Headache management

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Headache management

  1. 1. Headache Management in Family Practice
  2. 2. <ul><li>“ In Theory” </li></ul><ul><li>There is no difference between theory and practice. </li></ul><ul><li>“ In Practice” </li></ul><ul><li>There is! </li></ul>
  3. 3. Approach <ul><li>Top Down </li></ul><ul><li>Bottom Up </li></ul>
  4. 4. Is it Brain Tumor?
  5. 5. Brain tumor is Rare cause of headache? <ul><li>Headache Incidence 5-15% in general population </li></ul><ul><li>Tumor incidence 50/100,000 per year </li></ul><ul><li>1/200 patient with “tension or migraine headache ” may have tumor </li></ul>
  6. 6. Headache is common in brain tumor <ul><li>Headache as presenting symptom in 60% of tumor </li></ul><ul><li>77% similar to tension headache </li></ul><ul><li>9% Migraine like </li></ul><ul><li>8% Classic brain tumor headache </li></ul>
  7. 7. Other serious headache <ul><li>Granuloma </li></ul><ul><li>Brain abscess </li></ul><ul><li>Chronic subdural hematoma </li></ul><ul><li>Benign intracranial hypertension </li></ul><ul><li>TB/Fungal meningitis </li></ul><ul><li>Temporal arteritis </li></ul>
  8. 8. Is it a brain abscess? <ul><li>Fever present in 50% of cases </li></ul><ul><li>Headache is present in 70% of cases </li></ul><ul><li>Focal neurological signs are seen if located in strategic location </li></ul><ul><li>Look for ear, sinus or systemic infection </li></ul><ul><li>Cyanotic heart disease in children </li></ul><ul><li>Immunocompromised state </li></ul>
  9. 10. Chronic subdural hematoma? <ul><li>Common in elderly population </li></ul><ul><li>Indolent chronic headache without obvious neurologic signs or symptoms </li></ul><ul><li>60% to 70% have a history of antecedent trauma, often trivial </li></ul><ul><li>Changes in personality or cognitive abilities </li></ul><ul><li>Focal and sometimes intermittent weakness, seizures, or sensory changes </li></ul><ul><li>Excessive sleepiness, lethargy, or decreasing level of consciousness </li></ul>
  10. 11. Idiopathic intracranial hypertension <ul><li>Common in fat adolescent and young women </li></ul><ul><li>Headache </li></ul><ul><ul><li>dull, like pressure </li></ul></ul><ul><ul><li>Usually symmetrical </li></ul></ul><ul><ul><li>may be associated with visual disturbances </li></ul></ul><ul><li>CT: normal or small ventricles </li></ul><ul><li>LP: </li></ul><ul><ul><li>high pressure </li></ul></ul><ul><ul><li>normal cytology </li></ul></ul><ul><ul><li>headache better with CSF drainage </li></ul></ul>
  11. 12. What Investigations? <ul><li>Neuroimaging </li></ul><ul><li>Lumber puncture </li></ul><ul><li>EEG- no role </li></ul>
  12. 13. When Neuroimaging? <ul><li>Decreased alertness or cognition </li></ul><ul><li>Onset of pain with exertion, coitus, coughing, or sneezing </li></ul><ul><li>Worsening under observation </li></ul><ul><li>Nuchal rigidity </li></ul><ul><li>Focal neurological signs </li></ul><ul><li>First headache in patient older than 50 years </li></ul><ul><li>Worst headache ever experienced </li></ul><ul><li>Headache not fitting a defined pattern </li></ul>
  13. 14. When No Neuroimaging? <ul><li>When all of the following are present: </li></ul><ul><ul><li>History of similar headaches </li></ul></ul><ul><ul><li>Normal vital signs </li></ul></ul><ul><ul><li>Alertness and cognition intact </li></ul></ul><ul><ul><li>Supple neck </li></ul></ul><ul><ul><li>No neurological signs </li></ul></ul><ul><ul><li>Improvement in headache without analgesics or abortive medications </li></ul></ul>
