praphan yodnopaklow, m.d. surin hospitalลัักษณะการปวดเป นอย ......

Praphan Yodnopaklow, M.D.Surin Hospital

HeadacheHeadache Clearity terminologyClearity terminology

Hx, PE & NEHx, PE & NE(Key Questions, characters, temporal pattern)(Key Questions, characters, temporal pattern)Close F.U.Close F.U.

Not sureNot sureLook for warning sign& symptomLook for warning sign& symptom

Secondary HeadacheSecondary Headache

AcuteAcuterecurrentrecurrentHeadacheHeadache

Chronic Chronic dialydialyHeadacheHeadache

PrimaryPrimaryshortshort--livedlivedHeadacheHeadache

•• OthersOthers•• check for check for

coco--mormid disordersmormid disorders

Systemic Extracranial NeuralgiaSystemic Extracranial Neuralgia

IntracranialIntracranialMeingealMeingealirritationirritation

ICPICP ICPICP

++ Localizing signs & symptomLocalizing signs & symptom

InvestigationsInvestigations

Primary HeadachePrimary Headache

Primary headache Secondary headachePrevalence Prevalence

Type (%) Type (%)

MigraineMigraine 1616 Systemic infectionSystemic infection 6363Tension typeTension type 6969 Head injuryHead injury 4 4 Cluster headacheCluster headache 0.10.1 SubarachnoidSubarachnoid <1<1

hemorrhagehemorrhageIdiopathicIdiopathic 22 Vascular disordersVascular disorders 11stabbingstabbingExertionalExertional 11 Brain tumorBrain tumor 0.10.1

* After data form Rassussen.* After data form Rassussen.

Common causes of headache*

Pitfall in Hx taking is about“attitude” in Hx taking

“The details of the case are important ; their analysis distinguishes the

expert from the journey man” Fisher’s Rules

การซกัประวัติการซกัประวัติpatient profile patient profile : age, sex, socioeconomic, occupation, : age, sex, socioeconomic, occupation,

psychosocial, lefe style psychosocial, lefe style clinical course : onset, sequence, progression, severityclinical course : onset, sequence, progression, severity

คาํถามสําหรับผูปวยปวดศีรษะคาํถามสําหรับผูปวยปวดศีรษะ1. ปวดศีรษะมานานเทาไหรเคยปวดมากอนหรือเปลา?1. ปวดศีรษะมานานเทาไหรเคยปวดมากอนหรือเปลา?2. ปวดมากขึ้นเรื่อย ๆ หรือเปลา?2. ปวดมากขึ้นเรื่อย ๆ หรือเปลา?3. ปวด ๆ หาย ๆ หรือปวดตลอดเวลา?3. ปวด ๆ หาย ๆ หรือปวดตลอดเวลา?4. ปวดบอยแคไหน (ช.ม./วนั/สัปดาห/เดอืน/ป) ?4. ปวดบอยแคไหน (ช.ม./วนั/สัปดาห/เดอืน/ป) ?5. ปวดนานเทาไหรในแตละครั้ง?5. ปวดนานเทาไหรในแตละครั้ง?6. ลักษณะการปวดเปนอยางไร?6. ลักษณะการปวดเปนอยางไร?

คําถามสําหรับผูปวยปวดศีรษะคําถามสําหรับผูปวยปวดศีรษะ7. เริ่มปวดที่บริเวณไหนกอน?7. เริ่มปวดที่บริเวณไหนกอน?8. อะไรทําใหปวดมากขึ้น อะไรทําใหปวนอยลง?8. อะไรทําใหปวดมากขึ้น อะไรทําใหปวนอยลง?9. แผกระจายหรือราวไปทีไ่หนบาง?9. แผกระจายหรือราวไปทีไ่หนบาง?10. มีสิ่งกระตุนใหเริ่มมีการปวดศีรษะหรือเปลา?10. มีสิ่งกระตุนใหเริ่มมีการปวดศีรษะหรือเปลา?11. ความรุนแรงสองการปวดมากนอยขนาดไหน?11. ความรุนแรงสองการปวดมากนอยขนาดไหน?12. มีอาการอื่นรวมดวยหรือเปลา?12. มีอาการอื่นรวมดวยหรือเปลา?13. เวลาปวดศรีษะทําอยางไร?13. เวลาปวดศรีษะทําอยางไร?14. เวลาเริ่มปวดมากขึ้น มากขึ้น ทีละนอยหรือทันททีันใด?14. เวลาเริ่มปวดมากขึ้น มากขึ้น ทีละนอยหรือทันททีันใด?

History : What For ?Temporal Patterns (clinical course, setting, Temporal Patterns (clinical course, setting, Natural Hx)Natural Hx)Seek for warning sign & symptom for Seek for warning sign & symptom for secondary Headachesecondary HeadacheMMapping for specific Headache Disorderapping for specific Headache DisorderFind coFind co--morbid or related factorsmorbid or related factors

Hypothesis : Diff DxHypothesis : Diff Dx

Key Questions Key Questions Key Physical ExamKey Physical Exam

Five Temporal Patterns of Headache Five Temporal Patterns of Headache Acute headacheAcute headacheSingle episode of head pain withoutSingle episode of head pain withouthistory of previous eventshistory of previous events

ChronicChronic--progressive headacheprogressive headacheGradual increase in frequencyGradual increase in frequencyand severityand severity

AcuteAcute--recurrent headacherecurrent headachePattern of head pain separated byPattern of head pain separated bysymptomsymptom--free intervalsfree intervals

ChronicChronic--nonprogressivenonprogressive(Or chronic(Or chronic--daily) daily) headacheheadacheFrequent or constant headacheFrequent or constant headacheMixed headacheMixed headacheAcuteAcute--recurrent headache (Usuallyrecurrent headache (Usuallymigraine) superimposed on a chronicmigraine) superimposed on a chronic--dialy background pattern (represent a dialy background pattern (represent a variant of chronicvariant of chronic--daily headache)daily headache)

TimeTimeSeve

ritySe

verity

TimeTimeSeve

ritySe

verity

TimeTimeSeve

ritySe

verity

TimeTimeSeve

ritySe

verity

TimeTimeSeve

ritySe

verity

first time or change pattern of headachefirst time or change pattern of headachesevere pain , “worst” headache ever experiencedsevere pain , “worst” headache ever experiencedsudden onsetsudden onsetprogressively worsening painprogressively worsening painonset, with exertion, coughing, straining or sexual activityonset, with exertion, coughing, straining or sexual activityonset after age 50 yearsonset after age 50 yearsrelated symptomsrelated symptoms

drowsiness, confusion, memory lossdrowsiness, confusion, memory losschronic malaise, myalgia, arthralgiachronic malaise, myalgia, arthralgiafeverfeverprogressive visual disturbancesprogressive visual disturbancesweakness, clumsiness, loss lf balanceweakness, clumsiness, loss lf balancenight pain that awake patient at nightnight pain that awake patient at nightwell localized head painwell localized head pain

characteristic of headache indication characteristic of headache indication possible organic causespossible organic causes

Headache begins after Headache begins after age 50age 50

Very sudden onset of Very sudden onset of headacheheadache

Headaches increase inHeadaches increase infrequency and severityfrequency and severity

NewNew--onset headache in onset headache in patient who has risk patient who has risk factors for HIV, cancerfactors for HIV, cancer

Headache with symptomsHeadache with symptomsor illness (fever, stiff neck, or illness (fever, stiff neck, rash) rash)

Focal neurologicalFocal neurologicalsymptoms or signs of symptoms or signs of disease (other than disease (other than typical aura)typical aura)

PapilledemaPapilledema

Headache following Headache following head traumahead trauma

DIAGNOSTIC ALARMS IN THE EVALUATION OF HEADACHE DISORDERSDIAGNOSTIC ALARMS IN THE EVALUATION OF HEADACHE DISORDERSTemporal arthritis, mass lesionTemporal arthritis, mass lesion

Subarachnoid hemorrhage, Subarachnoid hemorrhage, pituitary appoplexy, pituitary appoplexy, hemorrhage into a mass lesion orhemorrhage into a mass lesion orvascular malformation, mass lesion vascular malformation, mass lesion (especially posterior fossa)(especially posterior fossa)

Mass lesions, subdural hematoma, Mass lesions, subdural hematoma, medication overusemedication overuse

Meningitis (chronic or Meningitis (chronic or carcinomatous), braincarcinomatous), brainabscess (includingabscess (includingtoxoplasmosis), metastasistoxoplasmosis), metastasis

Meningitis, encephalitis, Lyme Meningitis, encephalitis, Lyme disease, systemic infection, disease, systemic infection, collagen vascular diseasecollagen vascular disease

Mass lesion, vascularMass lesion, vascularmalformation, stroke, malformation, stroke, collagen vascular diseasecollagen vascular disease

Mass lesion, pseudotumor, Mass lesion, pseudotumor, meningitismeningitis

Intracrenial hemorrhage, subdural Intracrenial hemorrhage, subdural hematoma, epidural hematoma, hematoma, epidural hematoma, posttraumatic headacheposttraumatic headache

Erythrocyte sedimentationErythrocyte sedimentationrate, neuroimagingrate, neuroimaging

Neuroimaging, lumbarNeuroimaging, lumbarpuncture, if CT is negativepuncture, if CT is negative

Neuroimaging, drug screenNeuroimaging, drug screen

Neuroimaging, lumbarNeuroimaging, lumbarpuncture, if neuroimagingpuncture, if neuroimagingis negativeis negative

