WHAT A HEADACHE !/?

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WHAT A HEADACHE !/?

• Paul Hart
• Consultant Neurologist
• Epsom St Helier 0208 296 3355 (M Tu Th)
• AMW SGH 0208 725 4107 (Wed Fri)
• RMH

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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

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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 bvs
• Extracranial
• ECA branches, scalp neck muscles, skin cut
  nerves, cervical ns nerve roots, sinus
  mucosa, teeth.
• (via V VII IX and X to CNS)

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• Pain localisation
• Pain modulation

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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

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• 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

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Primary Headaches 1 - Migraine

• Hemikranios
• 200 AD Aretaeus of Cappadocia
• 90 Onset lt40 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

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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

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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 (usuallygt40)

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Migraine cont

• Basilar migraine
• Ophthalmoplegic migraine
• Complications of Migraine
• Hemiparesis
• Facioplegic migraine
• Field defect
• Migraine stroke
• O/E
• Investigations

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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

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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
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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 -

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• 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
•  

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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.

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Migraine cont

• Side effects Contraindications
• Which triptan
• NV sc or in
• Headache peaks rapidly Almo Riza Zolmi
• Benign but intolerable triptan SEs
• Almo Nara Frova
• Recurrent HA after initial benefit
• Nara Frova DHE
• Combine with simple analgesia or antiemetic

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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

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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)

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• 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

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Primary Headaches 2 - 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.

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Primary Headaches 3 - 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) gt1 year without a remission
  of gt2 weeks

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Cluster cont

• Clinical features
• MgtF
• 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

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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

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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 FM 21
• Daily attacks (5/day) of severe short lived (20
  min) unilateral pain (orbital temporal)
• At least 1 autonomic feature

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Cluster cont

• Hemicrania continua
• Continuous unilateral hemicrania or focal area
• Moderate intensity
• Onset 28 (5-67)
• FM 21
• Autonomic features more subtle
• Indomethacin

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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

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Other types of headache facial pain

• CO2 CO
• Hypoxia
• Hypoglycemia
• HT
• Phaeochromocytoma
• (Pre) eclampsia

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Primary Headaches 4 - Other Primary Headaches

• Cough Headache
• Secs mins
• MF 41 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

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Primary Headaches 4 - 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
• MgtF
• Rarely recurs
• Rx Indomethacin, propranolol, diltiazem

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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

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• 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
• amgtpm NV worse with cough sneeze strain

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• Warning signs of a non-benign HA
• (Purdy 2001 Med Clin North Amer)
• Subacute progressive
• New onset in those gt40 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

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• Intraventricular tumours
• Rare but can present dramatically
• Colloid cyst
• Intraventricular meningioma
• Choroid plexus papilloma
• CASE

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• 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

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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

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Secondary Headaches9 - HA attributed to
infection

• Meningitis
• Acute
• Chronic
• TB
• Fungal
• Meningoencephalitis
• Sinusitis
• Mastoiditis
• Epidural / intraparenchymal abscess
• Skull osteomyelitis

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Secondary Headaches6 - HA attributed to
cranial or cervical vascular disorders

• Aneurysms, AVMs, and thunderclap headache
• Parenchymal haemorrhage
• Cerebral ischaemia
• Dissection
• Giant cell arteritis

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• Table 75-3. Symptoms of giant cell arteritis
  n166
• 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

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Secondary Headaches11 - HA caused by disorders
of..

• Eyes
• Nose
• TMJ
• Other dental disorders
• Cervical spine
• Other facial cranial structures

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Headaches Top Tips

• An accurate diagnosis of the headache syndrome is
  essential
• Its all in the history
• Investigations atypical features or secondary
  headache
• Treatment rules - multimodal adequate trials of
  adequate doses improve not cure