  14. 15. CT or MRI ? <ul><li>Headache producing lesion is large enough to be seen in CT </li></ul><ul><li>MR is better in differentiating tumors </li></ul><ul><li>Contrast helps in knowing the break of BBB </li></ul><ul><li>Acute bleed and Calcification seen better by CT </li></ul>
  15. 16. (CT/MR) Normal Headache <ul><li>Chronic continuous headache </li></ul><ul><ul><li>Tension type headache </li></ul></ul><ul><li>Chronic recurring headache </li></ul><ul><ul><li>Migraine </li></ul></ul><ul><ul><li>Cluster/ chronic paroxysmal hemicrania </li></ul></ul><ul><ul><li>episodic tension type headache </li></ul></ul>
  16. 17. Migraine without aura (common migraine). <ul><li>Headache attacks last 4 to 72 hours. </li></ul><ul><li>Headache has at least 2 of the following: </li></ul><ul><ul><li>Unilateral location </li></ul></ul><ul><ul><li>Pulsating quality </li></ul></ul><ul><ul><li>Moderate or severe intensity (inhibits daily activity) </li></ul></ul><ul><ul><li>Aggravation by routine physical activity </li></ul></ul><ul><li>During the headache, at least 1 of the following: </li></ul><ul><ul><li>Nausea or vomiting </li></ul></ul><ul><ul><li>Photophobia and phonophobia </li></ul></ul><ul><li>No organic cause found by history, PE, neurologic exam. </li></ul>Must have at least 5 attacks that meet the following criteria:
  17. 18. Migraine with aura (classical migraine). Must have at least 2 attacks fulfilling the following criteria : <ul><li>.At least 3 of the following are present: </li></ul><ul><ul><li>One of more fully reversible aura symptoms indicating focal cerebral cortical or brainstem dysfunction. </li></ul></ul><ul><ul><li>At least one aura symptom develops gradually over more than 4 minutes.         </li></ul></ul><ul><ul><li>No aura symptom lasts more than 60 minutes (duration proportionally increases if >1 aura symptom present). </li></ul></ul><ul><ul><li>HA follows aura with free interval of less than 60 minutes (may begin before or with the aura). HA usually lasts 4 to 72 hours but may be absent. </li></ul></ul><ul><li>No organic cause found by history, PE, neurologic exam. </li></ul>
  18. 19. Treatment of Migraine <ul><li>General. Taper off analgesics to prevent rebound HA and start preventive medications. Depression (if identified) needs to be treated. </li></ul><ul><li>Dietary changes. </li></ul><ul><ul><li>Avoid monosodium glutamate, nitrates, and alcohol. </li></ul></ul><ul><ul><li>Spread out caffeine evenly. </li></ul></ul><ul><li>Lifestyle changes. </li></ul><ul><ul><li>Regular eating, sleeping, and exercise patterns. </li></ul></ul><ul><li>3. Behavioral therapies. </li></ul><ul><ul><li>Biofeedback, stress management, and self-help groups. </li></ul></ul>