Neuroimaging, lumbarNeuroimaging, lumbarpuncture, serologypuncture, serology

Neuroimaging, collagenNeuroimaging, collagenvascular evaluationvascular evaluation(including antiphospholipid(including antiphospholipidantibodies)antibodies)

Neuroimaging, lumbar Neuroimaging, lumbar puncturepuncture

Neuroimaging of brain, skull,Neuroimaging of brain, skull,and possibly cervical spineand possibly cervical spine

Pitfalls in Physical ExaminationToo many doctors do systemetic without Too many doctors do systemetic without

hypothesis physical examinatiionhypothesis physical examinatiionA A --To confirm hypothesis in diagnostic secondary headacheTo confirm hypothesis in diagnostic secondary headacheB B --To exclude mimicked primary headache To exclude mimicked primary headache

(secondary Headache)(secondary Headache)•• Migraine syndromeMigraine syndrome•• Tension type headacheTension type headache•• Myofascial painMyofascial pain

C C --screening for systemic diseasescreening for systemic disease

PHYSICAL EXAMINATION••Systemic examinationSystemic examination••Paracranial structure examinationParacranial structure examination••Neurological examinationNeurological examination

DEFINITE OR PROBABLE TYPE OF THAIDACHEDEFINITE OR PROBABLE TYPE OF THAIDACHE

1. Vita sign โดยเฉพาะ 1. Vita sign โดยเฉพาะ fever BPfever BP-- HTHT--2. Optic fundi & of 2. Optic fundi & of icpicp3. Extracranial structures3. Extracranial structures4. meningeal sign4. meningeal sign5. detection of “soft sign”5. detection of “soft sign”6. neuro examination6. neuro examination

การตรวจรางกายที่สําคัญนอกเหนือจากการตรวจรางกายที่สําคัญนอกเหนือจากgeneral Examinationgeneral Examination

MigraineMigraine

TensionTension--typetype

ClusterCluster

Mass lesionMass lesion

SubarachnoidSubarachnoidhemorrhagehemorrhage

TrigeminalTrigeminalneurolgianeurolgia

Giant Giant -- cell cell artheritisartheritis

DIFFERENTIAL DIAGNOSIS OF SELECTED HEADACHE DISORDERSDIFFERENTIAL DIAGNOSIS OF SELECTED HEADACHE DISORDERS

1010--3030

2020--5050

2020--4040

AnyAny

AdultAdult

5050--7070

> 55> 55

Hemicranial,Hemicranial,but demon but demon strates sidestrates side--shiftshift

BilateralBilateral

Unilateral peri/Unilateral peri/retroretro--orbitalorbital

AnyAny

Global, oftenGlobal, oftenoccipitonuchaloccipitonuchal

2nd2nd--3rd>1st 3rd>1st divisiondivision

Temporal, any Temporal, any regionregion

44--72 72 hourshours

30 minutes30 minutes-->>7days7days

1515--180 180 minutesminutes

VariableVariable

VariableVariable

Seconds, occurSeconds, occurin volleysin volleys

IntermittentIntermittentthen continuousthen continuous

ModerateModerate--severesevere

Dull ache; mayDull ache; maywax/wanewax/wane

ExcruciatingExcruciating

ModerateModerate

ExcruciationExcruciation

ExcruciatingExcruciating

VariableVariable

VariableVariable

VariableVariable

11--8x/day, noc8x/day, noc--turnal attacksturnal attacks

Intermittent, nocIntermittent, noc--turnal,upon arisingturnal,upon arising

Not applicableNot applicable

ParoxysmalParoxysmal

Constant? Worse Constant? Worse at nightat night

ModerateModerate--severesevere

Throbbing?Throbbing?Steady acheSteady ache

Vicelike, bandVicelike, band--like, pressurelike, pressure

Dull steadyDull steadythrobbignthrobbign

ExplosiveExplosive

ElectriclikeElectriclike

VariableVariable

Nausea, vomiting, Nausea, vomiting, photo/phono/osmophoto/phono/osmo--phobia, scotomata, phobia, scotomata, neurological deficitsneurological deficits(rarely)(rarely)

Nausea, photophobiaNausea, photophobiaor photophobia,or photophobia,no vomitingno vomiting

Ipsilaateral conjunctivalIpsilaateral conjunctivalinjection, lacrimation,injection, lacrimation,nasal congestion,nasal congestion,rhinorrhea, miosis,rhinorrhea, miosis,facial sweatingfacial sweating

Vomiting, nuchal rigidity,Vomiting, nuchal rigidity,neurological deficitsneurological deficits

Nausea, vomiting, nuchalNausea, vomiting, nuchalrigidity, loss of consciousness,rigidity, loss of consciousness,neurological deficitsneurological deficits

Facial trigger points,Facial trigger points,ipsilateral sposm of facialipsilateral sposm of facialmuscles (tic)muscles (tic)

Tender scalp arteries, Tender scalp arteries, polymyalgia rheumatica,polymyalgia rheumatica,jaw claudicationjaw claudication

Headache Age of ) Location Duration Frequency Severity Quality Associated FeaturesType onset (yr.) Timing

The bedside can be your laboratory, study the patient seriously.

Fisher’s Rules.

Investigations•• Systemic disease eg. ESRSystemic disease eg. ESR Giant cell arteritisGiant cell arteritis•• Neuroimaging eg. CTNeuroimaging eg. CT-- scan Intracranial, paracraniallesionscan Intracranial, paracraniallesion•• Lumbar puncture meningitisLumbar puncture meningitis•• Other : angiogram, venogram, sinus, bone etc.Other : angiogram, venogram, sinus, bone etc.

DEFINITE DIAGNOSIS OF HEADACHE TYPEDEFINITE DIAGNOSIS OF HEADACHE TYPEPrimary headachePrimary headache oror Secondary HeadacheSecondary HeadacheAcute TreatmentAcute Treatment Sysmptomatic treatmentSysmptomatic treatment

++Prophylactic Prophylactic TreattmentTreattment Treatment of specific causesTreatment of specific causesFollowFollow-- upup

Therapeutic response evaluationTherapeutic response evaluationLong term followLong term follow-- up of primary headacheup of primary headache

Temporal profile and headache features1. The “first or worst” headache (ask about Thunderclap heada1. The “first or worst” headache (ask about Thunderclap headache) che) 2. Subacute headache with increasing frequency or severity2. Subacute headache with increasing frequency or severity3. A progressive or new daily persistent headache Chronic dai3. A progressive or new daily persistent headache Chronic daily headachely headache4. Chronic daily headache4. Chronic daily headache5. Headache always on the same side5. Headache always on the same side6. Headache not responding to treatment6. Headache not responding to treatment

Demographics7. New7. New--onset headache in patients who have cancer or who test positive onset headache in patients who have cancer or who test positive for human for human

imunodeficiency virusimunodeficiency virus8. New8. New--onset headache after age 50onset headache after age 509. Patients with headache and seizures9. Patients with headache and seizures

Associated symptoms and signs10. Headache associated with symptoms and signs such as fever, s10. Headache associated with symptoms and signs such as fever, stiff neck, nausea, tiff neck, nausea,

and vomitingand vomiting11. Headaches other than migraine with aura associated with f11. Headaches other than migraine with aura associated with focal neuralgic ocal neuralgic

symptoms or signssymptoms or signs12. Headaches associated with papilledema, cognitive impairme12. Headaches associated with papilledema, cognitive impairment, or personality nt, or personality

changechange

Reasons to consider neuroimaging for headachesReasons to consider neuroimaging for headaches

Technology must remain the servantof the clinician and never become the master.

Bradly W.G.

Low cost Doctor Maxims

•• History taking is the Key to diagnosisHistory taking is the Key to diagnosis•• HypothesisHypothesis--based physical examination,based physical examination,

HxHx taking back and fortetaking back and forte•• The observation is the investigationThe observation is the investigation•• sharp shooter > sharp shooter > short gun> machine gunshort gun> machine gun

Hx & GE

SystemicSystemic••FeverFever••hypertensionhypertension••MetabolicMetabolic••Sleep Sleep apnoeaapnoea••etcetc

ExtracranialExtracranial••EyesEyes••ENTENT••DentistalDentistal••CergicalCergical spinespine••etcetc

Neuralgic painNeuralgic pain••trigeminaltrigeminal neuralgianeuralgia••etcetc

Warning sign & symptom Warning sign & symptom suspected secondary Headachesuspected secondary Headache

IntracvanialIntracvanialMeningealMeningeal ICPICP ICPICPIrritationIrritation ++Locallzing Locallzing signs & symptomssigns & symptoms

investigationsinvestigationsDiagnoses & treatmentDiagnoses & treatment

••Recurrent attacksRecurrent attacks••Symptoms free between the attacksSymptoms free between the attacks••Clinical syndromes IHS/* criteriaClinical syndromes IHS/* criteria••Physical examination normalPhysical examination normal••No organic causesNo organic causes••Exception : drug Exception : drug –– abuse headacheabuse headache*international headache society*international headache society

MIGRAINECRITERIACRITERIACLASSIFICATIONCLASSIFICATION

ClassicClassic(migraine c aura)(migraine c aura)

••Common (migrainesCommon (migrainesaura)aura)

••migraine variant ent ormigraine variant ent oraccompanymentaccompanyment

••complicated misrainecomplicated misraine••complication ofcomplication of

migrainemigraine

AURAAURA ATTACK POST ATTACLKATTACK POST ATTACLK

Opthalmopegie migraine, retinal migraine, Basilar Art migraine

PATHOGENESISPATHOGENESISRELATIONSHIP TO TENSION HEADACHERELATIONSHIP TO TENSION HEADACHE

Pitfall in Secondary Headache Management

•• Diagnosis is the key.Diagnosis is the key.•• Treatment is quite straight forward.Treatment is quite straight forward.

