HEADACHEPost Basic Neurosciences Course 2015

Dr Ahmad Shahir bin MawardiSpecialist Registrar,

Neurology DepartmentHospital Kuala Lumpur

1st October 2015

Myth about Headache

Headache = Migraine

Headache = CT scan

Outlines

1.Introduction 2.Classification of headache3.Diagnosis of headache

• History, Examination, Ix

4.Red flag for headche5.Common causes of headache

• Migraine, TTH, CH,MOH

6.Management of headache

Introduction

• Headache affects nearly everyone at least occasionally.

• Most frequent causes of consultation in GP and neurological clinics.

• 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.

The International Classification of Headache Disorders, 2nd Edition

HEADACHEHEADACHE

Primary Secondary Neuralgias &other headaches

The International Classification of Headache Disorders, 2nd Edition

HEADACHEHEADACHE

Primary Secondary Neuralgias &other headaches

•inflammation medium and large arteries. •involving branches of the carotid artery and the ophthalmic artery•Sx: headache, visualdisturbances & jaw claudication.

•blockage of the drainage of fluid from the eye. •Sx : headache,painful red eye and misty vision or haloes, nausea. •semi-dilated pupil

The International Classification of Headache Disorders, 2nd Edition

HEADACHEHEADACHE

Primary Secondary Neuralgias &other headaches

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

1) History of headache

Differential diagnoses

• Posterior headache- functional or structural derangement of the neck (cervicogenic headache)

• Acute exacerbation of chronic sinusitis

• Refraction Errors - mild, frontal, absent on waking & confined to eyes only

• Diseases of ears, temporomandibular joints or teeth

2) Examination of headache

• Normal most of time

• BP

• Fundoscopy- papiloedema

• Head and neck - muscle tenderness, stiffness, limitation in range of movement and crepitation

3) Investigations

• Neuroimaging (CT/MRI brain)– not required for diagnosis of migraine or tension-type headache.– history or examination suggest secondary headache – therapeutic value of convincing a patient

• Cervical spine x-rays

• Eye tests

Red Flag of Headache (I)1. Headache that is new or unexpected in an individual

patient

2. Thunderclap headache (intense headache with abrupt or “explosive” onset)

3. Headache with atypical aura (duration >1 hour, or including motor weakness)

4. Aura occurring for the first time in a patient during use of combined oral contraceptives

5. New onset headache in a patient older than 50 years

Red Flag of Headache (II)6. New onset headache in a patient younger than 10 years

7. Persistent morning headache with nausea

8. Progressive headache, worsening over weeks or longer

9. Headache associated with postural change

10. New onset headache in a patient with a history of cancer

11. New onset headache

Common types of headache

• Migraine• Tension-type headache (TTH)• Cluster headache (CH)• Medication overuse headache (MOH)

Common types of headache

Migraine with aura

• 1/3 of migraine sufferers

• Aura:– 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, and aura

involving motor weakness-> further Ix• familial hemiplegic migraine

Scintillating scotoma

Migraine

• Typical history– recurrent episodic moderate or severe headaches– unilateral and/or pulsating– duration: 4-72 hours– a/w GI symptoms– limit activity – prefer dark and quiet– symptoms free between attacks

Migraine without aura

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 (TTH)

• 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 tension-type headache: >15 days a month, and may be daily

Cluster headache (CH)

• CH affects mostly men – (male to female ratio 6:1)

• Age 20s or older and very often smokers.

• Typically headaches occur in bouts for 6-12 weeks, once a year or two years, often at the same time each year.

Cluster headache (CH)

• Nature of pain:– intense, unilateral– focused in one or other eye, --> spread over

• Occurs daily, at a similar time each day, always at night, 1-2 hours after falling asleep.

• Duration: 30-60 minutes

• Associated features:– ipsilateral conjunctival injection and lacrimation, – rhinorrhoea or nasal blockage– ptosis/ Horner’s syndrome

Medication overuse headache (MOH)

• Headache caused by overuse of medication – phenacetin, ergotamine, triptan– analgesics containing barbiturates, caffeine, and codeine– aspirin and paracetamol

• 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- General

During 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

Management- General

Headache diary (minimum of 8/52):

• frequency, duration and severity of headaches

• any associated symptoms

• all prescribed and over the counter medications taken to relieve headaches

• possible precipitants

• relationship of headaches to menstruation

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 WITH OR WITHOUT AURA

Prophylactic treatment

First line: Topiramate or propranolol

Alternative: Gabapentine, Acupuncture

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 AURA

Other 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 HEADACHE

Acute treatment

Offer oxygen and/or a subcutaneous or nasal triptan.

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

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

References

Thank you