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Headache lecture for student2


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Headache lecture for student2

  1. 1. Headache and increased intracranial pressure
  2. 2. Causes of Headaches <ul><li>1. Traction, tension, or displacement of pain-sensitive structures </li></ul><ul><li>2. Distention or dilation of intracranial arteries </li></ul><ul><li>3. Inflammation of pain-sensitive structures </li></ul><ul><li>4. Obstruction of CSF pathways with consequent increased intraventricular pressure </li></ul><ul><li>5. Primary central pain: involvement of pain-modulating systems </li></ul>
  3. 3. Tentorium cerebri Meninges
  4. 4. Vascular-arteries
  5. 5. Cranial nerves
  6. 6. The Fifth cranial nerve <ul><li>Trigeminal nerve </li></ul><ul><li>V1 (Ophthalmic)  sensation </li></ul><ul><li>V2 (Maxillary)  sensation </li></ul><ul><li>V3 (Mandibular)  sensation </li></ul>
  7. 7. Trigeminal neuralgia <ul><li>Intense momentary spasms of pain make the patient wince </li></ul><ul><li>Pain occur in the face, usually radiating from the corner of the mouth or from the gums towards the cheek and ear </li></ul><ul><li>Sudden electric-shock-like quality </li></ul><ul><li>Pain triggered by touching, shaving, cold winds, eating </li></ul><ul><li>Usually occur in elderly. If occurs in young adults, multiple sclerosis should be suspected. </li></ul>
  8. 8. Headache classification <ul><li>Pain sensitive </li></ul><ul><li>meninges </li></ul><ul><li>vascular </li></ul><ul><li>nerves </li></ul>Headache Primary Secondary Migraine Tension Cluster Miscellaneous Extracranial Intracranial
  9. 9. Secondary headache <ul><li>Intracranial </li></ul><ul><li>Extracranial </li></ul>
  10. 10. What should be asked when you see a patient with headache ??
  11. 11. History <ul><li>Temporal profile </li></ul><ul><ul><li>Age of onset </li></ul></ul><ul><ul><li>Time to maximum intensity </li></ul></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><li>Time of the day </li></ul></ul><ul><ul><li>Duration </li></ul></ul><ul><li>Headache feature </li></ul><ul><ul><li>Location </li></ul></ul><ul><ul><li>Quality of pain </li></ul></ul><ul><ul><li>Severity of pain </li></ul></ul>
  12. 12. <ul><li>Associated symptoms and signs </li></ul><ul><ul><li>Before, during, and after headache </li></ul></ul><ul><li>Aggravating or precipitating factors </li></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Medical conditions; pregnancy, obese women, pheochromocytoma, HIV-cryptococcal meningitis, metastatic disease </li></ul></ul><ul><ul><li>Triggers : menstruation, loud noise, heat, alcohol, stress </li></ul></ul><ul><ul><li>Activity and postures </li></ul></ul><ul><ul><li>Pharmacologic : drug-abused headache, oral contraceptive pills </li></ul></ul>
  13. 13. <ul><li>Relieving factors </li></ul><ul><ul><li>Nonpharmacologic </li></ul></ul><ul><ul><li>Pharmacologic </li></ul></ul><ul><li>Evaluation and treatment history </li></ul><ul><li>Psychosocial history </li></ul><ul><ul><li>Substance use </li></ul></ul><ul><ul><li>Occupational and personal life </li></ul></ul><ul><ul><li>Psychologic history </li></ul></ul><ul><ul><li>Sleep history </li></ul></ul><ul><ul><li>Impact of headache </li></ul></ul><ul><li>Family history </li></ul>
  14. 14. Headache <ul><li>Primary headache </li></ul><ul><li>Secondary headache </li></ul>
  15. 15. DIAGNOSIS AND TESTING Red flag Primary headache? Secondary headache Diagnostic testing Detailed history and physical examination Atypical features No Yes
