Classification of headaches Professor Yasser Metwally Primary headaches OR Idiopathic headaches THE HEADACHE IS ITSELF THE DISEASE NO ORGANIC LESION IN THE BEACKGROUND TREAT THE HEADACHE! Secondary headaches OR Symptomatic headaches THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER UNDERLYING DISEASE TREAT THE UNDERLYING DISEASE!

Primary headaches

OR Idiopathic headaches

THE HEADACHE IS ITSELF THE DISEASE

NO ORGANIC LESION IN THE BEACKGROUND

TREAT THE HEADACHE!

Secondary headaches

OR Symptomatic headaches

THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER UNDERLYING DISEASE

TREAT THE UNDERLYING DISEASE!

HISTORY AND EXAMINATIONS SHOULD CLARIFY IF THE PATIENT HAS PRIMARY OR SECONDARY HEADACHE IS THERE ANY URGENCY IN CASE OF PRIMARY HEADACHE ONLY THE HEADACHE ATTACKS SHOULD BE TREATED („ATTACK THERAPY”), OR PROPHYLACTIC THERAPY IS ALSO NECESSARY („PREVENTIVE THERAPY, INTERVAL THERAPY”)

THE PATIENT HAS PRIMARY OR SECONDARY HEADACHE

IS THERE ANY URGENCY

IN CASE OF PRIMARY HEADACHE ONLY THE HEADACHE ATTACKS SHOULD BE TREATED („ATTACK THERAPY”), OR PROPHYLACTIC THERAPY IS ALSO NECESSARY („PREVENTIVE THERAPY, INTERVAL THERAPY”)

SECONDARY, SYMPTOMATIC HEADACHES THE HEADACHE IS A SYMPTOM OF AN UNDERLYING DISEASE, LIKE Hypertension Sinusitis Glaucoma Eye strain Fever Cervical spondylosis Anaemia Temporal arteriitis Meningitis, encephalitis Brain tumor, meningeal carcinomatosis Haemorrhagic stroke…

THE HEADACHE IS A SYMPTOM OF AN UNDERLYING DISEASE, LIKE

Hypertension

Sinusitis

Glaucoma

Eye strain

Fever

Cervical spondylosis

Anaemia

Temporal arteriitis

Meningitis, encephalitis

Brain tumor, meningeal carcinomatosis

Haemorrhagic stroke…

Secondary headache disorders Headache attributed to ... 5. head and/or neck trauma 6. cranial or cervical vascular disorder 7. non-vascular intracranial disorder 8. a substance or its withdrawal 9. infection 10. disorder of homoeostasis 11. disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures 12. psychiatric disorder 13. cranial neuralgias and central causes of facial pain

Secondary headache disorders

Headache attributed to ...

5. head and/or neck trauma

6. cranial or cervical vascular disorder

7. non-vascular intracranial disorder

8. a substance or its withdrawal

9. infection

10. disorder of homoeostasis

11. disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures

12. psychiatric disorder

13. cranial neuralgias and central causes of facial pain

Primary, idiopathic headaches Tension type of headache Migraine Cluster headache Other, rare types of primary headaches

Tension type of headache

Migraine

Cluster headache

Other, rare types of primary headaches

Treatment of tension type of headache Acute, episodic form: NSAID drugs, 500-1000 mg ASA, paracetamol, or noraminophenazon Indication of prophylactic treatment : tension type of headache in at least 14 days per moth

Acute, episodic form: NSAID drugs, 500-1000 mg ASA, paracetamol, or noraminophenazon

Indication of prophylactic treatment : tension type of headache in at least 14 days per moth

Prophylactic treatment of the chronic tension type of headache Tricyclic antidepressants Guidelines: Start with low dose (10-25 mg) and increase the dose if no beneficial effect after 1-2 weeks Maximal dose should not be more than 75 mg/day Change to other tricyclic antidepressant only after 6-8 weeks Ask the patient to use headache diary Use the tricyclic antidepressant for 6-9 months Decrease the dose gradually

Tricyclic antidepressants

Guidelines:

Start with low dose (10-25 mg) and increase the dose if no beneficial effect after 1-2 weeks

Maximal dose should not be more than 75 mg/day

Change to other tricyclic antidepressant only after 6-8 weeks

Ask the patient to use headache diary

Use the tricyclic antidepressant for 6-9 months

Decrease the dose gradually

First choice of drug: amitryptiline (Teperin tabl, 25 mg) 1st week: 25 mg in the evening 2nd week: 50 mg in the evening 3rd week: 75 mg in the evening continuously Change to other drug (e.g. clomipramine) if no beneficial effect within 6 weeks Prophylactic treatment of the chronic tension type of headache

