Headache

1. Headache

2. Epidemiology of Headache • Nuprin Pain Report (1985) • American Migraine Study I (1989) • American Migraine Study II (1999)

3. Primary Migraine (without aura, with aura, basilar, familial hemiplegic, ophthalmoplegic, retinal) Tension-type (episodic vs chronic) Cluster (acute vs chronic) Chronic paroxysmal hemicrania Secondary Head trauma; vascular disorders; CNS infection; alteration in intracranial pressure, associated with substance use or withdrawal; metabolic abnormalities; inflammatory disorders; structural HEENT disorders; neuralgias; ice cream; post-coital Classification of Headaches CNS = central nervous system; HEENT = head, eyes, ears, nose, throat

4. Headache Evaluation • History (duration, onset, frequency) • Is there a family history of headache? • Are there any known causes of headache? • What is the typical location(s)? • What does the pain feel like? • What makes it worse? • What makes it better? • What are the results of past evaluations? • Are there associated symptoms? Exam findings? • What is the patient’s sex?

5. Headache: Diagnostic Red Flags • Rash, meningeal signs, or fever • Onset after age 50 • Onset in a person with HIV or cancer • Abrupt onset • Worsening pain • Signs of focal neurologic disease

6. Migraine Headache Without Aura • Previously known as “common” migraine • Chronic, idiopathic disorder • Generally lasts 4–72 h • Often unilateral, of moderate or severe intensity, and pulsating • Associated with nausea, photophobia, phonophobia • Aggravated by physical activities • Triggers may be related to certain foods/beverages, menstruation, and changes in sleep patterns or in stress levels

7. Migraine Headache With Aura • Previously known as “classic” migraine • Generally preceding headache: neurologic symptoms (cortex or brain stem) that develop over 5–20 min and last less than 1 h • Headache and other features of migraine then follow • The headache phase can be absent in some instances (migraine sine hemicrania)

8. Other Types of Migraine Headaches • Ophthalmoplegic migraine • CN 3, 4, or 6 palsies • Palsies are ipsilateral to the headache and may occur before or during the headache phase • Retinal migraine: associated visual loss • Childhood migraine • Similar to adult migraine • Boys are more commonly affected than girls • Attacks tend to be shorter with motion sickness, vertigo, and lightheadedness common

9. Migraine Headache: Complications • Cerebrovascular accidents • Risk is slightly increased with migraine, especially for women • Presence of known stroke risk factors increases risk • Oral contraceptive use and/or smoking increases risk slightly • Epilepsy • Psychiatric disorders

10. Chronic Daily Headache • Up to 30% of headache-center patients complain of daily headache. • Controversy: Is this a separate category or the result of a “transformation” of a previously known episodic disorder into a daily one? • Persons with either migraine or tension-type headache may develop this syndrome. • Postulated contributing factors • Medication overuse • Stress • Hypertension • Psychologic disturbances

11. Tension-Type Headache • Typically pressing, tight pain • Mild-to-moderate pain intensity • Bilateral • Doesn’t worsen with physical activity • Nausea absent but photophobia or phonophobia may be present • Attacks last hours to days • Termed chronic if more than 15 d/mo for 6 mo

12. Cluster Headache • Occurrence: 6 times more common in men than women • Onset usually third or fourth decade • Attacks • Often awaken the patient • Come in clusters and recur at regular, often annual, intervals • Common triggers: alcohol and nitroglycerin • Characteristic: unilateral and periorbital; excruciating, burning, and knife-like pain; often associated with lacrimation, conjunctival injection, rhinorrhea, and miosis • Last 15 min to 3 h

13. Cluster Headache • Chronic paroxysmal hemicrania is a headache disorder with pain intensity/location similar to cluster, BUT attacks are shorter and more frequent (up to 30 times/d)

14. Pharmacologic Management of Headache: Symptomatic Therapies • Stratified, NOT step-care, approach! • NSAIDs, combination therapies including acetaminophen/aspirin/caffeine, or butalbital combinations should be used for mild-to-moderate pain • Oral/parenteral triptans and dihydroergotamine should be used for severe migraine or for those individuals with less severe pain but who have not responded to other agents • REMEMBER: overuse of symptomatic therapies can lead to an analgesic rebound headache syndrome

15. Pharmacologic Management of Migraine: Prophylactic Therapies • Indications • 3 headaches/mon with disability or • Lack of efficacy with symptomatic therapies or • Presence of headache types with any risk for neurologic injury • Therapy should be individualized

16. Pharmacologic Management of Headache: Prophylactic Therapies • Proven types of prophylactic agents include: beta-blockers, antidepressants, calcium channel blockers, NSAIDs, anticonvulsants, methylsergide, and alpha-adrenergic agents • Other types of prophylactic agents that have been used but whose role has not been as clearly established include topiramate and botulinum toxin

17. Nonpharmacologic Managementof Headache • Diet • Exercise • Biofeedback/relaxation training • Acupuncture • Consistent sleep/wake cycles