Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Getting ahead of headaches


Published on

  • Be the first to comment

Getting ahead of headaches

  1. 1. GETTING AHEAD OF HEADACHES Ruben T. Dela Cruz MD FPNA Acute Stroke Unit - Manila Adventist Medical Center
  3. 3. COMMUNITY PREVALENCE OF HEADACHE <ul><li>PRIMARY HEADACHES </li></ul><ul><li>TYPE PREVALENCE </li></ul><ul><li> Migraine 16% </li></ul><ul><li> Tension- type 69% </li></ul><ul><li> Cluster headache 0.1% </li></ul><ul><li> Idiopathic- stabbing 2% </li></ul><ul><li> Exert ional 1% </li></ul>
  4. 4. COMMUNITY PREVALENCE OF HEADACHES <ul><li>SECONDARY HEADACHES </li></ul><ul><li>TYPE PREVALENCE </li></ul><ul><li>Systemic infection 63% </li></ul><ul><li>Head injury 4% </li></ul><ul><li>Subarachnoid hemorrhage 1% </li></ul><ul><li>Vascular disorder 1% </li></ul><ul><li>Brain tumor 0.1% </li></ul>
  5. 5. PAINFUL BUT BENIGN HEADACHES (PRIMARY HEADACHES) <ul><li>MIGRAINE </li></ul><ul><li>CLUSTER HEADACHE </li></ul><ul><li>TENSION-TYPE HEADACHE </li></ul><ul><li>BENIGN EXERTIONAL HA </li></ul><ul><li>ORGASMIC HA </li></ul>
  6. 6. SERIOUS HEADACHE (SECONDARY HEADACHES) <ul><li>Raised Intracranial pressure from any cause </li></ul><ul><li>CNS infections (meningitis, encephalitis) </li></ul><ul><li>Subarachnoid hemorrhage </li></ul><ul><li>Cranial arteritis (eg. Giant cell arteritis) </li></ul><ul><li>Metabolic disturbances (ie. hypoglycemia, carbon monoxide poisoning) </li></ul><ul><li>Pheochromocytoma and malignant hypertension </li></ul><ul><li>Acute glaucoma </li></ul><ul><li>Head trauma </li></ul><ul><li>Focal CNS ischemia or hemorrhage </li></ul>
  7. 7. GENERAL CONSIDERATIONS IN EVALUATING HEADACHES <ul><li>QUALITY </li></ul><ul><li>SEVERITY </li></ul><ul><li>LOCATION </li></ul><ul><li>DURATION </li></ul><ul><li>TIME COURSE </li></ul><ul><li>CONDITIONS THAT PRODUCE, EXACERBATE, OR RELIEVE IT </li></ul>
  8. 8. HEADACHE SYMPTOMS- SUGGESTING SERIOUS DISORDER <ul><li>“ Worst” headache ever </li></ul><ul><li>First severe headache </li></ul><ul><li>Sub acute worsening over days or weeks </li></ul><ul><li>Abnormal neurologic examination </li></ul><ul><li>Fever or unexplained systemic signs </li></ul><ul><li>Vomiting precedes headache </li></ul><ul><li>Induced by bending, lifting, coughing </li></ul><ul><li>Disturbs sleep or present immediately upon awakening </li></ul><ul><li>Known systemic illness </li></ul><ul><li>Onset after age 55 </li></ul>
  9. 9. SYMPTOMS OF SERIOUS UNDERLYING CAUSES OF HEADACHE May present with a unilateral pounding headache. Onset generally in older patients (>50 years) and frequently associated with visual changes. The ESR is the best screening test and is usually markedly elevated (>50). Definitive diagnosis made by arterial biopsy Usually consists of severe eye pain. May have nausea and vomiting. The eye is usually painful and red. The pupils may be partially dilated. Temporal arteritis Glaucoma May present with prostrating pounding headaches that are associated with nausea and vomiting. Should be suspected in progressively severe new “migraine” that is invariably unilateral Brain tumor Nuchal rigidity and headache; may not have clouded consciousness or seizures. Hemorrhage may not be seen on CTscan. Lumbar puncture shows “bloody tap” that does not clear by the last tube. A fresh hemorrhage may not be xanthochromic. Intracranial hemorrhage Nuchal rigidity, headache, photophobia, and prostration; may not be febrile, lumbar puncture is diagnostic Meningitis SYMPTOMS CAUSE