  16. 16. Red flags in the diagnosis of headache(1) <ul><li>Sudden onset headache </li></ul><ul><ul><li>Subarachnoid hemorrhage </li></ul></ul><ul><li>Worsening pattern headache </li></ul><ul><ul><li>Mass lesion, subdural hematoma </li></ul></ul><ul><ul><li>Medication overuse </li></ul></ul><ul><li>Headache with systemic illness </li></ul><ul><ul><li>Meningitis, encephalitis </li></ul></ul><ul><ul><li>Systemic infection </li></ul></ul><ul><ul><li>Collagen vascular disease, arteritis </li></ul></ul>
  17. 17. Red flags in the diagnosis of headache(2) <ul><li>Focal neurological signs or symptoms </li></ul><ul><ul><li>Mass lesion </li></ul></ul><ul><ul><li>AVM </li></ul></ul><ul><li>Triggered by cough, exertion, or Valsalva </li></ul><ul><ul><li>SAH </li></ul></ul><ul><ul><li>Mass lesion </li></ul></ul><ul><li>New headache type in a patient </li></ul><ul><ul><li>with cancer : metastasis </li></ul></ul><ul><ul><li>With HIV : opportunistic infection, tumor </li></ul></ul>
  18. 18. Causes of Secondary headache Intracranial Paracranial Extracranial <ul><li>Head trauma </li></ul><ul><li>Vascular disorders </li></ul><ul><li>Nonvascular disorder </li></ul><ul><li>Disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, other facial or cranial structures </li></ul><ul><li>Substances or their withdrawal </li></ul><ul><li>Noncephalic infection </li></ul><ul><li>Metabolic disorder </li></ul>
  19. 19. Sinusitis <ul><li>Pain is </li></ul><ul><li>localized to the cheek : maxillary sinusitis </li></ul><ul><li>To the forehead : frontal sinusitis </li></ul><ul><li>Midline behind the nose : ethmoid and sphenoid sinusitis </li></ul>* the pain is throbbing and tenderness of overlying skin
  20. 20. Posttraumatic headaches <ul><li>Mild head injury and postconcussion syndrome </li></ul><ul><ul><li>Mild head injury >= 75% of all brain injuries </li></ul></ul><ul><ul><li>Mild closed head injury </li></ul></ul><ul><ul><li>50% of patient with mild Head injury will develop postconcussion syndrome </li></ul></ul>
  21. 21. Postconcussion syndrome <ul><li>Headache : within 14 days or 3 months </li></ul><ul><li>Cranial nerve signs and symptoms </li></ul><ul><li>Psychologic and somatic complaint </li></ul><ul><li>Cognitive impairment </li></ul><ul><li>Rare sequelae </li></ul><ul><ul><li>Subdural and epidural hematoma, cerebral venous thrombosis, seizure </li></ul></ul>
  22. 23. Subarachnoid hemorrhage (SAH) <ul><li>Abrupt onset : subarachnoid hemorrhage(SAH) </li></ul><ul><li>Headache on awakening after lying down or occur everyday : suspect raised intracranial pressure </li></ul><ul><li>Focal neurological deficit : brain tumor, stroke, abscess, encephalitis </li></ul>
  23. 24. Subarachnoid hemorrhage (SAH) <ul><li>Headache occurs in about 90% of SAH patient </li></ul><ul><li>Classic : acute, severe, continuous, and generalized and is often associated with nausea, vomiting, meningismus, focal neurologic symptoms, and loss of consciousness </li></ul><ul><li>“ worst headache of my life” </li></ul>
  24. 25. Investigation in suspected SAH <ul><li>CT brain </li></ul><ul><ul><li>First 24 hrs ---- detect SAH ~95% </li></ul></ul>
  25. 26. Investigation in suspected SAH <ul><li>Lumbar puncture in suspected SAH with normal CT or MRI brain </li></ul><ul><ul><li>Differentiate traumatic tap from SAH by xanthochromia (colored supernatant) </li></ul></ul>
  26. 27. Further investigation for SAH <ul><li>4 vessel cerebral arteriogram </li></ul><ul><li>MRA (magnetic resonance angiography) </li></ul><ul><li>Spiral (helical) CT angiography </li></ul>
  27. 28. Stroke <ul><li>Headaches may be due to electrochemical or mechanical stimulation of trigeminovascular afferent system </li></ul><ul><li>Headache occurred in infarcts, parenchymal hemorrhage, TIA, lacunar infarcts </li></ul><ul><li>Quality, onset, duration of headache varied widely </li></ul>
