Headache

ByWael Hamdy Mansy, MD

Assistant Professor of Clinical PharmacyKing Saud University

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!

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…

Primary, idiopathic headaches

• Tension type of headache• Migraine• Cluster headache• Other, rare types of primary headaches

Tension headache

• Renamed tension-type headaches by the International Headache Society in 1988, are the most common type of primary headaches.

• The pain can radiate from the neck, back, eyes, or other muscle groups in the body.

• Tension-type headaches account for nearly 90% of all headaches. Approximately 3% of the population has chronic tension-type headaches

• Tension –type headaches can be episodic or chronic.

• Episodic tension-type headaches occur 15 days a month.

• Chronic tension-type headaches 15 days or more a month for at least 6 months.

• Can last from minutes to days, months or even years, though a typical tension headache lasts 4-6 hs

Cluster headache• Nicknamed "suicide headache", is a neurological

disease that involves an immense degree of pain. • "Cluster" refers to the tendency of

these headaches to occur periodically, with active periods interrupted by spontaneous remissions.

• The cause of the disease is currently unknown. It affects approximately 0.1% of the population, and men are more commonly affected than women

Migraine Headache

Prevalence

• Familial• Young, healthy women; F>M: 3:1– 17 – 18.2% of adult females– 6 – 6.5% adult males

• 2-3rd decade onset… can occur sooner• Peaks ages 22-55.• ½ migraine sufferers not diagnosed.• 94% of patients seen in primary care settings

for headache have migraines

• Common misdiagnoses for migraine:– Sinus Headache (HA)– Stress HA

• Referral to ENT for sinus disease and facial pain.

• The International Headache Society (IHS) classifies migraine headache

• The IHS defines the intensity of pain with a verbal, four-point scale:

Number Pain Annotations

0 NO

1 Mild does not interfere with usual activities

2 Moderate inhibits, but does not wholly prevent usual activities

3 Severe prevents all activities

Migraine Definition• IHS Diagnostic criteria: migraine w/o aura

– HA lasting for 4-72 hrs– HA w/2+ of following:

• Unilateral• Pulsating• Mod/severe intensity.• Aggravated by routine physical

activity.– During HA at least 1 of following

• N/V• Photophobia• Phonophobia

• IHS criteria: Migraine/aura (3 out of 4)– One or more fully reversible aura

symptoms indicates focal cerebral cortical or brainstem dysfunction.

– At least one aura symptom develops gradually over more than 4 minutes.

– No aura symptom lasts more than one hour.

– HA follows aura w/free interval of less than one hour and may begin before or w/aura.

History, PE, Neuro exam show no other organic disease.

At least five attacks occur

Aura Mechanism• Cortical spreading depression

– Self propagating wave of neuronal and glial depolarization across the cortex• Activates trigeminal afferents

– Causes inflammation of pain sensitive meninges that generates HA through central/peripheral reflexes.

• Alters blood-brain barrier.– Associated with a low flow state in the dural sinuses.

• Auras– Vision – most common

neurologic symptom– Paresthesia of lips, lower face

and fingers… 2nd most common

– Typical aura• Flickering uncolored zigzag

line in center and then periphery

• Motor – hand and arm on one side

• Auras (visual, sensory, aphasia) – 1 hr

• Prodrome– Lasts hours to days…

MIGRAINE WITH AURA• DURING AURA: – VASOCONSTRICTION – HYPOPERFUSION

• DURING HEADACHE– VASODILATION– HYPERPERFUSION

BUT: AURA SYMPTOM IS NOT CONSEQUENCE OF VASOCONSTRICTION INDUCED HYPOPERFUSION

CUASE OF THE AURA: SPREADING DEPRESSION. THE VASOCONSTRICTION AND HYPOPERFUSION ARE CONSEQUENCES OF THE SPREADIND DEPRESSION

SPREADING DEPRESSIONAURA

VASOCONSTRICTION, HYPOPERFUSION

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%).

Clinical manifestations

• Clinical manifestations– Lateralized in severe attacks – 60-

70%– Bifrontal/global HA – 30%– Gradual onset with crescendo

pattern.– Limits activity due to its intensity.– Worsened by rapid head motion,

sneezing, straining, constant motion or exertion.

– Focal facial pain, cutaneous allodynia, GI dysfunction, facial flushing, lacrimation, rhinorrhea, nasal congestion and vertigo…

Precipitating factorsstresshead and neck infectionhead trauma/surgeryaged cheesedairyred winenutsshellfishcaffeine withdrawalvasodilatorsperfumes/strong odorsirregular diet/sleeplight

Treatment

• Abortive– Stepped– Stratified– Staged

• Preventive

Abortive Therapy• Reduces headache recurrence.• Alleviation of symptoms.• Analgesics

– Tylenol, opioids…• Antiphlogistics

– NSAIDs• Vasoconstrictors

– Caffeine– Sympathomimetics– Serotoninergics

• Selective - triptans• Nonselective – ergots

• Metoclopramide

Abortive care strategies• Stepped

– Start with lower level drugs, then switch to more specific drugs if symptoms persist or worsen.• Analgesics – Tylenol, NSAIDs…• Vasoconstrictors – sympathomimetics…• Opioids (try to avoid) - Butorphanol• Triptans – sumatriptan (oral, SQ, nasal), naratriptan, rizatripatan,

zomatriptan.– Limited by patient compliance.

• Stratified– Adjusts treatment according to symptom intensity.

• Mild – analgesics, NSAIDs• Moderate – analgesic plus caffeine/sympathomimetic• Severe – opioids, triptans, ergots…

– Severe sx treatment limited due to concomitant GI sx’s.• Staged

– Bases treatment on intensity and time of attacks.– HA diary reviewed with patient.– Medication plan and backup plans.

Preventive therapy• Consider if pt has more than 3-4 episodes/month.• Reduces frequency by 40 – 60%.• Breakthrough headaches easier to abort.• Beta blockers• Amitriptyline• Calcium channel blockers• Lifestyle modification.• Biofeedback.

Botox51% migraineurs treated had

complete prophylaxis for 4.1 months.

38% had prophylaxis for 2.7 months.

Randomized trial showed significant improvement in headache frequency with multiple treatments.

Conclusions

• Migraine is common but unrecognized.• Keep migraine and its variants in the

differential diagnosis.

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