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![Introduction
NO pain receptors in the parenchyma [the brain tissue itself]
Pain receptors ARE present in:
Blood vessels
Meninges
Scalp
Skull
Pain sensitive structures are supplied by upper cervical nerves and
trigeminal nerve.](https://image.slidesharecdn.com/headaches-240911024822-bd1cef99/75/Headaches-and-management-physiotherapy-ppt-2-2048.jpg)
![Migraine
Migraine without aura [common migraine]
Migraine with aura [classic migraine]](https://image.slidesharecdn.com/headaches-240911024822-bd1cef99/75/Headaches-and-management-physiotherapy-ppt-10-2048.jpg)
Headaches and management (physiotherapy).ppt
- 1.
- 2. Introduction NO painreceptors in the parenchyma [the brain tissue itself] Pain receptors ARE present in: Blood vessels Meninges Scalp Skull Pain sensitive structures are supplied by upper cervical nerves and trigeminal nerve.
- 3. Definition Headache isa frequently encountered neurological symptom but is seldom associated with significant neurological deficit unless accompanied by other symptoms.
- 4. Prevalence ½ -¾ of adults have suffered from a headache within the past year. 30% have had a migraine in the past year. 1.7-4% have had a headache at least 15 days or more each month.
- 5. Types Migraine Medicationoveruse headache Tension type headache Cluster headache Benign paroxysmal headache
- 6.
- 7. Introduction Prevalence: Women25% (lifetime) Men 8% (lifetime) 28 million persons have migraine each year in the U.S. Highest from 25-50 years of age Genetics About 70% of migraine patients have a positive family history in a first-degree relative Unknown mode of transmission
- 8. Strange (Scary) Facts Increased prevalence of: HTN Stroke Epilepsy Asthma Irritation bowel disorder Depression Bipolar disease Anxiety disorders Panic attacks
- 9. Migraine The International Classificationof Headache Disorders, 3rd edition A. At least five attacks fulfilling criteria B–D B. Headache attacks lasting 4–72 hours (when untreated or unsuccessfully treated) C. Headache has at least two of the following four characteristics: 1. unilateral location 2. pulsating quality 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs) D. During headache at least one of the following: 1. nausea and/or vomiting 2. photophobia and phonophobia E. Not better accounted for by another ICHD-3 diagnosis. Cephalalgia 2018, Vol. 38(1) 1–211
- 10. Migraine Migraine withoutaura [common migraine] Migraine with aura [classic migraine]
- 11.
- 12. Pathophysiology Theneurovascular theory: Vasodilatation of extradural blood vessels calcitonin gene-related peptide (CGRP) activation of primary afferent neurons of trigeminal nerve activation of trigeminal innervated and cervical innervated painful structures leads to migraine
- 13. STAGES OF MIGRAINE STAGESOF MIGRAINE Adapted from Cady RK. Clin Cornerstone. 1999;1(6):21-32. Phases of a Migraine Attack Premonitory/ Prodrome Aura Mild Moderate to Severe HA Postdrome Pre-HA Post-HA Headache Time Intensity
- 14. Prodrome Mood Changes Irritability, depression, sleepy, apathy Neurologic symptoms Yawning, photo/phonophobia, vision changes Constitutional symptoms Fatigue, pallor, fluid retention, myalgia Alimentary symptoms Hunger, anorexia, nausea, diarrhea
- 15. Aura 15% ofpatients Episode of focal neurologic changes Develop over 5 to 15 minutes & last up to 60 minutes Visual, weakness, numbness, confusion
- 16. Headache Headache lastshours to days Migraine head pain unilateral in 56 – 68% of patients 90% of patients have coexisting nausea Constitutional symptoms common
- 17. Postdrome Depression Drowsiness Cognitive changes Memory loss Difficulty with concentration
- 18. Medication Overuse Headache Also known as Rebound Headache Defined as: Headache present on >15 days/month. Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache. Headache has developed or markedly worsened during medication overuse. Ther Adv Drug Saf. 2014 Apr; 5(2): 87–99.
