Case-Based Teaching Didactic Component: Headache

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Case-Based TeachingDidactic ComponentHeadache
Migraine

• Department of Neurology
• University of Miami School of Medicine

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Headache MigraineLearning Objectives

• Describe the diagnostic criteria for migraine
• Describe when how to perform a diagnostic
  evaluation in a pt w/ headache
• Describe the appropriate abortive prophylactic
  therapies for migraine

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Diagnosis Management of Headaches Primary vs.
Secondary Headaches

• primary headache
• a condition in which headache is a primary
  manifestation no underlying disease is present,
  e.g., migraine and cluster
• due to chronic conditions w/recurrent acute
  attacks
• secondary headache
• a condition in which headache is a secondary
  manifestation of an underlying disease process
• often due to diseases that require both urgent
  prolonged care

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Diagnosis Management of Headaches Goals of the
Clinician

• diagnose the cause of headache
• provide emergency therapy
• provide a means for long-term care

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Primary HeadachePractical Migraine Definition

• genetic condition in which a person has a
  predisposition to suffering recurrent episodes of
  any of the following
• headache
• GI dysfunction
• neurologic dysfunction

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Primary HeadacheMigraine Pathophysiology

• autosomal dominant inheritance multiple genes
• origin is neurologic, not vascular
• focal decrease in brain serotonergic activity
• dysfunction of brainstem serotonergic
  noradrenergic pain pathways
• vasoactive neuropeptide release by CN V
• secondary arterial dilatation, constriction

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Primary HeadacheMigraine Epidemiology

• by far, most common cause of headache
• prevalence estimates
• range of most estimates is 1-31
• more likely prevalence is 70
• problems in determining prevalence include
• no objective pathology or diagnostic test
• variable definitions based on clinical criteria
• variable populations methods of data collection

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Primary HeadacheMigraine Triggers

• hormonal changes
• stress, stress letdown, hyperthyroidism
• menarche, menses, pregnancy, BCPs, menopause
• changes in sleep, eating habits, weather
• smoke, scents, fumes
• foods
• esp. nitrates, MSG, tyramine, aspartame, citrus
• alcohol (esp. red wine)
• exercise, head trauma, motion

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Primary HeadacheMigraine Phases

• prodrome
• aura
• headache
• postdrome

• mood changes
• difficulty concentrating
• fatigue, malaise
• autonomic symptoms
• food cravings
• esp. foods high in serotonin, e.g., chocolate,
  bananas, peanut butter

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Primary HeadacheMigraine Phases

• visual
• photopsia, scintillating scotomata
• silvery, clear
• fortification spectra, zig-zag lines
• wavy lines, heat-off-the-pavement
• spots, dots, bubbles
• vibrating, evolving, coalescing
• other (often migratory, stereotypical)
• numbness, hemiparesis, aphasia
• ataxia, vertigo, tinnitus, diplopia

• prodrome
• aura
• headache
• postdrome

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Primary HeadacheMigraine Phases

• prodrome
• aura
• headache
• postdrome

• headache characteristics
• unilateral, bilateral, variable location
• throbbing, pulsating, pounding, pressure,
  squeezing, dull, aching
• severe, moderate, mild, absent
• hours, days, weeks
• associated symptoms
• photophobia, phonophobia
• nausea, vomiting
• cramping, flatulence, diarrhea
• hypertension (dysautonomia)

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Primary HeadacheMigraine Phases

• prodrome
• aura
• headache
• postdrome

• fatigue, malaise
• difficulty concentrating
• mood changes
• muscle aches
• scalp tenderness

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Primary HeadacheIHS Definition of Migraine w/o
Aura
Useful for scientific studies, but impractical
for daily use

• frequency
• gt 5 episodes
• duration
• 4-72 h untreated
• HA quality (gt 2)
• unilateral
• pulsating
• moderate or severe
• ? w/physical activity

• associated features (gt 1)
• nausea /or vomiting
• photo- phonophobia
• no other cause of sxs

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Primary HeadacheTypes of Migraine

• migraine aura w/o HA
• acephalgic
• accompaniments
• equivalents
• abdominal
• benign paroxysmal vertigo

• migraine w/o aura
• common
• migraine with aura
• classic
• hemiplegic
• hemiparesthetic
• aphasic
• basilar
• retinal, ocular
• ophthalmoplegic

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Primary HeadacheDifficulties in Diagnosing
Migraine

