Chronic Daily Headaches David V. Lardizabal, M.D.


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Chronic Daily Headaches David V. Lardizabal, M.D.

  1. 1. Chronic Daily Headaches David V. Lardizabal, M.D. Assistant Professor, Kirksville College of Medicine
  2. 2. Objectives <ul><li>To learn the systematic approach in the diagnosis of chronic daily headaches </li></ul><ul><li>To present different cases of chronic daily headaches </li></ul>
  3. 3. Basic Components of the History <ul><li>Onset </li></ul><ul><li>Location </li></ul><ul><li>Quality </li></ul><ul><li>Duration </li></ul><ul><li>Frequency </li></ul><ul><li>Associated Symptoms </li></ul><ul><li>Triggers </li></ul><ul><li>Relieving Factors </li></ul><ul><li>Medication: dose/frequency </li></ul><ul><li>General and Neurologic Examination </li></ul>
  4. 4. Case #1 <ul><li>A previously healthy 38 year old man presented with 4 month history of daily headache. The headache began gradually and without provocation. The pain was continuous and became progressively more severe and disabling. The headache was moderately intense holocranial pressure that lasted throughout the day and was not associated with gastrointestinal or autonomic symptoms. </li></ul>
  5. 5. Case #1 continued <ul><li>He tried over-the-counter analgesics without relief prior to receiving acetaminophen with codeine from his family physician. A prior neurological examination and non-enhanced MRI of the head were unremarkable. His alleviating factors was “resting and relaxing” were the only thing that helped. His headache was improved when he is supine i.e. resting in bed, resting in the sofa, or mid-day naps. When he rises from bed, his headache would invariably intensity. </li></ul>
  6. 6. Diagnosis? MRI brain With Contrast Coronal View
  7. 7. Diagnosis? Benign Intracranial Hypotension
  8. 8. Case #2 <ul><li>15 year old boy has been having daily headaches for the past 6 months. It is a constant pressure. He has incontinence and difficulty in looking up. He has tried different analgesics without relief. He wakes up in the morning vomiting. The neurologic examination showed no upgaze and papilledema. </li></ul>
  9. 9. Diagnosis?
  10. 10. Diagnosis? Pineal Gland Tumor
  11. 11. Case #3 <ul><li>18 year old female had a minor head trauma from an altercation. She has daily headaches and posterior neck pain for 2 weeks. She vomits daily. She has no nausea, light or sound sensitivity. Her neurological examination is normal. The CT scan was negative. She was told to have post-traumatic headache. </li></ul>
  12. 12. Diagnosis?
  13. 13. Diagnosis? SUBDURAL HEMATOMA
  14. 14. Lesson Number 1 <ul><li>Secondary Headaches should be vigilantly investigated in daily headache patients. </li></ul><ul><li>Neurologic Examination is important </li></ul><ul><li>CT is not the diagnostic test of choice </li></ul><ul><li>MRI with/without contrast should be performed in new daily headaches. </li></ul>
  15. 15. Secondary Chronic Daily Headaches <ul><li>Post-Traumatic Headache </li></ul><ul><li>Cervical Spine Disorders </li></ul><ul><li>Headaches associated with Vascular Disorders; AVM; arteritis including GCA, dissection, subdural hematoma </li></ul><ul><li>Headache associated with Non-Vascular disorders (EBV, HIV, tumor) </li></ul><ul><li>TMJ, Sinus infections (sphenoid), Chronic CNS infections </li></ul><ul><li>Intracranial Hypotension or hypertension </li></ul>
  16. 16. Primary Chronic Daily Headaches
  17. 17. Definition of CDH <ul><li>> 15 or more headache days </li></ul><ul><li>> 3 or more months </li></ul>
  18. 18. Chronic Daily Headaches <ul><li>Duration of head pain </li></ul><ul><li>Autonomic Features </li></ul><ul><li>Medication History </li></ul><ul><li>Neurologic Examination </li></ul>
  19. 19. Duration of the Head Pain <ul><li>More than 4 hours </li></ul><ul><li>Less than 4 hours </li></ul>
  20. 20. Autonomic Features <ul><li>Eyelid swelling </li></ul><ul><li>Ptosis “drooping” </li></ul><ul><li>Miosis or Mydriasis </li></ul><ul><li>Conjunctival injection </li></ul><ul><li>Lacrimation “Tearing” </li></ul><ul><li>Rhinorrhea “runny nose” </li></ul>
  21. 21. Medication History <ul><li>What are the medication used for abortive and/or prophylactic therapy? </li></ul><ul><li>What is the monthly consumption? </li></ul>
  22. 22. Case #4 <ul><li>23 year old woman presented for evaluation of intractable and disabling daily headache of 6 months duration. Her headache began 3 years ago, occurring one to 3 times per month. Initially, her headache were left temporal in location and were severe and throbbing and associated with prominent nausea and photo- or phonophobia. </li></ul>
  23. 23. Case #4 continued <ul><li>Over the past 6 months, she has had a moderate intensity, diffuse, daily, and continuous headache with only mild photophobia and occasional nausea. To allow herself to function at school, throughout the past year, she escalated her abortive medication use, initially using 4 to 8 acetaminophen-aspirin-caffeine tablets daily and in the past 6 months, 4 to 8 perscription acetaminophen-caffeine-butalbital tablets daily. </li></ul>
  24. 24. Case #4 continued <ul><li>Prophylactic therapy with tricyclic antidepressant and anticonvulsant was unhelpful. Her neurological examination and brain MRI were normal. </li></ul>
  25. 25. Case #4 <ul><li>Fulfills criteria for CDH </li></ul><ul><li>Normal MRI and exam </li></ul><ul><li>Secondary causes excluded. </li></ul>
  26. 26. Diagnosis? Chronic Daily Headaches?
