Neurological lectures...Headaches

3,175 views
2,962 views

Published on

Neurological lectures...Headaches
http://yassermetwally.com
http://yassermetwally.net

Published in: Education, Health & Medicine
0 Comments
4 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
3,175
On SlideShare
0
From Embeds
0
Number of Embeds
14
Actions
Shares
0
Downloads
184
Comments
0
Likes
4
Embeds 0
No embeds

No notes for slide

Neurological lectures...Headaches

  1. 1. Classification of headaches Professor Yasser Metwally Primary headaches • Secondary headaches OR Idiopathic headaches • OR Symptomatic headaches – THE HEADACHE IS ITSELF – THE HEADACHE IS ON LY A THE DISEASE SYMPTOM OF AN OTHER UNDERLYING DISEASE – NO ORGANIC LESION IN THE BEACKGROUND – TREAT THE UNDERLYING DISEASE! – TREAT THE HEADACHE!
  2. 2. 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”)
  3. 3. 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…
  4. 4. • Secondary headache disorders Headache attributed to ... 5. head and/or neck trauma 6. cranial or cervical vascular disorder 7. non-vascular intracranial disorder vascular 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
  5. 5. Primary, idiopathic headaches • Tension type of headache • Migraine • Cluster headache • Other, rare types of primary headaches
  6. 6. Treatment of tension type of headache • Acute, episodic form: NSAID drugs, 500-1000 mg ASA, paracetamol, or noraminophenazon • Indication of prophylactic treatment tension treatment: type of headache in at least 14 days per moth
  7. 7. Prophylactic treatment of the chronic tension type of headache • Tricyclic antidepressants • Guidelines:  Start with low dose (10-25 mg) and increase the dose if 25 no beneficial effect after 1 weeks 1-2  Maximal dose should not be more than 75 mg/day  Change to other tricyclic antidepressant only after 6 6-8 weeks  Ask the patient to use headache diary  Use the tricyclic antidepressant for 6 months 6-9  Decrease the dose gradually
  8. 8. 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
  9. 9. 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)
  10. 10. 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
  11. 11. Migraine: epidemiology • Life-time prevalence 10% time 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
  12. 12. 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
  13. 13. 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
  14. 14. Migraine • WITHOUT AURA • WITH AURA + – VISUAL • Typical headache 2/4 – SENSORY – Unilateralsi – MOTOR – Severe – SPEECH DISTURBANCE – Pulsating before migraineous headache – Physical activity • AURA SYMPTOMS aggravates – USUALLY<1/2 HOUR • Accompanying signs 1/2 – LESS THAN 1 HOUR – Photophobia and phonophobia – Nausea, or vomitus
  15. 15. MIGRAINE WITH AURA • DURING AURA: • DURING HEADACHE – VASOCONSTRICTION – VASODILATION – HYPOPERFUSION – 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 AURA SPREADING DEPRESSION VASOCONSTRICTION, HYPOPERFUSION
  16. 16. 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 55%! IS ABOUT 25%).
  17. 17. 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!
  18. 18. Treatment of migraine attack • Try to sleep • Antiemetics • Analgetics • Ergot derivatives • Triptans
  19. 19. 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
  20. 20. 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) 400 400-800 mg per os – Diclofenac (Voltaren, Cataflam etc) mg per os etc)50 – Naproxen (Naprosyn, Apranax) 250250-550 mg per os
  21. 21. Treatment of migraine attack III. Ergot derivatives • 1. Ergotamin tartarate – 2-4 mg per os, sublinguali or rectal 4 – 1 mg nasal spray • 2. Dihydrergotamin (Neomigran) nasal spray – no more available
  22. 22. Treatment of migraine attack IV. Combinations in Hungary • Migpriv: – lizin-acetylsalicilate + metoclopramid acetylsalicilate • Quarelin: – aminophenazon+coffein+drotaverin • Kefalgin – ergotamin tartarate+ atropin+coffein+aminophenazon