• rationalization of symptoms
• regular, mild, tension, or sinus headaches
• GI virus, food poisoning, IBS/spastic colon
• interview significant other
• unknown family history
• symptoms most prominent in early adulthood
• pt was too young to realize parent had headaches
• pt no longer lives with parents or siblings
• interview relatives directly

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Primary HeadacheConditions Due to (or Related
to) Migraine

• episodic tension headache
• sinus headache
• regular or ordinary headache
• premenstrual syndrome
• irritable bowel syndrome/spastic colon
• recurrent vertigo (?Menieres disease)
• motion sickness
• postconcussion/posttraumatic headache
• transient global amnesia
• atypical chest pain

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Primary HeadacheImportance of Diagnosing Migraine

• common
• disabling
• avoiding iatrogenic disease
• hysterectomy/oophorectomy
• abdominal surgery
• sinus and ear surgeries
• anxiolytics, antidepressants

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Primary HeadacheMigraine Abortive Therapy

• selective 5-HT1D/1B agonists
• sumatriptan (Imitrex)
• naratriptan (Amerge)
• rizatriptan (Maxalt)
• zolmitriptan (Zomig)
• nonselective 5-HT1D agonists
• Cafergot, Wygraine
• DHE 45

• nonspecific combinations
• Midrin, Excedrin Migraine
• Fiorinal, Fioricet, Esgic
• BC Goody Powders
• nonspecific single agents
• aspirin, Tylenol, NSAIDs
• Vistaril, narcotics
• phenothiazine-related
• Thorazine, Compazine, Phenergan

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Primary HeadacheMigraine Prophylactic Therapy

• beta-blockers
• propranolol (Inderal)
• nadolol (Corgard)
• atenolol (Tenormin)
• timolol (Blocadren)

• verapamil
• (Calan, Isoptin, Verelan)
• valproic acid (Depakote)
• topiramate (Topamax)
• lamotrigine (Lamictal)
• naproxen (Naprosyn)
• nortriptyline (Pamelor)
• amitriptyline (Elavil)
• Mg gluconate or oxide
• /- feverfew

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Secondary HeadacheSuggestive Headache Features

• first, worst, persistent, or different
• onset after
• Valsalvas maneuver
• head trauma
• age 50
• exacerbation with head position

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Secondary HeadacheSuggestive Associated Features

• focal neurologic signs or symptoms
• change in consciousness
• fever
• seizure
• nuchal rigidity
• papilledema
• (pre)retinal hemorrhages

• history of
• bleeding diathesis
• hypercoagulable state
• cancer
• HIV or AIDS risk factors
• daily or near-daily use of analgesics

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Secondary HeadacheGiant-Cell (Temporal) Arteritis

• HA onset after age 50
• Incidence ?s w/ age
• Associated sxs signs
• temporal tenderness
• jaw claudication
• polymyalgia rheumatica (neck/shoulder/hip pain)
• fever, night sweats
• weight loss
• monocular visual loss (arteritic AION)
• MI or stroke (esp. PCA territory)
• anemia, ? ESR CRP

• Management
• draw ESR CRP
• if no visual sxs, start
• prednisone 80 mg qd
• if visual sxs, start
• IV methylprednisolone 1 g qd x 5 d, then
  prednisone 80 mg qd
• arrange temporal artery biopsy (ophthalmologist
  or neurosurgeon) within 2 weeks of starting
  steroids
• attempt to taper prednisone to off only after sxs
  resolve

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Secondary HeadacheAnalgesic Rebound

• most common cause of daily chronic HA
• relationship to migraine
• more common in migraineurs
• renders migraine therapies ineffective
• caused by
• excessive analgesic use (gt 2 d/wk)
• any analgesic (over-the-counter to narcotic)
• treatment
• withdraw analgesic, begin migraine prophylactic
• sedate (e.g., w/ Vistaril) for 3-5 d (?d pain
  3d-4wk)

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Secondary HeadacheDiagnostic Testing

• brain CT scan (w/ w/o contrast)
• brain MRI (w/ w/o contrast) and MRV
• lumbar puncture
• cerebral angiogram
• sed rate (ESR), C-reactive protein (CRP)
• other labs (CBC, chemistries, etc.)

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Secondary HeadacheEmergency Management

• First Consideration
• Surgical Therapy
• subdural hematoma
• brain tumor
• brain abscess
• ICH
• SAH
• AVM
• hydrocephalus

• First Consideration
• Medical Therapy
• meningitis
• cerebral vein thrombosis
• giant-cell arteritis
• systemic illness

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The End

• Department of Neurology
• University of Miami School of Medicine