First choice of drug:

amitryptiline (Teperin tabl, 25 mg)

1st week: 25 mg in the evening

2nd week: 50 mg in the evening

3rd week: 75 mg in the evening continuously

Change to other drug (e.g. clomipramine) if no beneficial effect within 6 weeks

Common side effects of tricyclic antidepressants Anticholinergic side effects: Dry mouth Increased pulse rate Urinary retention (in prostate hyperplasia!!!) Increased intraocular pressure (glaucoma!!!) Sleepiness or hyperactivity Serotonine syndrome (do not use if the patient takes SSRI drug)

Anticholinergic side effects:

Dry mouth

Increased pulse rate

Urinary retention (in prostate hyperplasia!!!)

Increased intraocular pressure (glaucoma!!!)

Sleepiness or hyperactivity

Serotonine syndrome (do not use if the patient takes SSRI drug)

If the patient does not tolerate the TCA drugs, or cannot be administared because of danger of interaction Anxiolytics (e.g.: alprasolam, clonazepam…) and selective antidepressants (e.g. SSRI) Change of lifestyle Psychotherapy, psychological treatments, biofeedback, behavioral therapy, relaxation methods

Anxiolytics (e.g.: alprasolam, clonazepam…)

and selective antidepressants (e.g. SSRI)

Change of lifestyle

Psychotherapy, psychological treatments, biofeedback, behavioral therapy, relaxation methods

Migraine: epidemiology Life-time prevalence 10%-12% 1% chronic migraine (>15 days/months) Sex ratio 2.5 (f) to 1 (m); in childhood 1 to 1 Mean frequency 1.2/month Mean duration 24 h (untreated) 10% always with aura, >30% sometimes with aura 30% treated by physicians

Life-time prevalence 10%-12%

1% chronic migraine (>15 days/months)

Sex ratio 2.5 (f) to 1 (m); in childhood 1 to 1

Mean frequency 1.2/month

Mean duration 24 h (untreated)

10% always with aura, >30% sometimes with aura

30% treated by physicians

Migraine: pathophysiology Genetic disposition , hormonal influence Activation of brainstem nuclei by trigger factors Neurovascular inflammation of intracranial vessels Impaired antinociception „ Spreading Depression“ as mechanism of aura

Genetic disposition , hormonal influence

Activation of brainstem nuclei by trigger factors

Neurovascular inflammation of intracranial vessels

Impaired antinociception

„ Spreading Depression“ as mechanism of aura

Migraine classification 1.1 migraine without aura 1.2 migraine with aura 1.3 periodic syndromes in childhood 1.4 retinal migraine 1.5 migraine complications 1.6 probable migraine

Migraine WITH AURA + VISUAL SENSORY MOTOR SPEECH DISTURBANCE before migraineous headache AURA SYMPTOMS USUALLY<1/2 HOUR LESS THAN 1 HOUR WITHOUT AURA Typical headache 2/4 Unilateralsi Severe Pulsating Physical activity aggravates Accompanying signs 1/2 Photophobia and phonophobia Nausea, or vomitus

WITH AURA +

VISUAL

SENSORY

MOTOR

SPEECH DISTURBANCE before migraineous headache

AURA SYMPTOMS

USUALLY<1/2 HOUR

LESS THAN 1 HOUR

WITHOUT AURA

Typical headache 2/4

Unilateralsi

Severe

Pulsating

Physical activity aggravates

Accompanying signs 1/2

Photophobia and phonophobia

Nausea, or vomitus

MIGRAINE WITH AURA DURING AURA: VASOCONSTRICTION HYPOPERFUSION DURING HEADACHE VASODILATION HYPERPERFUSION BUT: AURA SYMPTOM IS NOT CONSEQUENCE OF VASOCONSTRICTION INDUCED HYPOPERFUSION CUASE OF THE AURA: SPREADING DEPRESSION. THE VASOCONSTRICTION AND HYPOPERFUSION ARE CONSEQUENCES OF THE SPREADIND DEPRESSION SPREADING DEPRESSION AURA VASOCONSTRICTION, HYPOPERFUSION

DURING AURA:

VASOCONSTRICTION

HYPOPERFUSION

DURING HEADACHE

VASODILATION

HYPERPERFUSION

IMPORTANT TO KNOW! MIGRAINE WITH AURA IS A RISK FACTOR FOR ISCHAEMIC STROKE THEREFORE PATIENTS SUFFERING FROM MIGRAINE WITH AURA SHOULD NOT SMOKE!!! SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!! THE PROPROTION OF PATENT FORAMEN OVALE IN PATIENTS WITH MIGRAINE WITH AURA IS ABOUT 50-55%! (IN THE POPULATION IS ABOUT 25%).