- 19. Medication Overuse Headache Can be precipitated by many agents: NSAIDs Acetaminophen Aspirin Caffeine Triptans Opioids
- 20. Treatment of Migraine If the pain can be stopped early, the cascade of pain responses can be controlled Headache needs to be caught before central sensitization occurs Patients may receive the greatest benefit from their migraine medication if they: Practice early intervention Use a fast-acting migraine medication
- 21. General Treatment Avoidtriggers! Maintain regular sleep schedule Maintain regular meal schedule Low tyramine Limit caffeine Avoid nitrates/nitrites Limit chocolate Reduce stress Adequate water intake
- 22. Treatment Options Two TreatmentApproaches •Acute therapy Work quickly to relieve migraine pain and other symptoms Are taken only at migraine onset •Preventative therapy Prevent or reduce the number of migraine attacks Are taken on a daily basis
- 23. Acute Treatment NSAIDS Inhibit prostaglandin formation, thus reducing inflammation Naproxen Ibuprofen ASA COX2 inhibitors
- 24. Acute Treatment Triptans Selective 5-HT1B/1D agonists Block actions of 5-HT such as dilation of cranial arteries/AV anastomoses, neurogenic dural plasma extravasation e.g Sumatriptan (Imitrex), Almotriptan (Axert) Triptans side effects: Chest pressure/heaviness, Jaw tightness, Dizziness, Somnolence, Fatigue Nausea, Paresthesias Use early! More effective in mild/moderate pain Caution about rebound
- 25. Prophylactic Treatment Startlow and go slow! Adequate trial with adequate dose Consider comorbid conditions when choosing a medication May add a second medication
- 26. Other treatment options Magnesium glycinate 400mg bid Riboflavin 400mg daily Melatonin CoQ10 Butterbur/Feverfew/Skullcap Acupuncture Biofeedback/Yoga/Meditation
- 27. Other treatment options Vagus Nerve Stimulation Spring TMS Transcranial magnetic stimulation Cefaly Tens-like unit
- 28.
- 29. Tension-Type Headache: Diagnostic Criteria AtLeast 10 Episodes Fulfilling the Criteria Below Olesen J. Cephalalgia. 1988;8(Suppl 7):1-96. Two of the following: AND Associated Symptoms No nausea or vomiting Photophobia and phonophobia are absent, or one but not the other is present Description of Headache Pressing/tightening quality (nonpulsating) Mild or moderate intensity (may inhibit, does not prohibit activities) Bilateral location No aggravation by walking up stairs or similar routine physical activity Headache lasting 30 minutes to 7 days Both of the following: AND
- 30. Treatment Acute NSAIDs Acetaminophen Muscle relaxers ? Chronic TCA Physical Therapy Osteopathic Manual Treatments Occipital Nerve Block
- 31.
- 32. Cluster Headache: Diagnostic Criteria AtLeast 5 Attacks Fulfilling the Criteria Below Olesen J. Cephalalgia. 1988;8(Suppl 7):1-96. Associated Symptoms One of the Following Description of Headache All of the Following: Severe Unilateral orbital, supraorbital, and/or temporal location Lasts 15 to 180 minutes (untreated) Conjunctival injection Lacrimation Rhinorrhea Nasal congestion Forehead and facial sweating Miosis Ptosis Eyelid edema Frequency of attacks: 1 every other day to 8 per day Present on the Pain Side: AND AND
- 33. Cluster Headache Location:strictly unilateral, often periorbital or temporal Pain characteristics: constant, severe, burning, or boring Frequency: 1-6(+) per day Demographics: Males : Females 6 : 1 Duration: 15-180 minutes Associated symptoms: autonomic symptoms – (ipsilateral to pain) tearing, rhinorrhea, conjunctival injection, eyelid edema, ptosis, pupillary miosis, restlessness
- 34. Cluster Headache Triggers:ETOH, REM sleep, diurnal or annual cycles Treatment: high-flow oxygen, DHE, parenteral triptans Steroids Prophylactic: Verapamil, Divalproate Sodium, Topirimate, Lithium
- 35.
