headache and associated emergencies
TRANSCRIPT
HEADACHE& associated emergencies
Dr Ahmad Shahir bin MawardiNeurology Registrar,
Neurology DepartmentHospital Kuala Lumpur
17th October 2016
Myths about HeadacheHeadache = Migraine
Headache = CT scan
1.Introduction 2.Classification of headache3.Red flag for headache4.Diagnosis of headache
• History, Examination, Ix5.Common causes of headache
• Migraine, TTH, CH,MOH6.Management
Outlines
lifetime prevalence of over 90% of the general population in the United Kingdom (UK)
It accounts for 4.4% of consultations in primary care and 30% of neurology outpatient consultations
Headache
Migraine occurs in 15% of the UK adult population women more than men in a ratio of 3:1
>100,000 people are absent from work or school because of migraine every working day.
migraine costs the UK almost £2 billion a year
Most frequent causes of consultation in GP and neurological clinics.
Introduction
Healthcare professionals often find the diagnosis of headache difficult but treatments can cause headache themselves
Most primary headache can be managed in primary care and investigations are rarely needed
When to refer?
ICH Disorders, 3 rd Edition
HEADACHEHEADACHE
Primary Secondary Neuralgias &other headaches
not associated with an underlying
pathology
attributed to an underlying
pathological condition
> 200 headache types> 200 headache types
ICH Disorders, 3 rd Edition
HEADACHEHEADACHE
Primary Secondary Neuralgias &other headaches
1. Migraine (+ aura)2. Tension-type headache 3. Trigeminal autonomic cephalalgias (CH, Paroxysmal hemicrania, Short-lasting unilateral neuralgiform headache attacks-SUNCT/SUNA, Hemicrania continua)4. Other primary headache disorders
1. Primary cough headache2. Primary exercise headache3. Primary headache associated with sexual activity4. Primary thunderclap headache5. Cold-stimulus headache6. External-pressure headache7. Primary stabbing headache8. Nummular headache9. Hypnic headache10.New daily persistent headache (NDPH)
4. Other primary headache disorders
ICH Disorders, 3 rd Edition
HEADACHEHEADACHE
Primary Secondary Neuralgias &other headaches
1. Migraine (+ aura)2. Tension-type headache 3. Trigeminal autonomic cephalalgias (CH, Paroxysmal hemicrania, Short-lasting unilateral neuralgiform headache attacks-SUNCT/SUNA, Hemicrania continua)4. Other primary headache disorders
ICH Disorders, 3 rd Edition
HEADACHEHEADACHE
Primary Secondary Neuralgias &other headaches
6. Headache attributed to cranial or cervical vascular disorder 7. Headache attributed to non-vascular intracranial disorder 8. Headache attributed to a substance or its withdrawal 9. Headache attributed to infection10. Headache attributed to disorder of homoeostasis 11. Headache or facial pain attributed to disorder of the cranium, neck,eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure12. Headache attributed to psychiatric disorder
ICH Disorders, 3 rd Edition
HEADACHEHEADACHE
Primary Secondary Neuralgias &other headaches
13. Painful cranial neuropathies and other facial pains 14. Other headache disorders
Patients may have more than one type of primary headache each headache type should be dealt with separately
secondary headache is rare
primary headache, findings on neurological examination are usually normal Ix are not helpful for diagnosis
Diagnosis of headache
1)History2)Physical examination3)Investigations
1) History of headache The history is all-important
Headache diary- pattern of headache
Excludes sinister causes of headcahe Intracranial tumor Meningitis Sudarachoid Haemorrhages Giant Cell Arteritis Primary angle-glaucoma Idiopathic Intracranial Hypertension Carbon Monoxide posioning
Weekly Headache Diary
1) History of headache
Red Flag of Headache (I)
1.new onset or change in headache in patients aged > 50
2.thunderclap: rapid time to peak headache intensity (seconds to 5 mins)
3. focal neurological symptoms (eg limb weakness, aura <5 min or >1 hr)
4.non-focal neurological symptoms (eg cognitive disturbance)
5.change in headache frequency, characteristics or associated symptoms
6.abnormal neurological examination
7.headache that changes with posture
Red Flag of Headache (II)8. headache wakening the patient up
9.headache precipitated by physical exertion or valsalva manoeuvre (eg coughing, laughing, straining)
10.patients with risk factors for cerebral venous sinus thrombosis
11.jaw claudication or visual disturbance
12. neck stiffness
13. fever
14. new onset headache in a patient with a history of HIV infection
15. new onset headache in a patient with a history of cancer.
2) Examination of headache
Neurological examination in patients first presenting with headache:
1.fundoscopy2.cranial nerve assessment, especially pupils, visual
fields, eye movements, facial power and sensation and bulbar function (soft palate, tongue movement)
3.assessment of tone, power, reflexes and coordination in all four limbs
4.plantar responses5.assessment of gait, including heel-toe walking.