  28. 29. Clinical manifestations of headache in stroke <ul><li>Unilateral and focal headache </li></ul><ul><li>Mild to moderate severity </li></ul><ul><li>Abrupt or gradual in onset </li></ul><ul><li>throbbing or nonthrobbing </li></ul><ul><li>More often ipsilateral than contralateral to side of cerebral ischemia </li></ul><ul><li>Associated symptoms : nausea, vomiting, light and noise sensitivity </li></ul>
  29. 30. Unruptured AVM and migraine <ul><li>Migraine-like headaches with and without visual symptoms </li></ul><ul><li>Typical migraine-like due to an AVM </li></ul><ul><ul><li>Unusual associated signs (papilledema, field cut, bruit) </li></ul></ul><ul><ul><li>Short duration of headache attacks </li></ul></ul><ul><ul><li>Brief scintillating scotoma </li></ul></ul><ul><ul><li>Absent family history </li></ul></ul><ul><ul><li>Atypical sequence of aura, headache and vomiting </li></ul></ul><ul><ul><li>seizure </li></ul></ul>
  30. 31. MRI T1 and Angiogram of AVM
  31. 32. Carotid and vertebral artery dissections <ul><li>Dissections occur due to penetration of circulating blood through an intimal tear into subintimal, medial, and, less commonly adventitial layers of vascular wall </li></ul>
  32. 33. Clinical manifestation of carotid or vertebral artery dissection <ul><li>Head, face, orbital, or neck pain </li></ul><ul><li>Cerebral ischemic symptoms </li></ul><ul><li>SAH [intracranial artery dissection] </li></ul><ul><li>Incomplete ipsilateral Horner’s syndrome [extracranial ICA dissection] </li></ul><ul><li>Subjective or objective bruits </li></ul>
  33. 34. Character of headache in artery dissection <ul><li>Onset : gradual 75%, thunderclap headache 10-20%, </li></ul><ul><li>Constant, steady aching or steady sharp pain or less commonly as throbbing </li></ul>
  34. 35. Headache in CVT <ul><li>Usually due to raised intracranial pressure </li></ul><ul><ul><li>Diffuse, progressive and constant </li></ul></ul><ul><li>Almost always associated with </li></ul><ul><ul><li>Papilledema </li></ul></ul><ul><ul><li>Focal deficits </li></ul></ul><ul><ul><li>Partial/ generalized seizures </li></ul></ul>
  35. 36. Diagnostic evaluation in CVT <ul><li>CT brain </li></ul><ul><ul><li>Exclude cerebral infarction and hemorrhage </li></ul></ul><ul><ul><li>‘ Empty delta sign’ ; nonenhancing clot within the sinus is present in only 35% </li></ul></ul><ul><li>MRI and MRV </li></ul><ul><ul><li>Best way to detect CVT </li></ul></ul><ul><li>Lumbar puncture ---should be avoided if there is a large cerebral infarction or hemorrhage </li></ul><ul><ul><li>Document elevated intracranial pressure and help exclude infectious or leptomeningeal malignancy </li></ul></ul>
  36. 37. MRV of Superior sagittal, transverse sinus thrombosis
  37. 38. Temporal arteritis (Giant cell arteritis) <ul><li>Systemic panarteritis that selectively involves arterial walls with significant amount of elastin </li></ul><ul><li>50% of patient with temporal arteritis have polymyalgia rheumatica </li></ul><ul><li>15% of patient with polymyalgia rheumatica have temporal arteritis </li></ul><ul><li>Mean age of onset ~70 years </li></ul>
  38. 39. <ul><li>Temporal arteritis (giant cell arteritis) </li></ul>
  39. 40. Temporal arteritis (Giant cell arteritis) <ul><li>Headache 60-90% </li></ul><ul><ul><li>Often throbbing </li></ul></ul><ul><ul><li>Intermittent or continuous </li></ul></ul><ul><ul><li>Severe </li></ul></ul><ul><ul><li>Location : temporofrontal, temple, not involve temple, generalized </li></ul></ul><ul><ul><li>50% tenderness or decreased pulsation of superficial temporal artery </li></ul></ul>