Causes of headache in the Emergency roomCauses of headacheCauses of headachePrimary headachePrimary headache

Refractory migraineRefractory migraineTension type headacheTension type headache

Secondary headacheSecondary headacheCerebrovascularCerebrovascular diseasediseaseBrain tumor and Brain tumor and granulomagranulomaMeningitisMeningitisParacranialParacranial lesionlesionSystemic diseaseSystemic diseaseCerebritisCerebritis and encephalitisand encephalitisSubduralSubdural hematomahematomaPseudotumorPseudotumor cerebricerebri

10%10%4%4%6%6%90%90%27%27%20%20%16%16%10%10%7%7%6%6%2%2%1%1%

PhanthumchindaPhanthumchinda K, J K, J NeurolNeurol 20022002

Conclusions•• Investigations for causes of headache are guidedInvestigations for causes of headache are guided

by history and information from physical by history and information from physical examinations.examinations.

•• Approach of patient with severe headache in theApproach of patient with severe headache in theemergency room should be performed in an emergency room should be performed in an organized fashionorganized fashion

PhanthumchindaPhanthumchinda K, J K, J NeurolNeurol 20022002

Systemic Infection or CNS infectionSystemic Infection or CNS infectionToxic vascular headacheToxic vascular headache

Headache attributed to disorder of homeostasis

HypothyroidHypothyroidFastingFasting

Not sufficiently validated : anemia, Not sufficiently validated : anemia, hypercapniahypercapniapolycythemiapolycythemia, , hyperviscosityhyperviscosity syndrome, syndrome, cushingcushing’’ssdisease, SLE, etc.disease, SLE, etc.

Comment :Mild (140-159/90-99mmHg) or moderate (160-179/ 100-109 mmHg) chronic arterial hypertension does not appear to cause headsche. Whether moderate hypertension predisposes to headache at all remains controversial, but there is little evidence that it does.Ambulatory blood pressure monitoring in patients with mild and moderate hypertension has shown no convincing relationship between blood pressure fluctuation over a 24-hour period and presence or absence of headache.

Diagnostic criteria :

A. Recurrent headache with at least one of the following characteristics and fulfilling criteria C and D :

1. Occurs on > 15 day per month2. Bilateral, pressing quality and not accompanied by

nausea, photophobia or phonophobia3. Each headache resolves within 30 minutes

B. Sleep apnoea (Respiratory Disturbance Index >= 5demonstrated by overnight polysomnography)

C. Headache is present upon awakeningD. Headache ceases within 72 hours, and does not

recur, after effective treatment of sleep apnoea

Diagnostic criteria :A. Recurrent mild headache, frontal and in the eyes

themselves, fulfilling criteria C and DB. Uncorrected or miscorrected refractive error (eg,

hyperopia, astigmatism, presbyopia, wering of incorrectglasses)

C. Headache and eye pain first develop in closetemporal relation to the refractive error, are absenton awakening and aggravated by prolonged visualtasks at the distance or angle where vision isimpaired

D. Headache ceases within 72 hours, and does notrecur, after effective treatment of sleep apnoea

Diagnostic criteria :A. Pain in the eye and behide or above it, fulfilling

criteria C and DB. Raised intraocular pressure,with at least one of

the following :

C. Pain develops simultaneously with glaucomaD. Pain resolves within 72 hours of effective

treatment of glaucoma

1. Conjunctival injection2. Clouding of cornea3. Visual disturbances

Diagnostic criteria :A. Pain in the eye and behind or around it, fulfilling criteria C and D

B. Ocular inflammation diagnosed by appropriate investigations

C. Headache develops during inflammation

D. Headache resolves within 7 days after relief of the inflammatory disorder

Diagnostic criteria :A. Frontal headache accompanied by pain in one ormore region of the face, ears or teeth and fulfilling criteria C and DB. Clinical, nasal endoscopic, CT and/or MRI imaging and/ or laboratory evidence of acute or acute-on-chronic rhinosinusitisC. Headache and/or facial pain develop simultaneously with onset or acute exacerbation of rhinosinusitisD. Headache and/or facial pain resolve within 7 days afterremission or successful treatment of acute or acute-on-chronic rhinosinusitis

Diagnostic criteria :A. Headache accompanied by pain in the teeth and/or jaw(s) and fulfilling criteria C and D

B. Evidence of disorder of teeth, jaws or related structures

C. Headache and pain in teeth and/or jaw(s) develop in close temporal relation to the disorder

D. Headache and pain in teeth and/or jaw(s) resolve within 3 months after successful treatment of the disorder

Diagnostic criteria :A. Recurrent pain in one or regions of the head and/or face fulfilling criteria C and DB. X-ray, MRJ and/or bone scintigraphy demonstrate TMJ disorderC. Evidence that pain can be atrributed to the TMJ disorder, based on at least one of the following

D. Headache resolves within 3 months, and does not recur, after successful treatment of the TMJ disorder

1. Pain is precipitated by jaw movements and/or chewing of hard or tough food2. Reduced range of or irregular jaw opening3. Noise from one or both TMJs during jaw movements4. Tendache of the joint capsule(s) of one or both TMJs

Symptoms and signs in giant cell arteritisHeadacheHeadacheFatigueFatigueMyalgiaMyalgiaArthralgiaArthralgiaDepressed moodDepressed moodJaw Jaw claudicationclaudicationFeatures of the temporal arteryFeatures of the temporal artery

tendermesstendermessindurationindurationdiminished or absent pulsediminished or absent pulse

Diagnostic criteria :A. Headache, no typical characteristics known, fulfilling criteria C and DB. Head trauma with at least one of the following:

C. Headache develops within 7 days after head trauma or after regaining consciousness following head traumaD. One or other of the following :

1. Loss of consciousness for >30 minutes2. Glasgow Coma Scale (GCS) <133. Post-traumatic amnesia for >48 hours 4. Imaging demonstration of a traumatic brain lesion (cerbral haematoma,

intracerebral and/or subarachnoid haemorrhage, brain contusion and/or skullfracture )

1. Headache resolves within 3 months after head trauma 2. Headache persists but 3 monts have not yet passed since head trauma

Diagnostic criteria :A. Headache, no typical characteristics known, fulfilling criteria C and DB. History of whiplash (sudden and significant acceleration/decleration movement of the neck) associated at the time neck painC. Headache and pain in teeth and/or jaw(s) develop in close temporal relation to the disorder

D. Headache and pain in teeth and/or jaw(s) resolve within 3 months after successful treatment of the disorder

1. Headache resolves within 3 months after whiplash injury2. Headache persists but 3 months have not yet passed since

whiplash injury

Diagnostic criteria :A. Headache, no typical characteristics known, fulfilling criteria C and D

B. Head trauma with at least one of the following:

C. Headache develops within 7 days after head trauma or after regainingconsciousness following head trauma

D. Headache persists for > 3 months after head trauma

1. Loss of consciousness for >30 minutes2. Glasgow Coma Scale (GCS) <133. Post-traumatic amnesia for >48 hours 4. Imaging demonstration of a traumatic brain lesion (cerbral haematoma,

intracerebral and/or subarachnoid haemorrhage, brain contusion and/or skullfracture )

Diagnostic criteria :A. Progressive headache with at least one of the following characteristics and fulfilling criteria C and D :

B. Intracranial hypertension fulfilling the following criteria :1. alert patient with neurological examination that either is normal or

demonstrates any of the following abnormalities :a) papilloedemab) enlarged blind spotc) visual field defect (progressive if untreated)

d) sixth nerve palsy2. Incresed CSF pressure (>200 mm H2O in the non-obese, > 250 mm H2O in

the obese) measured by lumbar puncture in the recumbent position or by epidural or

1. daily occurrence2. diffuse and/or constant (non-pulsating) pain 3. aggravated by coughing or straining

3. normal CSF chemistry (low CSF protein is acceptable) and cellularity

4. Intracranial diseases (including venous sinus thrombosis) ruled out by appropriate investigations

5. no metabolic, toxic or hormonal cause of intracranialhypertension

C. Headache develops in close temporal relation to increased intracranial pressure

D. Headache improves after withdrawal of CSF to reduce pressure to 120-170 mm H2O and resolves within 72 hours of persistent normalisation of intracranial pressure

Treatment of idiopathic intracranial hypertension

1. Eliminate symptomatic causes.1. Eliminate symptomatic causes.2. Weight loss (if patient is obese).2. Weight loss (if patient is obese).3. Standard headache treatment.3. Standard headache treatment.4. Carbonic 4. Carbonic anhydraseanhydrase inhibitors and loop diuretics.inhibitors and loop diuretics.5. Short course of high dose 5. Short course of high dose corticosteroids.corticosteroids.6. Serial lumbar punctures.6. Serial lumbar punctures.7. 7. LumboperitonealLumboperitoneal or or ventriculoperitonealventriculoperitoneal shunt.shunt.8. Optic nerve sheath fenestration.8. Optic nerve sheath fenestration.

