Classification of headaches

1
Classification of headaches

• Primary headaches
• OR Idiopathic headaches
• THE HEADACHE IS ITSELF THE DISEASE
• NO ORGANIC LESION IN THE BEACKGROUND
• TREAT THE HEADACHE!

• Secondary headaches
• OR Symptomatic headaches
• THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER
  UNDERLYING DISEASE
• TREAT THE UNDERLYING DISEASE!

2
HISTORY AND EXAMINATIONS SHOULD CLARIFY IF

• THE PATIENT HAS PRIMARY OR SECONDARY HEADACHE
• IS THERE ANY URGENCY
• IN CASE OF PRIMARY HEADACHE ONLY THE HEADACHE
  ATTACKS SHOULD BE TREATED (ATTACK THERAPY), OR
  PROPHYLACTIC THERAPY IS ALSO NECESSARY
  (PREVENTIVE THERAPY, INTERVAL THERAPY)

3
SECONDARY, SYMPTOMATIC HEADACHES

• THE HEADACHE IS A SYMPTOM OF AN UNDERLYING
  DISEASE, LIKE
• Hypertension
• Sinusitis
• Glaucoma
• Eye strain
• Fever
• Cervical spondylosis
• Anaemia
• Temporal arteriitis
• Meningitis, encephalitis
• Brain tumor, meningeal carcinomatosis
• Haemorrhagic stroke

4

• Secondary headache disorders
• Headache attributed to ...
• 5. head and/or neck trauma
• 6. cranial or cervical vascular disorder
• 7. non-vascular intracranial disorder
• 8. a substance or its withdrawal
• 9. infection
• 10. disorder of homoeostasis
• 11. disorder of cranium, neck, eyes, ears, nose,
  sinuses, teeth, mouth or other facial or cranial
  structures
• 12. psychiatric disorder
• 13. cranial neuralgias and central causes of
  facial pain

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Primary, idiopathic headaches

• Tension type of headache
• Migraine
• Cluster headache
• Other, rare types of primary headaches

6
Treatment of tension type of headache

• Acute, episodic form NSAID drugs, 500-1000 mg
  ASA, paracetamol, or noraminophenazon
• Indication of prophylactic treatment tension
  type of headache in at least 14 days per moth

7
Prophylactic treatment of the chronic tension
type of headache

• Tricyclic antidepressants
• Guidelines
• Start with low dose (10-25 mg) and increase the
  dose if no beneficial effect after 1-2 weeks
• Maximal dose should not be more than 75 mg/day
• Change to other tricyclic antidepressant only
  after 6-8 weeks
• Ask the patient to use headache diary
• Use the tricyclic antidepressant for 6-9 months
• Decrease the dose gradually

8
Prophylactic treatment of the chronic tension
type of headache

• First choice of drug
• amitryptiline (Teperin tabl, 25 mg)
• 1st week 25 mg in the evening
• 2nd week 50 mg in the evening
• 3rd week 75 mg in the evening continuously
• Change to other drug (e.g. clomipramine) if no
  beneficial effect within 6 weeks

9
Common side effects of tricyclic antidepressants

• Anticholinergic side effects
• Dry mouth
• Increased pulse rate
• Urinary retention (in prostate hyperplasia!!!)
• Increased intraocular pressure (glaucoma!!!)
• Sleepiness or hyperactivity
• Serotonine syndrome (do not use if the patient
  takes SSRI drug)

10
If the patient does not tolerate the TCA drugs,
or cannot be administared because of danger of
interaction

• Anxiolytics (e.g. alprasolam, clonazepam)
• and selective antidepressants (e.g. SSRI)
• Change of lifestyle
• Psychotherapy, psychological treatments,
  biofeedback, behavioral therapy, relaxation
  methods

11
Migraine epidemiology

• Life-time prevalence 10-12
• 1 chronic migraine (gt15 days/months)
• Sex ratio 2.5 (f) to 1 (m) in childhood 1 to 1
• Mean frequency 1.2/month
• Mean duration 24 h (untreated)
• 10 always with aura, gt30 sometimes with aura
• 30 treated by physicians

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Migraine pathophysiology

• Genetic disposition, hormonal influence
• Activation of brainstem nuclei by trigger factors
• Neurovascular inflammation of intracranial
  vessels
• Impaired antinociception
• Spreading Depression as mechanism of aura

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Migraine classification

• 1.1 migraine without aura
• 1.2 migraine with aura
• 1.3 periodic syndromes in childhood
• 1.4 retinal migraine
• 1.5 migraine complications
• 1.6 probable migraine

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Migraine

• WITH AURA
• VISUAL
• SENSORY
• MOTOR
• SPEECH DISTURBANCE before migraineous
  headache
• AURA SYMPTOMS
• USUALLYlt1/2 HOUR
• LESS THAN 1 HOUR

