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Headache – practical scenario
- 1. Headache – Practical Scenario Dr. Thomas Mathew MD,DNB,DM(Neurology) Associate Professor Department of Neurology St.John’s Medical College and Hospital Bangalore-560034
- 2. Case 1
- 3. On history… • 24 year old lady • Episodic vertigo lasting 30 minutes • 1-2/ week for the past 2 years • No history of tinnitus/deafness • No history of loss of consciousness
- 4. On examination… • No focal neurological deficits • Fundus normal
- 5. What will you ask next ?
- 6. Options are… A. Postural variation B. Head trauma C. Alcohol intake D. History of headache
- 8. How will you manage ? Options are… A. Cinnarizine B. Prochlorperazine C. Betahistine D. None of the above
- 9. What you should do ? • Flunarizine • Topiramate • Betablockers • Amitriptyline • Valproate
- 10. Flunarizine – Practical Scenario Prof. A.V. SRINIVASAN, MD, DM, Ph.D,DSc(HON) F.A.A.N, F.I.A.N. Emeritus Professor The Tamilnadu Dr. M.G.R. Medical University Former Head Institute of Neurology, Madras Medical College Adjunct Prof. IIT Madras
- 11. Flunarizine: Indications • Prophylaxis of migraine • Symptomatic treatment of dizziness • (Peripheral vascular disease) • (Alternating hemiplegia) • (Epilepsy adjuvant)
- 12. Contra-indications • Parkinson’s disease • History of EP syndromes • History of depression • Breast feeding • (Pregnancy) Caution • Elderly • Hepatic disease
- 13. Adverse effects • Weight gain • Sedation • Depression • EP syndrome (de Melo-Souza syndrome) • Headache/insomnia/asthenia/GI
- 14. Interactions • Alcohol • Hypnotics /tranquilizers • COC • Anticholinergics • Anticonvulsants
- 15. HC Deiner et al Cephalalgia 2002;22:209-221 • 808 patients • Double blind 16 week treatment phase • Flunarizine 10mg(5days/week) v Flunarizine 5mg v Propranolol 160mg • Responders (50% reduction) 5mg:46%. 10mg:53%. Propranolol:48% • Drop out due to adverse effects 5mg:16.7%. 10mg: 19.3%. Propranolol:16.7%
- 16. M. Thomas Headache 31:613-615, 1991 • India • 29 patients (14 dropped out) • 6months double blind crossover • 10mg v placebo • No decrease in migraine frequency • Reduced duration and severity
- 17. Experience of use • Reduce if excessive daytime drowsiness • Watch for mood change • Use 5-15mg • Very useful even for refractory patients/prolonged aura/hemiplegic aura/severe migrainous vertigo
- 19. Headache – Practical Scenario Dr. Thomas Mathew MD,DNB,DM(Neurology) Associate Professor Department of Neurology St.John’s Medical College and Hospital Bangalore-560034
- 20. Case 2
- 21. On history… • 28 year old • Episodic headaches • 12 hours • 4-5/week • Severe/throbbing/worsens with exertion
- 22. On History… • Photo/phonophobia/vomiting • Family history of headache present • Feels like crying/sad/thought of even suicide • Takes vasograine 4-5/week
- 23. On examination… • Obese . BP 130/90 mm of Hg • BMI >35 • No deficits • Fundus normal
- 24. What is the drug of choice? A. Flunarizine B. Betablocker C. Amitriptyline D. Valproate E. Topiramate
- 25. Patient was started on topiramate • 25 mg per day
- 26. What else you will advise ?
- 27. Options are… A. Stop vasograine abuse B. Identify precipitating factors C. Life style modification D. All the above
- 28. Patient comes back after 1 week of Topiramate • “ I can’t see clearly from today morning”
- 29. What will you do ?
- 30. Options are… A. Fundus examination B. Urgent ophthalmological consult C. Check Intraocular pressure D. IV mannitol E. All the above
- 31. Diagnosis Topiramate induced acute angle closure glaucoma
- 32. Thank you
- 33. Practice Patterns in Headache Management E- Voting Module
- 34. When would you initiate prophylaxis for migraine? A. Patients with 4 or 5 migraine days per month with normal functioning B. 3 migraine days with some impairment C. 2 migraine days with severe impairment D. Any one of the above
- 35. What can be the duration of therapeutic trial for a migraine prophylactic drug? A. Less than 1 week B. 2-4 weeks C. 2- 6 months D. 4-6 weeks
- 36. What are the ‘red flags’ in headache history? A. New headache onset in an older patient B. Rapid onset of headache C. Systemic Symptoms such as fever or weight loss D. All of the above
- 37. Which channels are blocked by Flunarizine? A. Calcium channels B. Sodium channels C. Both D. None of the above
- 38. What is the typical characteristic of migraine headache? A. Pulsating, throbbing B. Pressing, tightening but not pulsating C. Boring, searing D. None of the above
- 39. Thank you
Editor's Notes
- D
- D
- E
- D
- E
- DAs per IHS guidelines
- Silberstein SD. Trends in Pharmacological Sciences 2006; 27: 410-415C
- D
- C
- A