  40. 41. Temporal arteritis (cont) <ul><li>Intermittent jaw claudication 38% </li></ul><ul><li>Neurologic manifestation are common </li></ul><ul><ul><li>Ophthalmologic findings ; visual loss, ophthalmoparesis </li></ul></ul><ul><ul><li>Mononeuropathies and peripheral neuropathies </li></ul></ul><ul><ul><li>TIA or stroke </li></ul></ul><ul><ul><li>others </li></ul></ul>
  41. 42. Diagnosis of temporal arteritis <ul><li>Based on clinical suspicion that is usually confirmed by laboratory testing </li></ul><ul><li>3 best test : westergren ESR, C-reactive protein(CRP), temporal artery biopsy </li></ul>
  42. 43. Headache due to severe HT <ul><li>Usually bioccipital throbbing </li></ul><ul><li>Can be generalized or frontal throbbing </li></ul><ul><li>Often present in the morning on awakening </li></ul><ul><li>Diastolic BP usually elevated to 120 mmHg or higher </li></ul>
  43. 44. Headaches and neoplasms <ul><li>Brain tumors are an uncommon cause of headache </li></ul><ul><li>8% of patient with headaches and brain tumors have a normal neurological examination </li></ul><ul><li>Papilledema is present in 40% </li></ul><ul><li>Headache related to size of tumor and amount of midline shift </li></ul>
  44. 45. Headaches and neoplasms (cont) <ul><li>Most common location of headaches is bifrontal </li></ul><ul><li>Most of headache are intermittent with moderate to severe intensity </li></ul><ul><li>‘ classic’ brain tumor headache---severe, worse in the morning, associated N/V---occurs in a minority of patients </li></ul>
  45. 46. Headache and intracranial pressure
  46. 48. Pseudotumor cerebri (idiopathic intracranial hypertension) <ul><ul><li>Neurological examination is normal except papilledema, visual loss, cranial nerve VI palsy </li></ul></ul><ul><ul><li>CSF pressure is increased (>20 cm H2O in nonobese and >25 cmH2O in obese patient) </li></ul></ul><ul><ul><li>CSF analysis is normal except decreased protein </li></ul></ul><ul><ul><li>No hydrocephalus or mass lesion </li></ul></ul><ul><ul><li>There are no other identifiable causes </li></ul></ul>
  47. 49. Pseudotumor cerebri <ul><li>>90% of patients are young obese women </li></ul><ul><li>Usually Primary or idiopathic </li></ul><ul><li>Secondary causes and associations </li></ul><ul><ul><li>Intracranial mass </li></ul></ul><ul><ul><li>Obstruction of ventricular system </li></ul></ul><ul><ul><li>Cerebral venous thrombosis </li></ul></ul><ul><ul><li>Meningitis/ encephalitis </li></ul></ul><ul><ul><li>Medications : Vitamin A, Minocycline, Anabolic steroids, Corticosteroid withdrawal </li></ul></ul>
  48. 50. Clinical manifestation of Pseudotumor cerebri <ul><li>Headache </li></ul><ul><ul><li>Pulsatile, daily, continuous </li></ul></ul><ul><ul><li>Unilateral, bilateral, frontal, occipital </li></ul></ul><ul><ul><li>[ bifrontotemporal is the most common ] </li></ul></ul><ul><ul><li>Nausea/vomiting </li></ul></ul><ul><ul><li>Orbital pain </li></ul></ul><ul><li>Papilledema </li></ul><ul><ul><li>Visual symptoms : transient visual obscuration, diplopia, visual loss, cranial nerve VI palsy </li></ul></ul>
  49. 51. Diagnostic evaluation of Pseudotumor cerebri <ul><li>CT or MRI brain </li></ul><ul><ul><li>Exclude tumor or hydrocephalus </li></ul></ul><ul><li>Lumbar puncture </li></ul><ul><ul><li>If the scans show no other explanation for papilledema </li></ul></ul><ul><ul><li>Measure opening pressure </li></ul></ul><ul><ul><li>CSF analysis should be normal except low protein level in some cases </li></ul></ul><ul><li>Ophthalmologist consultation </li></ul><ul><ul><li>Evaluate fundus, visual acuity, visual field </li></ul></ul>
