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  • 1. Headache Management in Family Practice
  • 2.
    • “ In Theory”
    • There is no difference between theory and practice.
    • “ In Practice”
    • There is!
  • 3. Approach
    • Top Down
    • Bottom Up
  • 4. Is it Brain Tumor?
  • 5. Brain tumor is Rare cause of headache?
    • Headache Incidence 5-15% in general population
    • Tumor incidence 50/100,000 per year
    • 1/200 patient with “tension or migraine headache ” may have tumor
  • 6. Headache is common in brain tumor
    • Headache as presenting symptom in 60% of tumor
    • 77% similar to tension headache
    • 9% Migraine like
    • 8% Classic brain tumor headache
  • 7. Other serious headache
    • Granuloma
    • Brain abscess
    • Chronic subdural hematoma
    • Benign intracranial hypertension
    • TB/Fungal meningitis
    • Temporal arteritis
  • 8. Is it a brain abscess?
    • Fever present in 50% of cases
    • Headache is present in 70% of cases
    • Focal neurological signs are seen if located in strategic location
    • Look for ear, sinus or systemic infection
    • Cyanotic heart disease in children
    • Immunocompromised state
  • 9.  
  • 10. Chronic subdural hematoma?
    • Common in elderly population
    • Indolent chronic headache without obvious neurologic signs or symptoms
    • 60% to 70% have a history of antecedent trauma, often trivial
    • Changes in personality or cognitive abilities
    • Focal and sometimes intermittent weakness, seizures, or sensory changes
    • Excessive sleepiness, lethargy, or decreasing level of consciousness
  • 11. Idiopathic intracranial hypertension
    • Common in fat adolescent and young women
    • Headache
      • dull, like pressure
      • Usually symmetrical
      • may be associated with visual disturbances
    • CT: normal or small ventricles
    • LP:
      • high pressure
      • normal cytology
      • headache better with CSF drainage
  • 12. What Investigations?
    • Neuroimaging
    • Lumber puncture
    • EEG- no role
  • 13. When Neuroimaging?
    • Decreased alertness or cognition
    • Onset of pain with exertion, coitus, coughing, or sneezing
    • Worsening under observation
    • Nuchal rigidity
    • Focal neurological signs
    • First headache in patient older than 50 years
    • Worst headache ever experienced
    • Headache not fitting a defined pattern
  • 14. When No Neuroimaging?
    • When all of the following are present:
      • History of similar headaches
      • Normal vital signs
      • Alertness and cognition intact
      • Supple neck
      • No neurological signs
      • Improvement in headache without analgesics or abortive medications
  • 15. CT or MRI ?
    • Headache producing lesion is large enough to be seen in CT
    • MR is better in differentiating tumors
    • Contrast helps in knowing the break of BBB
    • Acute bleed and Calcification seen better by CT
  • 16. (CT/MR) Normal Headache
    • Chronic continuous headache
      • Tension type headache
    • Chronic recurring headache
      • Migraine
      • Cluster/ chronic paroxysmal hemicrania
      • episodic tension type headache
  • 17. Migraine without aura (common migraine).
    • Headache attacks last 4 to 72 hours.
    • Headache has at least 2 of the following:
      • Unilateral location
      • Pulsating quality
      • Moderate or severe intensity (inhibits daily activity)
      • Aggravation by routine physical activity
    • During the headache, at least 1 of the following:
      • Nausea or vomiting
      • Photophobia and phonophobia
    • No organic cause found by history, PE, neurologic exam.
    Must have at least 5 attacks that meet the following criteria:
  • 18. Migraine with aura (classical migraine). Must have at least 2 attacks fulfilling the following criteria :
    • .At least 3 of the following are present:
      • One of more fully reversible aura symptoms indicating focal cerebral cortical or brainstem dysfunction.
      • At least one aura symptom develops gradually over more than 4 minutes.        
      • No aura symptom lasts more than 60 minutes (duration proportionally increases if >1 aura symptom present).
      • HA follows aura with free interval of less than 60 minutes (may begin before or with the aura). HA usually lasts 4 to 72 hours but may be absent.
