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Neurological lectures...Headaches

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Neurological lectures...Headaches
http://yassermetwally.com
http://yassermetwally.net

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Neurological lectures...Headaches

  1. 1. Classification of headaches Professor Yasser Metwally <ul><li>Primary headaches </li></ul><ul><li>OR Idiopathic headaches </li></ul><ul><ul><li>THE HEADACHE IS ITSELF THE DISEASE </li></ul></ul><ul><ul><li>NO ORGANIC LESION IN THE BEACKGROUND </li></ul></ul><ul><ul><li>TREAT THE HEADACHE! </li></ul></ul><ul><li>Secondary headaches </li></ul><ul><li>OR Symptomatic headaches </li></ul><ul><ul><li>THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER UNDERLYING DISEASE </li></ul></ul><ul><ul><li>TREAT THE UNDERLYING DISEASE! </li></ul></ul>
  2. 2. HISTORY AND EXAMINATIONS SHOULD CLARIFY IF <ul><li>THE PATIENT HAS PRIMARY OR SECONDARY HEADACHE </li></ul><ul><li>IS THERE ANY URGENCY </li></ul><ul><li>IN CASE OF PRIMARY HEADACHE ONLY THE HEADACHE ATTACKS SHOULD BE TREATED („ATTACK THERAPY”), OR PROPHYLACTIC THERAPY IS ALSO NECESSARY („PREVENTIVE THERAPY, INTERVAL THERAPY”) </li></ul>
  3. 3. SECONDARY, SYMPTOMATIC HEADACHES <ul><li>THE HEADACHE IS A SYMPTOM OF AN UNDERLYING DISEASE, LIKE </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Sinusitis </li></ul></ul><ul><ul><li>Glaucoma </li></ul></ul><ul><ul><li>Eye strain </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Cervical spondylosis </li></ul></ul><ul><ul><li>Anaemia </li></ul></ul><ul><ul><li>Temporal arteriitis </li></ul></ul><ul><ul><li>Meningitis, encephalitis </li></ul></ul><ul><ul><li>Brain tumor, meningeal carcinomatosis </li></ul></ul><ul><ul><li>Haemorrhagic stroke… </li></ul></ul>
  4. 4. <ul><li>Secondary headache disorders </li></ul><ul><li>Headache attributed to ... </li></ul><ul><li>5. head and/or neck trauma </li></ul><ul><li>6. cranial or cervical vascular disorder </li></ul><ul><li>7. non-vascular intracranial disorder </li></ul><ul><li>8. a substance or its withdrawal </li></ul><ul><li>9. infection </li></ul><ul><li>10. disorder of homoeostasis </li></ul><ul><li>11. disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures </li></ul><ul><li>12. psychiatric disorder </li></ul><ul><li>13. cranial neuralgias and central causes of facial pain </li></ul>
  5. 5. Primary, idiopathic headaches <ul><li>Tension type of headache </li></ul><ul><li>Migraine </li></ul><ul><li>Cluster headache </li></ul><ul><li>Other, rare types of primary headaches </li></ul>
  6. 6. Treatment of tension type of headache <ul><li>Acute, episodic form: NSAID drugs, 500-1000 mg ASA, paracetamol, or noraminophenazon </li></ul><ul><li>Indication of prophylactic treatment : tension type of headache in at least 14 days per moth </li></ul>
  7. 7. Prophylactic treatment of the chronic tension type of headache <ul><li>Tricyclic antidepressants </li></ul><ul><li>Guidelines: </li></ul><ul><ul><ul><li>Start with low dose (10-25 mg) and increase the dose if no beneficial effect after 1-2 weeks </li></ul></ul></ul><ul><ul><ul><li>Maximal dose should not be more than 75 mg/day </li></ul></ul></ul><ul><ul><ul><li>Change to other tricyclic antidepressant only after 6-8 weeks </li></ul></ul></ul><ul><ul><ul><li>Ask the patient to use headache diary </li></ul></ul></ul><ul><ul><ul><li>Use the tricyclic antidepressant for 6-9 months </li></ul></ul></ul><ul><ul><ul><li>Decrease the dose gradually </li></ul></ul></ul>