• WITHOUT AURA
• Typical headache 2/4
• Unilateralsi
• Severe
• Pulsating
• Physical activity aggravates
• Accompanying signs 1/2
• Photophobia and phonophobia
• Nausea, or vomitus

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MIGRAINE WITH AURA

• DURING AURA
• VASOCONSTRICTION
• HYPOPERFUSION

• DURING HEADACHE
• VASODILATION
• HYPERPERFUSION

BUT AURA SYMPTOM IS NOT CONSEQUENCE OF
VASOCONSTRICTION INDUCED HYPOPERFUSION CUASE OF
THE AURA SPREADING DEPRESSION.
THE VASOCONSTRICTION AND HYPOPERFUSION ARE
CONSEQUENCES OF THE SPREADIND DEPRESSION
AURA
SPREADING DEPRESSION
VASOCONSTRICTION, HYPOPERFUSION
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IMPORTANT TO KNOW! MIGRAINE WITH AURA

• IS A RISK FACTOR FOR ISCHAEMIC STROKE
• THEREFORE PATIENTS SUFFERING FROM MIGRAINE WITH
  AURA
• SHOULD NOT SMOKE!!!
• SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!!
• THE PROPROTION OF PATENT FORAMEN OVALE IN
  PATIENTS WITH MIGRAINE WITH AURA IS ABOUT 50-55!
  (IN THE POPULATION IS ABOUT 25).

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Is there a relationship between aura and patent
foramen ovale

• ?
• Paradoxic emboli theory is not likely
• Shunting of venous blood to the arterial side
  could be the reason ? no breakdown of certain
  neurotransmitters (5HT) in the lung!
• Comorbidity could be also an explanation.
• However, closure of patent foramen ovale
  decreases the frequency of migraine attacks.
• BUT! Migraine is a benign disease. Please do not
  indicate closure of patent foramen ovale just
  because of migraine with aura!

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Treatment of migraine attack

• Try to sleep
• Antiemetics
• Analgetics
• Ergot derivatives
• Triptans

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Treatment of migraine attack I. Antiemetics

• 1. Metoclopramid (Cerucal tabl 10 mg)
• 10-20 mg per os
• 20 mg rectal
• 10 mg parenteral
• 2. Domperidon (Motilium tabl 10 mg)
• 10-20 mg per os

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Treatment of migraine attack II. Analgetics

• 1. ASA (Aspirin, Colfarit, etc)
• 500-1000 mg per os
• 500 mg parenteral (Aspisol i.v.)
• 2. Paracetamol (Rubophen, Panadol, etc)
• 500-1000 mg per os
• 3. NSAIDs
• Ibuprofen (Ibuprofen, Humaprofen, etc) 400-800 mg
  per os
• Diclofenac (Voltaren, Cataflam etc) 50 mg per os
• Naproxen (Naprosyn, Apranax) 250-550 mg per os

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Treatment of migraine attack III. Ergot
derivatives

• 1. Ergotamin tartarate
• 2-4 mg per os, sublinguali or rectal
• 1 mg nasal spray
• 2. Dihydrergotamin (Neomigran) nasal spray
• no more available

22
Treatment of migraine attack IV. Combinations in
Hungary

• Migpriv
• lizin-acetylsalicilate metoclopramid
• Quarelin
• aminophenazoncoffeindrotaverin
• Kefalgin
• ergotamin tartarate atropincoffeinaminophenazon
  

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Treatment of migraine attack V. Triptans
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The ideal triptan

• Effective
• Rapid onset
• No recurrence
• Good consistency
• Different applications
• Good tolerability
• No interactions
• Cheap

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Attack treatment in emergency
Very severe migraine attack / status migrainosus

• Triptan (sumatriptan 6 mg s.c.)
• Lysin-ASA 1,000 mg i.v.
• Metamizol 500-1,000 mg i.v.
• Antiemetics i.v.
• Steroids i.v.

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Strategy of treatment of migraine attacks

• Step care accross or within attacks
• 1 NSAID
• 2 ergot
• 3 triptan
• Stratified care
• do not go through all the steps, but drug can be
  chosen depending on the severity of the attack

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Prophylactic treatment of migraine attacks

• Indication
• 2 or more attacks/month
• At least one long (gt4 days) attack/month
• Start of prophyalactic treatment gradually
• Duration of prophylactic treatment 2-9 months
• Stop of prophylactic treatment gradually, within
  4 weeks
• Use headache diary
• INFORM THE PATIENT ABOUT THE PROPHYLACTIC
  TREATMENT!!!

