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Headache for post basic neuroscience course 2015
- 1. HEADACHE Post Basic NeurosciencesCourse 2015 Dr Ahmad Shahir bin Mawardi Specialist Registrar, Neurology Department Hospital Kuala Lumpur 1st October 2015
- 2. Myth about Headache Headache= Migraine Headache = CT scan
- 3. Outlines 1.Introduction 2.Classification of headache 3.Diagnosisof headache • History, Examination, Ix 1.Red flag for headche 2.Common causes of headache • Migraine, TTH, CH,MOH 1.Management of headache
- 4. Introduction • Headache affectsnearly everyone at least occasionally. • Most frequent causes of consultation in GP and neurological clinics. • Migraine occurs in 15% of the UK adult population – women more than men in a ratio of 3:1 • >100,000 people are absent from work or school because of migraine every working day.
- 5. The International Classificationof Headache Disorders, 2nd Edition HEADACHEHEADACHE Primary Secondary Neuralgias & other headaches
- 6. The International Classificationof Headache Disorders, 2nd Edition HEADACHEHEADACHE Primary Secondary Neuralgias & other headaches •inflammation medium and large arteries. •involving branches of the carotid artery and the ophthalmic artery •Sx: headache, visual disturbances & jaw claudication. •blockage of the drainage of fluid from the eye. •Sx : headache,painful red eye and misty vision or haloes, nausea. •semi-dilated pupil
- 7. The International Classificationof Headache Disorders, 2nd Edition HEADACHEHEADACHE Primary Secondary Neuralgias & other headaches
- 8. Diagnosis of headache 1)History 2)Physicalexamination 3)Investigations
- 9. 1) History ofheadache • The history is all-important • Headache diary- pattern of headache • Excludes sinister causes of headcahe – Intracranial tumor – Meningitis – Sudarachoid Haemorrhages – Giant Cell Arteritis – Primary angle-glaucoma – Idiopathic Intracranial Hypertension – Carbon Monoxide posioning
- 10. 1) History ofheadache
- 11. Differential diagnoses • Posteriorheadache- functional or structural derangement of the neck (cervicogenic headache) • Acute exacerbation of chronic sinusitis • Refraction Errors - mild, frontal, absent on waking & confined to eyes only • Diseases of ears, temporomandibular joints or teeth
- 12. 2) Examination ofheadache • Normal most of time • BP • Fundoscopy- papiloedema • Head and neck - muscle tenderness, stiffness, limitation in range of movement and crepitation
- 13. 3) Investigations • Neuroimaging(CT/MRI brain) – not required for diagnosis of migraine or tension-type headache. – history or examination suggest secondary headache – therapeutic value of convincing a patient • Cervical spine x-rays • Eye tests
- 14. Red Flag ofHeadache (I) 1. Headache that is new or unexpected in an individual patient 2. Thunderclap headache (intense headache with abrupt or “explosive” onset) 3. Headache with atypical aura (duration >1 hour, or including motor weakness) 4. Aura occurring for the first time in a patient during use of combined oral contraceptives 5. New onset headache in a patient older than 50 years
- 15. Red Flag ofHeadache (II) 6. New onset headache in a patient younger than 10 years 7. Persistent morning headache with nausea 8. Progressive headache, worsening over weeks or longer 9. Headache associated with postural change 10. New onset headache in a patient with a history of cancer 11. New onset headache
- 16. Common types ofheadache • Migraine • Tension-type headache (TTH) • Cluster headache (CH) • Medication overuse headache (MOH)
- 17. Common types ofheadache
- 18. Migraine with aura •1/3 of migraine sufferers • Aura: – Visual blurring and “spots” – progressive, last 5-60 minutes prior to headache – transient hemianopic disturbance/ scintillating scotoma – can occur with: • unilateral paraesthesia,of hand, arm or face • dysphasia • functional cortical manifestations • disturbance of one cerebral hemisphere – may occur without migraine – aura persisting after resolution of the headache, and aura involving motor weakness-> further Ix • familial hemiplegic migraine
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- 20. Migraine • Typical history –recurrent episodic moderate or severe headaches – unilateral and/or pulsating – duration: 4-72 hours – a/w GI symptoms – limit activity – prefer dark and quiet – symptoms free between attacks
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- 22. Possible Triggers ofa Migraine Attack Food and food additives Bright lights/glare Smells/odors Dieting/hunger Loud noises/sounds Changes in altitude/ air travel Stress Weather changes Caffeine Alcoholic beverages Changes in sleep habits Hormonal fluctuations/ menstrual cycleWober C et al. J Headache Pain. 2006;7(4):188-195. Friedman DI and De Ver Dye T. Headache. 2009;49(6):941- 952.