  8. 8. <ul><li>First choice of drug: </li></ul><ul><li>amitryptiline (Teperin tabl, 25 mg) </li></ul><ul><li>1st week: 25 mg in the evening </li></ul><ul><li>2nd week: 50 mg in the evening </li></ul><ul><li>3rd week: 75 mg in the evening continuously </li></ul><ul><li>Change to other drug (e.g. clomipramine) if no beneficial effect within 6 weeks </li></ul>Prophylactic treatment of the chronic tension type of headache
  9. 9. Common side effects of tricyclic antidepressants <ul><li>Anticholinergic side effects: </li></ul><ul><ul><li>Dry mouth </li></ul></ul><ul><ul><li>Increased pulse rate </li></ul></ul><ul><ul><li>Urinary retention (in prostate hyperplasia!!!) </li></ul></ul><ul><ul><li>Increased intraocular pressure (glaucoma!!!) </li></ul></ul><ul><li>Sleepiness or hyperactivity </li></ul><ul><li>Serotonine syndrome (do not use if the patient takes SSRI drug) </li></ul>
  10. 10. If the patient does not tolerate the TCA drugs, or cannot be administared because of danger of interaction <ul><li>Anxiolytics (e.g.: alprasolam, clonazepam…) </li></ul><ul><li>and selective antidepressants (e.g. SSRI) </li></ul><ul><li>Change of lifestyle </li></ul><ul><li>Psychotherapy, psychological treatments, biofeedback, behavioral therapy, relaxation methods </li></ul>
  11. 11. Migraine: epidemiology <ul><li>Life-time prevalence 10%-12% </li></ul><ul><li>1% chronic migraine (>15 days/months) </li></ul><ul><li>Sex ratio 2.5 (f) to 1 (m); in childhood 1 to 1 </li></ul><ul><li>Mean frequency 1.2/month </li></ul><ul><li>Mean duration 24 h (untreated) </li></ul><ul><li>10% always with aura, >30% sometimes with aura </li></ul><ul><li>30% treated by physicians </li></ul>
  12. 12. Migraine: pathophysiology <ul><li>Genetic disposition , hormonal influence </li></ul><ul><li>Activation of brainstem nuclei by trigger factors </li></ul><ul><li>Neurovascular inflammation of intracranial vessels </li></ul><ul><li>Impaired antinociception </li></ul><ul><li>„ Spreading Depression“ as mechanism of aura </li></ul>
  13. 13. Migraine classification 1.1 migraine without aura 1.2 migraine with aura 1.3 periodic syndromes in childhood 1.4 retinal migraine 1.5 migraine complications 1.6 probable migraine
  14. 14. Migraine <ul><li>WITH AURA + </li></ul><ul><ul><li>VISUAL </li></ul></ul><ul><ul><li>SENSORY </li></ul></ul><ul><ul><li>MOTOR </li></ul></ul><ul><ul><li>SPEECH DISTURBANCE before migraineous headache </li></ul></ul><ul><li>AURA SYMPTOMS </li></ul><ul><ul><li>USUALLY<1/2 HOUR </li></ul></ul><ul><ul><li>LESS THAN 1 HOUR </li></ul></ul><ul><li>WITHOUT AURA </li></ul><ul><li>Typical headache 2/4 </li></ul><ul><ul><li>Unilateralsi </li></ul></ul><ul><ul><li>Severe </li></ul></ul><ul><ul><li>Pulsating </li></ul></ul><ul><ul><li>Physical activity aggravates </li></ul></ul><ul><li>Accompanying signs 1/2 </li></ul><ul><ul><li>Photophobia and phonophobia </li></ul></ul><ul><ul><li>Nausea, or vomitus </li></ul></ul>
  15. 15. MIGRAINE WITH AURA <ul><li>DURING AURA: </li></ul><ul><ul><li>VASOCONSTRICTION </li></ul></ul><ul><ul><li>HYPOPERFUSION </li></ul></ul><ul><li>DURING HEADACHE </li></ul><ul><ul><li>VASODILATION </li></ul></ul><ul><ul><li>HYPERPERFUSION </li></ul></ul>BUT: AURA SYMPTOM IS NOT CONSEQUENCE OF VASOCONSTRICTION INDUCED HYPOPERFUSION CUASE OF THE AURA: SPREADING DEPRESSION. THE VASOCONSTRICTION AND HYPOPERFUSION ARE CONSEQUENCES OF THE SPREADIND DEPRESSION SPREADING DEPRESSION AURA VASOCONSTRICTION, HYPOPERFUSION
