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Primary headache

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Primary headache

  1. 1. PRIMARY HEADACHE<br />Overview of diagnosis , classification and treatment<br />DR.SRIRAMA ANJANEYULU<br />
  2. 2. INTERNATIONAL HEADACHE SOCIETY<br />ICHD-1 IN 1998 BY IHS.<br />ICHD-2 IN 2004.<br />PRIMARY HA-<br /> 4 categories : migraine , TTH , TAC’S and other HA’S.<br /> Criteria is clinical and descriptive and exclusion of others but not on etiology.<br />SECONDARY HA-<br /> 8 cat, based on etiology and attributed to other disorder.<br />
  3. 3. CLASSIFICATION & DIAGNOSTIC CRITERIA<br />
  4. 4. IHS CLASSIFICATION<br /> Part I: The Primary Headaches<br />1. Migraine<br />2. Tension-type headache<br />3. Cluster headache and other trigeminal autonomic cephalalgias<br />4. Other primary headaches<br /> Part II: The Secondary Headaches<br />5. Headache attributed to head and/or neck trauma<br />6. Headache attributed to cranial or cervical vascular disorder<br />7. Headache attributed to non-vascular intracranial disorder<br />8. Headache attributed to a substance or its withdrawal<br />9. Headache attributed to infection<br />10. Headache attributed to disorder of homoeostasis<br />11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures<br />12. Headache attributed to psychiatric disorder<br /> Part III: Cranial Neuralgias Central and Primary Facial Pain and Other Headaches<br />13. Cranial neuralgias and central causes of facial pain<br />14. Other headache, cranial neuralgia, central or primary facial pain<br />
  5. 5. OPERATIONAL RULES FOR ICHD-2<br />HIERARCHICAL CLASSIFICATION.<br />EACH HA AND SUB TYPE IN LAST YEAR SHOULD BE GIVEN DIAGNOSIS.<br />PROBABLE CATEGORIES.<br />PRIMARY HA- DIAGNOSIS BY INCUSION AND EXCLUSION.<br />SEC.HA-TEMPORAL RELATIONSHIP AND ATTRIBUTION TO ANOTHER DISORDER.<br />DIAGNOSIS OF SEC.HA IN PRIMARY HA’S.<br />
  6. 6. PRIMARY HEADACHE<br />MIGRAINE.<br />TENSION TYPE.<br />TAC’S.<br />OTHER HA’S.<br />
  7. 7. MIGRAINE 1.0<br />1.1-MIGRAINE WITHOUT AURA.<br />1.2-MIGRAINE WITH AURA.<br />1.3-CHILDHOOD PERIODIC SYNDROMES .<br />1.4-RETINAL MIGRAINE.<br />1.5-COMPLICATIONS OF MIGRAINE.<br />1.6-PROBABLE MIGRAINE.<br />
  8. 8. 1.1-MIGRAINE WITHOUT AURA<br />
  9. 9. MIGRAINE WITH AURA -1.2<br />1.2.1-TYPICAL AURA WITH MIGRAINE.<br />1.2.2-TYPICAL AURA WITH NON MIGRAINE HEADACHE.<br />1.2.3-TYPICAL AURA WITHOUT HEADACHE.<br />1.2.4-FAMILIAL HEMIPLEGIC MIGRAINE.<br />1.2.5-SPORADIC HEMIPLEGIC MIGRAINE.<br />1.2.6-BASILAR TYPE MIGRAINE.<br />
  10. 10. 1.2.1-TYPICAL AURA WITH MIGRAINE HEADACHE<br />
  11. 11. TENSION TYPE HEADACHE<br />
  12. 12. CTTH<br />
  13. 13. DIAGNOSTIC CRITERIA FOR CLUSTER HEADACHE<br />
  14. 14. DIAGNOSTIC CRITERIA FOR PAROXYSMAL HEMICRANIA<br />
  15. 15. DIAG. CRITERIA FOR SUNCT(SHORT LASTING UNILATERAL NEURALGIFORM HEADACHE ATTACKS WITH CONJUNCTIVAL INJECTION AND TEARING)<br />
  16. 16. CLINICAL FEATURES OF TAC’S<br />
  17. 17. OTHER PRIMARY HEADACHES<br />PRIMARY STABBING HA.<br />PRIMARY COUGH HA.<br />PRIMARY EXERTIONAL HA.<br />PRIMARY HA ASSOCIATED WITH SEXUAL ACTIVITY.<br />HYPNIC HA.<br />PRIMARY THUNDER CLAP HA.<br />HEMICRANIA CONTINUA.<br />NDPH.<br />
  18. 18. DIAGNOSTIC CRITERIA FOR PRIMARY STABBING HA<br />