- 36. Benign Paroxysmal Headache It is also known as Sjaastad Syndrome It is characterized by chronic solitary limited attackes of unilateral headae that did not shift sied and this is known as hemicranias Pain is generally oculofrontotemporal It may radiate or involve ipsilateral shouldef and neck region During severe attack ther is excruciating pain that is throbbing, pulsating. It sis triggered by various stimuli like neck movement, excessive pressure on the neck, extreme light, photophobia ma be present. Other associative symptoms are red eyes, increased lacrimation, nasal congestion, rhinorrhea (leakage of CSF from nose).
- 37. Management Drugs :NSAIDS – Indomethacin, naproxen sodium, ibuprofen Calcium channel blockers – Verpamil Corticosteroids – prednisolone Anticonvulsants - topiramate
Editor's Notes
- #22 The good news is that if you are diagnosed with migraines, there are effective medicines that can help you manage your migraines. Most migraine headaches can be effectively treated with acute medicines. Acute medicines work quickly to relieve migraine pain and other symptoms. They are only taken when you have a migraine attack. Some patients with more frequent migraines may benefit from preventative medicines that are taken on a daily basis and can reduce the number of migraine attacks.
- #29 SLIDE 20. Tension-Type Headache: Diagnostic Criteria Tension-type headache attacks may be variable in duration, lasting from 30 minutes to 7 days Pain associated with tension-type headaches is typically pressing/tightening in quality (often a band around the head), of mild to moderate intensity, and bilateral in location, and is not aggravated by walking up stairs or similar routine physical activity Tension-type headaches are not typically associated with photophobia and phonophobia, but patients may experience one or the other of these symptoms Tension headaches can be differentiated from migraine by: Location: tension headaches are strictly bilateral, whereas migraine is typically, although not exclusively, unilateral Quality: headache pain associated with tension-type headache is characterized as pressing or tightening (ie, nonpulsating), whereas pain associated with migraine is often throbbing or pulsating Intensity: headache pain associated with tension-type headache is mild to moderate in severity and is generally less severe than the headache pain experienced by migraine sufferers Associated symptoms: photophobia and phonophobia are generally absent in tension-type headaches, although one but not the other symptom may be present, and tension-type headache is not associated with nausea or vomiting; migraine is associated with nausea, vomiting, photophobia, and phonophobia Impact of physical activity: tension-type headache is not aggravated by routine physical activity
- #32 SLIDE 21. Cluster Headache: Diagnostic Criteria Another primary headache type classified by the IHS diagnostic criteria is cluster headache Cluster headache reaches full intensity rapidly and comes in temporal clusters Cluster headache is accompanied by severe, recurrent headache pain Excruciating headache pain is one of the most salient features of cluster headache Cluster headache attacks are characterized by severe, strictly unilateral pain localized to the orbital, supraorbital, and/or temporal regions Cluster headache attacks last 15 to 180 minutes, occurring as little as once every other day to as frequently as 8 times per day over a period of weeks to months, separated by periods of remission Cluster headache is typically associated with at least 1 of the following signs or symptoms, which occur unilaterally on the same side as the headache pain: Conjunctival injection Lacrimation Rhinorrhea Nasal congestion Forehead and facial sweating Miosis (contraction of the pupil) Ptosis (eyelid drooping) Eyelid edema Cluster headaches can be differentiated from migraine by: Location: although cluster headache and migraine are both typically unilateral, cluster headache pain is strictly orbital, supraorbital, or temporal Duration: cluster headache pain occurs in short bursts (15 to 180 minutes) of pain, whereas migraine pain lasts 4 to 72 hours (untreated or treated unsuccessfully) Frequency: during headache attack periods or bouts, cluster headache occurs from once every other day to as many as 8 attacks per day; a period of remission between bouts occurs in episodic cluster headache Associated symptoms: while migraine is associated with nausea, vomiting, photophobia, and phonophobia, cluster headache is associated with unilateral autonomic signs and symptoms (eg, conjunctival injection, nasal congestion, rhinorrhea, lacrimation, ptosis), which occur on the same side as the headache pain