  19. 20. Acute therapy (outpatient). <ul><li>Sumatriptan (Imitrex) 6 mg SQ; may repeat in 1 hour; maximum 12 mg/24 hours. </li></ul><ul><li>Contraindicated if concomitant CAD or uncontrolled hypertension. </li></ul><ul><li>Do not use if patient is given an ergot alkaloid in the last 24 hours. Many (up to 50%) will require rescue medicine because of Sumatriptan 2-hour half-life. </li></ul><ul><li>Oral Sumatriptan 50-100mg </li></ul><ul><li>Cafergot 1 or 2 tablets upto 4 tabs/attack or 10/week. </li></ul><ul><li>Ergotamine 2 mg PO or SL; repeat in 30 minutes up to 6 mg/24 hours or 10 mg/week. </li></ul><ul><li>NSAIDs. ibuprofen 400 to 800 mg PO TID or QID or Naproxen sodium 550 mg PO BID or TID with food. </li></ul><ul><li>Prochlorperazine 25 mg PR BID PRN can be used to abort the migraine at home. </li></ul><ul><li>Metaclopramide help gastric emptying and vomiting </li></ul>
  20. 21. Acute therapy - Migraine <ul><li>Prochlorperazine 10 mg IV. </li></ul><ul><li>Metoclopramide 5 to 10 mg IV Q8h. Often given with dihydroergotamine (DHE) to prevent DHE-induced nausea. May be combined orally with ASA. </li></ul><ul><li>NSAIDs (ketorolac [Toradol] 60 mg IM, </li></ul><ul><li>Dihydroergotamine (DHE) 0.75 mg IV </li></ul><ul><li>Meperidine 50 to 100 mg IM Q3h PRN. </li></ul><ul><li>Dexamethasone 4 mg IM or a short course of prednisone (40 to 60 mg PO QD), combined with analgesics above, if migraine continues >24 hours. </li></ul><ul><li>Sumatriptan (Imitrex); see above for dose. Oral sumatriptan also available but less effective. </li></ul>
  21. 22. Migraine prophylaxis <ul><li>Propranolol 20 to 60 mg PD </li></ul><ul><li>Verapamil 40 to 80 mg PD </li></ul><ul><li>Flunarin – 10-20mg PD </li></ul><ul><li>NSAIDs, especially useful for menstrual migraine. </li></ul><ul><li>Amitriptyline 10 to 200 mg PO QHS. </li></ul><ul><li>Cyproheptadine 2 to 4 mg PO HS Childhood </li></ul>
  22. 23. Tension headache <ul><li>a. Headache with at least 2 of the following: </li></ul><ul><ul><li>Pressing or tightening quality </li></ul></ul><ul><ul><li>Mild or moderate intensity Bilateral location </li></ul></ul><ul><ul><li>No aggravation by routine physical activity </li></ul></ul><ul><li>b. No organic cause found by history, PE, neurologic exam. </li></ul><ul><li>c. Tension headache is separated into two subtypes based on frequency: </li></ul><ul><li>Episodic </li></ul><ul><li>   Headache lasting 30 minutes to 7 days </li></ul><ul><li>   No nausea or vomiting with headache </li></ul><ul><li>   Photophobia and phonophobia are absent, or one but not the other is present </li></ul><ul><li>   At least 10 previous headaches as above, with number of headache days <180/year and <15/month </li></ul><ul><li>Chronic </li></ul><ul><li>   Headache averages 15 days/month (180 days/year), 6 months </li></ul><ul><li>   No vomiting </li></ul><ul><li>   No more than 1 of the following: nausea, photophobia, or phonophobia </li></ul>
  23. 24. Cluster Headache <ul><li>Severe unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 minutes untreated. </li></ul><ul><li>Headache is associated with at least 1 of the following on the pain side: </li></ul><ul><ul><li>Conjunctival injection </li></ul></ul><ul><ul><li>Lacrimation </li></ul></ul><ul><ul><li>Nasal congestion </li></ul></ul><ul><ul><li>Forehead and facial sweating </li></ul></ul><ul><ul><li>Rhinorrhea </li></ul></ul><ul><ul><li>Miosis </li></ul></ul><ul><ul><li>Ptosis </li></ul></ul><ul><ul><li>Eyelid edema </li></ul></ul><ul><li>Frequency of attacks ranges from 1 to 8 daily. </li></ul><ul><li>At least 5 attacks occur as above. </li></ul>