  23. 23. Treatment of migraine attack V. Triptans 1. Sumatriptan (Imigran® 6 mg inj, 50 and 6 mg sc with autoinjector 100 mg tabl, Imitrex nasal spray, supp supp, 50-100 mg per os, Glaxo) nasal spray 20 mg 2. Zolmitriptan (Zomig®, Zeneca) 2,5 – 5 mg 3. Naratriptan (Naramig®, Glaxo) 2,5 mg 4. Rizatriptan (Maxalt®, MSD) 5 – 10 mg per os 5. Eletriptan (Relpax, Pfizer) 20 – 80 mg per os 6. Frovatriptan (Smith-Kleine Beecham) Kleine 2,5 mg per os 7. Avitriptan (Bristol-Myers Squibb) 75 – 150 mg 8. Alniditan (Janssen) 2 – 4 mg, nasal spray
  24. 24. The ideal triptan • Effective • Rapid onset • No recurrence • Good consistency • Different applications • Good tolerability • No interactions • Cheap
  25. 25. Attack treatment in emergency 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.
  26. 26. 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
  27. 27. 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, treatment: within 4 weeks • Use headache diary • INFORM THE PATIENT ABOUT THE PROPHYLACTIC TREATMENT!!!
  28. 28. 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
  29. 29. Prophylactic treatment of migraine • Beta-receptor-blockers (propranolol) blockers • Calcium channel blockers (flunarizine) • Antiepileptics (valproic acid) • Tricyclic antidepressants (amitriptyline) • Topiramate (Topamax) • Serotonin antagonists • NSAID
  30. 30. Beta-receptor-blockers Use: hypertension, tachycardia (propranolol 2x20-40 mg) Do not use: hypotension, bradicardia, heart conduction disturbances Calcium channel blockers Do not use: obesity, maior depression (flunarizine, 10 mg every evening) in the history Side effects: provokes depression, increases appetite, cause sleepiness Tricyclic antidepressants Use: if tension type of headache is amitryptiline, 10-75 mg every evening) present besides migraine Do not use: see above Antiepileptics Few side effects, but (valproic acid, 2x300-500 mg) Pregnancy should be avoided
  31. 31. Other prophylactic treatment of migraine • Change of life-style • Regular, not exhausting physical activities • Cognitive behavioral therapy • Regular sleeping • Avoid the precipitating factors • Acuouncture?
  32. 32. 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)
  33. 33. 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
  34. 34. Migraine in childhood II • Acute treatment: –First choice: ibuprofen 10 mg/kg First –Second choice: paracetamol 15 mg/kg Second –Third choice: sumatriptan nasal spray 10 Third 10-20 mg • Prophylaxis: –Flunarizine 5-10 mg –Propranolol 80 mg
  35. 35. 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., 5050-100 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
  36. 36. 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. – 10-15. days daily 20 mg 15. – 16-20. days daily 15 mg 20. – 21-25. days daily 10 mg 25. – 26-30. days daily 5 mg 30. – nothing
  37. 37. 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)
  38. 38. 3. Cluster headache and trigemino-autonomic cephalgias autonomic • Trigemino-autonomic cephalgias autonomic (TAC) –Cluster headache Cluster –Paroxysmal hemicrania Paroxysmal –SUNCT-syndrome syndrome –(Hemicrania continua) (Hemicrania
  39. 39. Headache of cervical origin • Lidocain infiltration • NSAID: 50-150 mg indomethacin, 20 150 20-40 mg piroxicam (Hotemin, Feldene), etc • Surgical methods (CV(CV-CVII fusion of vertebrae) • Other methods (physiotherapy, TENS)
  40. 40. 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 60 the dose after 1-2 weeks to 10 mg!!! 2 – Diagnosis: STA biopsy. – BUT Start the steroid before results of biopsy!!! – We, pain decrease
  41. 41. Facial pains • Tolosa-Hunt syndrome (ophthalmoplegia Hunt 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
  42. 42. Carotid dissection • After neck trauma, extensive neck turning • Neck pain • Horner’s syndrome • Diagnosis: carotid duplex, MRI MRI-T2

×