    • No organic cause found by history, PE, neurologic exam.
  • 19. Treatment of Migraine
    • General. Taper off analgesics to prevent rebound HA and start preventive medications. Depression (if identified) needs to be treated.
    • Dietary changes.
      • Avoid monosodium glutamate, nitrates, and alcohol.
      • Spread out caffeine evenly.
    • Lifestyle changes.
      • Regular eating, sleeping, and exercise patterns.
    • 3. Behavioral therapies.
      • Biofeedback, stress management, and self-help groups.
  • 20. Acute therapy (outpatient).
    • Sumatriptan (Imitrex) 6 mg SQ; may repeat in 1 hour; maximum 12 mg/24 hours.
    • Contraindicated if concomitant CAD or uncontrolled hypertension.
    • Do not use if patient is given an ergot alkaloid in the last 24 hours. Many (up to 50%) will require rescue medicine because of Sumatriptan 2-hour half-life.
    • Oral Sumatriptan 50-100mg
    • Cafergot 1 or 2 tablets upto 4 tabs/attack or 10/week.
    • Ergotamine 2 mg PO or SL; repeat in 30 minutes up to 6 mg/24 hours or 10 mg/week.
    • NSAIDs. ibuprofen 400 to 800 mg PO TID or QID or Naproxen sodium 550 mg PO BID or TID with food.
    • Prochlorperazine 25 mg PR BID PRN can be used to abort the migraine at home.
    • Metaclopramide help gastric emptying and vomiting
  • 21. Acute therapy - Migraine
    • Prochlorperazine 10 mg IV.
    • Metoclopramide 5 to 10 mg IV Q8h. Often given with dihydroergotamine (DHE) to prevent DHE-induced nausea. May be combined orally with ASA.
    • NSAIDs (ketorolac [Toradol] 60 mg IM,
    • Dihydroergotamine (DHE) 0.75 mg IV
    • Meperidine 50 to 100 mg IM Q3h PRN.
    • Dexamethasone 4 mg IM or a short course of prednisone (40 to 60 mg PO QD), combined with analgesics above, if migraine continues >24 hours.
    • Sumatriptan (Imitrex); see above for dose. Oral sumatriptan also available but less effective.
  • 22. Migraine prophylaxis
    • Propranolol 20 to 60 mg PD
    • Verapamil 40 to 80 mg PD
    • Flunarin – 10-20mg PD
    • NSAIDs, especially useful for menstrual migraine.
    • Amitriptyline 10 to 200 mg PO QHS.
    • Cyproheptadine 2 to 4 mg PO HS Childhood
  • 23. Tension headache
    • a. Headache with at least 2 of the following:
      • Pressing or tightening quality
      • Mild or moderate intensity Bilateral location
      • No aggravation by routine physical activity
    • b. No organic cause found by history, PE, neurologic exam.
    • c. Tension headache is separated into two subtypes based on frequency:
    • Episodic
    •    Headache lasting 30 minutes to 7 days
    •    No nausea or vomiting with headache
    •    Photophobia and phonophobia are absent, or one but not the other is present
    •    At least 10 previous headaches as above, with number of headache days <180/year and <15/month
    • Chronic
    •    Headache averages 15 days/month (180 days/year), 6 months
    •    No vomiting
    •    No more than 1 of the following: nausea, photophobia, or phonophobia
  • 24. Cluster Headache
    • Severe unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 minutes untreated.
    • Headache is associated with at least 1 of the following on the pain side:
      • Conjunctival injection
      • Lacrimation
      • Nasal congestion
      • Forehead and facial sweating
      • Rhinorrhea
      • Miosis
      • Ptosis
      • Eyelid edema
    • Frequency of attacks ranges from 1 to 8 daily.
    • At least 5 attacks occur as above.
  • 25. Cluster Headache Rx
    • Acute treatment :
      • O2 - 6 to 8 L/min .
      • Nasal lidocaine 4% solution (15 drops) or 5% ointment (3 swabs) intranasally on ipsilateral side may be abortive.
