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WHAT A HEADACHE !/?

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

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WHAT A HEADACHE !/?

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  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 bv’s Extracranial: ECA + branches, scalp + neck muscles, skin +cut nerves, cervical n’s + 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 Headaches1 - Migraine • Hemikranios • 200 AD Aretaeus of Cappadocia • 90% Onset <40 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 (usually>40)

  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 *Headache response is defined as a reduction in headache severity from moderate or severe pain to mild or no pain.†Recurrence of headache within 24 hours after initial headache response.Note: Composite data from product information inserts and literature.NA = not available.

  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 • N+V: sc or in • Headache peaks rapidly: Almo Riza Zolmi • Benign but intolerable triptan SE’s: 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 Headaches2 - 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 Headaches3 - 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): >1 year without a remission of >2 weeks

  22. Cluster cont… • Clinical features • M>F • 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 F:M 2:1 • 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) • F:M 2:1 • 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 Headaches4 - Other Primary Headaches • Cough Headache • Secs – mins • M:F 4:1 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 Headaches4 - 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 • M>F • Rarely recurs • Rx Indomethacin, propranolol, diltiazem

  30. Secondary Headaches7 - 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 am>pm; N+V; 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 >40 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. 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

  35. 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

  36. Secondary Headaches9 - HA attributed to infection • Meningitis • Acute • Chronic • TB • Fungal • Meningoencephalitis • Sinusitis • Mastoiditis • Epidural / intraparenchymal abscess • Skull osteomyelitis

  37. Secondary Headaches6 - HA attributed to cranial or cervical vascular disorders • Aneurysms, AVMs, and thunderclap headache • Parenchymal haemorrhage • Cerebral ischaemia • Dissection • Giant cell arteritis

  38. Table 75-3. Symptoms of giant cell arteritis n=166 • 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 • Tongue numbness 2 0 • Myelopathy 0.6 0

  39. Secondary Headaches11 - HA caused by disorders of….. • Eyes • Nose • TMJ • Other dental disorders • Cervical spine • Other facial + cranial structures

  40. Headaches: Top Tips • An accurate diagnosis of the headache syndrome is essential • It’s 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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