  16. 16. IMPORTANT TO KNOW! MIGRAINE WITH AURA <ul><li>IS A RISK FACTOR FOR ISCHAEMIC STROKE </li></ul><ul><ul><li>THEREFORE PATIENTS SUFFERING FROM MIGRAINE WITH AURA </li></ul></ul><ul><ul><ul><li>SHOULD NOT SMOKE!!! </li></ul></ul></ul><ul><ul><ul><li>SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!! </li></ul></ul></ul><ul><li>THE PROPROTION OF PATENT FORAMEN OVALE IN PATIENTS WITH MIGRAINE WITH AURA IS ABOUT 50-55%! (IN THE POPULATION IS ABOUT 25%). </li></ul>
  17. 17. Is there a relationship between aura and patent foramen ovale <ul><li>? </li></ul><ul><li>Paradoxic emboli theory is not likely </li></ul><ul><li>Shunting of venous blood to the arterial side could be the reason  no breakdown of certain neurotransmitters (5HT) in the lung! </li></ul><ul><li>Comorbidity could be also an explanation. </li></ul><ul><li>However, closure of patent foramen ovale decreases the frequency of migraine attacks. </li></ul><ul><li>BUT! Migraine is a benign disease. Please do not indicate closure of patent foramen ovale just because of migraine with aura! </li></ul>
  18. 18. Treatment of migraine attack <ul><li>Try to sleep </li></ul><ul><li>Antiemetics </li></ul><ul><li>Analgetics </li></ul><ul><li>Ergot derivatives </li></ul><ul><li>Triptans </li></ul>
  19. 19. Treatment of migraine attack I. Antiemetics <ul><li>1. Metoclopramid (Cerucal tabl 10 mg) </li></ul><ul><ul><li>10-20 mg per os </li></ul></ul><ul><ul><li>20 mg rectal </li></ul></ul><ul><ul><li>10 mg parenteral </li></ul></ul><ul><li>2. Domperidon (Motilium tabl 10 mg) </li></ul><ul><ul><li>10-20 mg per os </li></ul></ul>
  20. 20. Treatment of migraine attack II. Analgetics <ul><li>1. ASA (Aspirin, Colfarit, etc) </li></ul><ul><ul><li>500-1000 mg per os </li></ul></ul><ul><ul><li>500 mg parenteral (Aspisol i.v.) </li></ul></ul><ul><li>2. Paracetamol (Rubophen, Panadol, etc) </li></ul><ul><ul><li>500-1000 mg per os </li></ul></ul><ul><li>3. NSAIDs </li></ul><ul><ul><li>Ibuprofen (Ibuprofen, Humaprofen, etc) 400-800 mg per os </li></ul></ul><ul><ul><li>Diclofenac (Voltaren, Cataflam etc) 50 mg per os </li></ul></ul><ul><ul><li>Naproxen (Naprosyn, Apranax) 250-550 mg per os </li></ul></ul>
  21. 21. <ul><li>1. Ergotamin tartarate </li></ul><ul><ul><li>2-4 mg per os, sublinguali or rectal </li></ul></ul><ul><ul><li>1 mg nasal spray </li></ul></ul><ul><li>2. Dihydrergotamin (Neomigran) nasal spray </li></ul><ul><ul><li>no more available </li></ul></ul>Treatment of migraine attack III. Ergot derivatives
  22. 22. <ul><li>Migpriv: </li></ul><ul><ul><li>lizin-acetylsalicilate + metoclopramid </li></ul></ul><ul><li>Quarelin: </li></ul><ul><ul><li>aminophenazon+coffein+drotaverin </li></ul></ul><ul><li>Kefalgin </li></ul><ul><ul><li>ergotamin tartarate+ atropin+coffein+aminophenazon </li></ul></ul>Treatment of migraine attack IV. Combinations in Hungary
  23. 23. Treatment of migraine attack V. Triptans
  24. 24. The ideal triptan <ul><li>Effective </li></ul><ul><li>Rapid onset </li></ul><ul><li>No recurrence </li></ul><ul><li>Good consistency </li></ul><ul><li>Different applications </li></ul><ul><li>Good tolerability </li></ul><ul><li>No interactions </li></ul><ul><li>Cheap </li></ul>
  25. 25. Very severe migraine attack / status migrainosus: <ul><li>Triptan (sumatriptan 6 mg s.c.) </li></ul><ul><li>Lysin-ASA 1,000 mg i.v. </li></ul><ul><li>Metamizol 500-1,000 mg i.v. </li></ul><ul><li>Antiemetics i.v. </li></ul><ul><li>Steroids i.v. </li></ul>Attack treatment in emergency