IS A RISK FACTOR FOR ISCHAEMIC STROKE

THEREFORE PATIENTS SUFFERING FROM MIGRAINE WITH AURA

SHOULD NOT SMOKE!!!

SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!!

THE PROPROTION OF PATENT FORAMEN OVALE IN PATIENTS WITH MIGRAINE WITH AURA IS ABOUT 50-55%! (IN THE POPULATION IS ABOUT 25%).

Is there a relationship between aura and patent foramen ovale ? Paradoxic emboli theory is not likely Shunting of venous blood to the arterial side could be the reason  no breakdown of certain neurotransmitters (5HT) in the lung! Comorbidity could be also an explanation. However, closure of patent foramen ovale decreases the frequency of migraine attacks. BUT! Migraine is a benign disease. Please do not indicate closure of patent foramen ovale just because of migraine with aura!

?

Paradoxic emboli theory is not likely

Shunting of venous blood to the arterial side could be the reason  no breakdown of certain neurotransmitters (5HT) in the lung!

Comorbidity could be also an explanation.

However, closure of patent foramen ovale decreases the frequency of migraine attacks.

BUT! Migraine is a benign disease. Please do not indicate closure of patent foramen ovale just because of migraine with aura!

Treatment of migraine attack Try to sleep Antiemetics Analgetics Ergot derivatives Triptans

Try to sleep

Antiemetics

Analgetics

Ergot derivatives

Triptans

Treatment of migraine attack I. Antiemetics 1. Metoclopramid (Cerucal tabl 10 mg) 10-20 mg per os 20 mg rectal 10 mg parenteral 2. Domperidon (Motilium tabl 10 mg) 10-20 mg per os

1. Metoclopramid (Cerucal tabl 10 mg)

10-20 mg per os

20 mg rectal

10 mg parenteral

2. Domperidon (Motilium tabl 10 mg)

10-20 mg per os

Treatment of migraine attack II. Analgetics 1. ASA (Aspirin, Colfarit, etc) 500-1000 mg per os 500 mg parenteral (Aspisol i.v.) 2. Paracetamol (Rubophen, Panadol, etc) 500-1000 mg per os 3. NSAIDs Ibuprofen (Ibuprofen, Humaprofen, etc) 400-800 mg per os Diclofenac (Voltaren, Cataflam etc) 50 mg per os Naproxen (Naprosyn, Apranax) 250-550 mg per os

1. ASA (Aspirin, Colfarit, etc)

500-1000 mg per os

500 mg parenteral (Aspisol i.v.)

2. Paracetamol (Rubophen, Panadol, etc)

500-1000 mg per os

3. NSAIDs

Ibuprofen (Ibuprofen, Humaprofen, etc) 400-800 mg per os

Diclofenac (Voltaren, Cataflam etc) 50 mg per os

Naproxen (Naprosyn, Apranax) 250-550 mg per os

1. Ergotamin tartarate 2-4 mg per os, sublinguali or rectal 1 mg nasal spray 2. Dihydrergotamin (Neomigran) nasal spray no more available Treatment of migraine attack III. Ergot derivatives

1. Ergotamin tartarate

2-4 mg per os, sublinguali or rectal

1 mg nasal spray

2. Dihydrergotamin (Neomigran) nasal spray

no more available

Migpriv: lizin-acetylsalicilate + metoclopramid Quarelin: aminophenazon+coffein+drotaverin Kefalgin ergotamin tartarate+ atropin+coffein+aminophenazon Treatment of migraine attack IV. Combinations in Hungary

Migpriv:

lizin-acetylsalicilate + metoclopramid

Quarelin:

aminophenazon+coffein+drotaverin

Kefalgin

ergotamin tartarate+ atropin+coffein+aminophenazon

Treatment of migraine attack V. Triptans

The ideal triptan Effective Rapid onset No recurrence Good consistency Different applications Good tolerability No interactions Cheap

Effective

Rapid onset

No recurrence

Good consistency

Different applications

Good tolerability

No interactions

Cheap

Very severe migraine attack / status migrainosus: Triptan (sumatriptan 6 mg s.c.) Lysin-ASA 1,000 mg i.v. Metamizol 500-1,000 mg i.v. Antiemetics i.v. Steroids i.v. Attack treatment in emergency

Triptan (sumatriptan 6 mg s.c.)

Lysin-ASA 1,000 mg i.v.

Metamizol 500-1,000 mg i.v.

Antiemetics i.v.

