Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Mellss med yr3 headache
2. 1) Tension- type Headache
2) TrigeminalAutonomic Cephalgias
a) Cluster headache
b) Paroxysmal hemicrania
c) SUNCT/SUNA
3) Chronic Daily Headache
4) Other Primary Headache
3. Chronic head-pain
syndrome
Diagnosis:
No nausea, vomiting,
photophobia,
phonophobia,
No throbbing sensation
No aggravation with
movement
Differential diagnosis :
MIGRAINE
Certain patient may
haveTTH with migraine
Characteristic
Site : Bilateral
Onset: Builds slowly
Character: Tight, bandlike discomfort
Timing: continuously for many days
or episodic or chronic (>15
days/m).
Severity Flunctuates
4. Pathophysiology :incompletely understood.
Due to a primary disorder of CNS pain
modulation or genetic .
Treatment
Simple analgesics (acetaminophen, aspirin, or
NSAIDs)
Relaxation
Triptans inTTH with migraine.
ChronicTTH :amitriptyline
5. Group of primary headaches
Cluster headache
Paroxysmal hemicrania
Sunct /suna
Differential diagnosis:
Sinus headache, trigeminal neuralgia, primary stabbing headache,
and hypnic headache
IncreasedTACs presentation may be due to pituitary tumor.
Charact
Associat
ion:
lacrimation, conjunctival injection,nasal
congestion
Timing: Short , occur > 1/d
Severity Severe
6. Rare (0.1%.)
M>F
Patients tend to move
during attacks (pacing/
rocking/ rubbing their
head for relief)
Unilateral photophobia/
phonophobia on the same
side of the pain
S •Unilateral,retroorbital,
O •50% nocturnal , explosive
C •deep , stabbing
A •ipsilateral conjunctival injection/
lacrimation /rhinorrhea /nasal congestion /
ptosis
T •recurs at same hour for same duration
•daily 1-2 short attacks X 8 - 10 w/y followed
by a pain-free interval (<1y)
•Chronic ( no period of sustained remission)
S •excruciating ,nonfluctuating,
7. Acute attack
100% oxygen at
10-12L/min for
15-20min
Sumatriptan
6mg SC
Nasal sprays
▪ Sumatriptan (20
mg)
▪ zolmitriptan (5
mg)
Short –term
prevention
Long-term prevention
Episodic cluster
headache
Episodic & prolonged
chronic cluster headache
Prednisone 1 mg/kg
up to
Verapamil 160–960 mg/d
60 mg qd, tapering Lithium 400–800 mg/d
over 21 days Methysergide 3–12 mg/d
Topiramate 100–400 mg/d
Methysergide 3–12
mg/d
Gabapentin 1200–3600 mg/d
Verapamil 160–960
mg/d
Melatonin 9–12 mg/d
Ergotamine 1-2mg Deep brain stimulation of
posterior hypothalamus
8. Male:female ratio is 1:1.
Treatment
Indomethacin (25–75 mg tid),
Topiramate
Piroxicam
Secondary PH
If patient requires high doses
indomethacin (>200 mg/d)
Sella turcica lesions
(arteriovenous malformation,
cavernous sinus meningioma,
epidermoid tumors.)
Bilateral PH
Raised CSF pressure
Charact.
Site : Unilateral , retroorbital
Associat
ion:
lacrimation and nasal
congestion
Timing: Frequent(>5/d) ,
short ( 2-45min) and
rapid course(<72h)
Severity excruciating
9. SUNCT (short-lasting unilateral
neuralgiform headache attacks with
conjunctival injection and tearing)
SUNA (short-lasting unilateral
neuralgiform headache attacks with
cranial autonomic symptoms)
Basic patterns
short-lived single stab
groups of stabs
a longer attack ("saw-tooth" )
Differential diagnosis
trigeminal neuralgia (TN)
Secondary (Symptomatic) SUNCT
Posterior fossa or pituitary lesions.
Pituitary function tests ,brain MRI
Charac.
Site : unilateral orbital or
temporal
Character: stabbing or throbbing
Association: ipsilateral conjunctival
injection and
lacrimation
Timing: >20 attacks, lasting for
5–240s , no refractory
period
Exacerbatin
g factors:
Cutaneous triggers
Severity severe
10. AbortiveTherapy
IV lidocaine(hospitalized
patients.) to arrest
symptoms
PreventiveTherapy
Goal:minimize disability
and hospitalization
Medical approaches
▪ Lamotrigine, 200–400 mg/d.
▪ Topiramate and gabapentin.
▪ Carbamazepine, 400–500
mg/d
Surgical approaches
▪ Microvascular
decompression or
destructive trigeminal
procedures
▪ Greater occipital nerve
injection
▪ Occipital nerve stimulation
▪ deep-brain stimulation of
the posterior hypothalamic
region
Short-term prevention
(intractable cases)
▪ IV lidocaine
▪ occipital nerve stimulation.