  24. 25. Cluster Headache Rx <ul><li>Acute treatment : </li></ul><ul><ul><li>O2 - 6 to 8 L/min . </li></ul></ul><ul><ul><li>Nasal lidocaine 4% solution (15 drops) or 5% ointment (3 swabs) intranasally on ipsilateral side may be abortive. </li></ul></ul><ul><ul><li>Sumatriptan is especially effective for cluster headache because by definition they last <3 hours. </li></ul></ul><ul><li>Prophylactic treatment. </li></ul><ul><ul><li>Ergotamine, </li></ul></ul><ul><ul><li>Methy-sergide </li></ul></ul><ul><ul><li>Prednisone (60 mg QD for 1 week with a rapid tapering off), </li></ul></ul><ul><ul><li>Verapamil (80 to 160 mg TID), </li></ul></ul><ul><ul><li>Lithium carbonate 300 mg BID or TID, </li></ul></ul><ul><ul><li>Valproate 250 to 1500 mg </li></ul></ul>
  25. 26. Chronic paroxysmal hemicrania. <ul><li>Severe unilateral orbital, supraorbital, or temporal pain always on the same side, lasting 2 to 45 minutes. </li></ul><ul><li>Attack frequency >5 a day for more than half the time (periods of lower frequency may occur). </li></ul><ul><li>Headache is associated with at least 1 of the following on the pain side: </li></ul><ul><ul><li>Conjunctival injection </li></ul></ul><ul><ul><li>Lacrimation </li></ul></ul><ul><ul><li>Nasal congestion </li></ul></ul><ul><ul><li>Rhinorrhea </li></ul></ul><ul><ul><li>Eyelid edema </li></ul></ul><ul><ul><li>Ptosis </li></ul></ul><ul><li>Absolute effectiveness of indomethacin (150 mg/day or less). </li></ul><ul><li>At least 50 attacks occur as above. </li></ul><ul><li>No organic cause found by history, PE, neurologic exam. </li></ul>
  26. 27. Menstrual Migraine <ul><li>” True menstrual migraine,&quot; : 14% of migraineurs </li></ul><ul><li>60-70% women migraine menstrual related </li></ul><ul><li>Related to low estrogen level </li></ul><ul><li>Estradiol patch 1-2/day for 7 days 1-2 days before expected headache. </li></ul><ul><li>NSAIDs for prevention and attack </li></ul>
  27. 28. Oral Contraceptive and Migraine <ul><li>Some women - migraine improves </li></ul><ul><li>C ommon ly - migraine worsen (immediate or delayed) </li></ul><ul><li>Sometime - migraines precipitates </li></ul><ul><li>D iscontinuation of OCs may not result in improvement for many months. </li></ul><ul><li>Even non-estrogen hormonal methods of birth control such as Depo-Provera injection seem to aggravate headaches in some women. </li></ul>
  28. 29. Headache in Pregnancy <ul><li>Pre-existing migraine can become worse during the first trimester of pregnancy and then disappear for the last two. </li></ul><ul><li>25% of women with migraine will go through their pregnancy with their headache pattern unchanged. </li></ul><ul><li>Migraine can also appear for the first time during pregnancy or soon after giving birth </li></ul>
  29. 30. Analgesic in Pregnancy <ul><li>Acetaminophen B  </li></ul><ul><li>Caffeine B  </li></ul><ul><li>Fenoprofen, Ibuprofen, Meclofenamate, naproxen, Sulindac, Tolmetin </li></ul><ul><ul><li>B </li></ul></ul><ul><ul><li>D if used in 3rd trimester </li></ul></ul><ul><li>Aspirin </li></ul><ul><ul><li>C Risk factor D if used in 3rd trimester </li></ul></ul>
  30. 31. Antiemitic in Pregnancy <ul><li>Metoclopramide B  </li></ul><ul><li>Prochlorperazine, Promethazine, Chlorpromazine, Hydroxyzine, Trimethobenzamide C </li></ul>
  31. 32. Migraine Pophylactics in Pregnancy <ul><li>Amitriptyline, Nortriptyline, Imipramine D  </li></ul><ul><li>  Metoprolol (Lopressor) B  </li></ul><ul><li>Atenolol, Nadolol, P ropranolol C </li></ul><ul><ul><li>Propranolol may cause intrauterine growth retardation, prematurity, hypotension </li></ul></ul><ul><li>Verapamil C </li></ul>