  27. 27. Lesson Number 3 <ul><li>Chronic Daily Headache is a Symptom </li></ul><ul><li>It is NOT a Diagnosis </li></ul>
  28. 28. Migraine Medication Overuse Headaches ( MOH)
  29. 29. Medication Overuse Headaches (MOH) <ul><li>Simple analgesics </li></ul><ul><ul><li>> 15 days for > 3 months </li></ul></ul><ul><li>Opiods, Ergotamines, Triptans or Combination of medications </li></ul><ul><ul><li>> 10 days/month > 3 months </li></ul></ul><ul><li>Frequent/regular use 2-3 times per week </li></ul>
  30. 30. Lesson Number 4 <ul><li>Medication Overuse Headaches should be excluded or Treated before diagnosing Primary CDH disorders </li></ul>
  31. 32. What are the Primary Chronic Daily Headache Disorders?
  32. 34. Case #5 <ul><li>A 50 year old female has been complaining of right supraorbital pain for the past 1 year. The pain is brief, typically 15 minutes. It is stabbing, and electric-like. The attacks are sporadic and she can have 5 to 40 exquisitely painful episodes for 5 days every week. The neurologic examination is normal and MRI brain is normal. </li></ul>
  33. 35. Case #5 Continued <ul><li>Anticonvulsants failed. </li></ul><ul><li>Microvascular Decompression failed </li></ul><ul><li>Gamma Knife Therapy failed. </li></ul><ul><li>What was the presumptive diagnosis in this case? </li></ul>
  34. 36. Case #5 continued <ul><li>The patient had tearing, ptosis, and rhinorrhea on the same side of the pain. </li></ul>
  35. 37. Diagnosis? <ul><li>This is not Trigeminal Neuralgia </li></ul><ul><li>Trigeminal Autonomic Cephalalgia </li></ul><ul><ul><li>Chronic Paroxysmal Hemicrania </li></ul></ul>
  36. 40. Case #6 <ul><li>50 year old woman. She has been having right sided headache for the past 10 years. It is a dull pain that last almost the whole day. She has no nausea, no photophobia, no phonophobia, or vomiting. At times, there are “stabbing” pains just above the eyebrow. She has tearing in the right eye and ptosis in these acute stabbing headaches. She has tried “all the headache medications made by man.” Her examination and MRI, LP were normal. </li></ul>
  37. 42. Lesson Number 5 <ul><li>The presence of autonomic features is an important differential </li></ul><ul><ul><li>Chronic Paroxysmal Hemicrania (< 4 hrs HA) </li></ul></ul><ul><ul><li>Hemicrania Continua (> 4 hours HA) </li></ul></ul><ul><li>Patients with CDH with autonomic features should be therapeutically tried with Indomethacin </li></ul>
  38. 43. Primary Variety <ul><li>Headache Duration < 4 hours </li></ul><ul><ul><li>Cluster Headache </li></ul></ul><ul><ul><li>Chronic Paroxysmal Hemicrania </li></ul></ul><ul><ul><li>SUNCT </li></ul></ul><ul><ul><li>Hypnic Headache </li></ul></ul>
  39. 44. Criteria of Chronic Cluster <ul><li>Attacks occurs for more than 1 year without remission or with remission lasting less than 1 month. </li></ul><ul><li>Frequency: one every second day to eight day. </li></ul><ul><li>Associated with one of: </li></ul><ul><ul><li>Lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, miosis, eyelid edema, conjunctival injection, sense of restlessness or agitation during headache. </li></ul></ul>