      • Sumatriptan is especially effective for cluster headache because by definition they last <3 hours.
    • Prophylactic treatment.
      • Ergotamine,
      • Methy-sergide
      • Prednisone (60 mg QD for 1 week with a rapid tapering off),
      • Verapamil (80 to 160 mg TID),
      • Lithium carbonate 300 mg BID or TID,
      • Valproate 250 to 1500 mg
  • 26. Chronic paroxysmal hemicrania.
    • Severe unilateral orbital, supraorbital, or temporal pain always on the same side, lasting 2 to 45 minutes.
    • Attack frequency >5 a day for more than half the time (periods of lower frequency may occur).
    • Headache is associated with at least 1 of the following on the pain side:
      • Conjunctival injection
      • Lacrimation
      • Nasal congestion
      • Rhinorrhea
      • Eyelid edema
      • Ptosis
    • Absolute effectiveness of indomethacin (150 mg/day or less).
    • At least 50 attacks occur as above.
    • No organic cause found by history, PE, neurologic exam.
  • 27. Menstrual Migraine
    • ” True menstrual migraine,&quot; : 14% of migraineurs
    • 60-70% women migraine menstrual related
    • Related to low estrogen level
    • Estradiol patch 1-2/day for 7 days 1-2 days before expected headache.
    • NSAIDs for prevention and attack
  • 28. Oral Contraceptive and Migraine
    • Some women - migraine improves
    • C ommon ly - migraine worsen (immediate or delayed)
    • Sometime - migraines precipitates
    • D iscontinuation of OCs may not result in improvement for many months.
    • Even non-estrogen hormonal methods of birth control such as Depo-Provera injection seem to aggravate headaches in some women.
  • 29. Headache in Pregnancy
    • Pre-existing migraine can become worse during the first trimester of pregnancy and then disappear for the last two.
    • 25% of women with migraine will go through their pregnancy with their headache pattern unchanged.
    • Migraine can also appear for the first time during pregnancy or soon after giving birth
  • 30. Analgesic in Pregnancy
    • Acetaminophen B 
    • Caffeine B 
    • Fenoprofen, Ibuprofen, Meclofenamate, naproxen, Sulindac, Tolmetin
      • B
      • D if used in 3rd trimester
    • Aspirin
      • C Risk factor D if used in 3rd trimester
  • 31. Antiemitic in Pregnancy
    • Metoclopramide B 
    • Prochlorperazine, Promethazine, Chlorpromazine, Hydroxyzine, Trimethobenzamide C
  • 32. Migraine Pophylactics in Pregnancy
    • Amitriptyline, Nortriptyline, Imipramine D 
    •   Metoprolol (Lopressor) B 
    • Atenolol, Nadolol, P ropranolol C
      • Propranolol may cause intrauterine growth retardation, prematurity, hypotension
    • Verapamil C
  • 33. Post-partum headache
    • Cerebral venous thrombosis
    • Persistent headache seizure and coma
    • Diagnosed by MR venous angiography
    • Heparin is drug of choice even with hemorrhagic transformation
  • 34. Headache in Menopause
    • Headaches may r eappear
    • Commonly headaches reduces , and they often change in nature.
    • migraine with aura may continue to have the aura but without the subsequent headache.
    • Following natural menopause, 60% decrease
    • With surgical menopause 30% decreases
    • M enstrual migraine benefit most from menopause.
  • 35. Headache in elderly
    • Tumors
    • Subdural hematoma
    • Cervicogenic Headache
    • Obstructive airway disease with hypercapnea
    • Hypertension
    • Ocular: Glaucoma
  • 36. Therapeutic challenge in elderly
    • Reduced tolerance to medications
    • NSAIDs reduced renal clearance
    • Beta blockers, lethargy, hypotension
    • Tricyclic: confusional state
    • More contraindication; Heart failure, glaucoma, prostatism, Hypertension, depression
    • Methyldopa nitrates aggravates migraine
  • 37. Temporal arteritis
    • Seen at this age
    • Progressive headache with tender thickened temporal arteries and systemic symptom and raise ESR
    • Dramatic response to Steroid.