  32. 33. Post-partum headache <ul><li>Cerebral venous thrombosis </li></ul><ul><li>Persistent headache seizure and coma </li></ul><ul><li>Diagnosed by MR venous angiography </li></ul><ul><li>Heparin is drug of choice even with hemorrhagic transformation </li></ul>
  33. 34. Headache in Menopause <ul><li>Headaches may r eappear </li></ul><ul><li>Commonly headaches reduces , and they often change in nature. </li></ul><ul><li>migraine with aura may continue to have the aura but without the subsequent headache. </li></ul><ul><li>Following natural menopause, 60% decrease </li></ul><ul><li>With surgical menopause 30% decreases </li></ul><ul><li>M enstrual migraine benefit most from menopause. </li></ul>
  34. 35. Headache in elderly <ul><li>Tumors </li></ul><ul><li>Subdural hematoma </li></ul><ul><li>Cervicogenic Headache </li></ul><ul><li>Obstructive airway disease with hypercapnea </li></ul><ul><li>Hypertension </li></ul><ul><li>Ocular: Glaucoma </li></ul>
  35. 36. Therapeutic challenge in elderly <ul><li>Reduced tolerance to medications </li></ul><ul><li>NSAIDs reduced renal clearance </li></ul><ul><li>Beta blockers, lethargy, hypotension </li></ul><ul><li>Tricyclic: confusional state </li></ul><ul><li>More contraindication; Heart failure, glaucoma, prostatism, Hypertension, depression </li></ul><ul><li>Methyldopa nitrates aggravates migraine </li></ul>
  36. 37. Temporal arteritis <ul><li>Seen at this age </li></ul><ul><li>Progressive headache with tender thickened temporal arteries and systemic symptom and raise ESR </li></ul><ul><li>Dramatic response to Steroid. </li></ul><ul><li>Stop if no response and biopsy negative </li></ul>
  37. 38. Migraine with aura from TIA <ul><li>It should be remembered that a diagnosis of migraine does not preclude a superimposed TIA. </li></ul><ul><li>Migraine aura TIA </li></ul><ul><li>Multiple previous episodes New event </li></ul><ul><li>Gradual onset Sudden onset </li></ul><ul><li>Short duration May last 24 hours </li></ul><ul><li>Progression and regression pattern No increasing and decreasing symptom pattern </li></ul>
  38. 39. Hypnic headache <ul><li>Onset out of sleep , in elderly </li></ul><ul><li>Bilateral, 30 to 60 minutes </li></ul><ul><li>Almost daily, Nausea 50%. </li></ul><ul><li>Respond dramatically to treatment. </li></ul><ul><li>300 to 600 mg of lithium at bedtime </li></ul>
  39. 40. Headache in ischemic CVD <ul><li>10-15% of Ischemic CVD have headache </li></ul><ul><li>May precedes ischemia by hours to days </li></ul><ul><li>Varies in severity, quality and duration </li></ul><ul><li>More common with large vessel occlusive disease them small vessel </li></ul><ul><li>Posterior circulation stroke have more headache than anterior. </li></ul>
  40. 41. Cerebral arterial dissection <ul><li>Onset temporally related to cervical manipulation, sustained exertion, or trauma </li></ul><ul><li>Sudden unilateral neck pain or headache with radiation to ipsilateral face, eye, or ear </li></ul><ul><li>Amaurosis fugax </li></ul><ul><li>Pulsatile tinnitus </li></ul><ul><li>Horner's syndrome without anhidrosis </li></ul><ul><li>Ipsilateral tongue weakness (hypoglossal nerve palsy) and dysgeusia </li></ul><ul><li>Cervical bruit or tenderness </li></ul><ul><li>Diplopia </li></ul><ul><li>Syncope </li></ul>
