont
  • Side effects Contraindications
  • Which triptan
  • NV sc or in
  • Headache peaks rapidly Almo Riza Zolmi
  • Benign but intolerable triptan SEs
  • Almo Nara Frova
  • Recurrent HA after initial benefit
  • Nara Frova DHE
  • Combine with simple analgesia or antiemetic

17
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

18
Migraine cont
  • Hormones migraine
  • Menstrual migraine
  • Contraception
  • Pregnancy
  • Menopause
  • IHS task-force evidence based recommendations for
    the use of contraceptives and HRT in migraineurs
    (Bousser 2000)

19
  • 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

20
Primary Headaches 2 - Tension Type Headaches
  • TTHA ------- Migraine
  • Generally bilateral
  • Tight band / pressure / bursting
  • No N, V, photo, phono, phobia
  • Rx
  • Psychological
  • Physical
  • Pharmacological Asp NSAIDs (avoid codeine)
  • Amitriptyline or.

21
Primary Headaches 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) gt1 year without a remission
    of gt2 weeks

22
Cluster cont
  • Clinical features
  • MgtF
  • 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

23
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

24
Indomethacin-Responsive Headache syndromes
  • Prompt, absolute, and often permanent response to
    Indomethacin
  • May be confused with cluster
  • But shorter duration higher frequency
  • Paroxysmal hemicrania
  • Episodic (2w-5m, remissions 1-36m)
  • Chronic
  • Age 10-30 FM 21
  • Daily attacks (5/day) of severe short lived (20
    min) unilateral pain (orbital temporal)
  • At least 1 autonomic feature

25
Cluster cont
  • Hemicrania continua
  • Continuous unilateral hemicrania or focal area
  • Moderate intensity
  • Onset 28 (5-67)
  • FM 21
  • Autonomic features more subtle
  • Indomethacin

26
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

27
Other types of headache facial pain
  • CO2 CO
  • Hypoxia
  • Hypoglycemia
  • HT
  • Phaeochromocytoma
  • (Pre) eclampsia

28
Primary Headaches 4 - Other Primary Headaches
  • Cough Headache
  • Secs mins
  • MF 41 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

29
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
  • MgtF
  • Rarely recurs
  • Rx Indomethacin, propranolol, diltiazem

30
Secondary Headaches 7 - HA attributed to
non-vascular, non-infectious intracranial
disorders
  • High CSF pressure
  • Low CSF pressure
  • Non-infectious inflammatory disorders
  • Intracranial neoplasms
  • Chiari malformations
  • Seizure headache

31
  • Mass lesions
  • 50 of patients with brain tumours have headache
  • Primary complaint in 1/3 (17)
  • Pain depends upon
  • Location of lesion
  • Rate of growth
  • Affect on CSF flow
  • Cerebral oedema
  • Features of raised ICP
  • amgtpm NV worse with cough sneeze strain

32
  • Warning signs of a non-benign HA
  • (Purdy 2001 Med Clin North Amer)
  • Subacute progressive
  • New onset in those gt40 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

33
  • Intraventricular tumours
  • Rare but can present dramatically
  • Colloid cyst
  • Intraventricular meningioma
  • Choroid plexus papilloma
  • CASE

34
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35
  • 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

36
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

37
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38
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39
Secondary Headaches 9 - HA attributed to
infection
  • Meningitis
  • Acute
  • Chronic
  • TB
  • Fungal
  • Meningoencephalitis
  • Sinusitis
  • Mastoiditis
  • Epidural / intraparenchymal abscess
  • Skull osteomyelitis

40
Secondary Headaches 6 - HA attributed to
cranial or cervical vascular disorders
  • Aneurysms, AVMs, and thunderclap headache
  • Parenchymal haemorrhage
  • Cerebral ischaemia
  • Dissection
  • Giant cell arteritis

41
  • Table 75-3. Symptoms of giant cell arteritis
    n166
  • Symptom () initial symptom ()
  • Headache 72 33
  • PMR 58 25
  • Malaise, fatigue 56 20
  • Jaw claudication 40 4
  • Fever 35 11
  • Cough 17 8
  • Neuropathy 14 0
  • Sore throat, dysphagia11 2
  • Amaurosis fugax 10 2
  • Permanent vis loss 8 3
  • Claudication of limbs 8 0
  • TIA/stroke 7 0
  • Neuro-otology 7 0
  • Scintillating scotoma 5 0
  • Tongue claudication 4 0
  • Depression 3 0.6
  • Diplopia 2 0

42
Secondary Headaches 11 - HA caused by disorders
of..
  • Eyes
  • Nose
  • TMJ
  • Other dental disorders
  • Cervical spine
  • Other facial cranial structures

43
Headaches Top Tips
  • An accurate diagnosis of the headache syndrome is
    essential
  • Its all in the history
  • Investigations atypical features or secondary
    headache
  • Treatment rules - multimodal adequate trials of
    adequate doses improve not cure
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