11. Cluster
Headache
Paroxysmal
Hemicrania
SUNCT
Gender M > F F = M F ≈M
Type Stabbing, boring Throbbing, boring,
stabbing
Burning, stabbing,
sharp
Severity Excruciating Excruciating Severe to
excruciating
Site Orbit, temple Orbit, temple Periorbital
Attack
frequency
1/alternate day–8/d 1–40/d (>5/d for more
than half the time)
3–200/d
Duration 15–180 min 2–30 min 5–240 s
Alcohol trigger Yes No No
Cutaneous
triggers
No No Yes
Abortive
treatment
Sumatriptan injection
or nasal spray
Oxygen
No effective treatment Lidocaine (IV)
Prophylactic
treatment
Verapamil
Methysergide
Lithium
Indomethacin Lamotrigine
Topiramate
Gabapentin
13. If it is a medically
intractable
disablingCDH
Occipital nerve
stimulation
14. Most are female
Onset >60 years.
Differential diagnosis:
Poorly controlled hypertension.
Treatment:
Lithium carbonate (200–600 mg) at
bedtime
Verapamil (160 mg)
Methysergide (1–4 mg at bedtime)
One to two cups of coffee
/caffeine, 60 mg orally, at bedtime
Flunarizine, 5 mg nightly.
Chara
c.
Site : Uni/bilateral
Onset
:
a few hours after sleep
Chara
cter:
generalized /throbbing
Timin
g:
15 – 30 min , <3
repetitions/ night
Sever
ity
moderately severe
15. Essential features :
Moderate , continuous unilateral pain with fluctuations of severe pain
Complete resolution of pain with indomethacin
Associated with conjunctival injection, lacrimation, and photophobia
on same side
Age of onset :11 to 58 years.
Woman: man = 2:1
Treatment
IM injection of 100 mg indomethacin
Oral indomethacin (initial,25 mg tid, then 50 mg tid,75 mg
Topiramate
Patients unable to tolerate indomethacin
▪ Occipital nerve stimulation
16. Abrupt onset / gradual Primary NDPH
Migrainous type
unilateral
headache,throbbing pain,
nausea, photophobia,
phonophobia
Treatment :preventive
therapies of migraine
Featureless type
refractory to treatment
86% headache-free after
2 years
Primary
NDPH
Secondary NDPH
Migrainous-
type
Subarachnoid
hemorrhage
Featureless
(tension-type)
Low CSF volume
headache
Raised CSF pressure
headache
Posttraumatic
headache
Chronic meningitis
17. i. Low CSFVolume Headache
Dull, throbbing
occipitofrontal headache
that not present on waking
up , worsen as day progress
and relieved by
recumbency position
Cause :
CSF leak after lumbar puncture
(within 48 h -12 d)
index events (epidural injection
or vigorous Valsalva
maneuver)
Differential diagnosis:
Postural orthostatic
tachycardia syndrome [POTS ]
Investigations:
Brain MRI -diffuse meningeal
enhancement, chiari
malformation
Spinal MRI, CT
Treatment
Bed rest
IV caffeine (500 mg in 500 ml
saline administered over 2 h)
Abdominal binder
Autologous blood patch
Oral theophylline(intractable
pain)
18. ii. RaisedCSFVolume Headache
Generalized headache present on waking and improves as the day goes on,
worse with recumbency.
Investigations
Funduscopy-papilledema
MRI, including an MR venogram
Lumbar puncture
Differential diagnosis:
Obstructive sleep apnea
Poorly controlled hypertension
Idiopathic intracranial hypertension without visual problems
Treatment
Acetazolamide (250–500 mg bid)
Topiramate
Severe disabled patient that do not respond to medication -intracranial pressure
monitoring ,shunting
19. iii. Post-traumatic Headache
Headache that remit after several weeks or persist after the trauma
associated with dizziness, vertigo and impaired memory
Injury to the head
Carotid dissection and subarachnoid hemorrhage,and following intracranial surgery
Infection (viral meningitis / parasitic infection)
Differential diagnosis:
Chronic subdural hematoma
Iatrogenic low CSF volume headache
Treatment
Tricyclic antidepressants (amitriptyline)
Anticonvulsants (topiramate, valproate, and gabapentin)
MAOI (phenelzine)
Resolves within 3–5 years
20. Increased headache frequency
and induce - refractory daily
headache due to overuse of
analgesic for headache
Management : Outpatients
Reduce and stop analgesic
(reduce dose by 10% every
1–2 w)
A small dose NSAID
Naproxen, 500 mg bid (
overuse problems with more
frequent dosing )
Preventive medication (when
analgesic is stopped)
Management : Inpatients
Failed at outpatient withdrawal/
significant medical condition
Withdrawn analgesics
Antiemetics and fluids
Clonidine (opiate withdrawal )
Aspirin 1 g IV (acute intolerable
pain during day)
IM chlorpromazine (night)
After effect of withdrawn
substance settles (3-5d)
IV dihydroergotamine (DHE)
every 8 h for 5 days + 5-HT3
antagonists (ondansetron/
granisetron) or domperidone oral/
suppository
21. a) PRIMARY STABBING HEADACHE
Features:
Stabbing pain
Lasting from 1 to many seconds or minutes
Occurring as a single or series of stab
No associated cranial autonomic features
No cutaneous triggering of attacks
Recurrence at irregular intervals (hours to days).