3) Headache: Investigations majority of primary headaches do not require
neuroimaging
3) Headache: InvestigationsQ:When is neuroimaging required? individual basis Neuroimaging is not indicated in patients with a
clear history of migraine, without red flag features for potential secondary eadache, and a normal neurological examination.
Patient reassurance
3) Headache: InvestigationsQ: CT versus MRI? The European Federation of Neurological Societies guidelines
MRI is the imaging modality of choice because of this greater sensitivity
The US headache consortium MRI may be more sensitive than CT in identifying clinically
insignificant abnormalities, but not more sensitive in identifying clinically significant pathology
relevant to the cause of the headache.
Recomendation: Brain CT should be performed in patients with abnormal
neurological signs, unless the clinical history suggests MRI is indicated.
Brain MRI should be considered in patients with cluster headache, paroxysmal hemicrania or SUNCT.
Headache assessment tools1.Headache Impact Test (HIT /HIT 6)
www.headachetest.com
2. Migraine Disability Assessment (MIDAS)www.midasmigraine.net/edu/question/Default.asp
3. ID Migraine www.migraineclinic.org.uk
Types of headache Migraine Tension-type headache (TTH) Cluster headache (CH) Medication overuse headache (MOH)
Common types of headache
Migraine
1/3 of migraine sufferers
Recurrent headache disorder
4-72 hours.
Typical characteristics : unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.
Migraine with auraAura:
Visual blurring and “spots” progressive, last 5-60 minutes prior to headache transient hemianopic disturbance/ scintillating
scotoma can occur with:
unilateral paraesthesia,of hand, arm or face dysphasia functional cortical manifestations disturbance of one cerebral hemisphere
may occur without migraine aura persisting after resolution of the headache/aura
involving motor weakness-> further Ix familial hemiplegic migraine
Scintillating scotoma
Migraine with aura: Diagnostic criteria
Recurrent attacks, lasting minutes
unilateral
fully reversible visual, sensory or other central nervous system
symptoms develop gradually and are usually followed by headache and associated migraine symptoms.
Migraine without aura: Diagnostic criteria
Migraine
Migraine headache in children and adolescents is more often bilateral, unilateral pain usually emerges in late adolescence or early adult life.
Migraine headache is usually frontotemporal.
Possible Triggers of a Migraine Attack
Food and food additives
Bright lights/glareSmells/odors
Dieting/hungerLoud noises/soundsChanges in altitude/
air travel
StressWeather changesCaffeineAlcoholic beveragesChanges in sleep
habitsHormonal
fluctuations/ menstrual cycle
Wober C et al. J Headache Pain. 2006;7(4):188-195.Friedman DI and De Ver Dye T. Headache. 2009;49(6):941-952.
Tension type Headache
Episodic, very low frequency and short-lasting (< several hours)
Generalised but can be unilateral
Nature of pain: pressure or tightness,/tight band around the head spreads into or arises from the neck can be disabling for a few hours lacks of specific features and associated symptom
May be stress-related or a/w functional or structural cervical or cranial musculoskeletal abnormality.
Chronic TTH: >15 days a month, and may be daily
Diagnostic criteria: TTH
*Frequent episodic tension-type headache often coexistswith Migraine without aura.
Trigeminal Autonomic cephalalgias
rare characterised by attacks of severe unilateral pain in a
trigeminal distribution. a/w prominent ipsilateral cranial autonomic features.
Types1.Cluster headache is the most common (1 in 1,000). 2.Paroxysmal hemicrania (1 in 50,000)3.Short-lasting unilateral neuralgiform headache
attacks with conjunctival injection and tearing (SUNCT)
4.Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) .
very rare
TAC: Cluster headache
Severe, strictly unilateral pain. The pain is located in one or a combination of orbital,
supraorbital, or temporal regions.
Restless during an attack. Starts and ceases abruptly Duration: 15 minutes to three hours Frequency: EOD day to eight per day.
Striking circadian rhythm; 'attacks often occur at the same time each day and clusters occur at the same time each year'.
a/w ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema
and/or with restlessness or agitation
TAC: Cluster headache
TAC : Cluster headache (CH)
CH affects mostly men (male to female ratio 6:1)
Age 20s or older and very often smokers.
TAC : Short-lasting unilateral neuralgiform headache attacks
Attacks of moderate or severe, strictly unilateral head pain
Duration: seconds to minutes,
Frequency: at least once a day
usually a/w prominent lacrimation and redness of the ipsilateral eye
Trigeminal Autonomic cephalalgias
Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)
Short lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)
Features distinguishing TACs from migraine
Medication overuse headache (MOH)
> 15 or more days per month
developing as a consequence of regular overuse of acute or symptomatic headache medication for more than 3 months.
It usually, but not invariably, resolves after the overuse is stopped
Overused meds frequency/month duration
ergotamine >10 days >3 months
Triptan >10 days >3 months
paracetamol >15 days >3 months
acetylsalicylic acid >15 days >3 months
NSAIDs >15 days >3 months
opioid >10 days >3 months
combination analgesic medication >10 days >3 months
multiple drug classes not individually overused >10 days >3 months
unverified overuse of multiple drug classes >10 days >3 months
one or more medications other thanthose described above
>10 days >3 months
Medication overuse headache (MOH)
Mechanisms: not clear probably as a results in down-regulation of 5-HT1B/1D
receptors addictive properties changes in neural pain pathways
may take weeks to months for the headache to resolve after withdrawal.