Diagnostic criteria :A. Headache that worsens within 15 minutes after sitting or standing and improves within 15 minutes after lying, with at least one of the following after fulfilling criteria C and D :

B. Dural puncture has been performedC. Headache develops within 5 days after dural puncture

1. spontaneously within 1 week2. within 48 hours after effective treatment of the spinal fluid leak (usually by

epidural blood patch)

1. neck stiffness 2. tinnitus 3. hypacusia

4. photophobai 5. nausea

D. Headache resolves either :

Treatment of low-CSF pressure headacheNonphamacologicNonphamacologic

Bed restBed restAbdominal Abdominal biderbider

Intravenous and oral Intravenous and oral phamacologicphamacologicCaffeine, Caffeine, theophylinetheophylineCorticosteroidsCorticosteroids, ACTH, ACTH

EpiduralEpidural interventionsinterventionsBlood patchBlood patchSodium chlorideSodium chlorideDextranDextran patchpatchInjection of fibrin glueInjection of fibrin glueMorphine Morphine sulphatesulphate

SugicalSugical repair of the leakrepair of the leak

Diagnostic criteria :A. Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, affecting one or more divisions of the trigeminal nerve and fulfilling criteria B and CB. Pain has at least one of the following characteristics:

C. Attacks are stereotyped in the individual patientD. There is no clinically evident neurological deficit

1. intense, sharp superficial or stabbing2. precipitated from trigger areas or by trigger factors

E. Not attributed to another disorder

Diagnostic criteria :A. Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, with or without persistence to 2 minutes, with or without persistence of aching between paroxysms, affecting one or more divisions of the trigeminal nerve and fulfilling criteria B and C B. Pain has at least one of the following characteristics :

C. Attacks are stereotyped in the individual patientD. A causative lesion, other than vascular compression, has been demonstrared by special investigations and/or posterior fossaexploration

1. intense, sharp superficial or stabbing2. precipitated from trigger areas or by trigger factors

Diagnostic criteria :A. Paroxysmal attacks of facial pain lasting from a fraction of second to 2 minutes and fulfilling criteria B and CB. Pain has all of the following characteristics :

C. Attacks are stereotyped in the individual patientD. There is no clinically evident neurological deficit

1. unilateral location2. distribution within the posterior part of the tongue, tonsillar fossa, pharynx

or beneath the angle of the lower jaw and /or in the ear3. sharp, stabbing and severe4. precipitated by swallowing, chewing , talking ,coughing and/or yawning

E. Not attributed to another disorder

Diagnostic criteria :A. Paroxysmal attacks of facial pain lasting from a fraction of a second to 2 minutes, with or without persistence of aching between paroxysms, and fulfilling criteria B and CB. History of whiplash (sudden and significant acceleration/declerationmovement of the neck) associated at the time neck pain

C. Attacks are stereotyped in the individual patientD. A causative lesion has been demonstrated by special investigations and/or surgery

1. unilateral location2. distribution within the posterior part of the tongue, tonsillar fossa, pharynx

or beneath the angle of the lower jaw and /or in the ear3. sharp, stabbing and severe4. precipitated by swallowing , chewing , talking , coughing and /or yawning

Resist the temptation to prematurely place a case or disorder into a diagnostic cubbyhole that fits poorly

Fisher’s Rules

Hx & PENo warning S & SNo warning S & S


Acute RecurrentAcute Recurrent Chronic dailyChronic daily ShortShort--livedlived�� MigraineMigraine�� Tension typeTension type�� ClusterCluster�� CoCo--Morbid etc.Morbid etc.

Close F.U. and look for warning S & SClose F.U. and look for warning S & S

Abbreviated International Headache Society criteria for the common primary headachesMigraine without auraMigraine without aura

Headache lasting 4 hours to 3 daysHeadache lasting 4 hours to 3 daysNausea/vomiting and /or light and noise sensitivityNausea/vomiting and /or light and noise sensitivityTwo of the following:Two of the following:

Unilateral painUnilateral painModerate or severe intensity painModerate or severe intensity painAggravation by simple physical activityAggravation by simple physical activityPulsating painPulsating pain

Migraine with auraMigraine with auraAt least 3 of the following :At least 3 of the following :

Reversible focal brainstem or cortical dysfunctionReversible focal brainstem or cortical dysfunctionAura develops over > 4 minutes, or 2 auras in successionAura develops over > 4 minutes, or 2 auras in successionEach aura Each aura < 60 minutes< 60 minutesHeadache < 60 minutes following auraHeadache < 60 minutes following aura

Episodic tensionEpisodic tension--type headachetype headacheDuration 30 minutes to 7 daysDuration 30 minutes to 7 daysAt least 2 of following :At least 2 of following :

Mild or moderate intensity painMild or moderate intensity painBilateral painBilateral painNo aggravation by simple physical activityNo aggravation by simple physical activityPressing or tight (nonPressing or tight (non--pulsating) pulsating) painpain

No nausea/vomiting; may have light or noise sensitivity (not boNo nausea/vomiting; may have light or noise sensitivity (not both)th)Chronic tensionChronic tension--type headachetype headache

> 15 days pain per month, for > > 15 days pain per month, for > monthsmonthsAt least 2 of the following :At least 2 of the following :

Mild or moderate intensity painMild or moderate intensity painBilateral painBilateral painNo aggravation by simple physical activityNo aggravation by simple physical activityPressing or tight (nonPressing or tight (non--pulsating) painpulsating) pain

No vomiting ; one only of nausea, light sensitivity, noise sensiNo vomiting ; one only of nausea, light sensitivity, noise sensitivitytivity

Primary short lasting headachesProminent autonomicfeatures Sparse or no autonomic featuresCluster headacheCluster headache Tigeminal neuralgiaTigeminal neuralgiaParoxysmal hemicraniaParoxysmal hemicrania *Idiopathic stabbing headache*Idiopathic stabbing headacheSUNCT syndromeSUNCT syndrome Cough headacheCough headache

Benign exertional headache Benign exertional headache Headache associated with sexualHeadache associated with sexualactivityactivityHypnic headacheHypnic headache

* Likely to be renamed primary stabbing headache when the Internatinal Headache Society classification is revised.

Headaches must have each of:Headaches must have each of:Severe unilateral orbital, supraorbital, temporal pain Severe unilateral orbital, supraorbital, temporal pain lasting 15 minutes to 3 hourslasting 15 minutes to 3 hoursFrequency :1 every second day to 8 per dayFrequency :1 every second day to 8 per dayAssociated with 1 of:Associated with 1 of:

lacrimationlacrimationnasal congestionnasal congestionrhinorrhearhinorrheaforehead/facial sweatingforehead/facial sweatingmiosismiosisptosisptosiseyelid oedemaeyelid oedemaconjunctival injection or conjunctival injection or sense of restlessness or agitation during headache*sense of restlessness or agitation during headache*

Diagnostic features of cluster headache modified from the international Headache Society with

the proposed changes

MANAGEMENTPATIENT WILLINGPATIENT WILLING --medication advice (66%)medication advice (66%)

--explanation of causes of their headache (55%)explanation of causes of their headache (55%)--attentive listening (43%)attentive listening (43%)--reassure about the absence of serious dz.(40%)reassure about the absence of serious dz.(40%)

PRINCIPLE OF THE HEADACHE TREATMENTPRINCIPLE OF THE HEADACHE TREATMENT�� making and accurate diagnosismaking and accurate diagnosis�� reassuring the patientreassuring the patient�� educationeducation�� non pharmacologic treatmentnon pharmacologic treatment�� pharmacologic treatmentpharmacologic treatment

Management (Primary Headache)

Abortive prophylactic

pharmaco Non-pharmaco pharmaco Non-pharmaco

Migraine Management : IntegratedMigraine Management : IntegratedTreatment ApproachTreatment Approach

ACUTE

PREVENTIVEPREVENTIVE BEHAVIORALBEHAVIORAL

Management Goals in Acute MigraineAcute phraseAcute phrase

พยายามรักษาอาการปวดโดยเร็วพยายามรักษาอาการปวดโดยเร็วหลีกเลี่ยงการใชยาแกปวดจํานวนมากและบอยครั้งหลีกเลี่ยงการใชยาแกปวดจํานวนมากและบอยครั้งเลือกยาทีม่ีผลขางเคียงนอยที่สุดและราคาไมแพงเลือกยาทีม่ีผลขางเคียงนอยที่สุดและราคาไมแพง

Preventive Preventive PhrasePhraseใชยากรณีที่มีอาการปวดถี่ใชยากรณีที่มีอาการปวดถี่ใชยาในระบบเฉยีบพลันไมไดผลใชยาในระบบเฉยีบพลันไมไดผลเกิดผลขางเคียงจากยาในระยะเฉียบพลันเกิดผลขางเคียงจากยาในระยะเฉียบพลันในภาวะไมเกรนบางอยางเชนในภาวะไมเกรนบางอยางเชน HemiplegicHemiplegic M, basilar M.M, basilar M.การใชยาปองกนัการใชยาปองกนั อาจตองใชเวลานานอาจตองใชเวลานาน 2 2-- 3 เดือน3 เดือน

Evidence summary for treatment of acute attacks of migraineDrugDrug

TriptansTriptans ((serotoninserotoninIB/ID receptor IB/ID receptor agonistsagonists))sumatriptansumatriptan nasal spraynasal spray

Oral Oral triptanstriptansNaratriptanNaratriptanRizatriptanRizatriptanSumatriptanSumatriptanZolmitriptanZolmitriptan

SumatriptanSumatriptan SCSC

Ergot alkaloids andErgot alkaloids andderivativesderivatives

DHE IVDHE IVDHE SC/IMDHE SC/IM

DHE IV plus DHE IV plus entimeticsentimetics

DHE nasal sprayDHE nasal spray

ErgotanineErgotanine

Quality of Quality of evidenceevidence

AA

AAAAAAAAAA

BBBB

BB

AA

BB

Scientific Scientific Effect*Effect*

++++++

++++++++++++++++++++++++++++

+++++++/+++++/++

++++++

++++

++

ClinicalClinicalimpressionimpressionof effect*of effect*

++++++

++++++++++++++++++++++++++++

++++++++++++

++++++

++++++

++++

Adverse effectAdverse effect

OccasionalOccasional

InfrequentInfrequentOccasionalOccasionalOccasionalOccasionalOccasionalOccasionalFrequentFrequent

FrequentFrequentOccasionalOccasional

FrequentFrequent

OccasionalOccasional

FrequentFrequent

Role (by consensusRole (by consensus))

Moder5ateModer5ate--toto--severe migraine.severe migraine.Useful when Useful when nonormalnonormal routerouteneeded. Less severe migraineneeded. Less severe migrainewhen when nonopiatenonopiate medicationsmedicationsfall.fall.