"Ice-pick pains" or "jabs and jolts."
More common in patients with other primary headaches (migraine,
TACs, and hemicrania continua)
Treatment:
Indomethacin (25–50 mg two to three times daily
22. b) PRIMARY COUGH HEADACHE
Generalized headache that begins suddenly
Lasts for several minutes
Precipitated by coughing, preventable by avoiding coughing
Exclude serious etiology :
Chiari malformation /any lesion causing obstruction of CSF pathways
/displacing cerebral structures.
Cerebral aneurysm, carotid stenosis, and vertebrobasilar disease.
Can resemble benign exertional headache (patients is typically
younger)
Treatment:
Indomethacin 25–50 mg two to three times daily
Lumbar puncture
23. c) PRIMARY EXERTIONAL
HEADACHE
Features resembling both
cough headache and migraine
Precipitated by any form of exercise
Pulsatile
5 min - 24 h,
Bilateral and throbbing at onset
Migrainous features
Prevented by avoiding excessive
exertion,
Mechanism :unclear. ???
Possible etiologies:
Cardiac cephalgia
Pheochromocytoma
Intracranial lesions and stenosis of
the carotid arteries
Treatment:
Modest and progressive
exercise regimens
Indomethacin 25 to 150 mg
daily
Prophylactic measures.
Indomethacin (50 mg)
Ergotamine (1 mg orally)
Dihydroergotamine (2 mg by
nasal spray)
Methysergide (1–2 mg orally
given 30–45 min before
exercise)
24. d) PRIMARY SEX HEADACHE
Dull bilateral headache that intensify at
orgasm.
Prevented by ceasing sexual activity
before orgasm.
Types :
Dull ache in head and neck
Sudden, severe, explosive headache
Postural headache after coitus
5–12% are caused by subarachnoid
hemorrhage
Occur more in men than women
Subside within 5min -2 h. ( In patient who
stop sexual activity when notice headache)
Subside within 6 months.
More common in patients with
exertional headache and migraine
Treatment:
Recur irregularly and infrequently
Reassurance and advice about ceasing
sexual activity
Recurs regularly or frequently
Propranolol 40 to 200 mg/d
Diltiazem, 60 mg tid.
Ergotamine (1 mg) or
Indomethacin (25–50 mg) 30–45 min prior
to sexual activity
25. e) PRIMARYTHUNDERCLAP
HEADACHE
Differential diagnosis
Subarachnoid hemorrhage
Cervicocephalic arterial dissection
Cerebral venous thrombosis.
Ingestion of tyramine-containing
foods in a patient taking MAOIs
Pheochromocytoma.
If posterior leukoencephalopathy
present,
▪ Cerebral angiitis,
▪ Drug toxicity
(cyclosporine,methotrexate or cocaine)
▪ Postpartum angiopathy.
Excluding subarachnoid
hemorrhage
Patients do very well over the
long term.
Some developed migraine or
tension-type headache.
Investigations :
Neuroimaging (CT or, when
possible, MRI with MR
angiography)
CSF examination
Cerebral angiography
Treatment with nimodipine
26. 1) Tension- type
Headache
2) TrigeminalAutonomic
Cephalgias
a) Cluster headache
b) Paroxysmal hemicrania
c) SUNCT/SUNA
3) Chronic Daily
Headache
a) Primary (<4h/day and
>4h/day)
b) Secondary
4) Other Primary
Headache
a) Stabbing Headache
b) Exertional Headache
c) Cough Headache
d) Sex Headache
e) Thunderclap Headache
27. Harrison’s Principle of Internal Medicine, 18th
Edition,Volume 1
Davidson’s Principles and Practice of
Medicine, 22nd Edition
Editor's Notes
Peri symp deficit due to parasym activation with injury to ascending sympathetic fibers surrounding a dilated carotid artery as it passes into the cranial cavity.
Suma sc rapid onset and shorten attack to 15-20 min
To differentiate TN : have refractory period
many stabs between which the pain does not completely resolve, thus giving a "saw-tooth" phenomenon with attacks lasting many minutes.