  19. 19. DIAGNOSTIC CRITERIA FOR PRIMARY COUGH HA<br />
  20. 20. DIAGNOSTIC CRITERIA FOR PRIMARY EXERTIONAL HA<br />
  21. 21. DIAGNOSTIC CRITERIA FOR PRIMARY HA ASSO. WITH SEXUAL ACTIVITY<br />
  22. 22. DIAGNOSTIC CRITERIA FOR HYPNIC HA<br />
  23. 23. DIAGNOSTIC CRITERIA FOR THUNDER CLAP HA<br />
  24. 24. DIAGNOSTIC CRITERIA FOR HEMICRANIA CONTINUA<br />
  25. 25. DIAGNOSTIC CRITERIA FOR NEW DAILY PERSISTENT HEADACHE<br />
  26. 26. DIAGNOSTIC CRITERIA FOR NUMMULAR HEADACHE<br />
  27. 27. DIAGNOSIS<br />
  28. 28. RED FLAGS IN DIAGNOSIS OF HA<br />
  29. 29. ALGORITHM FOR HA DIAGNOSIS<br />
  30. 30. ALGORITHM FOR PRIMARY HEADACHE DIAGNOSIS<br />
  31. 31. TREATMENT<br />
  32. 32. TREATMENT OF MIGRAINE -AVOIDING TRIGGERS<br />
  33. 33. STAGED APPROACH<br />
  34. 34. NSAIDS TYPES<br />
  35. 35. ANALGESICS<br />
  36. 36. U.S HEADACHE CONSORTIUM CONCLUSIONS AND RECOMMENDATIONS<br />ASPRIN, NAPROXEN , IBUPROFEN, DICLONAC-K SHOULD BE USED FOR THE ACUTE TREATMENT OF NON -DISABLING MIGRAINE (LEVEL -A).<br />KETORLAC IV OR IM SHOULD BE CONSIDERED FOR ACUTE TREATMENT OF MIGRAINE FOR PATIENTS REQUIRING PARENTERAL THERAPY (LEV-B).<br />ACETAMINOPHEN SHOULD BE CONSIDERED FOR THE ACUTE TREATMENT OF NON DISABLING MIGRAINE (LEV-B).<br />AAC SHOULD BE USED FOR THE ACUTE TRATMENT OF MIGRAINE (LEV-A).<br />
  37. 37. REC. FOR BARBITURATE HYPNOTICS<br />BUTALBITAL CONTAINING ANALGESICS ARE NOT RECOMMENDED AS FIRST LINE THERAPY FOR THE ACUTE TREATMENT OF MIGRINE (LEV-U).<br />LIMIT AND CAREFULLY MONITOR PATIENT’S USE OF BUTALBITAL CONTAINING ANALGESICS BECAUSE OF RISK OF DEPENDENCY, MEDICATION OVER USE HEADACHE AND WITHDRAWAL CONCERNS (LEV-U).<br />
  38. 38. DOSES OF DOPAMINE ANTAGONISTS<br />
  39. 39. RECOMMENDATIONS FOR DOPAMINE ANTAGONISTS<br />ORAL METACLOPRAMIDE AS MONOTHERAPY SHOULD NOT BE USED FOR THE ACUTE TREATMENT OF MIGRAINE( LEV-A).<br />HOWEVER ,ORAL METACLOPRAMIDE PROBABLY SHOULD BE CONSIDERED AS ADJUNCT THERAPY TO NSAIDS OR TRIPTANS FOR ACUTE TEATMENT (LEV-B).<br />MET.IM SHOULD PROBABLY NOT BE USED AS MONOTHERAPY FOR ACUTE TEATMENT FOR PATIENTS REQUIRING PARENTERAL THERAPY (LEV-B).<br />MET.IV SHOULD BE CONSIDERED FOR THE ACUTE TREATMENT OF MIGRAINE FOR PATIENTS REQUIRING PARENTERAL THERAPY (LEV-B).<br />CHLORPROMAZINE IV AND PROCHLORPERAZINE IV SHOULD BE USED FOR ACUTE TREATMENT OF MIGRAINE FOR PATIENTS REQUIRING PARENTERAL THERAPY (LEV-A).<br />ONDASETRAON AND GRANISETRAN SHOULD NOT BE CONSIDERED FOR ACUTE TREATMENT OF MIGRAINE (LEV-B).<br />
  40. 40. 5-HT 1 AGONISTS<br />
  41. 41. RECOMMENDATIONS FOR DHE<br />DHE NS SHOULD BE USED FOR THE ACUTE TREATMENT OF MIGRAINE IN ADULTS (LEV-A).<br />DHE IM, SC, IV MAY BE USED IN THE TREATMENT OF MIGRAINE (LEV-B).<br />
  42. 42. HEADACHE RESPONSE FOR TRIPTANS<br />
  43. 43. RECOMMENDATIONS FOR TRIPTANS<br />ALL 7 TRIPTANS IN ALL FORMULATIONS ( ORAL TABLETS, ORAL DISINTEGRATING TABLETS, NS’S& INJECTABLES) SHOULD BE USED FOR THE ACUTE TREATMENT OF MILD, MODERATE OR SEVERE MIGRAINE (LEV-A).<br />FOR PATIENTS WHO EXPERIENCE MIGRAINE RELATED DISABILITY, TRIPTANS SHOULD BE USED BY ADULTS FOR THE ACUTE TREATMENT OF MIGRAINE UNLESS CONTRAINDICATED (LEV-A).<br />COMBINATIONS OF TRIPTANS AND NAPROXEN SHOULD BE USED IN THE ACUTE TREARMENT OF MIGRIAINE AND OFFERS IMPROVED CLINICAL RESPONSE OVER EITHER TREATMENT GIVEN AS MONOTHERAPY (LEV-A) .<br />