ModerateModerate--toto--severe migraine.severe migraine.Less severe migraine whenLess severe migraine whenNonopiateNonopiate medications fall.medications fall.

ModerateModerate--toto--severe migraine.severe migraine.Useful when normal routeUseful when normal routeneeded. Less severe migraineneeded. Less severe migrainewhen when nonopiatenonopiate medications medications fall.fall.

Low recurrence.Low recurrence.ModerateModerate--toto--severe migraine.severe migraine.Less severe migraine whenLess severe migraine whenNonopiateNonopiate medications fall.medications fall.

Status Status migrainosus.migrainosus. TherapyTherapyof choice in emergencyof choice in emergencydepartment.department.

ModerateModerate--toto--severe migraine.severe migraine.Less severe migraine whenLess severe migraine whennonopiatenonopiate medications fall.medications fall.

Low recurrence.Low recurrence.Consider for selected patientsConsider for selected patientswith moderatewith moderate--toto--severesevereMigraine.Migraine.


ErgotamineErgotamine plus caffeineplus caffeineAntiemeticsAntiemeticsCholorpromazineCholorpromazine IM/IVIM/IVMetoclopramideMetoclopramide IMIMPR/IVPR/IVProchlorperazineProchlorperazine PR/IMPR/IMIVIV

NSAIDsNSAIDs and and nonopiatenonopiateanalgesicsanalgesicsAcetaminophenAcetaminophenKetorolacKetorolac IMIMOral Oral NSAIDsNSAIDsAspirinAspirinDiclofenacDiclofenac KKFlurbiprofenFlurbiprofenIbuprofenIbuprofenNoproxenNoproxenNaproxenNaproxen sodiumsodium

Combination analgesicsCombination analgesicsAcetaminophen, aspirin,Acetaminophen, aspirin,

caffeinecaffeine


C/BC/BBBBBBBBB

BBBB

AABBBBAABBAAAA


++++++++++++++++++++++

00++

++++++++++++++++++++++++++


++++++

?/++?/+++/+++/++++++++

++++++

++++++++++++++++++++++++++++


Mild toMild tomoderatemoderateInfrequent to Infrequent to OccasionalOccasional

OccasionalOccasionalFrequentFrequent

InfrequentInfrequentInfrequentInfrequent

InfrequentInfrequent


Adjunct therapy. May be choiceAdjunct therapy. May be choiceforacuteforacute therapy.therapy.

Adjunct therapy. May be choiceAdjunct therapy. May be choicefor acute therapy.for acute therapy.

IM/IV adjunct firstIM/IV adjunct first--line therapyline therapyin emergency department orin emergency department oroffice ; office ; considreconsidre PR as adjunct.PR as adjunct.

Pregnant migraine.Pregnant migraine.Consider in emergencyConsider in emergencydepartmentdepartment


Barbiturate Barbiturate hypnoticshypnoticsButalbitalButalbital, ASA, caffeine, ASA, caffeine

ButalbitalButalbital, ASA, caffeine,, ASA, caffeine,codelinecodeline

Opiate analgesicsOpiate analgesicsButorphanolButorphanol nasal spraynasal sprayOpiatesOpiates--oral combinationsoral combinationsAcetaminophen, codeineAcetaminophen, codeineOpiatesOpiates--parenteralparenteral

ButorphanolButorphanol IMIMMeperideneMeperidene IM/IVIM/IV

Other medicationsOther medicationsCorticosteroidsCorticosteroids

IV plus IV plus antiemeedicsantiemeedicsDexamethasoneDexamethasoneHydrocortisoneHydrocortisone

IsomethptensIsomethptens compoundcompoundLidocaineLidocaine ININ


CC

BB

AAAA

CombinationsCombinationsBB

CC

BBBB


??

++++

++++++++++

++++

++

++++++


++++++

++++++

++++++++++

++++

++++

++++??


OCCasionalOCCasional

FrequentFrequentOcasionalOcasional

FrequentFrequent

InfrequentInfrequent

InfrequentInfrequentFrequentFrequent


Occasional use for moderateOccasional use for moderate--toto--serve migraine. Limitserve migraine. Limituse due to risk of overuse.use due to risk of overuse.

Moderate to severe migraine ;Moderate to severe migraine ;rescue therapy. Limit use,rescue therapy. Limit use,

Moderate Moderate otot severe migraine;severe migraine;rescue therapy. Limit use.rescue therapy. Limit use.

Reserved for emergencyReserved for emergencydepartment use of department use of rescue medication.rescue medication.Limit use.Limit use.

Rescue therapy in statusRescue therapy in statusMigraine.Migraine.

MildMild--to moderate headache,to moderate headache,UncertainUncertain

Is Migraine Progressive?Migraine: chronic Illness

Migraine May be a Progressive Disorder••Risk factors includeRisk factors include

••Attack frequencyAttack frequency••Acute medication overuseAcute medication overuse••Duration of diseaseDuration of disease••Obesity, snoringObesity, snoring••Stressful life eventsStressful life events

•• Can preventive treatment modify migraine progression?Can preventive treatment modify migraine progression?

Principles of PreventionPharmacotherapy

Treatment Pitfalls•• Acute medication overuse may aggravate headachesAcute medication overuse may aggravate headaches

•• Inform patients about medication overuseInform patients about medication overuse•• Screen headache patients for medication overuseScreen headache patients for medication overuse

•• Patients often do not seek medical care until pain Patients often do not seek medical care until pain becomes frequent or intensebecomes frequent or intense•• Opportunity for intervention missedOpportunity for intervention missed

Consider Preventive Therapy If any of Consider Preventive Therapy If any of the Following Criteria Are Met:the Following Criteria Are Met:

1.1. Migraine significantly interferes with patients’ daily Migraine significantly interferes with patients’ daily routine,despiteroutine,despite acute treatmentacute treatment

2. Frequency of attacks (2. Frequency of attacks (>>3 month) with risk of acute 3 month) with risk of acute medication overusemedication overuse

3. Acute medications ineffective, 3. Acute medications ineffective, cotraindicatedcotraindicated, , troublesome troublesome AEsAEs, or overused, or overused

4. Patient preference4. Patient preference5. Presence of uncommon migraine conditions5. Presence of uncommon migraine conditions

-- HemiplegicHemiplegic migrainemigraine-- Basilar migraineBasilar migraine-- Migraine with prolonged auraMigraine with prolonged aura-- MigrainousMigrainous infarctioninfarction

53% of 53% of migraineursmigraineursmeet disability andmeet disability andFrequency criteria Frequency criteria

for preventionfor prevention

<5 of <5 of migraineursmigraineurs are on are on Preventive therapyPreventive therapy

47%28%

25%

Start with low dose and increase slowly Start with low dose and increase slowly Need adequate trial (1 to 2 months)Need adequate trial (1 to 2 months)Avoid drug overuse and interfering drugsAvoid drug overuse and interfering drugsEvaluate therapyEvaluate therapy-- Use calendarUse calendar-- Taper (and stop?) if headaches well controlledTaper (and stop?) if headaches well controlledAvoid Avoid pregnancepregnance-- Ascertain birth control useAscertain birth control use

Evaluate therapyEvaluate therapy

Preventive therapies for migraineTherapiesTherapies

AntiepilepticsAntiepilepticsCarbamazepineCarbamazepineDivalproexDivalproex sodium/sodium sodium/sodium valproatevalproateGabapentinGabapentinTopiramateTopiramate

AntidepressantsAntidepressantsTricyclicTricyclic antidepressantsantidepressants

AmitriptylineAmitriptylineNortiptylineNortiptylineProtriptylineProtriptylineDoxepinDoxepin, , imipramineimipramine

Selective Selective serotoninserotonin reuptakereuptake inhibitorsinhibitorsFluoxetineFluoxetineFulvoxamineFulvoxamine, , paoxetinepaoxetine, , sertralinesertraline

Monoamine Monoamine oxidaseoxidase inhibitorsinhibitorsPhenelzinePhenelzine

Other antidepressantsOther antidepressantsBupropionBupropion, , mirtazepinemirtazepine, , trazodonetrazodone,,

venlafxinevenlafxineBetaBeta--blockersblockersAtnololAtnololMetoprololMetoprololNadololNadololPropranololPropranololTimololTimolol


BBAAAACCAA

AACCCCCCBBCCCCCC

BBBBBBAAAA


++++++++++++++++??

++++++

++++++??????++??????

++++++++++++++++++++


00++++++++++++++++++++++

++++++++++++++++++++++

++++++++

++++++++++++++++++++++++


Occasional to frequentOccasional to frequentOccasional to frequentOccasional to frequentOccasional to frequentOccasional to frequentOccasional to frequentOccasional to frequent

FrequentFrequentFrequentFrequentFrequentFrequentFrequentFrequentOccasional to frequentOccasional to frequentOccasional to frequentOccasional to frequentFrequentFrequentOccasional to frequentOccasional to frequent

Infrequent to occasionalInfrequent to occasionalInfrequent to occasionalInfrequent to occasionalPropranololPropranolol to occasionalto occasionalInfrequent to occasionalInfrequent to occasionalInfrequent to occasionalInfrequent to occasional

GroupGroup

5511223a3a

113a3a3a3a3a3a223a3a3b3b3a3a

2222111111

? = not known ; NSAIDs = nonsteroidal anti-inflammatory drugs.

