International Headache Society Classification

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International Headache Society Classification

• Two major categories
• Primary headache (benign disorders)
• Migraine (with or without aura)
• Tension (episodic or chronic)
• Cluster headache
• Other benign headaches
• Drug rebound headache
• Post traumatic
• Secondary headache
• Symptoms of organic disease

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Migraine Demographics

• 28 million Americans 1/4 households
• Up to 90 have family history
• One-year prevalence (one attack) - 12.6
• 6 men
• 15 - 18 women
• Productivity loss - US employers- 13 billion
• Increasing incidence ?
• Preventive therapy only used by 3 - 5

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Migraine Without Aura

• Duration of 4 - 72 hours
• At least two of the following
• Unilateral location
• Pulsating quality
• Moderate or severe intensity (inhibit / prohibit
  ADLs)
• Aggravation by routine physical activity (e.g.
  stairs)
• At least one of the following
• Nausea and / or vomiting
• Photophobia and phonophobia
• Can not be explained by a secondary cause
• At least five attacks

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Migraine With Aura

• Migraine without aura criteria
• Plus at least three of the following
• One or more fully reversible aura symptoms
• At least one symptom develops gradually (gt4 min)
  or two or more symptoms occur in succession
• No single aura symptom lasts longer than 60 min
• Headache follows aura within 60 min (may begin
  before or simultaneously with aura symptom(s)
• Secondary causes excluded
• At least two attacks

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Episodic Tension Headache

• At least two of the following
• Pressing/tightening (non-pulsating) quality
• Bilateral location
• Not aggravated with routine physical activity
• No nausea or vomiting
• No more than one of the following
• Photophobia
• Phonophobia
• Less than 15 days per month
• No evidence of organic disease

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The Headache Continuum
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Cluster Headache

• Rare primary HA with extraordinary morbidity
• Cluster period - weeks to months
• One headache every other day to eight / day
• Attacks shorter than migraine - 15 to 2 - 3 hrs
• Unilateral very severe (gt renal stones / birth)
• Periorbital pain with autonomic symptoms
• Lacrimation nasal congestion (PNS) Horners
  (SNS)
• Remissions that last months to years
• 10 have chronic cluster without remission
• Dreadful problem that drives otherwise normal
  people to extraordinary acts

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Cluster Headaches - IHS Criteria

• At least five attacks as below
• Severe unilateral orbital, supraorbital and / or
  pain lasting 15 - 180 minutes untreated
• One of following signs on the side of pain
• 1. Conjunctival injection 5. Miosis
• 2. Lacrimation 6. Forehead / facial
  sweating
• 3. Nasal congestion 7. Ptosis
• 4. Rhinorrhea 8. Eyelid edema
• Frequency 1 every other day to 8 / day

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Chronic Daily Headache / Transformed Migraine

• History of migraine (mainly without aura)
• Headaches grow more frequent
• Less severe pain, and less associated
  photophobia, phonophobia, and nausea
• Pattern of daily or near daily headaches
• Often (80) medication overuse
• Superimposed full blown migraine may occur
• 80 with depression

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Analgesic Rebound Headache (Mathew 1997)

• Perpetuation of head pain in chronic headache
  sufferers with the very frequent use of immediate
  relief medications
• Self-sustaining, rhythmic, headache-medication
  cycle characterized by daily headaches and
  irresistible and predictable use of immediate
  relief medications as the only means of relieving
  the headache attacks
• Headaches significantly improve with the
  discontinuation of the medications

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Analgesic Rebound Headaches

• Simple analgesics gt 5 days / wk
• Barbiturate combinations gt 3 days / wk
• Midrin gt 2 - 3 days / wk
• Opioids gt 2 days / wk
• Ergots gt 2 days / wk
• Triptans gt 2 days / wk
• ? Rebound susceptible individuals

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Brain Tumors
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Sub-Arachnoid Hemorrhage
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Pseudotumor Cerebri

• Young obese women, menstrual abnormalities
• Associations - medications (steroid, Vit A), PICA
• Dull, pressure-like headache, blurred vision,
  dizzy
• Visual obscurations, papilledma, VI nerve palsy
• ? Impaired re-absorption of CSF at arachnoid
  villi
• Risk of visual loss - not benign
• Dx normal MRI, CSF studies increased CSF
• Rx Repeated LPs, ? acetazolamide, shunts
• Monitor formal visual fields and blind spot
• Optic nerve sheath fenestration if vision
  threatened

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CNS Imaging in Headache

• The definitive diagnosis of migraine does not
  require negative imaging study
• AAN practice parameter - imaging studies are not
  indicated if the following hold
• no red flags in the headache history
• normal neurological examination with regards to
  causation of the headache pain

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Diagnostic Alarms - 1

• Headache gt age 50
• Sudden-onset headache
• Accelerating pattern of headache

• Temporal arteritis, mass lesion
• SAH, pituitary apoplexy, bleed into mass or AVM,
  mass lesion (posterior fossa)
• Mass lesion, SDH, medication overuse