  44. 44. Oral CGRP Receptor Antagonist <br />Multicentre, randomised, placebo-controlled clinical trial in adult patients with acute migraine. <br />A total of 1,703 patients were randomised into the study and 1,294 administered study treatment. <br />Telcagepant (MK-0974)at doses of either 300 mg (n=371), 150 mg (n=381), 50 mg (n=177) or placebo (n=365). <br />Analysing five primary endpoints at two hours post-dose: pain freedom (reduction to no pain), pain relief (reduction to mild or no pain), absence of photophobia (sensitivity to light), absence of phonophobia (sensitivity to sound), and absence of nausea.<br />Telcagepant was significantly greater than placebo for all five primary endpoints in the study (p<0.001 for both doses on all endpoints .<br />Most common side effects were fatigue (6.8 %), dizziness (5.4 %), dry mouth (5.1 %), nausea (5.1 %), upper abdominal pain (3.2 %) and somnolence (2.7 %) <br />European Headache and Migraine Trust International Congress 2008 in London.<br />
  45. 45. PROPHYLAXIS - INDICATIONS<br />RECURRING MIGRAINE ATTACKS THAT IN THE PATIENTS OPINION, SIGNIFICANTLY INTERFERE WITH HIS OR HER DAILY ROUTINES, DESPITE APPROPRIATE TREATMENT.<br />FREQUENT HEADACHES, >4/MONTH.<br />CONTRAINDICATION TO, FAILURE WITH, OVERUSE OF, OR INTOLERENCE TO ACUTE THERAPIES.<br />PATIENT PREFERENCE.<br />PRESENCE OF UNCOMMON MIGRAINE CONDITIONS, INCLUDING HEMIPLEGIC MIGRAINE, BASILAR MIGRAINE, MIGRAINE WITH PROLONGED AURA, OR MIGRAINOUS INFARCTION. <br />(Silberstein on behalf of the quality standards improvement committee,2007,revised US EBM guidelines)<br />
  46. 46. ANTIDEPRESSENTS IN PROPHYLAXIS<br />
  47. 47. PRINCIPLES OF ANTIDEPRESSENTS USE<br />TCA’S DOSE IS WIDE AND MUST BE INDIVIDULISED.<br />TCA’S CAUSE SEDATION EXCEPT PROTRIPTYLINE. START WITH LOW DOSE AT BED TIME .<br />IF TOO SEDATING SWITCH FROM TERTIARY TCA’S (AMITRIPTYLINE, DOXEPIN) TO SECONDARY TCA’S( NORTRIPTYLINE, PROTRIPTYLINE).<br />IF INSOMNIA OR NIGHTMARES DEVELOP GIVE TCA IN MORNING.<br />SSRI ‘S CAN BE USED OD MORNING OR EVENING, LESS SEDATING THAN TCA’S, MAY NEED HYPNOTIC FOR SLEEP INDUCTION.<br />BIPOLAR PATIENTS IN A DEPRESSED STATE CAN BECOME MANIC ON ANTIDEPRESSANTS.<br />
  48. 48. AED’S FOR MIGRAINE PROPHYLAXIS<br />
  49. 49. ß- BLOCKERS FOR PROPHYLAXIS<br />
  50. 50. Ca CHANNEL BLOCK ERS FOR PROPHYLAXIS<br />
  51. 51. MISCELLANEOUS MEDICINES<br />
  52. 52.
  53. 53. TREATMENT OF STATUS MIGRAINOUS<br />
  54. 54. TREATMENT OF TTH<br />
  55. 55. Treatment of TTH<br />
  56. 56. ABORTIVE MANAGEMENT OF CLUSTER HA<br />
  57. 57. PREVENTIVE MANAGEMENT OF CLUSTER HA<br />
  58. 58. TREATMENT OF PAROXYSMAL HEMICRANIA <br />PREVENTIVE.<br />INDOMETHACIN.<br />TYPICAL DOSE=25-100 mgs.<br />DOSAGE RANGE=12.5-300.<br />SKIPPING OR DELAYING DOSES- PROMPT REOCCURENCE OF HA.<br />DRUG WITHDRAWAL ADVISED AT LEAST ONCE IN EVERY 6 MONTHS.<br />GI SIDE EFFECTS.<br />
  59. 59. TREATMENT OF SUNCT<br />PREVENTIVE.<br />LAMOTRIGINE - TREATMENT OF CHOICE, 1 ST LINE.<br />TOPIRAMATE, GABAPENTINE- 2ND LINE DRUGS.<br />CARBAMAZEPINE –IF BOTH FAIL.<br />IF ACUTE INTERVENTIONS ARE NEEDED- IV LIDOCAINE.<br />

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