Steroids i.v.

Strategy of treatment of migraine attacks Step care accross or within attacks 1: NSAID 2: ergot 3: triptan Stratified care do not go through all the steps, but drug can be chosen depending on the severity of the attack

Step care accross or within attacks

1: NSAID

2: ergot

3: triptan

Stratified care

do not go through all the steps, but drug can be chosen depending on the severity of the attack

Prophylactic treatment of migraine attacks Indication: 2 or more attacks/month At least one long (>4 days) attack/month Start of prophyalactic treatment: gradually Duration of prophylactic treatment: 2-9 months Stop of prophylactic treatment : gradually, within 4 weeks Use headache diary INFORM THE PATIENT ABOUT THE PROPHYLACTIC TREATMENT!!!

Indication:

2 or more attacks/month

At least one long (>4 days) attack/month

Start of prophyalactic treatment: gradually

Duration of prophylactic treatment: 2-9 months

Stop of prophylactic treatment : gradually, within 4 weeks

Use headache diary

INFORM THE PATIENT ABOUT THE PROPHYLACTIC TREATMENT!!!

Aims of prophylactic treatment of migraine To decrease the frequency of attacks To decrease the intensity of the pain To increase the efficacy of attack therapy

To decrease the frequency of attacks

To decrease the intensity of the pain

To increase the efficacy of attack therapy

Prophylactic treatment of migraine Beta-receptor-blockers (propranolol) Calcium channel blockers (flunarizine) Antiepileptics (valproic acid) Tricyclic antidepressants (amitriptyline) Topiramate (Topamax) Serotonin antagonists NSAID

Beta-receptor-blockers (propranolol)

Calcium channel blockers (flunarizine)

Antiepileptics (valproic acid)

Tricyclic antidepressants (amitriptyline)

Topiramate (Topamax)

Serotonin antagonists

NSAID

Beta-receptor-blockers (propranolol 2x20-40 mg) Calcium channel blockers (flunarizine, 10 mg every evening) Side effects: provokes depression, increases appetite, cause sleepiness Tricyclic antidepressants (amitryptiline, 10-75 mg every evening) Antiepileptics (valproic acid, 2x300-500 mg) Use: hypertension, tachycardia Do not use: hypotension, bradicardia, heart conduction disturbances Do not use: obesity, maior depression in the history Use: if tension type of headache is present besides migraine Do not use: see above Few side effects, but Pregnancy should be avoided

Other prophylactic treatment of migraine Change of life-style Regular, not exhausting physical activities Cognitive behavioral therapy Regular sleeping Avoid the precipitating factors Acuouncture?

Change of life-style

Regular, not exhausting physical activities

Cognitive behavioral therapy

Regular sleeping

Avoid the precipitating factors

Acuouncture?

Migraine and pregnancy Migraine without aura in >70% of women less frequent or absent (prognostic factor: menstrual migraine) Significantly more manifestation of migraine with aura Acute treatment: paracetamol; NSAIDs in second trimenon Triptans not allowed Prophylaxis: magnesium, metoprolol, (fluoxetine)

Migraine without aura in >70% of women less frequent or absent (prognostic factor: menstrual migraine)

Significantly more manifestation of migraine with aura

Acute treatment: paracetamol; NSAIDs in second trimenon

Triptans not allowed

Prophylaxis: magnesium, metoprolol, (fluoxetine)

Migraine in childhood I Prevalence 5% Sex ratio 1:1 (boys with good prognosis) Abdominal symptoms often predominant Semiology of attacks as in adulthood except shorter duration of attacks Short sleep very effective

Prevalence 5%

Sex ratio 1:1 (boys with good prognosis)

Abdominal symptoms often predominant

Semiology of attacks as in adulthood except shorter duration of attacks

Short sleep very effective

Migraine in childhood II Acute treatment: First choice: ibuprofen 10 mg/kg Second choice: paracetamol 15 mg/kg Third choice: sumatriptan nasal spray 10-20 mg Prophylaxis: Flunarizine 5-10 mg Propranolol 80 mg Non-drug therapy very effective

Acute treatment:

First choice: ibuprofen 10 mg/kg

Second choice: paracetamol 15 mg/kg

Third choice: sumatriptan nasal spray 10-20 mg

Prophylaxis:

Flunarizine 5-10 mg

Propranolol 80 mg

Non-drug therapy very effective

Treatment of cluster attack Oxygen:7 liters/min 100% oxigén for 15 minutes Effective in 75% of patients within 10 minutes Sumatiptan 6 mg s.c., 50-100 mg per os Ergot derivatives (lot of side effects) Anaesthesia of the ipsilateral fossa sphenopalatina) 1 ml 4% Xylocain nasal drop The head is turned back and to the ipsilateral side in 45 degree