  26. 26. Strategy of treatment of migraine attacks <ul><li>Step care accross or within attacks </li></ul><ul><ul><li>1: NSAID </li></ul></ul><ul><ul><li>2: ergot </li></ul></ul><ul><ul><li>3: triptan </li></ul></ul><ul><li>Stratified care </li></ul><ul><ul><li>do not go through all the steps, but drug can be chosen depending on the severity of the attack </li></ul></ul>
  27. 27. Prophylactic treatment of migraine attacks <ul><li>Indication: </li></ul><ul><ul><ul><li>2 or more attacks/month </li></ul></ul></ul><ul><ul><ul><li>At least one long (>4 days) attack/month </li></ul></ul></ul><ul><li>Start of prophyalactic treatment: gradually </li></ul><ul><li>Duration of prophylactic treatment: 2-9 months </li></ul><ul><li>Stop of prophylactic treatment : gradually, within 4 weeks </li></ul><ul><li>Use headache diary </li></ul><ul><li>INFORM THE PATIENT ABOUT THE PROPHYLACTIC TREATMENT!!! </li></ul>
  28. 28. Aims of prophylactic treatment of migraine <ul><li>To decrease the frequency of attacks </li></ul><ul><li>To decrease the intensity of the pain </li></ul><ul><li>To increase the efficacy of attack therapy </li></ul>
  29. 29. Prophylactic treatment of migraine <ul><li>Beta-receptor-blockers (propranolol) </li></ul><ul><li>Calcium channel blockers (flunarizine) </li></ul><ul><li>Antiepileptics (valproic acid) </li></ul><ul><li>Tricyclic antidepressants (amitriptyline) </li></ul><ul><li>Topiramate (Topamax) </li></ul><ul><li>Serotonin antagonists </li></ul><ul><li>NSAID </li></ul>
  30. 30. Beta-receptor-blockers (propranolol 2x20-40 mg) Calcium channel blockers (flunarizine, 10 mg every evening) Side effects: provokes depression, increases appetite, cause sleepiness Tricyclic antidepressants (amitryptiline, 10-75 mg every evening) Antiepileptics (valproic acid, 2x300-500 mg) Use: hypertension, tachycardia Do not use: hypotension, bradicardia, heart conduction disturbances Do not use: obesity, maior depression in the history Use: if tension type of headache is present besides migraine Do not use: see above Few side effects, but Pregnancy should be avoided
  31. 31. Other prophylactic treatment of migraine <ul><li>Change of life-style </li></ul><ul><li>Regular, not exhausting physical activities </li></ul><ul><li>Cognitive behavioral therapy </li></ul><ul><li>Regular sleeping </li></ul><ul><li>Avoid the precipitating factors </li></ul><ul><li>Acuouncture? </li></ul>
  32. 32. Migraine and pregnancy <ul><li>Migraine without aura in >70% of women less frequent or absent (prognostic factor: menstrual migraine) </li></ul><ul><li>Significantly more manifestation of migraine with aura </li></ul><ul><li>Acute treatment: paracetamol; NSAIDs in second trimenon </li></ul><ul><li>Triptans not allowed </li></ul><ul><li>Prophylaxis: magnesium, metoprolol, (fluoxetine) </li></ul>
  33. 33. Migraine in childhood I <ul><li>Prevalence 5% </li></ul><ul><li>Sex ratio 1:1 (boys with good prognosis) </li></ul><ul><li>Abdominal symptoms often predominant </li></ul><ul><li>Semiology of attacks as in adulthood except shorter duration of attacks </li></ul><ul><li>Short sleep very effective </li></ul>
  34. 34. Migraine in childhood II <ul><li>Acute treatment: </li></ul><ul><ul><li>First choice: ibuprofen 10 mg/kg </li></ul></ul><ul><ul><li>Second choice: paracetamol 15 mg/kg </li></ul></ul><ul><ul><li>Third choice: sumatriptan nasal spray 10-20 mg </li></ul></ul><ul><li>Prophylaxis: </li></ul><ul><ul><li>Flunarizine 5-10 mg </li></ul></ul><ul><ul><li>Propranolol 80 mg </li></ul></ul><ul><li>Non-drug therapy very effective </li></ul>
