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HEADACHES CHRONIC HEADACHE

HEADACHES CHRONIC HEADACHE. Determining Its quality,severity ,location,duration,and time course as well as the conditions that produce ,exacerbate or relieve it. Ausculation-Palpation Quality of cephalic pain in most patients is dull (not sharp localize) Throbbing D.D Waxing&Waning

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HEADACHES CHRONIC HEADACHE

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  1. HEADACHES CHRONIC HEADACHE

  2. Determining Its quality,severity ,location,duration,and time course as well as the conditions that produce ,exacerbate or relieve it

  3. Ausculation-Palpation Quality of cephalic pain in most patients is dull (not sharp localize) Throbbing D.D Waxing&Waning The most Intense headaches : SAH-Meningitis—Migraine-Cluster-Tic doulourex

  4. LOCATION OF HEADACHE Supratentorial SOL:Frontotemporal Infratentorial SOL:Occipitonuchal Ear pain :Referal Vertex or Biparietal :Sphenoid or ethmoid sinus disease or thrombosis of SSS

  5. MODE OF ONSET &DURATION SAH:Abrup Meningitis:Hours or days Ophthalmodynia :A few seconds Ice pick headache:Seconds

  6. Classic migraine:early morning Cluster:Nightly SOL: Any time of day or night IICP :Worse in morning Tension headache :Persists for weeks

  7. RELATION OF HEADACHE TOCERTAIN BIOLOGIC EVENTS Premenstural headache:Tension or , Migraine Cervical spine disease:First movement of the neck is painful Eye strain headache Alcohol-Exercise-Straining-Coughing- e

  8. MIGRAINE CLINICAL FEATURES 90% <40 YEARS OLD F >M 90% Familial History Positive 20% of Women 6% Men

  9. MIGRAINE WITHOUT AURA Prodormal Phase: May awaken the subjects May be unilateral Lower half headache Prefer dark &quiet room Photophobia&phonophobia&osmopho

  10. Nausea-vomiting(delayed)-diarrhea Anorexia> Nausea Blurred vision-Lightheadedness- Epistaxis-subconjunctival hemorrhage Fever-PAT (rarely) Peak of pain :30min to several hours Frequency&severity is extremly variabl

  11. Status migrainosus = Hospitalization Chronic daily headache=Attack at less than weekly MIGRAIN WITH AURA Aura=Transient visual,sensory,motor,or language disturbance Headache is identical to common M

  12. prodormal symptoms may be accured Visual aura(most common) teichopsia Homonymous field (white or colored) Positive scotoma then negative scoto Metamorphopsia Photopsia--- Retinal migraine Contralateral headache

  13. Sensory aura(second most common) Paresthesias(positive)numbness(neg) Variable distibution 20-30min DD:TIA-seizure Language aura:dysphasia or aphasia Alexia-agraphia-mild confusion Weakness of the limbs or facial

  14. Transient abdominal symptoms-disturbed mentation-dejavu MIGRAINE AURA WITHOUTHEADACHE

  15. TREATMENT & MANAGEMENT Reassurance-lack of cure Normal CT or MRI Avoidance of trigger factors(caffeine-smoking-alcohol-reserpine-OCP-nifedipine-theophilline-estrogens) Avoidance of fasting & insomnia & tyramin

  16. PHARMACOTHERAPY Triptans : mechanisms : 5 HT1 B agonists 5 HT1 D agonists have beneficial effect on migraine associated symptoms side effects : Tingling Flash sensations Heaviness or pressure in neck or chest

  17. Contrandications : IHD , HTN , using ergo , peripheral vascular disease ,pregnancy , lactation , hemiplegic migraine, Well tolerated : naratriptan almotriptan , Triptan +NSAIDS Triptan + metoclopramide Ergots : vasoconstrictors and vasodilators 5 –HT receptors agonists oral –rectal –parenteral dose : 2mg + caffeine repeat : after 1 hour 1-2 mg rectally+analgesic orally 10mg metoclopramide

  18. Supp : chlorpromazine 25-100 mg or prochlorperazine 25mg or supp : acetaminophen Caution in : HTN , peripheral vascular disease Contraindicated : IHD , pregnancy , prolonged aura

  19. Subcutaneous and Intranasal Serotonin (5-HT) Agonists HEADACHE RESPONSE (%)*

  20. Oral Serotonin (5-HT)Agonists HEADACHE RESPONSE (%)'

  21. TABLE 73-5 Serotonin (5-HT) Agonists Used in Acute Migraine Treatment Serotonin (5-HT) Agonists Used in Acute Migraine Treatment

  22. Nonhormonal Prophylaxis for Menstrual Migraine CYCLIC (PERIMENSTURAL) DAYS -3THROUGH +3 Nonsteroidal anti-inflammatory drugs Naproxen sodium 550 mg bid Mefenamic acid 250 mg tid Ketoprofen 75mg tid Triptans and ergots Sumatriptan 25mg tid Naratriptan 1.0 mg tid or 2.5 mg bid Frovatriptan 2.5 mg once daily Zolmitriptan 2.5mg bid Ergotamine tartrate + caffeine (Wigraine) 1 mg qhs or bid Dihydroergotamine 0.5-1.0mg (SC, IM, or intranasal) bid