  41. 42. Drug induced headache in elderly <ul><li>Vasodilators, Antihypertensive </li></ul><ul><li>Sedatives </li></ul><ul><li>Brochodilators </li></ul><ul><li>Antiarrhythmic agents </li></ul><ul><li>Caffieine, Indomethacine, Propoxyphen </li></ul>
  42. 43. Headache n children <ul><li>Migraine </li></ul><ul><li>Migraine variants </li></ul><ul><li>Tumor </li></ul><ul><li>Hydrocephalus </li></ul>
  43. 44. Migraine in children <ul><li>With or without aura </li></ul><ul><li>Variants </li></ul><ul><ul><li>benign positional vertigo </li></ul></ul><ul><ul><li>Basilar migraine </li></ul></ul><ul><ul><li>Ophthalmologic migraine </li></ul></ul><ul><ul><li>Cyclic vomiting </li></ul></ul><ul><ul><li>Benign torticollis </li></ul></ul><ul><li>Hemiplegic migraine headache follows the hemiparesis, which lasts from hours to days. </li></ul><ul><li>Chromosome 9 that has been found in 50% to 60% of families </li></ul>
  44. 45. Treatment of migraine in Children <ul><li>Acute attack </li></ul><ul><ul><li>NSAIDs, Sumatryptan, DHE </li></ul></ul><ul><li>Prophylaxis </li></ul><ul><ul><li>Beta blockers: 0.5-1mg/kg bd </li></ul></ul><ul><ul><li>Calcium channel blocker </li></ul></ul><ul><ul><li>Amitryptiline </li></ul></ul><ul><ul><li>5HT2 antagonist: Cyproheptidine </li></ul></ul>
  45. 46. Emergency Headache <ul><li>Subarachnoid hemorrhage </li></ul><ul><li>Bleed in a tumor </li></ul><ul><li>Intracerebral hematoma </li></ul><ul><li>Sudden obstruction of ventricle </li></ul><ul><li>Acute pyogenic meningitis/meningoencephalitis </li></ul>
  46. 47. Subarachnoid hemorrhage <ul><li>Sudden severe headache, “bolt out of blue” </li></ul><ul><li>Sentinel; a milder variety which clears in a day or two </li></ul><ul><li>Neck stiffness, photophobia </li></ul><ul><li>may have LOC </li></ul><ul><li>May have neurological deficit </li></ul><ul><li>Causes: </li></ul><ul><ul><li>aneurysmal 75-80% </li></ul></ul><ul><ul><li>AVM, tumor bleed, coagulopathies </li></ul></ul>
  47. 48. Subarachnoid hemorrhage <ul><li>CT scan: </li></ul><ul><ul><li>Small bleed may be missed in CT (10%) </li></ul></ul><ul><ul><li>After 7 days CT may be normal in 50% cases </li></ul></ul><ul><ul><li>CSF examined if CT normal it should not precede CT </li></ul></ul><ul><li>Lumber puncture: </li></ul><ul><ul><li>opening pressure high </li></ul></ul><ul><ul><li>Definitive: RBC >100,000/cmm </li></ul></ul><ul><ul><li>Xanthochromia-develops in 1-2 days </li></ul></ul><ul><li>MRI </li></ul><ul><ul><li>sensitive for bleed >10 days old </li></ul></ul><ul><ul><li>useless for acute investigation </li></ul></ul>
  48. 50. Bleed in a tumor <ul><li>generally patients have preexisting </li></ul><ul><li>headache or neurological symptoms </li></ul><ul><li>Presents as a “stroke” </li></ul><ul><li>Usually in highly malignant tumors </li></ul><ul><ul><li>metastasis </li></ul></ul><ul><ul><li>high grade glioma </li></ul></ul><ul><ul><li>pituitary apoplexy </li></ul></ul>
  49. 52. Sudden obstruction of ventricles <ul><li>with intra-ventricular tumor </li></ul><ul><ul><li>colloid cyst </li></ul></ul><ul><ul><li>other intra-ventricular tumors </li></ul></ul><ul><li>usually depressed sensorium </li></ul><ul><li>may be position related </li></ul><ul><li>history of tumor headache </li></ul>
  50. 53. Thank You

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