Download headache

Case-Based Teaching
Didactic Component:
Headache & Migraine
Department of Neurology
University of Miami School of Medicine
Headache & Migraine
Learning Objectives
• Describe the diagnostic criteria for
migraine
• Describe when & how to perform a
diagnostic evaluation in a pt w/
headache
• Describe the appropriate abortive &
prophylactic therapies for migraine
Diagnosis & Management of Headaches
Primary vs. Secondary Headaches
• primary headache
– a condition in which headache is a primary
manifestation & no underlying disease is present,
e.g., migraine and cluster
– due to chronic conditions w/recurrent acute attacks
• secondary headache
– a condition in which headache is a secondary
manifestation of an underlying disease process
– often due to diseases that require both urgent &
prolonged care
Diagnosis & Management of Headaches
Goals of the Clinician
• diagnose the cause of headache
• provide emergency therapy
• provide a means for long-term care
Primary Headache
Practical Migraine Definition
• genetic condition in which a person has
a predisposition to suffering recurrent
episodes of any of the following:
– headache
– GI dysfunction
– neurologic dysfunction
Primary Headache
Migraine Pathophysiology
• autosomal dominant inheritance; multiple genes
• origin is neurologic, not vascular:
– focal decrease in brain serotonergic activity
– dysfunction of brainstem serotonergic &
noradrenergic pain pathways
– vasoactive neuropeptide release by CN V
– secondary arterial dilatation, constriction
Primary Headache
Migraine Epidemiology
• by far, most common cause of headache
• prevalence estimates:
– range of most estimates is 1-31%
– more likely prevalence is 70%
• problems in determining prevalence include:
– no objective pathology or diagnostic test
– variable definitions based on clinical criteria
– variable populations & methods of data collection
Primary Headache
Migraine Triggers
• hormonal changes
– stress, stress letdown, hyperthyroidism
– menarche, menses, pregnancy, BCPs, menopause
• changes in sleep, eating habits, weather
• smoke, scents, fumes
• foods
– esp. nitrates, MSG, tyramine, aspartame, citrus
• alcohol (esp. red wine)
• exercise, head trauma, motion
Primary Headache
Migraine Phases
•
•
•
•
prodrome
aura
headache
postdrome
•
•
•
•
•
mood changes
difficulty concentrating
fatigue, malaise
autonomic symptoms
food cravings
– esp. foods high in
serotonin, e.g., chocolate,
bananas, peanut butter
Primary Headache
Migraine Phases
•
•
•
•
prodrome • visual
– photopsia, scintillating scotomata
aura
– silvery, clear
headache
– fortification spectra, zig-zag lines
– wavy lines, heat-off-the-pavement
postdrome
– spots, dots, bubbles
– vibrating, evolving, coalescing
• other (often migratory, stereotypical)
– numbness, hemiparesis, aphasia
– ataxia, vertigo, tinnitus, diplopia
Primary Headache
Migraine Phases
•
•
•
•
prodrome
aura
headache
postdrome
• headache characteristics
– unilateral, bilateral, variable location
– throbbing, pulsating, pounding,
pressure, squeezing, dull, aching
– severe, moderate, mild, absent
– hours, days, weeks
• associated symptoms
–
–
–
–
photophobia, phonophobia
nausea, vomiting
cramping, flatulence, diarrhea
hypertension (dysautonomia)
Primary Headache
Migraine Phases
•
•
•
•
prodrome
aura
headache
postdrome
•
•
•
•
•
fatigue, malaise
difficulty concentrating
mood changes
muscle aches
scalp tenderness
Primary Headache
IHS Definition of Migraine w/o Aura
Useful for scientific studies, but impractical for daily use
• frequency
– > 5 episodes
• duration
– 4-72 h untreated
• HA quality (> 2)
–
–
–
–
unilateral
pulsating
moderate or severe
 w/physical activity
• associated features (> 1)
– nausea &/or vomiting
– photo- & phonophobia
• no other cause of sxs
Primary Headache
Types of Migraine
• migraine w/o aura
– common
• migraine with aura
–
–
–
–
–
–
–
classic
hemiplegic
hemiparesthetic
aphasic
basilar
retinal, ocular
ophthalmoplegic
• migraine aura w/o HA
–
–
–
–
–
acephalgic
accompaniments