Preventive therapies for migraineTherapiesTherapies

Calcium channel Calcium channel blockersblockersDiltiazemDiltiazemNimodipineNimodipineVerapamilVerapamil

NSAIDsNSAIDsAspirinAspirinFenoprofenFenoprofenFlurbiprofenFlurbiprofenMefenamicMefenamic acidacidIbuprofenIbuprofenMefenamicMefenamic acidacidIbuprofenIbuprofenKetoprofenKetoprofenNaproxenNaproxen//naproxennaproxen sodiumsodium

SerotoninSerotonin antagonistsantagonistsCyproheptadineCyproheptadineMethysergideMethysergide

OtherOtherFeverfewFeverfewMegnesiumMegnesiumVitamin B2Vitamin B2


CCBBBB

BB

CCBBBB

CCAA

BBBBBB


??++++

++

??++++

??++++++

++++++

++++++


00++++++++

++

++++++

++++++++

++++++++


Infrequent to occasionalInfrequent to occasionalInfrequent to occasionalInfrequent to occasionalInfrequent to occasionalInfrequent to occasional

infrequentinfrequent

infrequentinfrequentinfrequentinfrequentinfrequentinfrequent

FrequentFrequentFrequentFrequent

infrequentinfrequentinfrequentinfrequentinfrequentinfrequent

GroupGroup

3a3a2222

22

3a3a2222

3a3a44

222222

? = not known ; NSAIDs = nonsteroidal anti-inflammatory drugs.

Take advantage of drugTake advantage of drug’’s side effectss side effectsUnderweight patient: Use flunarizineUnderweight patient: Use flunarizineOverweight : Use topiramateOverweight : Use topiramateInsomniac : Use TCAsInsomniac : Use TCAsElderly or cardiac patient : Use divalproex Elderly or cardiac patient : Use divalproex or topiramateor topiramateAthlete : Avoid Athlete : Avoid --blockersblockersβ

Comorbid and coexistent diseaseComorbid and coexistent diseaseTherapeutic opportunity to treat two disorders Therapeutic opportunity to treat two disorders with single drugwith single drug-- Hypertension or angina : Hypertension or angina : --blockerblocker-- Depression : TCA or SSRIDepression : TCA or SSRI-- Epilepsy or mania : divalproex or topiramateEpilepsy or mania : divalproex or topiramateTherapeutic limitationsTherapeutic limitations-- Depression : avoid Depression : avoid --blockerblockerβ

Preventive TreatmentPreventive TreatmentDrug Treatment : ChoicesDrug Treatment : Choices

DrugDrugNeuromodulatorsNeuromodulators

DivalprexDivalprex

TopiramateTopiramate

AntidepressantsAntidepressantsTCAsTCAs

--BlockersBlockers

Calcium channelCalcium channelAntagonistsAntagonists

EfficacyEfficacy

++++++++

++++++++

++++

++++++++

++++++

AEsAEs

++++

++++

++++

++++

++

RelativeRelativeContraindicationContraindication

Liver disease,Liver disease,Bleeding disordersBleeding disorders

Kidney stonesKidney stones

Mania, urinaryMania, urinaryRetention,Retention,Heart blockHeart blockAsthma, depression,Asthma, depression,Raynaud disease,Raynaud disease,diabetesdiabetesConstipation,Constipation,hypotensionhypotension

RelativeRelativeIndicationIndication

Mania, epilepsy,Mania, epilepsy,Anxiety disordersAnxiety disorders

Epilepsy, risk of weight Epilepsy, risk of weight gaingain

Other pain disorders,Other pain disorders,Depression, anxietyDepression, anxietyDisorders, insomniaDisorders, insomniaHypertension, angina,Hypertension, angina,Congestive heartCongestive heartFailureFailureMigraine with aura, Migraine with aura, Hypertension, angina, Hypertension, angina, asthmaasthma

Comorbid ConditionComorbid Condition

••Education of patientsEducation of patients••ComplianceCompliance••Acute medicationsAcute medications

••Choice of drugsChoice of drugs••Appropriate timeAppropriate time

••Preventive medicationsPreventive medications••Choice of drugsChoice of drugs••Duration of treatmentDuration of treatment••NonNon--pharmacologic treatmentpharmacologic treatment

••Side effects of drugsSide effects of drugs

••Patient educationPatient education••Understand diseaseUnderstand disease••Lifestyle modificationsLifestyle modifications••Avoid triggersAvoid triggers••Headache diaryHeadache diary•• NonNon--pharmacologic therapiespharmacologic therapies••Relaxation/Stress managementRelaxation/Stress management••BiofeedbackBiofeedback••AcupunctureAcupuncture••Cognitive Behavioral TherapyCognitive Behavioral Therapy••Massage/ice/heat/restMassage/ice/heat/rest

Disease ManagementDisease Management

••Migraine is common in neurological practiceMigraine is common in neurological practice••Most patients are referred or transferred from Most patients are referred or transferred from other physiciansother physicians

••Most patients are in productive life periodMost patients are in productive life period••Ergotamine is commonly used by physicians whileErgotamine is commonly used by physicians whileanalgesics is commonly used by neurologistsanalgesics is commonly used by neurologists

••Common coCommon co-- morbidity includes : dizzinessmorbidity includes : dizziness-- vertigo, vertigo, anxiety, sleep disturbanceanxiety, sleep disturbance

••Tricyclic antidepressants, betaTricyclic antidepressants, beta-- blockers and blockers and anticonvulsant are commonly used as prophylactic anticonvulsant are commonly used as prophylactic treatmenttreatment

••More than half of migraine sufferers need prophylactic treatmentMore than half of migraine sufferers need prophylactic treatment••A significant number of patients did not received appropriate A significant number of patients did not received appropriate prophylactic treatmentprophylactic treatment

Look For Warning sign & symptom


InvestigationsInvestigationsAcute Acute RecurrentRecurrent

Chronic DailyChronic DailyHeadacheHeadache

Chronic MigraineChronic MigraineChronic Tension typeChronic Tension typeAnalgesic InducedAnalgesic Inducedetc.etc.

Prevalence and Clinical Features of Chronic DailyHeadache in a Headache Clinic

200200 patients visiting patients visiting ChulalongkornChulalongkorn Headache Clinic were Headache Clinic were examinedexaminedSixty cases(27.3%) were diagnosed as suffering from chronic Sixty cases(27.3%) were diagnosed as suffering from chronic daily headache (male to female ration 1:5.7)daily headache (male to female ration 1:5.7)The average age of these patients was 3.27The average age of these patients was 3.27++9.6 years.9.6 years.Based on the International Headache Society (IHS)Based on the International Headache Society (IHS) criteria, criteria, 30% of patients with chronic daily tension30% of patients with chronic daily tension-- type could be type could be diagnosed as suffering from migraine and 36.7% from chronic diagnosed as suffering from migraine and 36.7% from chronic tensiontension-- type headache, whereas the remainder had combined type headache, whereas the remainder had combined features of both headache types and were not classifiablefeatures of both headache types and were not classifiable

Diffused steady pain was the most common headache type Diffused steady pain was the most common headache type reported (65%), however, associated feature characteristic reported (65%), however, associated feature characteristic of migraine were often noted.of migraine were often noted.These included photophobia (70%), These included photophobia (70%), phonophobiaphonophobia (56.7%) (56.7%) and nausea (43%)and nausea (43%)ThirtyThirty-- four cases (56.7%) reported that their headache couldfour cases (56.7%) reported that their headache couldbe aggravated by stress.be aggravated by stress.Daily use of analgesics was reported in 58.3% of cases Daily use of analgesics was reported in 58.3% of cases Conclusion : chronic daily headache is a common problem Conclusion : chronic daily headache is a common problem in headache clinic and analgesics abuses headache shouldin headache clinic and analgesics abuses headache shouldbe a major concern.be a major concern.