  11. 11. PAIN – SENSITIVE STRUCTURES OF THE HEAD <ul><li>Distention, traction, or dilatation of intracranial or extracranial arteries </li></ul><ul><li>Traction, or displacement of large intracranial veins or their dural envelope </li></ul><ul><li>Compression, traction, or inflammation of cranial and spinal nerves </li></ul><ul><li>Spasm, inflammation, or trauma to cranial and cervical muscles </li></ul><ul><li>Meningeal irritation and raised intracranial pressure </li></ul><ul><li>Activation of brainstem structures </li></ul>
  12. 12. NEUROANATOMY OF HEADACHE <ul><li>PERIPHERAL INNERVATION </li></ul><ul><li>Trigeminal ganglion (Ophthalmic)- supratentorial structures </li></ul><ul><li>Branches of Cervical 2- posterior fossa structures </li></ul><ul><li>CENTRAL TERMINATION </li></ul><ul><li>Trigeminocervical complex-caudalis neurons and neurons of superficial laminae of C1-C2 </li></ul><ul><li>Non-trigeminal projections- brainstem periaqueductal gray and ventroposterior thalamus </li></ul>
  13. 13. PHYSIOLOGY OF HEAD PAIN <ul><li>Craniovascular vasodilatation </li></ul><ul><li>Peripheral trigeminal nerve activation </li></ul><ul><li>* Elevation of neuropeptide levels- CGRP (calcitonin gene-related peptide); substance P </li></ul><ul><li>* Plasma protein extravasations </li></ul><ul><li>Central trigeminal neuronal activation </li></ul><ul><li>* Trigeminal nucleus </li></ul><ul><li>* Non-trigeminal transmission- medial thalamic and </li></ul><ul><li>ventroposterior thalamic neurons </li></ul>
  14. 14. STEPS IN THE OPTIMUM MANAGEMENT OF PRIMARY HEADACHES <ul><li>Make a confident diagnosis </li></ul><ul><li>Assess headache-related disability and impact on patients quality of life (QOL). </li></ul><ul><li>Address behavioral and educational issues in headache management </li></ul><ul><li>Discuss and prescribe preventive medications, if indicated </li></ul><ul><li>Prescribe an acute treatment based on diagnosis, disability assessment and patient’s preference </li></ul><ul><li>Monitor patient outcomes and modify treatment as necessary </li></ul>
  15. 15. DRUGS EFFECTIVE IN THE TREATMENT OF TENSION-TYPE HA 650 mg PO q4-6h 650 mg PO q4-6h 50-100 mg q4-6h max 200mg/d 400 mg PO q3-4h 220-550mg bid 1-2 tbs mx 6 tbs/d 1-2 tbs mx 6 tbs/d 1-2 tbs mx 6tbs/d 10-50 MG at Bedtime 25-75 mg at bedtime 10-75 mg at bt Tylenol Generic Cataflam Advil, Motrin Naproxen,Aleve Phrenelin Fioricet, Fiorinal ELAVIL Pamelor Sinequan NONSTEROIDAL ANTIINFLAMMATORY AGENTS Acetaminophen Aspirin Diclofenac Ibuprofen Naprosyn sodium COMBINATION ANALGESICS Acetaminophen + butalbital Aceta + butalbital + caffeine Aspirin + butalbital + cafeine PROPHYLACTIC MEDICATIONS Amitriptyline Nortriptyline Doxepin DOSAGE TRADE NAME DRUG
  16. 16. Symptoms Accompanying Severe Migraine Attacks <ul><li>Nausea 87% </li></ul><ul><li>Photophobia 82% </li></ul><ul><li>Lightheadedness 72% </li></ul><ul><li>Scalp tenderness 65% </li></ul><ul><li>Vomiting 56% </li></ul><ul><li>Visual disturbances 36% </li></ul><ul><ul><li>Photopsia 26% </li></ul></ul><ul><ul><li>Fortification spectra 10% </li></ul></ul><ul><li>Paresthesias 33% </li></ul><ul><li>Vertigo 33% </li></ul><ul><li>Alteration of consciousness 18% </li></ul><ul><ul><li>Syncope 10% </li></ul></ul><ul><ul><li>Seizure 04% </li></ul></ul><ul><ul><li>Confusional state 04% </li></ul></ul><ul><li>Diarrhea 16% </li></ul>
  17. 17. NONPHARMACOLOGIC APROACHES TO MIGRAINE <ul><li>Identify and then avoid trigger factors such as: </li></ul><ul><ul><li>Alcohol (e.g. Red wine) </li></ul></ul><ul><ul><li>Foods (e.g. chocolate, certain cheeses, monosodium glutamate, nitrate containing foods) </li></ul></ul><ul><ul><li>Hunger (avoid missing meals) </li></ul></ul><ul><ul><li>Irregular sleep patterns (both lack of sleep and excessive sleep) </li></ul></ul><ul><ul><li>Organic odors </li></ul></ul><ul><ul><li>Sustained exertion </li></ul></ul><ul><ul><li>Acute changes in stress levels </li></ul></ul><ul><ul><li>Miscellaneous (glare, flashing lights) </li></ul></ul><ul><li>Attempt to manage environmental shifts </li></ul><ul><ul><li>Time zone shift </li></ul></ul><ul><ul><li>High altitude </li></ul></ul><ul><ul><li>Barometric pressure changes </li></ul></ul><ul><ul><li>Weather changes </li></ul></ul><ul><li>Assess menstrual cycle relationship </li></ul>