    • Stop if no response and biopsy negative
  • 38. Migraine with aura from TIA
    • It should be remembered that a diagnosis of migraine does not preclude a superimposed TIA.
    • Migraine aura TIA
    • Multiple previous episodes New event
    • Gradual onset Sudden onset
    • Short duration May last 24 hours
    • Progression and regression pattern No increasing and decreasing symptom pattern
  • 39. Hypnic headache
    • Onset out of sleep , in elderly
    • Bilateral, 30 to 60 minutes
    • Almost daily, Nausea 50%.
    • Respond dramatically to treatment.
    • 300 to 600 mg of lithium at bedtime
  • 40. Headache in ischemic CVD
    • 10-15% of Ischemic CVD have headache
    • May precedes ischemia by hours to days
    • Varies in severity, quality and duration
    • More common with large vessel occlusive disease them small vessel
    • Posterior circulation stroke have more headache than anterior.
  • 41. Cerebral arterial dissection
    • Onset temporally related to cervical manipulation, sustained exertion, or trauma
    • Sudden unilateral neck pain or headache with radiation to ipsilateral face, eye, or ear
    • Amaurosis fugax
    • Pulsatile tinnitus
    • Horner's syndrome without anhidrosis
    • Ipsilateral tongue weakness (hypoglossal nerve palsy) and dysgeusia
    • Cervical bruit or tenderness
    • Diplopia
    • Syncope
  • 42. Drug induced headache in elderly
    • Vasodilators, Antihypertensive
    • Sedatives
    • Brochodilators
    • Antiarrhythmic agents
    • Caffieine, Indomethacine, Propoxyphen
  • 43. Headache n children
    • Migraine
    • Migraine variants
    • Tumor
    • Hydrocephalus
  • 44. Migraine in children
    • With or without aura
    • Variants
      • benign positional vertigo
      • Basilar migraine
      • Ophthalmologic migraine
      • Cyclic vomiting
      • Benign torticollis
    • Hemiplegic migraine headache follows the hemiparesis, which lasts from hours to days.
    • Chromosome 9 that has been found in 50% to 60% of families
  • 45. Treatment of migraine in Children
    • Acute attack
      • NSAIDs, Sumatryptan, DHE
    • Prophylaxis
      • Beta blockers: 0.5-1mg/kg bd
      • Calcium channel blocker
      • Amitryptiline
      • 5HT2 antagonist: Cyproheptidine
  • 46. Emergency Headache
    • Subarachnoid hemorrhage
    • Bleed in a tumor
    • Intracerebral hematoma
    • Sudden obstruction of ventricle
    • Acute pyogenic meningitis/meningoencephalitis
  • 47. Subarachnoid hemorrhage
    • Sudden severe headache, “bolt out of blue”
    • Sentinel; a milder variety which clears in a day or two
    • Neck stiffness, photophobia
    • may have LOC
    • May have neurological deficit
    • Causes:
      • aneurysmal 75-80%
      • AVM, tumor bleed, coagulopathies
  • 48. Subarachnoid hemorrhage
    • CT scan:
      • Small bleed may be missed in CT (10%)
      • After 7 days CT may be normal in 50% cases
      • CSF examined if CT normal it should not precede CT
    • Lumber puncture:
      • opening pressure high
      • Definitive: RBC >100,000/cmm
      • Xanthochromia-develops in 1-2 days
    • MRI
      • sensitive for bleed >10 days old
      • useless for acute investigation
  • 49.  
  • 50. Bleed in a tumor
    • generally patients have preexisting
    • headache or neurological symptoms
    • Presents as a “stroke”
    • Usually in highly malignant tumors
      • metastasis
      • high grade glioma
      • pituitary apoplexy
  • 51.  
  • 52. Sudden obstruction of ventricles
    • with intra-ventricular tumor
      • colloid cyst
      • other intra-ventricular tumors
    • usually depressed sensorium
    • may be position related
    • history of tumor headache
  • 53. Thank You