Download - Acute Headache Diagnosis and Management
Acute HeadacheDiagnosis and Management
Dr Jas Dulay
Case presentation
• A 28-year-old woman presented with a 4-hour history of a bifrontal-temporal throbbing headache.
• The headache was initially mild and then progressed over about 1 hour to a severe intensity ( 10/10) the worst headache she had ever had, associated with nausea, vomiting, light and noise sensitivity.
• She had no visual symptoms, fever, or systemic symptoms.
• There was a history of occasional mild headaches relieved with Ibuprofen.
• No Past medical history . Observations were normal.
• The neurological examination was normal-including Fundi and neck exam(no neck stiffness).
• She was given sumatriptan 6 mg subcutaneously. The headache and associated symptoms resolved within 2 hours.
• Diagnosis?
Case presentationDiagnosis?
• SAH• TTH• Migraine headache• Medication overuse headache• IIH
Headache
• History from patient/ carer and examination
• Recognisable primary headache syndrome
• Evidence of CNS infection
• Acute onset headache syndrome– CT brain and CSF examination
– ? SAH
• Other causes of acute onset headache
Primary vs Secondary headache
• Migraine
• Tension type
• Cluster
Migraine
• 1. 1 in 7 people in the UK suffer from migraine.
• 2. M:F= 1:2
• 3.All age groups –commonly “productive years”
• 4. Migraine costs the UK more than £2 billion per annum.
• 5. The World Health Organisation has classified headache as a major health disorder and has rated migraine amongst the top 20 most disabling lifetime conditions.
• 6. A migraine attack can last for between 4 and 72 hours. However other migraine symptoms, such as mood changes and lethargy can last for longer as they can occur before or after the headache phase.
• 7. Sufferers experience an average of 13 attacks each year
• Ref: Migraine.org.uk
Pathophysiology
• Neurovascular– Neural events cause dilation of blood vessels
• A “dysfunction of brain-stem or diencephalic nuclei that are involved in sensory modulation of craniovascular afferents”
• – Goadsby et al NEJM 2002
Selected Diagnostic Criteria from International Headache Society Classification (ICHD-II)• 1.1 Migraine without aura
• Diagnostic criteria:
• A At least 5 attacks, 1 fulfilling criteria B–D
• B Headache attacks lasting 4–72 hours (untreated or unsuccessfully treated)
•• C Headache has at least two of the following characteristics:
• 1. unilateral location
• 2. pulsating quality
• 3. moderate or severe pain intensity
• 4. aggravation by or causing avoidance of routine physical activity (e.g walking or climbing stairs)
• D During headache at least one of the following:
• 1. nausea and/or vomiting
• 2. photophobia and phonophobia
• E Not attributed to another disorder
Migraine aura
• Migraine with aura or stroke?
• Visual, sensory,speech, motor(hemiplegic migraine)
• Usually marches, +ve or -ve
• Duration normally 10-30 mins, then headache
• Lasts less than 60 mins(except hemiplegic migraine)
Migraine - acute treatment
• ASA-900mg Paracetamol 1000mg
• NSAIDS-Ibuprofen/Naproxen
• Antiemetics-Domperidone/Metoclopramide
• Triptans
• Avoid opioids
• Prophylaxis:b-blockers Atenolol (BASH)• Amitriptyline,Topiramate,valproate
Mechanism of Action
• Triptans activate 5-HT (serotonin) receptor sites, causing
– cranial vasoconstriction
– peripheral neuronal inhibition
– inhibition of transmission through second-order neurons of the trigeminocervical complex
• Unclear which mechanism predominates
Triptans, the Treatment of Choice
• Many on the market now• Sumatriptan , almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan and zolmitriptan
• Advantages• Selective pharmacology, well established efficacy and safety, moderate side effects
• Disadvantages• Higher cost and C/I in CV disease
Triptans, cont.
• Side effects• Tingling, paraesthesias, warm sensations in chest, head, dizziness, neck pain, flushing, rare MI
• Contraindications• CAD, uncontrolled HTN, cerebrovasc dis, pregnancy, renal or liver dis, familial hemiplegic migraine, basilar migraine, Raynaud’s, MAO or ergots
• Efficacy: • 76% response rate at 10 mins after sumatriptan 6 mg Sc; 86-92% relief by 2 hours
Triptan Interactions
• Watch for rare possibility of serotonin syndrome if combining triptans and
SSRIs/SNRIs.