  50. 52. Management of Pseudotumor cerebri <ul><li>Treat causes </li></ul><ul><li>Treatment of idiopathic Pseudotumor cerebri </li></ul><ul><ul><li>Lose weight for obese patients </li></ul></ul><ul><ul><li>Repeated LP to reduce pressure to 12-17.5 cm H2O </li></ul></ul><ul><ul><li>Medication for persistent headache </li></ul></ul><ul><ul><ul><li>drug for migraine headache </li></ul></ul></ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul><ul><ul><ul><li>Acetazolamide </li></ul></ul></ul><ul><ul><li>Surgical treatments for papilledema and headache </li></ul></ul><ul><ul><ul><li>Optic nerve sheath fenestration </li></ul></ul></ul><ul><ul><ul><li>Lumboperitoneal shunt </li></ul></ul></ul>
  51. 53. Low CSF pressure headache <ul><li>Most often due to </li></ul><ul><ul><li>Post LP </li></ul></ul><ul><ul><li>Spontaneous occurrence </li></ul></ul><ul><ul><li>CSF shunt overdrainage </li></ul></ul>
  52. 54. Diagnostic evaluation of low CSF pressure headache <ul><li>Repeat LP : opening pressure 0-7cmH2O or in normal range </li></ul><ul><li>CSF analysis: normal or moderate, primarily lymphocytic pleocytosis, RBC, elevate protein </li></ul><ul><li>MRI brain : diffuse meningeal enhancement with gadolinium or subdural fluid collection </li></ul>
  53. 55. Intracranial hypotension
  54. 56. Post-Lumbar puncture headache <ul><li>Most common complication of lumbar puncture </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>Female </li></ul></ul><ul><ul><li>Age 18-30 years </li></ul></ul><ul><ul><li>Lesser body mass index </li></ul></ul><ul><ul><li>Prior chronic or recurrent headache </li></ul></ul><ul><ul><li>Prior PLPH </li></ul></ul><ul><ul><li>Larger-diameter needle, perpendicular orientation of bevel, not reinsert the stylet </li></ul></ul>
  55. 57. Clinical manifestation of PLPH <ul><li>Bilateral, frontal, occipital, generalized pressure or throbbing occurring in upright position and decreasing or resolving when supine </li></ul><ul><li>Worse with headache movement, coughing, straining, sneezing, jugular venous compression </li></ul><ul><li>Begins within 48 hrs or 72 hrs </li></ul><ul><li>Additional symptoms : neck stiffness, nausea, vomiting </li></ul>
  56. 58. Headaches caused by Vasoactive substances <ul><li>Dilation of intracranial vessels </li></ul><ul><ul><li>Throbbing in nature and made worse by sudden head movement </li></ul></ul><ul><li>Examples </li></ul><ul><ul><li>Alcohol </li></ul></ul><ul><ul><li>Marijuana </li></ul></ul><ul><ul><li>Cocaine </li></ul></ul><ul><ul><li>Monosodium glutamate “Chinese restaurant syndrome” </li></ul></ul><ul><ul><li>Nitrite and Nitrates </li></ul></ul><ul><ul><li>Histamine headache </li></ul></ul><ul><li>Rebound headache : nicotine and caffeine </li></ul>
  57. 59. Headache due to infection and inflammation <ul><li>HIV and headache </li></ul><ul><ul><li>Cryptococcal meningitis, neurosyphilis, tuberculous meningitis, toxoplasmosis, CMV encephalitis, tumors, sinusitis, medications, primary headache </li></ul></ul><ul><li>Brain abscess </li></ul><ul><li>Meningitis and encephalitis </li></ul><ul><li>Drug-induced aseptic meningitis : NSAIDs, ATBs, vaccines, others,… </li></ul>
  58. 60. Metabolic disorders and headache <ul><li>Fever </li></ul><ul><li>Hypoxia </li></ul><ul><li>Hypercapnia </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Dialysis </li></ul><ul><li>High altitude </li></ul><ul><li>Decompression sickness </li></ul><ul><li>Hyperventilation syndrome </li></ul>
  59. 61. Primary Headache <ul><li>Migraine </li></ul><ul><li>Tension-type headache </li></ul><ul><li>Cluster </li></ul>
