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Classification of headaches

HISTORY AND EXAMINATIONS SHOULD CLARIFY IF . THE PATIENT HAS PRIMARY OR SECONDARY HEADACHE IS THERE ANY URGENCYIN CASE OF PRIMARY HEADACHE ONLY THE HEADACHE ATTACKS SHOULD BE TREATED (ATTACK THERAPY"), OR PROPHYLACTIC THERAPY IS ALSO NECESSARY (PREVENTIVE THERAPY, INTERVAL THERAPY"). . SECONDARY

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Classification of headaches

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    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…

    5. 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. 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 Prophylactic treatment of the chronic tension type of headache

    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

    13. Migraine classification

    14. Migraine WITH AURA + VISUAL SENSORY MOTOR SPEECH DISTURBANCE before migraineous headache AURA SYMPTOMS USUALLY<1/2 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

    15. MIGRAINE WITH AURA DURING AURA: VASOCONSTRICTION HYPOPERFUSION DURING HEADACHE VASODILATION HYPERPERFUSION

    16. 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%).

    17. 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!

    18. Treatment of migraine attack Try to sleep Antiemetics Analgetics Ergot derivatives Triptans

    19. 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

    20. 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

    21. 1. Ergotamin tartarate 2-4 mg per os, sublinguali or rectal 1 mg nasal spray 2. Dihydrergotamin (Neomigran) nasal spray no more available Treatment of migraine attack III. Ergot derivatives

    22. Migpriv: lizin-acetylsalicilate + metoclopramid Quarelin: aminophenazon+coffein+drotaverin Kefalgin ergotamin tartarate+ atropin+coffein+aminophenazon Treatment of migraine attack IV. Combinations in Hungary

    23. Treatment of migraine attack V. Triptans

    26. 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

    27. Prophylactic treatment of migraine attacks Indication: 2 or more attacks/month At least one long (>4 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!!!

    28. 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

    29. Prophylactic treatment of migraine Beta-receptor-blockers (propranolol) Calcium channel blockers (flunarizine) Antiepileptics (valproic acid) Tricyclic antidepressants (amitriptyline) Topiramate (Topamax) Serotonin antagonists NSAID

    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 >70% 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 1:1 (boys with good prognosis) Abdominal symptoms often predominant Semiology of attacks as in adulthood except shorter duration of attacks Short sleep very effective

    34. 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 Oxygen:7 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

    36. 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. 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) Prophylactic treatment of the chronic form of cluster headache

    38. 3. Cluster headache and trigemino-autonomic cephalgias Trigemino-autonomic cephalgias (TAC) Cluster headache Paroxysmal hemicrania SUNCT-syndrome (Hemicrania continua) Episodic and chronic forms

    39. 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)

    42. Carotid dissection After neck trauma, extensive neck turning Neck pain Horner’s syndrome Diagnosis: carotid duplex, MRI-T2

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