  40. 45. Hypnic Headache <ul><li>Attacks of pain may be unilateral/bilateral and always occur after falling asleep. </li></ul><ul><li>15-180 minutes </li></ul><ul><li>15 times per month </li></ul><ul><li>None or one of the following: </li></ul><ul><ul><li>Nausea, photophobia, phonophobia </li></ul></ul><ul><li>Not attributable to another disorder </li></ul>
  41. 46. SUNCT <ul><li>Short-Lasting Unilateral Neuralgiform Headache with Conjunctival injection and Tearing </li></ul><ul><li>At least 20 attacks </li></ul><ul><li>Unilateral moderately severe orbital or temporal stabbing or throbbing pain lasting 10-120 seconds </li></ul><ul><li>Not attributable to another disorder </li></ul><ul><li>At least one: nasal congestion, rhinorrhea, or eyelid edema. </li></ul>
  42. 47. Primary CDH <ul><li>Headache Duration > 4 hours </li></ul><ul><ul><li>Chronic Migraine </li></ul></ul><ul><ul><li>Chronic Tension-Type Headache </li></ul></ul><ul><ul><li>New Daily Persistent Headache </li></ul></ul><ul><ul><li>Hemicrania Continua (indomethacin responsive) </li></ul></ul>
  43. 48. Chronic Migraine (CM) <ul><li>“ transformed migraine” </li></ul><ul><li>Migraine without aura with CDH features in the absence of medication overuse. </li></ul><ul><li>When CM is associated with medication oversue, only a diagnosis of probable Chronic mgraine and probable MOH. </li></ul><ul><li>Only after withdrawal of overused medications and the persistence of migraine on more than 15 days per month can a diagnosis of CM be made. </li></ul>
  44. 49. Chronic Tension-Type HA <ul><li>Fulfills CDH definition </li></ul><ul><li>At least 2 of of the pain characteristics </li></ul><ul><ul><li>Pressing/tightening quality </li></ul></ul><ul><ul><li>Mild to moderate severity </li></ul></ul><ul><ul><li>Bilateral location </li></ul></ul><ul><ul><li>No aggravation by walking stairs or similar routine physical activity </li></ul></ul><ul><li>Historyof episodic TT HA </li></ul><ul><li>No vomiting, no more than one: nausea, photophobia </li></ul><ul><li>Does not meet criteria for NDPH or HC </li></ul>
  45. 50. New Daily Persistent Headache <ul><li>Abrupt development (< 3 days) of headache that does not remit. </li></ul>
  46. 51. Summary <ul><li>Chronic Daily Headache should be approached in a systematic manner </li></ul><ul><li>Secondary HA should be excluded </li></ul><ul><li>It must fulfill CDH definition </li></ul><ul><li>Do no over-medicate patients or educate them in avoiding overmedication </li></ul><ul><li>Always remember the associated symptoms; not just the pain </li></ul>
  47. 52. Thank You
  48. 53. DIHYDROERGOTAMINE PROTOCOL Metoclopramide 10 mg I.V. DHE 0.25 or 0.5 mg I.V. (2-3 min.) Nausea NO DHE for 8 hours DHE 0.3 or 0.4 mg + 10 mg metoclopramide IV q8H for 3 days Nausea No Nausea DHE 0.75 mg q8H I.V. q8H x 3 days Metoclopramide 10 mg DHE 1.0 mg q8H I.V. x 3 days Metoclopramide 10 mg
  49. 54. DIHYDROERGOTAMINE PROTOCOL Metoclopramide 10 mg I.V. DHE 0.25 or 0.5 mg I.V. (2-3 min.) Head Pain; No Nausea DHE 0.5 mg IV in one hour (metoclopramide) Nausea No Nausea DHE 0.75 mg q8H I.V. q8H x 3 days Metoclopramide 10 mg DHE 1.0 mg q8H I.V. x 3 days Metoclopramide 10 mg
  50. 55. DIHYDROERGOTAMINE PROTOCOL Metoclopramide 10 mg I.V. DHE 0.25 or 0.5 mg I.V. (2-3 min.) No Head Pain; No Nausea DHE 0.5 mg + Metoclopramide 10 mg IV q8H x 3 days Nausea No Nausea DHE 0.75 mg q8H I.V. q8H x 3 days Metoclopramide 10 mg DHE 1.0 mg q8H I.V. x 3 days Metoclopramide 10 mg