  60. 62. Headache type Migraines Tension-type Cluster Age at onset 10-40 20-50 15-40 Location Hemicranial Bilateral Unilateral peri/retro-orbital duration Several hours to 3 days 30 min to 7days+ 30-120 min Frequency/timing Variable Variable 1-8/day, nocturnal attacks severity Moderate to severe Dull ache may wax/wane Excruciating quality Throbbing, steady ache Band-like pressure Boring, piercing Associated features N/V, photo/phono/osmophobia, scotoma, neurologic deficits Generally none Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, miosis, facial sweating
  61. 63. Migraine headache
  62. 64. Age- And Gender-specific Prevalence Of Migraine Lipton RB, Stewart WF. Neurology . 1993. Migraine Prevalence (5)
  63. 65. Migraine Without Aura
  64. 66. Migraine without aura <ul><li>A . At least 5 attacks fulfilling criteria B - D </li></ul><ul><li>B . Headache attacks lasting 4-72 hours ( untreated or unsuccessfully treated ) </li></ul><ul><li>C . Headache has at least 2 of the following characteristics : </li></ul><ul><li>- Unilateral location </li></ul><ul><li>- Pulsating quality </li></ul><ul><li>- Moderate or severe pain intensity </li></ul><ul><li>- Aggravation by or causing avoidance of routine physical activity ( eg, walking or climbing stairs ) </li></ul><ul><li>D . During headache at least 1 of the following : </li></ul><ul><li>- Nausea and / or vomiting </li></ul><ul><li>- Photophobia and phonophobia </li></ul><ul><li>E . Not attributed to another disorder </li></ul><ul><li>  </li></ul>
  65. 67. Migraine With Aura
  66. 68. Typical aura with Migraine headache(1) <ul><li>A . At least 2 attacks fulfilling criteria B - D </li></ul><ul><li>B . Aura consisting of at least 1 of the following, but no motor weakness : </li></ul><ul><li>- Fully reversible visual symptoms including positive features ( eg, flickering lights, spots or lines ) and / or negative features ( ie, loss of vision ) </li></ul><ul><li>- Fully reversible sensory symptoms including positive features ( ie, pins and needles ) and / or negative features ( ie, numbness ) </li></ul><ul><li>- Fully reversible dysphasic speech disturbance </li></ul>
  67. 69. Typical aura with Migraine headache(2) <ul><li>C . At least two of the following : </li></ul><ul><li>- Homonymous visual symptoms and / or unilateral sensory symptoms </li></ul><ul><li>- At least one aura symptom develops gradually over > /= 5 minutes and / or different aura symptoms occur in succession over > /= 5 minutes </li></ul><ul><li>- Each symptom lasts > /= 5 and < /= 60 minutes </li></ul><ul><li>D . Headache fulfilling criteria B - D for “Migraine without aura” begins during the aura or follows aura within 60 minutes </li></ul><ul><li>E . Not attributed to another disorder </li></ul><ul><li>  </li></ul>
  68. 70. Visual Aura
  69. 71. Aura-Numbness
  70. 72. <ul><li>1. Prodrome </li></ul><ul><li>2. Aura </li></ul>Phases of Migraine Attack 3. Headache 4. Postdrome
  71. 73. Migraine Treatment <ul><li>Reassure and educate patient </li></ul><ul><li>Identify and remove triggers </li></ul><ul><li>Start a wellness program : exercise, balanced meals, adequate sleep, smoking cessation </li></ul><ul><li>pharmacotherapy </li></ul><ul><li>physical therapy </li></ul><ul><li>psychological therapy </li></ul>
  72. 74. Migraine Triggers <ul><li>Stress and emotion </li></ul><ul><li>Hormonal changes </li></ul><ul><li>Diet </li></ul><ul><li>Environmental factors </li></ul><ul><li>Too much or too little sleep </li></ul><ul><li>Physical factors </li></ul>
  73. 75. Acute vs Preventive Therapy <ul><li>Acute (Abortive) : Taken after attack has begun to relieve pain and disability and stop progression </li></ul><ul><li>Preventive Therapy : Taken daily to reduce attack frequency, severity, and duration </li></ul>