  35. 35. Treatment of cluster attack <ul><li>Oxygen:7 liters/min 100% oxigén for 15 minutes </li></ul><ul><ul><li>Effective in 75% of patients within 10 minutes </li></ul></ul><ul><li>Sumatiptan 6 mg s.c., 50-100 mg per os </li></ul><ul><li>Ergot derivatives (lot of side effects) </li></ul><ul><li>Anaesthesia of the ipsilateral fossa sphenopalatina) </li></ul><ul><ul><li>1 ml 4% Xylocain nasal drop </li></ul></ul><ul><ul><li>The head is turned back and to the ipsilateral side </li></ul></ul><ul><ul><li>in 45 degree </li></ul></ul>
  36. 36. Prophylactic treatment of the episodic form of cluster headache <ul><li>Epizodic form: prednisolon </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>1-5. days 40 mg </li></ul></ul><ul><ul><li>6-10. days daily 30 mg </li></ul></ul><ul><ul><li>10-15. days daily 20 mg </li></ul></ul><ul><ul><li>16-20. days daily 15 mg </li></ul></ul><ul><ul><li>21-25. days daily 10 mg </li></ul></ul><ul><ul><li>26-30. days daily 5 mg </li></ul></ul><ul><ul><li>nothing </li></ul></ul>
  37. 37. <ul><li>Lithium carbonate </li></ul><ul><li>Daily 600-700 mg </li></ul><ul><li>Can be decreased after 2 weeks remission </li></ul><ul><li>Control of serum level is necessary (0,4 - 0,8 mmol/l) </li></ul>Prophylactic treatment of the chronic form of cluster headache
  38. 38. 3. Cluster headache and trigemino-autonomic cephalgias <ul><li>Trigemino-autonomic cephalgias (TAC) </li></ul><ul><ul><li>Cluster headache </li></ul></ul><ul><ul><li>Paroxysmal hemicrania </li></ul></ul><ul><ul><li>SUNCT-syndrome </li></ul></ul><ul><ul><li>(Hemicrania continua) </li></ul></ul><ul><li>Episodic and chronic forms </li></ul>
  39. 39. Headache of cervical origin <ul><li>Lidocain infiltration </li></ul><ul><li>NSAID: 50-150 mg indomethacin, 20-40 mg piroxicam (Hotemin, Feldene), etc </li></ul><ul><li>Surgical methods (CV-CVII fusion of vertebrae) </li></ul><ul><li>Other methods (physiotherapy, TENS) </li></ul>
  40. 40. Arteriitis temporalis <ul><li>Arteriitis temporalis (age>50y, We>50 mm/h) </li></ul><ul><li>Autoimmune disease, granulomatose inflammation of branches of ECA </li></ul><ul><ul><li>Unilateral headache </li></ul></ul><ul><ul><li>Pulsating pain, more severe at night </li></ul></ul><ul><ul><li>Larger STA </li></ul></ul><ul><ul><li>1/3 jaw claudication  inflammation of internal maxillary artery </li></ul></ul><ul><ul><li>Weakness, loss of appetite, low fever, </li></ul></ul><ul><ul><li>Danger of thrombosis of ophthalmic or ciliary artery!!! </li></ul></ul><ul><ul><li>Amaurosis fugax may precede the blindness </li></ul></ul><ul><ul><li>Treatment: steroid – 45-60 mg methylprednisolone – decrease the dose after 1-2 weeks to 10 mg!!! </li></ul></ul><ul><ul><li>Diagnosis: STA biopsy. </li></ul></ul><ul><ul><li>BUT Start the steroid before results of biopsy!!! </li></ul></ul><ul><ul><li> We, pain decrease </li></ul></ul>
  41. 41. Facial pains <ul><li>Tolosa-Hunt syndrome (ophthalmoplegia dolorosa) – granulomatose inflammation in cavernous sinus, superior orbital fissure – Treatment: steroid </li></ul><ul><li>Gradenigo’s syndrome: otitis media –inflammation of apex of petrous bone – lesion of ipsilateral abducent nerve and facial pain around the ear and forehead </li></ul>
  42. 42. Carotid dissection <ul><li>After neck trauma, extensive neck turning </li></ul><ul><li>Neck pain </li></ul><ul><li>Horner’s syndrome </li></ul><ul><li>Diagnosis: carotid duplex, MRI-T2 </li></ul>

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