  23. NONCYCLIC (THROUGHOUT CYCLE) Tricyclic antidepressants Nortriptyline or amitriptyline 10-150 mg qhs Beta-blocker Propranolol or nadotlol 40-240 mg daily Calcium-channel blocker Verapamil 240-480mg daily Anticonvulsant Divalproex 250-500 mg bid Topamax 75mgqhs to 100mg bid Dopamine agonists Bromocriptine2.5-5.0mg tid Other Magnesium 360-600mg daily

  24. PROPHYLACTIC TREATMENT Beta blockers :Propranolol 80-240mg/d for 2-3months side effects (lethargy –depression -hypotension-bradycardia -impotence-insomnia-nightmare)-Group* C Timolol - Nadolol- Atenolol-Motoprolol

  25. Antidepressants : Amitriptyline : effect :blockade of noradrenaline uptake inhibition of serotonin re uptake unknown Side effects : morning drowsiness , dryness of the mouth , weight gain, tachycardia ,vertigo , constipation , B.M depression Group :D duration: 3months

  26. Phenelzine (MAOI) : drug interactions : sympathomimetics , anticholinergic , TCA , oppioids ( meperidine ) Side effects : HTN , hallucinations , retention of urine , agitation

  27. Calcium channel blockers : mechanism : unknown , vasoconstriction , prevention of platelet aggregation ,alteration in release and reuptake of serotonin. Verapamil : 80-160mg TDS ,effective in classic migraine Side effects: vertigo ,constipation ,HF bradycardia ,V.F: half life:2.8-4.7h form:tab:40-80mg FC tab:240mg ing:5mg / 2mg metabolism :liver excretion :kidney group :C , flunarizine? nimodipine? Diltiazem?

  28. Anticonvulsants : mechanisms: unknown Sodium channel inhibition, GABA Na-valproate :dose: 500-1750mg/d Side effects: sedation , dizziness, appetite, BT, LFT, hair loss, • Group :D Form :tab 200-500mg • syrup 200mg /5cc HL :6-16 h • Gabapentin : relative well tolerated side effects : dizziness ,sedation ,depression , ataxia , fatigue , leukopenia dose:900-2400mg/d cap: 100- 300-400 mg HL:5-7h contraindication <12 years group:C

  29. Topiramate : mechanisms : Ca channel blocker , GABA • Dose : 15-25 mg/d 75-200 mg/d Form: tab : 25-50-100-200 mg • Side effects : sedation cognitive problems , paresthesia , weight loss, ataxia , depression Group :C HL : 21h excretion: kidney

  30. Serotonergic agents : • 1)methysergide Side effects: retroperitoneal fibrosis 1/1000 pulmonary and heart valve fibrosis ,nausea, leg pain, abdominal cramp ,agitation, hallucination 6 months after 4 weeks stop restart U/A + Cr . CT or MRI of abdomen ,CXR Dose: 2mg /d 7-10 days 6-8mg/d

  31. 2) Cyproheptadine : antibradykinin, antiplatelet aggregation, serotonin antagonist ,minor role in adults Side effects: weight gain drowsiness group: B tab: 4mg • breast feeding contraiadicoted Riboflavin dose: 400mg/d Group :A

  32. Mg supplementation : dose : 600 mg/d Side effects : diarrhea, DTR , hypotension , cardiac block , respiratory paralysis . Contraindication : heart block vial : 10-20 -50 % Group : D HL : 0.5 -4 h Aspirin : 325 mg • NSAIDS :

  33. Botulinum : release of proinflammatory and vasodilating neuropeptide block of glutamate Dose : 100 units beginning of effect after 7- 10 days persists to 3 months • Imipramine-Desipramine-Nortriptyline • Fluoxetine&Sertraline ?

  34. STATUS MIGRAINOSUS Fluid replecement-Correction of electrolyte imbalance-- Suppression of vomiting DHE&Antiemetics TID Dexamethasone or Prednisolone 20 mg QID --- taper 2-3 days

  35. Tention Type Headache The most common almost always mild-rare CCTH Criteria for diagnosis : lasts from 30 min to a week and has 2 or more fallowing 1)bilateral 2)pressure nonpulsatile3)mild to moderate 4)not aggravated by routin activity

  36. TTH unassociated with nausea and vomiting can have photophobia or phonophobia but not both—tension and stress are associated Treatment : NSAIDS- butalbital +analgesics Preventive therapy: TCA-mirtazapine-topiramate-venlafaxine-tizanidine -botulinium toxin SSRIs not effective

  37. CLUSTER HEADACHE Episodic type:1-3 attack of periorbital pain each day for 4-8 weeks- pain free interval one year Chronic form :attacks are similar there are no sustained remission M/F=8/1 no hereditary prevalence =69/100000 Age= 20-50y

  38. Clinical features : periorbital( temporal or maxillary) pain without warning reach crescendo 5min-sever and deep-nonflactuating rarely pulsatile-strictly unilateral usually same side-lasts 30 min to 2 hours-homolateral lacrimation,red eye, nasal stuffiness and ptosis nausea is uncommon-alcohol provokes attack in 70% on-off vulnerability to alcohol is pathognomonic

  39. Treatment :the most satisfactory treatment is prevention” lithium 600-900 mg/d particulary chronic form prednisone 10days ;beginning 60 mg daily for 7days and rapidly tapering melatonin9 mg HS occasionally ergotamine 1mg is most effective when given 1-2hours before a single nocturnal attack

  40. ……..Treatment: occipital nerve stimulation-hypothalamic S Treatment of attack : oxygen inhalation 10 lit/min for 15 min – intranasal lidocaine 4%topical or 2%viscous-sumatriptan 6mg shorten attack 10-15 min

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