equivalents
abdominal
benign paroxysmal
vertigo
Primary Headache
Difficulties in Diagnosing Migraine
• rationalization of symptoms
– “regular, mild, tension, or sinus” headaches
– “GI virus, food poisoning, IBS/spastic colon”
– interview significant other
• unknown family history
– symptoms most prominent in early adulthood:
• pt was too young to realize parent had headaches
• pt no longer lives with parents or siblings
– interview relatives directly
Primary Headache
Conditions Due to (or Related to) Migraine
•
•
•
•
•
•
•
•
•
•
episodic tension headache
sinus headache
“regular” or “ordinary” headache
premenstrual syndrome
irritable bowel syndrome/spastic colon
recurrent vertigo (?Meniere’s disease)
motion sickness
postconcussion/posttraumatic headache
transient global amnesia
atypical chest pain
Primary Headache
Importance of Diagnosing Migraine
• common
• disabling
• avoiding iatrogenic disease
– hysterectomy/oophorectomy
– abdominal surgery
– sinus and ear surgeries
– anxiolytics, antidepressants
Primary Headache
Migraine Abortive Therapy
• selective 5-HT1D/1B
agonists
–
–
–
–
sumatriptan (Imitrex)
naratriptan (Amerge)
rizatriptan (Maxalt)
zolmitriptan (Zomig)
• nonselective 5-HT1D
agonists
– Cafergot, Wygraine
– DHE 45
• nonspecific combinations
– Midrin, Excedrin Migraine
– Fiorinal, Fioricet, Esgic
– BC & Goody Powders
• nonspecific single agents
– aspirin, Tylenol, NSAIDs
– Vistaril, narcotics
• phenothiazine-related
– Thorazine, Compazine,
Phenergan
Primary Headache
Migraine Prophylactic Therapy
• beta-blockers
–
–
–
–
propranolol (Inderal)
nadolol (Corgard)
atenolol (Tenormin)
timolol (Blocadren)
• verapamil
(Calan, Isoptin, Verelan)
•
•
•
•
•
•
•
•
valproic acid (Depakote)
topiramate (Topamax)
lamotrigine (Lamictal)
naproxen (Naprosyn)
nortriptyline (Pamelor)
amitriptyline (Elavil)
Mg gluconate or oxide
+/- feverfew
Secondary Headache
Suggestive Headache Features
• first, worst, persistent, or different
• onset after:
– Valsalva’s maneuver
– head trauma
– age 50
• exacerbation with head position
Secondary Headache
Suggestive Associated Features
• focal neurologic signs or
symptoms
• change in consciousness
• fever
• seizure
• nuchal rigidity
• papilledema
• (pre)retinal hemorrhages
• history of:
– bleeding diathesis
– hypercoagulable
state
– cancer
– HIV or AIDS risk
factors
• daily or near-daily
use of analgesics
Secondary Headache
Giant-Cell (Temporal) Arteritis
• HA onset after age 50
• Incidence s w/ age
• Associated sxs & signs:
– temporal tenderness
– jaw claudication
– polymyalgia rheumatica
(neck/shoulder/hip pain)
– fever, night sweats
– weight loss
– monocular visual loss
(arteritic AION)
– MI or stroke (esp. PCA
territory)
– anemia,  ESR & CRP
• Management:
– draw ESR & CRP
– if no visual sxs, start:
• prednisone 80 mg qd
– if visual sxs, start:
• IV methylprednisolone 1
g qd x 5 d, then
prednisone 80 mg qd
– arrange temporal artery
biopsy (ophthalmologist
or neurosurgeon) within 2
weeks of starting steroids
– attempt to taper
prednisone to off only
after sxs resolve
Secondary Headache
Analgesic Rebound
• most common cause of daily chronic HA
• relationship to migraine:
– more common in migraineurs
– renders migraine therapies ineffective
• caused by:
– excessive analgesic use (> 2 d/wk)
– any analgesic (over-the-counter to narcotic)
• treatment:
– withdraw analgesic, begin migraine prophylactic
– sedate (e.g., w/ Vistaril) for 3-5 d (d pain 3d-4wk)
Secondary Headache
Diagnostic Testing
•
•
•
•
•
•
brain CT scan (w/ & w/o contrast)
brain MRI (w/ & w/o contrast) and MRV
lumbar puncture
cerebral angiogram
sed rate (ESR), C-reactive protein (CRP)
other labs (CBC, chemistries, etc.)
Secondary Headache
Emergency Management
First Consideration
Surgical Therapy
• subdural hematoma
• brain tumor
• brain abscess
• ICH
• SAH
• AVM
• hydrocephalus
First Consideration
Medical Therapy
• meningitis
• cerebral vein
thrombosis
• giant-cell arteritis
• systemic illness
The End
Department of Neurology
University of Miami School of Medicine