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Diagnostic Alarms - 2

• Meningitis (chronic or carcinomatous), brain
  abcess, metastasis
• Menigitis, encephalitis, Lyme, systemic
  infection, collagen vascular disease
• Mass lesion, AVM, stroke, collagen vascular
  (including APL ab)
• Mass lesion, pseudotumor, meningitis

• New onset of HA in pt with Cancer or HIV
• Headache with systemic illness (fever, stiff
  neck, rash)
• Focal neuro sxs or signs (other than aura)
• Papilledema

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Headache - Diagnostic Algorithm
Headache history
Physical and neurological examination
Laboratory and imaging evaluation
Classify Headache Primary vs. Secondary
Individualize treatment based on type, severity,
and comorbidity
Treat primary disorder
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Goals of Migraine Treatment

• Reduce severity
• reduce frequency
• no cure - increase
• function
• Quality of life
• Requires
• Partner with patient
• Internalize locus of control

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Approaches to HA Pharmacotherapy

• Abortive
• Used to relieve pain and N / V during after
  individual headache attack has started
• Goal is to stop the attack and pain
• Prophylactic (preventive)
• Taken in absence of headache on daily basis
• Goal is to prevent attacks

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Abortive Medications

• DRUG Effects Side Effects
• Acetaminaphen 1 1
• Aspirin 1 1
• Excedrin 2 1
• Midrin 2 1
• NSAIDS 2 1
• Ergot-PO 2 2
• Butalbital 2 2

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Abortive Medications

• DRUG Effect Side Effects
• DHE, NS 3 1
• Triptan 3 1
• Triptan,PO 3 1
• Ergot, PR 3 3
• Narcotics 3 3
• DHE, inj 4 2
• Triptan,inj 4 1

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Triptan Therapy

• Indication
• clearly established diagnosis of migraine
• acute treatment of migraine
• Contraindications
• basilar or hemiplegic migraine
• use of ergot like drug within 24 hours
• uncontrolled hypertension
• history, symptoms, or signs of CAD, CVA, PVD, or
  vasospastic conditions

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Preventive Therapy

• Considerations
• More than 2 - 3 attacks per month
• Marked disability with attacks
• Patient preference
• Inability to satisfactorily abort attacks
• Menstrual migraine
• Complicated migraine

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Preventive Management

• Nonpharmacological strategies
• healthy lifestyle
• smoke, alcohol, exercise, regular schedule
• headache diary
• relaxation / stress techniques
• education
• psychological support

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Preventive Medications

• Select agent based on side effects and
  comorbidity
• Start low and escalate slowly
• Give an adequate trial (2 - 6 months)
• Minimize analgesic use
• Periodic, slow taper to see if still needed or
  whether lower dose would suffice
• Women need to be on adequate contraception and
  informed of risk - benefit ratio

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Preventive Medications
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VA Wholesale Costs (/mo.)

• Naproxen 250 30/mo 1.04
• Midrin 40/mo 9.48
• Fioricet/Fiorinal 30/mo 0.45 0.66
• Darvocet N100 30/mo 1.11
• Tylenol 3 30/mo 2.70
• Vicodin 5/500 30/mo 0.52
• Percocet 30/mo 2.54
• Cafergot 30/mo 14.01
• Sumatriptan 25 18/mo 129.38
• Rizatriptan 10 wafer 18/mo 128.64
• Sumatiptan inj refill 6/mo 62.50

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Status Migrainosus

• Severe persistent headache intractable N /V
• First step is rehydration then pretreatment with
  IV
• prochloroperazine 5 mg or metoclopramide 10 mg
• DHE IV Or Sumatriptan SC
• Additions
• Dexamethasone or diazepam
• Alternatives
• Ketorolac
• Chloropromazine
• Compazine
• IV Depakote
• Narcotics

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Tension Type Headache - Treatment

• Pharmacological therapy
• Abortive (AVOID FIORICET / FIORINAL)
• NSAIDs and rest if needed
• Preventive
• Tricyclic (or SSRI), ? Depakote
• Psychophysiological therapy
• Reassurance, stress management / relaxation
  therapy
• Physical therapy
• Modality treatments (heat, cold, ultrasound,
  electrical)
• Stretching, exercise, traction
• Trigger point injections and occipital nerve
  blocks
• Chronobiological regulation (exercise, meals,
  sleep)

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Cluster Headache - Abortive Treatment

• 100 oxygen at 7 - 10 L / min for 15 min
• Sumatriptan 6 mg SQ
• 20 mg NS
• DHE 1.0 mg I.M. or I.V.
• 1-2 mg NS
• ? Nasal lidocaine (4 - 6 )
• ? Stadol NS
• Nocturnal attacks - ? ergot

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Episodic Cluster HA - Preventive Rx

• Steroid at onset of cluster, 5 7 days
• Verapamil - ? preventive agent of choice
• 120 - 480 mg / day
• Depakote (can be used with verapamil)
• 250 - 1500 mg / day (level 50 - 120 mg/ml )
• Lithium
• 300 mg bid level in one week (0.4-0.8 mEq/L)
• ? HS ergot to prevent nocturnal attack
• Continue until HA free for 2 weeks
• Taper as opposed to abrupt withdrawal
• ?? Gabapentin, topiramate