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Aims of prophylactic treatment of migraine

• To decrease the frequency of attacks
• To decrease the intensity of the pain
• To increase the efficacy of attack therapy

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Prophylactic treatment of migraine

• Beta-receptor-blockers (propranolol)
• Calcium channel blockers (flunarizine)
• Antiepileptics (valproic acid)
• Tricyclic antidepressants (amitriptyline)
• Topiramate (Topamax)
• Serotonin antagonists
• NSAID

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Beta-receptor-blockers (propranolol 2x20-40 mg)
Use hypertension, tachycardia Do not use
hypotension, bradicardia, heart conduction
disturbances
Calcium channel blockers (flunarizine, 10 mg
every evening) Side effects provokes depression,
increases appetite, cause sleepiness
Do not use obesity, maior depression in the
history
Tricyclic antidepressants (amitryptiline, 10-75
mg every evening)
Use if tension type of headache is present
besides migraine Do not use see above
Antiepileptics (valproic acid, 2x300-500 mg)
Few side effects, but Pregnancy should be avoided
31
Other prophylactic treatment of migraine

• Change of life-style
• Regular, not exhausting physical activities
• Cognitive behavioral therapy
• Regular sleeping
• Avoid the precipitating factors
• Acuouncture?

32
Migraine and pregnancy

• Migraine without aura in gt70 of women less
  frequent or absent (prognostic factor menstrual
  migraine)
• Significantly more manifestation of migraine with
  aura
• Acute treatment paracetamol NSAIDs in second
  trimenon
• Triptans not allowed
• Prophylaxis magnesium, metoprolol, (fluoxetine)

33
Migraine in childhood I

• Prevalence 5
• Sex ratio 11 (boys with good prognosis)
• Abdominal symptoms often predominant
• Semiology of attacks as in adulthood except
  shorter duration of attacks
• Short sleep very effective

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Migraine in childhood II

• Acute treatment
• First choice ibuprofen 10 mg/kg
• Second choice paracetamol 15 mg/kg
• Third choice sumatriptan nasal spray 10-20 mg
• Prophylaxis
• Flunarizine 5-10 mg
• Propranolol 80 mg
• Non-drug therapy very effective

35
Treatment of cluster attack

• Oxygen7 liters/min 100 oxigén for 15 minutes
• Effective in 75 of patients within 10 minutes
• Sumatiptan 6 mg s.c., 50-100 mg per os
• Ergot derivatives (lot of side effects)
• Anaesthesia of the ipsilateral fossa
  sphenopalatina)
• 1 ml 4 Xylocain nasal drop
• The head is turned back and to the ipsilateral
  side
• in 45 degree

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Prophylactic treatment of the episodic form of
cluster headache

• Epizodic form prednisolon
• Treatment
• 1-5. days 40 mg
• 6-10. days daily 30 mg
• 10-15. days daily 20 mg
• 16-20. days daily 15 mg
• 21-25. days daily 10 mg
• 26-30. days daily 5 mg
• nothing

37
Prophylactic treatment of the chronic form of
cluster headache

• Lithium carbonate
• Daily 600-700 mg
• Can be decreased after 2 weeks remission
• Control of serum level is necessary
  (0,4 - 0,8 mmol/l)

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3. Cluster headache and trigemino-autonomic
cephalgias

• Trigemino-autonomic cephalgias (TAC)
• Cluster headache
• Paroxysmal hemicrania
• SUNCT-syndrome
• (Hemicrania continua)
• Episodic and chronic forms

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Headache of cervical origin

• Lidocain infiltration
• NSAID 50-150 mg indomethacin, 20-40 mg piroxicam
  (Hotemin, Feldene), etc
• Surgical methods (CV-CVII fusion of vertebrae)
• Other methods (physiotherapy, TENS)

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Arteriitis temporalis

• Arteriitis temporalis (agegt50y, Wegt50 mm/h)
• Autoimmune disease, granulomatose inflammation of
  branches of ECA
• Unilateral headache
• Pulsating pain, more severe at night
• Larger STA
• 1/3 jaw claudication ? inflammation of internal
  maxillary artery
• Weakness, loss of appetite, low fever,
• Danger of thrombosis of ophthalmic or ciliary
  artery!!!
• Amaurosis fugax may precede the blindness
• Treatment steroid 45-60 mg methylprednisolone
  decrease the dose after 1-2 weeks to 10 mg!!!
• Diagnosis STA biopsy.
• BUT Start the steroid before results of biopsy!!!
• ?We, pain decrease

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Facial pains

• Tolosa-Hunt syndrome (ophthalmoplegia dolorosa)
  granulomatose inflammation in cavernous sinus,
  superior orbital fissure Treatment steroid
• Gradenigos syndrome otitis media inflammation
  of apex of petrous bone lesion of ipsilateral
  abducent nerve and facial pain around the ear and
  forehead

42
Carotid dissection

• After neck trauma, extensive neck turning
• Neck pain
• Horners syndrome
• Diagnosis carotid duplex, MRI-T2