SrikiatkhachornSrikiatkhachorn A, A, PhanthumchindaPhanthumchinda K.K.Prevalence and clinical features of Prevalence and clinical features of

Chronic daily headache in a headache clinic. Chronic daily headache in a headache clinic. Headache 1997;37:277Headache 1997;37:277--8080

Primary>4 hours daily <4 hours daily Secondary

Chronic migraine*Chronic migraine* Chronic clusterChronic cluster PostPost-- traumatictraumaticheadacheheadache # Head injury# Head injury

# latrogenic# latrogenic# Post # Post -- infectiousinfectious

Chronic tension type Chronic paroxysmal Inflammatory, suchChronic tension type Chronic paroxysmal Inflammatory, suchheadache*headache* HemicraniaHemicrania as :as :

## Giant cell arthritisGiant cell arthritis## SarcoidosisSarcoidosis# # Behcet’s syndromeBehcet’s syndrome

HemicraniaHemicrania SUNCTSUNCT Chronic CNSChronic CNScontinua*continua* infectioninfectionNew daily persistentNew daily persistent Hypnic headacheHypnic headache Substance abuseSubstance abuseheadache*headache* headache*headache*

Classification of chronic daily headache

Headache classification for chronic daily headacheDaily or near daily headache lasting > 4 hours/day for> 15 days/mouth

1.8 Transformed migraine (TM)1.8 Transformed migraine (TM)1.8.1 with medication overuse1.8.1 with medication overuse1.8.2 without medication overuse1.8.2 without medication overuse

2.2 Chronic tension2.2 Chronic tension--type headache (CTTH)type headache (CTTH)2.2.1 with medication overuse2.2.1 with medication overuse2.2.2 without medication overuse2.2.2 without medication overuse

4.7 New daily persistent headache (NDPH)4.7 New daily persistent headache (NDPH)4.7.1 with medication overuse4.7.1 with medication overuse4.7.2 without medication oveeruse4.7.2 without medication oveeruse

4.8 Hemicrania continua (HC)4.8 Hemicrania continua (HC)4.8.1 with medication overuse4.8.1 with medication overuse4.8.2 without medication overuse4.8.2 without medication overuse

Revised criteria for chronic migraine1.8 Chronic migraine

A. Daily or almost daily (>15 days/month) head pain for>1month)B. Average headache duration for>4 hours/days (if untreated)C. At least one of the following:

1. History of episodic migraine meeting any HIS criteria 1.1 to 1.62. History of increasing headache frequency with decreasing severity of

migrainous features over at least 3 months3. Headache at some time meets HIS criteria for migraine 1.1 to 1.6 other

than durationD. Does not meet criteria for new daily persistent headache (4.7) or hemicrania

continua (4.8)E. At least one of the following:

1. There is no suggestion of one of the disorders listed in groups 5-112. Such a disorder is suggested, but it is ruled out by appropriate

investigations3. Such a disorder is present, but first migraine attacks do no occur in close

temporal relation to the disorder

Proposed criteria for Chronic tension-type2.2 Chronic tension-type headache

A. Average headache frequency > 15 days/month (180 days/year) with average duration of > 4 hours/day (if untreated) for 6 mouthsfulfillin criteria B-D listed below

B. At least 2 of the following pain characteristics:1. Pressing/tightening quality2. Mild or moderate severity (may inhibit, but does not prohibit,

activities)3. Bilateral location4. No aggravation by walking stairs or similar routine physical

activityC. History of episodic tension-type headache in the past (needs to

be tested)

Proposed criteria for Chronic tension-type2.2 Chronic tension-type headache

E. Both of the following:1. No vomiting2. No more than one of nausea, photophobia, or phonophobia

(needs to be tested)F. Does not meet criteria for hemicrania continua (4.8), new daily

persistent headache (4.7), or chronic migraine (1.8)G. At least one of the following:

1. There is no suggestion of one of the disorders listed in groups 5-11

2. Such a disorder is suggested, but it is ruled out by appropriate investigations

3. Such a disorder is present, but first headache attacks do notoccur in close temporal relation to the disorder

Chronic daily headache : key pointsChronic daily headache (CDH) implies headache on a daily or Chronic daily headache (CDH) implies headache on a daily or near daily basis, for 15 days or more a monthnear daily basis, for 15 days or more a monthCDH may be seen in both primary and secondary headache CDH may be seen in both primary and secondary headache forms; the latter need careful consideration, while the forms; the latter need careful consideration, while the primary forms are more commonprimary forms are more commonThe two most common forms of CDH are chronic migraine and The two most common forms of CDH are chronic migraine and chronic tension type headachechronic tension type headacheMedication overuse in a common complication issue in Medication overuse in a common complication issue in CDH ; it consists of using an acute attack treatment more CDH ; it consists of using an acute attack treatment more than two days a week regularly, usually with the dosethan two days a week regularly, usually with the doseescalating over timeescalating over timeStopping medication overuse will improve many but not all Stopping medication overuse will improve many but not all patients with CDH, although it is essential since concomitanpatients with CDH, although it is essential since concomitanttoveruse significantly reduces the effectiveness of headache overuse significantly reduces the effectiveness of headache preventative medicationspreventative medications

Ergotamine-overuse headacheDiagnostic criteria :Diagnostic criteria :

A. Headache present on >15days/month with at least one of A. Headache present on >15days/month with at least one of the following characteristics and fulfilling criteria C and the following characteristics and fulfilling criteria C and D:D:

1. Bilateral1. Bilateral2. Pressing/tightening quality2. Pressing/tightening quality3. Mild or moderate intensity3. Mild or moderate intensity

B. B. ErgotamineErgotamine intake on intake on >>10 days/month 10 days/month onaona regular basis regular basis forfor>>3 months3 months

C. Headache has developed or markedly worsened during C. Headache has developed or markedly worsened during ergotamineergotamine overuseoveruse

D. Headache resolves or reverts to its previous pattern within D. Headache resolves or reverts to its previous pattern within 2 months after discontinuation of 2 months after discontinuation of ergotamineergotamine

Triptan-Overuse headacheDiagnostic criteria :Diagnostic criteria :


1. predominantly unilateral1. predominantly unilateral2. pulsating quality2. pulsating quality3. Moderate or severe intensity3. Moderate or severe intensity4. Aggravated by or causing avoidance of routine physical 4. Aggravated by or causing avoidance of routine physical

activity (activity (egeg, walking or climbing stairs), walking or climbing stairs)5. Associated with at least one of the following :5. Associated with at least one of the following :

a) nausea and /or vomitinga) nausea and /or vomitingb) photophobia and b) photophobia and ponophobiaponophobia

B. B. TriptanTriptan intake (any formulation) on intake (any formulation) on >>10 10 days/month on a days/month on a regular basis for regular basis for >>3months3months

C. Headache frequency has markedly increased during C. Headache frequency has markedly increased during triptantriptanoveruseoveruse

D. Headache resolves or reverts to its previous pattern within D. Headache resolves or reverts to its previous pattern within 2 months after discontinuation of 2 months after discontinuation of triptantriptan

Analgesic-overuse headacheDiagnostic criteria :Diagnostic criteria :


1. Bilateral1. Bilateral2. Pressing/tightening (non2. Pressing/tightening (non-- pulsating) qualitypulsating) quality3. Mild or moderate intensity3. Mild or moderate intensity

B. Intake of simple analgesics onB. Intake of simple analgesics on>>15days month for>3 15days month for>3 montsmontsC. Headache has developed or markedly worsened during C. Headache has developed or markedly worsened during

analgesic overuseanalgesic overuseD. Headache resolves or reverts to its previous pattern within D. Headache resolves or reverts to its previous pattern within

2 months after discontinuation of analgesics2 months after discontinuation of analgesics

Management of Analgesic Rebound Headache

Discontinuation of the offending medicine to detoxificationDiscontinuation of the offending medicine to detoxification

break the cycle of headache by pharmacotherapentic agentsbreak the cycle of headache by pharmacotherapentic agentsInitiate prophylactic Initiate prophylactic pharmacotherapypharmacotherapyManagement of breakthrough headaches by spiff agentsManagement of breakthrough headaches by spiff agentsConcomitant behaviovot intervention and alternative medicineConcomitant behaviovot intervention and alternative medicine

Why treatment failsDiagnosis is incomplete or incorrectDiagnosis is incomplete or incorrect

An undiagnosed secondary headache disorder is presentAn undiagnosed secondary headache disorder is presentA primary headache disorder is misdagnosedA primary headache disorder is misdagnosedTwo or more different headache disorders are present Two or more different headache disorders are present

Important exacerbating factors may have been missedImportant exacerbating factors may have been missedMedication overuse (including overMedication overuse (including over-- thethe-- counter)counter)Caffeine overuseCaffeine overuseDietary or lifestyle triggersDietary or lifestyle triggersHormonal triggersHormonal triggersPsychosocial factorsPsychosocial factorsOther medications that trigger headachesOther medications that trigger headaches

Why treatment failsPharmacotherapy has been inadequatePharmacotherapy has been inadequate

Ineffective drugIneffective drugExcessive initial dosesExcessive initial dosesInadequate final dosesInadequate final dosesInadequate duration of treatmentInadequate duration of treatment

Other factorsOther factorsUnrealistic expectationsUnrealistic expectationsComorbid conditions complicate therapyComorbid conditions complicate therapyInpatient treatment requiredInpatient treatment required

Diagnostic features of cluster headache modified from the international Headache Society with

the proposed changes

Cluster headache has two key forms :Cluster headache has two key forms :Episodic ; occurs in periods lasting 7 days to 1 year Episodic ; occurs in periods lasting 7 days to 1 year separated by painseparated by pain--free periods lasting one month*free periods lasting one month*Chronic: attacks Occur for more than one year Chronic: attacks Occur for more than one year without remission or with remissions lasting less thanwithout remission or with remissions lasting less thanone month*one month*

Survival Guide : SGSG Define the problem (S)SG Define the problem (S)

SG Approach and diff DxSG Approach and diff Dx

-- Listen to the patientListen to the patient-- Clearify terminologyClearify terminology-- Sea taxtsSea taxts

-- Hypothesis basedHypothesis basedHx & PEHx & PE

-- Hypothesis basedHypothesis based-- Short gunShort gun-- Sharp shooterSharp shooter

SG CommonSG Commonthings (diseases)things (diseases)happen commonlyhappen commonly

TypicalTypicalpresentationpresentation

SG Rx and F.U.SG Rx and F.U.

Definite diagnosisDefinite diagnosis

SG Aware and R/OSG Aware and R/OSerious diseaseSerious disease

AtypicalAtypicalpresentationpresentationcoursecourse

SG InvestigationSG Investigation

11

22

3344

6655

Low Cost Doctor Maxims•• The doctor with macheine gunThe doctor with macheine gun•• The doctor with short gunThe doctor with short gun•• The sharp shooter doctorThe sharp shooter doctor

Hey! Hey! I’m too busy to make hypothesisI’m too busy to make hypothesis!!