Oxygen:7 liters/min 100% oxigén for 15 minutes

Effective in 75% of patients within 10 minutes

Sumatiptan 6 mg s.c., 50-100 mg per os

Ergot derivatives (lot of side effects)

Anaesthesia of the ipsilateral fossa sphenopalatina)

1 ml 4% Xylocain nasal drop

The head is turned back and to the ipsilateral side

in 45 degree

Prophylactic treatment of the episodic form of cluster headache Epizodic form: prednisolon Treatment: 1-5. days 40 mg 6-10. days daily 30 mg 10-15. days daily 20 mg 16-20. days daily 15 mg 21-25. days daily 10 mg 26-30. days daily 5 mg nothing

Epizodic form: prednisolon

Treatment:

1-5. days 40 mg

6-10. days daily 30 mg

10-15. days daily 20 mg

16-20. days daily 15 mg

21-25. days daily 10 mg

26-30. days daily 5 mg

nothing

Lithium carbonate Daily 600-700 mg Can be decreased after 2 weeks remission Control of serum level is necessary (0,4 - 0,8 mmol/l) Prophylactic treatment of the chronic form of cluster headache

Lithium carbonate

Daily 600-700 mg

Can be decreased after 2 weeks remission

Control of serum level is necessary (0,4 - 0,8 mmol/l)

3. Cluster headache and trigemino-autonomic cephalgias Trigemino-autonomic cephalgias (TAC) Cluster headache Paroxysmal hemicrania SUNCT-syndrome (Hemicrania continua) Episodic and chronic forms

Trigemino-autonomic cephalgias (TAC)

Cluster headache

Paroxysmal hemicrania

SUNCT-syndrome

(Hemicrania continua)

Episodic and chronic forms

Headache of cervical origin Lidocain infiltration NSAID: 50-150 mg indomethacin, 20-40 mg piroxicam (Hotemin, Feldene), etc Surgical methods (CV-CVII fusion of vertebrae) Other methods (physiotherapy, TENS)

Lidocain infiltration

NSAID: 50-150 mg indomethacin, 20-40 mg piroxicam (Hotemin, Feldene), etc

Surgical methods (CV-CVII fusion of vertebrae)

Other methods (physiotherapy, TENS)

Arteriitis temporalis Arteriitis temporalis (age>50y, We>50 mm/h) Autoimmune disease, granulomatose inflammation of branches of ECA Unilateral headache Pulsating pain, more severe at night Larger STA 1/3 jaw claudication  inflammation of internal maxillary artery Weakness, loss of appetite, low fever, Danger of thrombosis of ophthalmic or ciliary artery!!! Amaurosis fugax may precede the blindness Treatment: steroid – 45-60 mg methylprednisolone – decrease the dose after 1-2 weeks to 10 mg!!! Diagnosis: STA biopsy. BUT Start the steroid before results of biopsy!!!  We, pain decrease

Arteriitis temporalis (age>50y, We>50 mm/h)

Autoimmune disease, granulomatose inflammation of branches of ECA

Unilateral headache

Pulsating pain, more severe at night

Larger STA

1/3 jaw claudication  inflammation of internal maxillary artery

Weakness, loss of appetite, low fever,

Danger of thrombosis of ophthalmic or ciliary artery!!!

Amaurosis fugax may precede the blindness

Treatment: steroid – 45-60 mg methylprednisolone – decrease the dose after 1-2 weeks to 10 mg!!!

Diagnosis: STA biopsy.

BUT Start the steroid before results of biopsy!!!

 We, pain decrease

Facial pains Tolosa-Hunt syndrome (ophthalmoplegia dolorosa) – granulomatose inflammation in cavernous sinus, superior orbital fissure – Treatment: steroid Gradenigo’s syndrome: otitis media –inflammation of apex of petrous bone – lesion of ipsilateral abducent nerve and facial pain around the ear and forehead

Tolosa-Hunt syndrome (ophthalmoplegia dolorosa) – granulomatose inflammation in cavernous sinus, superior orbital fissure – Treatment: steroid

Gradenigo’s syndrome: otitis media –inflammation of apex of petrous bone – lesion of ipsilateral abducent nerve and facial pain around the ear and forehead

Carotid dissection After neck trauma, extensive neck turning Neck pain Horner’s syndrome Diagnosis: carotid duplex, MRI-T2

After neck trauma, extensive neck turning

Neck pain

Horner’s syndrome

Diagnosis: carotid duplex, MRI-T2