Headaches

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Headaches

• Alan Chan, MD

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• 12-16 prevalence
• Tension most common
• Cluster HA men gt women
• All other types women gt men
• International Headache Society (IHS)
  classification updated in 2004
• HA, cranial neuralgia, facial pain syndromes.

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HA

• Migraine 2/3 unilat, 1/3 bilat or global
  crescendo pattern, pulsating 4-72 hr /- aura
• Tension bilat, pressure/tightness variable
  indeterminate length
• Cluster unilat, quick and explosive patient
  active lt 3 hr ipsilat facial symptoms
  tearing, nasal congestion, Horners, rarely focal
  neuro symptoms

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Ddx less common

• Paroxysmal hemicrania
• Idiopathic stabbing headache
• Cold-stimulus headache
• Benign cough headache
• Benign exertional headache
• Headache associated with sexual activity

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Other HA

• Secondary HA associated with trauma, vascular
  disorder, nonvascular intracranial disorder,
  substance use or withdrawal, infection, metabolic
  disorder, other facial or cranial structures

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Get some hx

• Triggers
• Diet, stress, hormones, sensory stimuli, change
  in habit or environment
• Important questions in history
• frequency of severe headache (difficult to
  function)
• frequency of milder HA
• frequency of taking analgesics
• change in HA

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Image if

• recent significant change in pattern, frequency,
  or severity
• worsening despite therapy
• focal neurological signs/symptoms
• HA with exertion, cough, or sexual activity
• Orbital bruit
• Onset after age 40

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Migraine

• episodes of severe HA typically with nausea /-
  photo/phonophobia

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Pathophysiology - NOT vascular dilatation of
blood vessels

• Primary neuro dysfunction leading to premonitory
  symptoms, aura, HA, and postdrome
• Central process either brainstem or cortical
  spreading depression
• causes aura, activates trigeminal nerve afferent
  fibers, alter blood brain barrier (BBB)
  permeability

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• trigeminovascular system activity leading to
  stimulation releases vasoactive neuropeptides of
  substance P, calcitonin gene-related protein
  (CGRP, which is a profound endogenous
  vasodilator), neurokinin A, activation of
  arachadonic acid cascade
• sensitization neurons get progressive more
  sensitive to nociceptive and non-nociceptive
  stimulation

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More

• Genetics approx 3x risk in patients with
  relatives who had migraines. Non-Mendelian
  pattern of inheritance
• Prodrome 60 of people with migraine can occur
  1-2 days prior to HA onset. Includes depression,
  irritability, constipation, euphoria, food
  craving, increased yawning.
• Aura 25 typically visual like scotoma, but
  can be sensory, verbal, or motor
• Headache typically unilateral and throb/pulse
• Postdrome exhausted, sudden head mvt causes pain

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Diagnosis without aura

• Headache attacks last 4 to 72 hours
• Headache has at least two of the following
  characteristics unilateral location pulsating
  quality moderate or severe intensity
  aggravation by routine physical activity
• During headache at least one of the following
  occurs nausea and/or vomiting photophobia and
  phonophobia
• At least five attacks occur fulfilling the above
  criteria
• History, physical examination, and neurologic
  examination do not suggest any underlying organic
  disease

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Aura

• At least one of the following characteristics
  without motor weakness
• Fully reversible visual symptoms including
  positive features (eg, flickering lights, spots,
  or lines) and/or negative features (eg, loss of
  vision)
• Fully reversible sensory symptoms including
  positive features (eg, pins and needles) and/or
  negative features (eg, numbness)
• Fully reversible dysphasic speech disturbance
• Aura has at least two of the following
  characteristics
• Homonymous visual symptoms and/or unilateral
  sensory symptoms
• At least one aura symptom develops gradually over
  5 minutes and/or different aura symptoms occur
  in succession over 5 minutes
• Each symptom lasts 5 and 60 minutes

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Complications

• Chronic (gt15 days a month for gt 3 months in
  absence of drug overuse)
• Status migrainosus - gt 72 hr and debilitating
• Persistent aura without infarction aura gt 1 wk
• Migrainous infarction deficit gt 1 hr and
  positive imaging
• Migraine triggered seizure

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Acute therapy

• NSAIDs, combo Tylenol/ASA/caffeine, triptans,
  ergots like dihydroergotamine (DHE), opioids (but
  weak evidence only for butorphanol nasal and
  worry about abuse and transformation into chronic
  daily HA), IV metoclopramide.

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Preventive Tx can take as long as 2-3 months to
see benefit.

• Treat if gt2 a month that last gt 3 days of
  disability, contraindication to acute tx, gt 2
  times a week use of acute tx, presence of
  uncommon conditions
• Nonselective beta blockers propranolol studied
  the most
• TCA (better for mixed migraine and tension HA)
  like amitriptylline as others not studies as
  much limited evidence for fluoxetine
• Anticonvulsants - divalproex sodium and sodium
  valproate, limited evidence for gabapentin
• NSAIDs only naproxen with modest effect, but
  overuse syndrome
• Serotonergic agent ergot like DHE

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• Keep a headache diary of related activities and
  triggers!

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Cluster Headache

• trigeminal autonomic cephalalgias, which are
  short, unilat, severe with autonomic symptoms
  (ptosis, miosis, lacrimation, conjunctival
  injection, rhinorrhea, nasal congestion)

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• Prevalence - lt1
• Dx very typical. lt 3 hrs
• Tx Acute
• O2, triptans, octreotide, lidocaine (intranasal),
  ergot
• Preventive CCB like verapamil, glucocorticoids,
  lithium (limited evidence), topiramate
• Others less used pizotifen (anti
  serotonergic), valproic acid, capsaicin, ergot,
  melatonin, indomethacin, triptans

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Tension type headache (TTH)

• Most common
• Types infrequent episodic (lt 1 /month), freq
  episodic (1-14/month), and chronic (gt 15 days a
  month)
• PP multifactorial. Normally innocuous stimuli
  are interpreted as pain in the dorsal horn
  neurons. Some genetic role. Women slightly more
  than men. Blacks less than whites.

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Dx usually non descript!

• TTH is characterized by having at least two of
  the following four features
• The location of the pain is bilateral in either
  the head or neck
• The quality of the pain is steady (eg, pressing
  or tightening) and nonthrobbing
• The intensity of the pain is mild to moderate
• There is no aggravation of the headache by normal
  physical activity

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• In addition to these criteria, there must be at
  least 10 headache episodes fulfilling all other
  ICHD-2 criteria, which include the following
• The duration of pain is between 30 minutes to 7
  days
• The headache is not attributable to another
  disorder

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Tx

• Acute early tx, some may require a higher dose,
  avoid overuse, consider preventive. Tylenol,
  NSAIDs, ASA. Add some caffeine, but may get side
  effects. Butalbital and opioids generally not
  recommended.
• Preventive TCAs, Serotonin-NE reuptake
  inhibitors like venlafaxine, behavioral like CBT,
  relaxation, biofeedback

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References

• Uptodate.com
• Snow V, Weiss K, Wall EM, et al. Pharmacologic
  Management of Acute Attacks of Migraine and
  Prevention of Migraine Headache. Ann Int Med.
  2002. 137(10) 840-849.
• Clinch CR. Evaluation of Acute Headaches in
  Adults. Am Fam Physician. 2001. 63(4) 685-693.
• Tepper SJ, Spears RC. Acute Treatment of
  Migraine. Neuro Clinics 2009. 27(2) 417-427