•• Almotriptan , eletriptan , frovatriptan , or naratriptan may be used with MAOIs.
• Use Zolmitriptan 2.5mg dose if given with cimetidine –cytochrome p450 1A2
• Avoid using eletriptan or DHE with other medications that are broken down by CYP3A4(e.g Clarithromycin)
• Use rizatriptan (Maxalt) 5mg dose if given with propranolol (Inderal).
TTH
• Episodic vs Chronic(>15days/mo)
• Featureless headache
• m/s abnormalities
• Treatment:
• regular exercise,physio,relaxation therapy
• Limited NSAIDS-Ibuprofen,Naproxen(250-500 bd-break cycle 3/52)
• Amitriptyline
• Treat concurrent depression
• Cognitive therapy
• Care with medication overuse headache(MOH)
Cluster headache-(TAC)• International Classification of Headache Diseases 2004• Severe unilateral pain lasting 15-180 minutes untreated.• At least one of the following, ipsilaterally:-• • Conjunctival injection and/or lacrimation• • Nasal congestion and/or rhinorrhoea• • Eyelid oedema• • Forehead and facial sweating• • Miosis and/or ptosis• • A sense of restlessness or agitation
• Frequency between one on alternate days to 8 per day.• Not attributable to another disorder• Smoking/Alcohol
• Treatment- oxygen, triptan(sumatriptan s/c, nasal),lignocaine(1ml-10%)
• Prophylaxis- verapamil 80 tds +,Pred 60 mg 2-5 days
CLUSTER HEADACHE
• The underlying pathophysiology of CH is incompletely understood
• The periodicity of the attacks suggests the involvement of a biologic clock within the
hypothalamus (which controls circadian rhythms), with central disinhibition of the
nociceptive and autonomic pathways—specifically, the trigeminal nociceptive
pathways.
• Positron emission tomography (PET) have identified the posterior hypothalamic gray
matter as the key area for the basic defect in CH.
• Functional hypothalamic dysfunction has been confirmed by abnormal metabolism
based on the N-acetylaspartate neuronal marker in magnetic resonance
spectroscopy.
Case
• A 60 year old man presented to the emergency department with nausea and vomiting after sudden onset of headache two days previously that had radiated to his cervical spine.
• PMH migraine since childhood
• He had associated dizziness and had fallen twice.
• On examination, he had blood pressure 180/88 mm Hg, Glasgow coma score 15, normal reactive pupils, and no other signs or focal neurology.He still had a 6/10 headache
• Blood tests showed a mild neutrophilia and mildly raised C reactive protein. His clotting and all other blood tests were normal
• What investigation next?
CT head
Acute onset headache‘thunderclap headache’
• Sudden headache of unusual severity reaching maximum intensity in a few seconds(<1min)
• Of patients with thunderclap headache 11-25% have SAH
• BMJ 2012;345:e8557 doi: 10.1136/bmj.e8557
Subarachnoid haemorrhagea few background details
• Women > men, 1.6:1
• ADPKD in only 2% of SAH
• 50% mortality, of survivors 30% dependent
• Only 70% say onset instantaneous
• GCS affected in 50%
Subarachnoid haemorrhageinvestigations
• CT brain
• Negative in 2-10% of SAH
• After a few days MRI superior
• CSF
• 12 hrs post onset in CT negative
• Spectrophotometry required - bilirubin
Subarachnoid haemorrhagegeneral management
• Refer to neurosurgical unit(GCS ready!)