Medication overuse headache (MOH)
Small amounts are sufficient to induce MOH >15 days a month or of codeine-containing analgesics, >10 or more days a month of ergot or triptans
Frequency is important: low doses daily carry greater risk than larger doses
weekly.
Nature of pain worst on awakening in the morning increases after physical exertion In the end-stage, headache persists all day, fluctuating with
medication use repeated every few hours.
Medication overuse headache (MOH)
Prophylactic medication aggravate the condition
Headache diary
The (presumptive) diagnosis made based on symptoms and drug used.
Confirmed when symptoms improve after medication is withdrawn.
Treatment for migraine: history
Aretaeus A.D. 81?
For the treatment of headache,
Aretaeus recommended
inducing sneezing by placing testicle of beaver powder
intranasally to “bring off phlegm”
Management- GeneralDuring consultation:1. Explanation of the diagnosis and reassurance
that other pathology has been excluded
2. the options for management
3. recognition that headache is a valid medical disorder with significant psychosocial impact
*headache diary (minimum of 8/52)
MIGRAINE WITH OR WITHOUT AURAAcute treatment
Monotherapy: oral triptan, NSAID, aspirin(900 mg) or paracetamol
Combination: Oral triptan + an NSAID/
Oral triptan + paracetamol.
Consider an anti-emetic even in the absence of nausea and vomiting.Do not offer ergots or opioids
If ineffective or not tolerated:IV NSAID or IV triptan + IV metoclopramide or prochlorperazine
Migraine
Triptans
Triptans provide significant pain relief to patients with acute migraine within two hours & improve patients’ QoL
Anti-emetics prochlorperazine 3-6 mg buccal tablets or domperidone 10 mg oral or 30 mg rectal metoclopramide 10 mg or * domperidone 20 mg *
are also useful as a prokinetic to promote gastric emptying
Caffeine?? Evidence was limited to the inclusion of
caffeine with combinations of other therapies
MIGRAINE WITH OR WITHOUT AURAProphylactic treatment
First line: Topiramate or propranolol
Review the meds after 6 months.
Diet: riboflavin (400 mg OD) may be effective in reducing migraine frequency and intensity for some people
MIGRAINE WITH OR WITHOUT AURAOther meds
Amitriptyline is widely used, off-label, to treat chronic painful disorders, including migraine. Inadequate evidence. If effective--> continue the current treatment
Pizotifen is a popular treatment for migraine prevention, been in use since the 1970s and appears to be well tolerated. Inadequate evidence.
Treatment of migraine during pregnancy: PCM
TENSION-TYPE HEADACHE Acute treatment
Aspirin, paracetamol or an NSAID Do not offer opioids
Prophylactic treatment Acupuncture (10 sessions over 5–8 weeks)
CLUSTER HEADACHEAcute treatment
Offer oxygen and/or a subcutaneous 6 mg or nasal triptan (if cannot tolerate subcute).
use 100% oxygen at a flow rate of at least 12 litres per minute with a non- rebreathing mask and a reservoir bag
Do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans
Prophylactic treatment
Verapamil 240-960 mg/day
Medication overuse headache Treated by withdrawing overused medication--> Explain,
explain, explain!!!
Advise: to stop all overused meds abruptly rather than gradually for < 1
month headache symptoms are likely to get worse in the short term before
they improve + withdrawal symptoms
Consider prophylactic treatment for the underlying primary headache disorder
Consider specialist referral for people who are using strong opioids withdrawal (Addiction team)
Review the diagnosis & mx 4–8 weeks after the start of withdrawal of overused medic
Headaches That Require Emergency Attention
Stroke (focal neurological deficit, nausea, vomiting)
Aneurysm (The worst headache ever!) subarachnoid hemorrhage (SAH)
Meningitis (fever & neck pain)
Subarachnoid hemorrhage
severe and sudden, peaking in seconds (thunderclap headache) or minutes.
mortality rate is 40–50% 10–20% of patients die
before arriving at hospital;
50% of survivors are left disabled
Subarachnoid hemorrhage
Subarachnoid hemorrhage
Plain CT scan, sensitivity of 98% in the first 12 hours after onset 93% at 24 hours 50% at 7 days)
Lumbar puncture (if CT results are non-diagnostic) Xanthochromia 100% of cases if collected between 12 hours
and 2 weeks
MRI is not indicated FLAIR and gradient-echo T2-weighted images may be
useful when the CT is normal and the CSF abnormal.
Subarachnoid hemorrhage
SAH is a neurointerventional emergency. the next urgent step
is to identify a ruptured aneurysm (80% of cases - ruptured saccular aneurysms).
References
Subarachnoid hemorrhage
Thank you