  74. 76. Acute Migraine Medications <ul><li>Non-specific </li></ul><ul><ul><li>NSAIDs : naproxen, ibuprofen </li></ul></ul><ul><ul><li>Combination analgesics : acetaminophen/aspirin/caffeine </li></ul></ul><ul><ul><li>Neuroleptics/antiemetics : metoclopramide, prochlorperazine </li></ul></ul><ul><li>Specific </li></ul><ul><ul><li>Ergotamine/DHE </li></ul></ul><ul><ul><li>Triptans : sumatriptan, zolmitriptan </li></ul></ul><ul><ul><li>CGRP antagonist :olcegepant, MK-0974 </li></ul></ul>
  75. 77. Migraine Prevention <ul><li>Classes of preventive drugs: </li></ul><ul><ul><li>Antiepileptics : topiramate, valproate, gabapentin </li></ul></ul><ul><ul><li>Tricyclic antidepressant : amitryptyline, nortriptyline </li></ul></ul><ul><ul><li>SNRI : venlafaxine, duloxetine </li></ul></ul><ul><ul><li>Beta-blockers : propanolol </li></ul></ul><ul><ul><li>Calcium channel blockers : flunarizine </li></ul></ul><ul><ul><li>Other treatment : magnesium, riboflavin, co-enzyme Q10, feverfew, butterbur root, botulinum toxin </li></ul></ul><ul><ul><li>No efficacy : nimodipine, clonidine, fluoxetine </li></ul></ul>
  76. 78. Tension-type Headache
  77. 79. Tension - type headache ( TTH ) <ul><li>- Headache lasting from 30 minutes to 7 days </li></ul><ul><li>- Headache has at least 2 of the following characteristics : </li></ul><ul><li>- Bilateral location </li></ul><ul><li>- Pressing / tightening ( non - pulsating ) quality </li></ul><ul><li>- Mild or moderate intensity </li></ul><ul><li>- Not aggravated by routine physical activity such as walking or climbing stairs </li></ul><ul><li>- Both of the following : </li></ul><ul><li>- No nausea or vomiting ( anorexia may occur ) </li></ul><ul><li>- No more than one of photophobia or phonophobia </li></ul><ul><li>- Not attributed to another disorder </li></ul><ul><li>  </li></ul>
  78. 80. TTH management <ul><li>Simple analgesic : acetaminophen, aspirin, NSAIDs </li></ul><ul><li>Behavioral approach : relaxation </li></ul><ul><li>Triptans in pure TTH are not helpful </li></ul><ul><li>For chronic TTH : amitryptyline </li></ul>
  79. 81. Cluster Headache <ul><li>Severe unilateral pain </li></ul><ul><li>Associated with lacrimation, sweating, ptosis, conjunctival injection, and eyelid edema </li></ul><ul><li>May be precipitated by alcohol, histamine, or nitroglycerine </li></ul>
  80. 82. Cluster Headache <ul><li>A . At least 5 attacks fulfilling criteria B - D </li></ul><ul><li>B . Severe or very severe unilateral orbital, supraorbital and / or temporal pain lasting 15-180 minutes if untreated </li></ul><ul><li>C . Headache is accompanied by at least 1 of the following : </li></ul><ul><li>- Ipsilateral conjunctival injection and / or lacrimation </li></ul><ul><li>- Ipsilateral nasal congestion and / or rhinorrhea </li></ul><ul><li>- Ipsilateral eyelid edema </li></ul><ul><li>- Ipsilateral forehead and facial sweating </li></ul><ul><li>- Ipsilateral miosis and / or ptosis </li></ul><ul><li>A sense of restlessness or agitation </li></ul><ul><li>D . Attacks have a frequency from 1 every other day to 8 / day </li></ul><ul><li>E . Not attributed to another disorder </li></ul>
  81. 83. Treatment of Cluster Headache <ul><li>Acute treatment </li></ul><ul><ul><ul><li>100% Oxygen inhalation </li></ul></ul></ul><ul><ul><ul><li>Rapid acting DHE </li></ul></ul></ul><ul><ul><ul><li>Sumatriptan subcutaneously </li></ul></ul></ul>
  82. 84. Cluster Headache Preventive Treatment <ul><li>Short-term </li></ul><ul><ul><li>Prednisolone 1 mg/kg/d tapering over 21 days </li></ul></ul><ul><ul><li>Verapamil </li></ul></ul><ul><ul><li>Greater occipital nerve injection </li></ul></ul><ul><li>Long-term </li></ul><ul><ul><li>verapamil </li></ul></ul><ul><ul><li>Lithium </li></ul></ul><ul><ul><li>Topiramate </li></ul></ul><ul><ul><li>Gabapentin </li></ul></ul><ul><ul><li>melatonin </li></ul></ul>
  83. 85. Thank you for your attention