• Attention to feeding and fluids
• Do not treat hypertension unless end organ damage
• Pain relief
• Compression stockings
• Nimodipine 60 mg 4 hrly for 3 weeks
• BMJ
• 2010;341:c5204 • Variables included in each of three proposed rules For each rule, patients
should be investigated if one or more of the variables are present
• Rule 1
• Age >40 Complaint of neck pain or stiffness Witnessed loss of consciousness Onset with exertion
• Rule 2
• Arrival by ambulance Age >45 Vomiting at least once Diastolic blood pressure >100 mm Hg
• Rule 3
• Arrival by ambulance Systolic blood pressure >160 mm Hg Complaint of neck pain or stiffness Age 45-55
High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study
The Ottawa SAH rule
• Investigate if 1 or more high-risk variables present:
• 1. Age >40 y
• 2. Neck pain or stiffness
• 3. Witnessed loss of consciousness
• 4. Onset during exertion
• 5. Thunderclap headache (instantly peaking pain)
• 6. Limited neck flexion on examination
• JAMA. 2013;310(12):1248-1255
Algorithm for approachingheadache in the ED
• History from patient/ carer and examination
• Recognisable primary headache syndrome
• Evidence of CNS infection
• Acute onset headache syndrome• CT brain and CSF examination
• ? SAH
• Other causes of acute onset headache
Acute onset headache‘thunderclap headache’
• Vascular disorders• Subarachnoid haemorrhage• Intracerebral haemorrhage• Venous sinus thrombosis• RCVS
• Infections• Meningitis / encephalitis
• Primary headache disorders• Crash migraine• Exertional or coital headache(HASA)• Cluster headache
• Rare causes• Pituitary apoplexy• Cervical artery dissection
TCH - Venous sinus thrombosis
• Headache onset usually sub acute but 10% of CVST present as TCH
• CT normal in over 50% presenting as headache and raised ICP
• MRI (V) investigation of choice
• OCP,IBD,post partum• Anticoag >=6 mo
RCVS
• RCVS affects patients of all ages and has a female preponderance.
• Recurrent thunderclap headaches or cryptogenic stroke, especially post partum /vasoactive drugs.
• Removal of precipitants such as vasoactive substances, lowering of blood pressure when highly increased(PRES), control of seizures
RCVS• Diagnostic criteria for Reversible Cerebral Vasoconstriction
Syndrome:
• • Acute and severe headache (often thunderclap) with or without focal deficits or seizures
• • Uniphasic course without new symptoms more than 1 month after clinical onset
• • Segmental vasoconstriction of cerebral arteries shown by indirect (eg, magnetic resonance or CT) or direct catheter angiography
• • No evidence of aneurysmal subarachnoid haemorrhage
• • Normal or near-normal CSF (protein concentrations <100 mg/dL, <15 white blood cells per µL)
• Complete or substantial normalisation of arteries shown by follow-up indirect or direct angiography within 12 weeks of clinical onset
• Lancet Neurol 2012; 11: 906–17
Previous names for reversible cerebral vasoconstriction syndrome
• Isolated benign cerebral vasculitis
• • Acute benign cerebral angiopathy
• • Reversible cerebral segmental vasoconstriction
• • Call or Call-Fleming syndrome
• • CNS pseudovasculitis
• • Benign angiopathy of the CNS
• • Post-partum angiopathy
• • Migraine angiitis
• • Migrainous vasospasm
• • Primary(idiopathic) thunderclap headache*
• • Cerebral vasculopathy
• • Vasospasm in fatal migrainous infarction
• Calabrese LH et al Ann Intern Med 2007; 146: 34–44.
RCVS
TCH – idiopathic thunderclapheadache
• Has been referred to as benign vascular headache, crash migraine, benign sexual (coital) headache type II
• Onset over 30 seconds, may last days
• 1/3 get recurrence with precipitants e.g. exercise, sexual activity
• 40% have history of migraine
• May have abnormal angiograms with alternating constriction and dilatation(RCVS)
Headache associated with sexualactivity (= coital headache)
• Usually men, usually bilateral• Type 1 – dull pain, increasing in intensity as sexual excitement increases –
associated with tensing of the face, neck, and shoulders• Type 2 – vascular type, onset at orgasm, usually fades by 2 hrs• 25-50% have had migraine or family history of migraine
Differentiated from SAH by duration of headache?(4-11% of SAH occurs during sexual activity)
• Usually no vomiting, meningism, focal symptoms• CT scan if first presentation• Responds to ß blockers
Related to benign exertional headache• Type 3 – like low pressure headache after LP - ? Due to dural tear
TCH - pituitary apoplexy
• Sudden infarction or haemorrhage into pituitary gland – usually adenoma
• Uncommon
• Headache, opthalmoplegia
• CT may be normal
TCH – cervical artery dissection
• Headache common presenting symptom in ICA dissection
• Headache and Horner’s think dissection
• 15% of ICA dissections may present as TCH
Other important Causes of headache
• GCA
• Glaucoma
• CO
• IIH