Other substance overuse and with drawal

caffeinecaffeineopioidopioidexogenous hormoneexogenous hormonealcolholalcolholcocaine, cocaine, canabiscanabis, etc, etc

Diagnostic criteria :A. Recurrent non-pulsatile mild-to-moderate frontal headache

fulfiling criteria C and D

1. Intermittent blurred vision or diplopia2. Difficulty in adjusting focus from near to distant objects

or vice versa

B. Heterophoria or heterotropia has been demonstrated, withat least one of the following:

C. At least one of the following:1. Headache develops or worsens during a visual task,

epecially one that is tiring2. Headache is resolves within 7days, and does not recur,

after appropriate correction of visionD. Headache ceases within 72 hours, and does not

recur, after effective treatment of sleep apnoea

Diagnostic criteria :A. Recurrent mild headache, frontal and in the eyes

themselves, fulfilling criteria C and DB. Uncorrected or miscorrected refractive error (eg,

hyperopia, astigmatism, presbyopia, wering of incorrectglasses)

C. Headache and eye pain first develop in closetemporal relation to the refractive error, are absenton awakening and aggravated by prolonged visualtasks at the distance or angle where vision isimpaired

D. Headache ceases within 72 hours, and does notrecur, after effective treatment of sleep apnoea

Headache f sudden onsetPrimary headache disordersPrimary headache disorders

Crash migraineCrash migraineClusterClusterBenign Benign exertionalexertional headacheheadacheBenign orgasmic Benign orgasmic cephalgiacephalgia

Secondary headache disordersSecondary headache disordersAssociated with vascular disordersAssociated with vascular disordersUnrupturedUnruptured saccularsaccular aneurysmaneurysmSubarachnoidSubarachnoid haemorrhagehaemorrhageInternal carotid artery dissectionInternal carotid artery dissectionCerebral venous thrombosisCerebral venous thrombosisAcute hypertensionAcute hypertension

pressorpressor responseresponsephaeochromocytomaphaeochromocytoma

Associated with nonAssociated with non--vascular vascular intracranialintracranial disordersdisordersIntermittent hydrocephalusIntermittent hydrocephalusBenign Benign intracranialintracranial hypertensionhypertensionPituitary Pituitary appoplexyappoplexyCephatalicCephatalic apoplexyapoplexy

meningoencephalitismeningoencephalitisacute sinusitisacute sinusitis

Acute mountain sicknessAcute mountain sicknessDisorders of eyesDisorders of eyes

acute optic neuritisacute optic neuritisacute glaucomaacute glaucoma

Acute therapies for migraineGroup 1*Group 1*

SpecificSpecific

NaratriptanNaratriptan POPO

RizatriptanRizatriptan POPO

SumatriptanSumatriptan SC,SC,IN, POIN, PO

ZolmitriptanZolmitriptan POPODHE SC, IM,DHE SC, IM,IV, INIV, IN

NonspecificNonspecificAcetaminophen,Acetaminophen,

aspirin, plusaspirin, pluscaffeine POcaffeine PO

Aspirin POAspirin POButorphanolButorphanol ININButorphanolButorphanol ININIbuprofen POIbuprofen PONaproxenNaproxen sodiumsodiumPOPOProchlorperazineProchlorperazineIVIV

Group 2**Group 2**

Acetaminophen plusAcetaminophen pluscodeine POcodeine PO

ButalbitalButalbital, aspirin., aspirin.caffeine, pluscaffeine, pluscodeine POcodeine PO

ButorphanolButorphanol IMIM

Chlorpromazine IM. IVChlorpromazine IM. IV

DiclofenacDiclofenac K, POK, POFlurbiprofenFlurbiprofen, PO, PO

IsometheptenseIsometheptense CPD, POCPD, POKetopolacKetopolac IMIM

LidocaineLidocaine ININMeperidineMeperidine IM,IVIM,IVMethadone IMMethadone IMMetoclopramideMetoclopramide IVIV

NaproxenNaproxen POPOProchlorperazineProchlorperazine IM, PR IM, PR

Group 3***Group 3***

ButabitalButabital, plus, pluscaffeine POcaffeine PO

ErgotamineErgotamine POPO

ErgotamineErgotamine pluspluscaffeine POcaffeine PO

MetoclopramideMetoclopramide IM.IM.PRPR

Group 4****Group 4****

Acetaminophen POAcetaminophen PO

Chlorpromazine IMChlorpromazine IM

GranisetronGranisetron IvIv

LidocaineLidocaine IVIV

Group 5*****Group 5*****

DexamethasoneDexamethasone IVIV

Hydrocortisone IVHydrocortisone IV

* Proven, pronounced statistical and clinical benefit (at * Proven, pronounced statistical and clinical benefit (at two doubletwo double--blind, blind, placeboplacebo--controlled studies and clinical impression of effect).controlled studies and clinical impression of effect).

** Moderate statistical and clinical benefit (one double** Moderate statistical and clinical benefit (one double--blind, blind, placeboplacebo--controledcontroled study and clinical impression of effect).study and clinical impression of effect).

*** Statistically but not proven clinically or clinically but*** Statistically but not proven clinically or clinically but not proven statistically not proven statistically effective (effective (conflictionconfliction or inconsistent evidence).or inconsistent evidence).

**** Proven to be statistically or clinically ineffective (fai**** Proven to be statistically or clinically ineffective (failed efficacy versus led efficacy versus placebo)placebo)

***** Clinical and statistical benefits unknown (insufficient ***** Clinical and statistical benefits unknown (insufficient evidence available)evidence available)

Preventive therapties for migraineGroup 1*Group 1*

AmitriptylineAmitriptylineDivalproexDivalproex sodiumsodium

PropronololPropronolol//timololtimololFluoxetineFluoxetine ((racemicracemic))GabapentinGabapentin

Group 2**Group 2**

BB--blockersblockersAtenololAtenolol//metoprololmetoprolol//

nadololnadolol

CaCa--blockersblockersNimodipineNimodipine//verapamilverapamil

NASIDsNASIDsAspirin/Aspirin/fenoprofenfenoprofen//FlurbiprofenFlurbiprofen

KetoprofenKetoprofenMefenamicMefenamic acidacidNeproxenNeproxenNaproxenNaproxen sodiumsodium

OtherOtherFeverfewFeverfewMagnesium vitamin B2 Magnesium vitamin B2

Group 3***Group 3***

A:AntidepressantsA:AntidepressantsDoxepineDoxepine

FluvoxamineFluvoxamine

ImipramineImipramineMirtazepineMirtazepineNortriptylineNortriptylineParoxetineParoxetineProtriptylintProtriptylint

SertralineSertraline trazodonetrazodoneVenlafaxineVenlafaxineCyproheptadineCyproheptadineDiltiazemDiltiazemIbuprofenIbuprofenTiagabineTiagabineTopiramateTopiramateB:(side effect concerns)B:(side effect concerns)MethyklergfonovineMethyklergfonovine ((methylergometrinemethylergometrine))PhenelzinePhenelzine

Group 4****Group 4****

MethysergideMethysergide

Group 5*****Group 5*****

AcebjutololAcebjutololCarbamazepineCarbamazepine

ClomipramineClomipramine,,clonazepamclonazepam

ClonidineClonidineIndomethacineIndomethacineNicardipineNicardipineNifedipineNifedipinePindololPindolol

* Proven, pronounced statistical and clinical benefit (at * Proven, pronounced statistical and clinical benefit (at two doubletwo double--blind, placeboblind, placebo--controlled studies and clinical impression of effect).controlled studies and clinical impression of effect).** Moderate statistical and clinical benefit (one double** Moderate statistical and clinical benefit (one double--blind, placeboblind, placebo--controledcontroled study and clinical impression of effect).study and clinical impression of effect).*** Statistically but not proven clinically or clinically bu*** Statistically but not proven clinically or clinically but not proven statistically effective (t not proven statistically effective (conflictionconfliction or inconsistent evidence).or inconsistent evidence).**** Proven to be statistically or clinically ineffective (fa**** Proven to be statistically or clinically ineffective (failed efficacy versus placebo)iled efficacy versus placebo)***** Clinical and statistical benefits unknown (insufficient ***** Clinical and statistical benefits unknown (insufficient evidence available)evidence available)

Principles of PreventionPharmacotherapy

Treatment Pitfalls•• Acute medication overuse may aggravate headachesAcute medication overuse may aggravate headaches

•• Inform patients about medication overuseInform patients about medication overuse•• Screen headache patients for medication overuseScreen headache patients for medication overuse

•• Patients often do not seek medical care until pain Patients often do not seek medical care until pain becomes frequent or intensebecomes frequent or intense•• Opportunity for intervention missedOpportunity for intervention missed

Conclusions•• Acute severe headache is a common presenting Acute severe headache is a common presenting

symptoms of symptoms of intracranialintracranial diseases in the diseases in the emergency room.emergency room.•• Some diseases may be lifeSome diseases may be life--threatening conditionsthreatening conditions•• Characters of headache can usually differentiate Characters of headache can usually differentiate various various pathophysiologypathophysiology machanismsmachanisms which causewhich causeheadache.headache.•• Refractory migraine or severe tensionRefractory migraine or severe tension--typetypeheadache may mimic organic headache andheadache may mimic organic headache andusually need further investigations to rule outusually need further investigations to rule outorganic causes of headache.organic causes of headache.

PhanthumchindaPhanthumchinda K, J K, J NeurolNeurol 20022002กลับสูเมนูหลักกลับสูเมนูหลัก

praphan yodnopaklow, m.d. surin hospitalลัักษณะการปวดเป นอย ......

Documents