  18. 18. A staged Approach to Migraine Pharmacotherapy Stage Diagnoses Therapies SC, IM, or IV 5-HT1 agonist IM or IV dopamine antagonist Prophylactic medications Severe headaches >3x per month Significant functional impairment Marked nausea and/or vomiting Severe Migraine Oral, nasal, or SC 5-HT1 agonist Oral dopamine antagonist Moderate or severe headaches Nausea common Some impairment of functioning Moderate Migraine NSAIDs Combination analgesics Oral 5-HT1 agonists Occasional throbbing headaches No major impairment of functioning Mild Migraine
  19. 19. STEP-CARE vs STRATIFIED-CARE in HEADACHE MANAGEMENT <ul><li>STEP-CARE : Begins at the bottom of therapeutic pyramid- simple, least expensive agent and escalated according to patient’s need. </li></ul><ul><li>STRATIFIED- CARE: Provides a systematic method to match the treatment needs of the patient with the intensity of treatment. </li></ul>
  20. 20. A STAGED APPROACH TO MIGRAINE PHARMACOTHERAPY SC, IM, or IV 5-HT1 agonist IM or IV dopamine antagonist Prophylactic medications Severe HA >3x / mo Significant functional impairment Marked nausea and/or vomiting Severe migraine Oral, nasal r SC 5-HT1 agonist Oral dopamine antagonists Moderate or severe HA Nausea common Some impairment of functioning Moderate Migraine NSAIDs Combination analgesics Oral 5-HT1 agonist Occasional throbbing HA No major impairment of functioning Mild Migraine THERAPIES DIAGNOSIS STAGE
  21. 21. DRUGS EFFECTIVE IN ACUTE TREATMENT OF MIGRAINE 0ne 2-mg sl tab at onsetand q 1/2h mx 3/d; 5/wk 2.5 mg tb at onset, rpt after 4 hrs 5-10 mg at onset rpt after 2 hrs, mx-10mg/d 50 to 100 mg tb at onset, rpt after 2 hrs. mx 200 mg/d 2.5 mg at onset, rpt after 2 hrs, mx 10mg/d Ergomer Ercaf; Wigraine Amerge Maxalt Imitrex, Imigran Zomig (Rapimelt) 5-HT1 AGONIST ORAL: Ergotamine Ergotamine-caffeine Naratriptan Rizatriptan Sumatriptan Zolmitriptan 2 tab q6h max 8/day Excedrin- Migraine NSAIDs________________ Acetaminophen, aspirin, caffeine DOSAGE TRADE NAME DRUG
  22. 22. DRUGS EFFECTIVE IN ACUTE TREATMENT OF MIGRAINE One spray per nostril then 15 minutes after 5 to 20 mg spray as 4 sprays of 5 mg per nostril may rpt once after 2 hrs. mx 40mg/d 1 mg IV<IM<or SC at onset and q1h mx. 3mg/d; 6mg/wk 6 mg SC at onset, rpt once after 1 hr mx- 2 doses/d Migranal nasal spray Imitrex nasal spray DHE-45 Imitrex inj 5-HT1 agonist NASAL Dihydroergotamine Sumatriptan PARENTERAL Dihydroergotamine Sumatriptan
  23. 23. DRUGS EFFECTIVE IN ACUTE TREATMENT OF MIGRAINE <ul><li>DOPAMINE ANTAGONIST </li></ul><ul><li>ORAL </li></ul><ul><li>Metoclopramide Reglan,generic 5-10 mg/d </li></ul><ul><li>Prochlorperazine Compazine, 1-25mg/d </li></ul><ul><li>PARENTERAL </li></ul><ul><li>Chlorpromazine generic 0.1 mg/kg IV at 2 mg /min mx 35mg/d Metoclopramide Reglan 10mg IV </li></ul><ul><li>Prochlorperazine Compazine 10 mg/IV </li></ul>
  24. 24. DRUGS EFFECTIVE IN PROPHYLACTIC TREATMENT OF MIGRAINE 80-320mg qd 20-60 mg qd 250 mg bid (mx:1000mg/d) 10-5-mg qhs 25-75 mg qhs 15 mg qd 10 mg qd 4-8 mg qd 4-16 mg qd 40-240 mg qd Inderal Blocadren Depakote Elavil, generic Pamelor Nardil Marplan Sansert Periactin Isoptin B- Adrenergic agents Propranolol Timolol Anticonvulsant Sodium valproate Tricyclic antidepressant Amitriptyline Nortriptyline Monoamine oxidase inhibitor Phenelzine Isocarboxazid Serotonergic drugs Methysergide Cyproheptadine Other Verapamil DOSAGE TRADE NAME DRUG