- 23. Tension type Headache(TTH) • Episodic, very low frequency and short-lasting (< several hours) • Generalised but can be unilateral • Nature of pain: – pressure or tightness,/tight band around the head – spreads into or arises from the neck – can be disabling for a few hours – lacks of specific features and associated symptom • May be stress-related or a/w functional or structural cervical or cranial musculoskeletal abnormality • Chronic tension-type headache: >15 days a month, and may be daily
- 24. Cluster headache (CH) •CH affects mostly men – (male to female ratio 6:1) • Age 20s or older and very often smokers. • Typically headaches occur in bouts for 6-12 weeks, once a year or two years, often at the same time each year.
- 25. Cluster headache (CH) •Nature of pain: – intense, unilateral – focused in one or other eye, --> spread over • Occurs daily, at a similar time each day, always at night, 1-2 hours after falling asleep. • Duration: 30-60 minutes • Associated features: – ipsilateral conjunctival injection and lacrimation, – rhinorrhoea or nasal blockage – ptosis/ Horner’s syndrome
- 29. Medication overuse headache(MOH) • Headache caused by overuse of medication – phenacetin, ergotamine, triptan – analgesics containing barbiturates, caffeine, and codeine – aspirin and paracetamol • Mechanisms: not clear – probably as a results in down-regulation of 5-HT1B/1D receptors – addictive properties – changes in neural pain pathways • may take weeks to months for the headache to resolve after withdrawal.
- 30. Medication overuse headache(MOH) • Small amounts are sufficient to induce MOH – >15 days a month or of codeine-containing analgesics, – >10 or more days a month of ergot or triptans • Frequency is important: – low doses daily carry greater risk than larger doses weekly. • Nature of pain – worst on awakening in the morning – increases after physical exertion – In the end-stage, headache persists all day, fluctuating with medication use repeated every few hours.
- 31. Medication overuse headache(MOH) • Prophylactic medication aggravate the condition • Headache diary • The (presumptive) diagnosis made based on symptoms and drug used. • Confirmed when symptoms improve after medication is withdrawn.
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- 33. Aretaeus A.D. 81? For thetreatment of headache, Aretaeus recommended inducing sneezing by placing testicle of beaver powder intranasally to “bring off phlegm”
- 34. Management- General During consultation: 1.Explanation of the diagnosis and reassurance that other pathology has been excluded 2. the options for management 3. recognition that headache is a valid medical disorder with significant psychosocial impact
- 35. Management- General Headache diary(minimum of 8/52): • frequency, duration and severity of headaches • any associated symptoms • all prescribed and over the counter medications taken to relieve headaches • possible precipitants • relationship of headaches to menstruation
- 36. MIGRAINE WITH ORWITHOUT AURA Acute treatment Monotherapy: oral triptan, NSAID, aspirin(900 mg) or paracetamol Combination: Oral triptan + an NSAID/ Oral triptan + paracetamol. Consider an anti-emetic even in the absence of nausea and vomiting. Do not offer ergots or opioids If ineffective or not tolerated: IV NSAID or IV triptan + IV metoclopramide or prochlorperazine
- 37. MIGRAINE WITH ORWITHOUT AURA Prophylactic treatment First line: Topiramate or propranolol Alternative: Gabapentine, Acupuncture Review the meds after 6 months. Diet: riboflavin (400 mg OD) may be effective in reducing migraine frequency and intensity for some people
- 38. MIGRAINE WITH ORWITHOUT AURA Other meds Amitriptyline is widely used, off-label, to treat chronic painful disorders, including migraine. Inadequate evidence. If effective--> continue the current treatment Pizotifen is a popular treatment for migraine prevention, been in use since the 1970s and appears to be well tolerated. Inadequate evidence. Treatment of migraine during pregnancy: PCM
- 39. TENSION-TYPE HEADACHE • Acutetreatment – Aspirin, paracetamol or an NSAID – Do not offer opioids • Prophylactic treatment – Acupuncture (10 sessions over 5–8 weeks)
- 40. CLUSTER HEADACHE Acute treatment Offeroxygen and/or a subcutaneous or nasal triptan. use 100% oxygen at a flow rate of at least 12 litres per minute with a non- rebreathing mask and a reservoir bag Do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans Prophylactic treatment Verapamil
- 41. Medication overuse headache •Treated by withdrawing overused medication--> Explain, explain, explain!!! • Advise: – to stop all overused meds abruptly rather than gradually for < 1 month – headache symptoms are likely to get worse in the short term before they improve – + withdrawal symptoms • Consider prophylactic treatment for the underlying primary headache disorder • Consider specialist referral for people who are using strong opioids withdrawal (Addiction team) • Review the diagnosis & mx 4–8 weeks after the start of withdrawal of overused medic
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