Download HEADACHE for INTERNAL MEDICINE

HEADACHE for FAMILY
MEDICINE
Christopher S Calder MD PhD
Interim Chair Neurology
Associate Professor UNM Neurology
Conflicts of Interest
• I have headaches, literal and figuratively!
• I have be an investigator in many clinical trials
in the past.
• Otherwise no conflicts
OBJECTIVES
• Recognize and treat common headache
syndromes
• Understand basic headache pathophysiology
• Gain a knowledge of practical headache
management
Headache categories
• Primary HA (migraine, tension, others)
• Secondary HA (SAH, mass lesions, pressure
syndromes, sinus thrombosis)
TABLE 6
Red Flags for Secondary
Headache Disorders.
Tension-Type Headache.
Kaniecki, Robert
CONTINUUM: Lifelong Learning in Neurology. 18(4,
Headache):823-834, August 2012.
DOI: 10.1212/01.CON.0000418645.32032.32
TABLE 6 -2 Red Flags for Secondary Headache Disorders
© 2012 American Academy of Neurology. Published by LWW_American Academy of Neurology.
2
HEADACHES of MASS LESIONS
Brain abscess – fever in <50%
- focal HA
- seizures
- impaired sensorium
Subdural hematoma 80% have HA and also sensorium altered
Brain Tumor HA more common if prior 1 HA, but only 1% have HA as
sole manifestation. Inc w Valsalva; awaken from sleep
Only 5% of structural lesions have HA and none of these were sole
concern
TABLE 1
Migraine Diagnosis and Pathophysiology.
Ward, Thomas; MD, FAAN
CONTINUUM: Lifelong Learning in Neurology. 18(4,
Headache):753-763, August 2012.
DOI: 10.1212/01.CON.0000418640.07405.31
TABLE 1 -1 Migraine Without Auraa
© 2012 American Academy of Neurology. Published by LWW_American Academy of Neurology.
2
TABLE 1
Migraine Diagnosis and Pathophysiology.
Ward, Thomas; MD, FAAN
CONTINUUM: Lifelong Learning in Neurology. 18(4,
Headache):753-763, August 2012.
DOI: 10.1212/01.CON.0000418640.07405.31
TABLE 1 -2 Typical Aura With Migraine Headachea
© 2012 American Academy of Neurology. Published by LWW_American Academy of Neurology.
2
TABLE 6
Tension-Type Headache.
Kaniecki, Robert
CONTINUUM: Lifelong Learning in Neurology. 18(4,
Headache):823-834, August 2012.
DOI: 10.1212/01.CON.0000418645.32032.32
TABLE 6 -1 International Classification of Headache
Disorders, Second Edition Diagnostic Criteria for TensionType Headachea
© 2012 American Academy of Neurology. Published by LWW_American Academy of Neurology.
2
A 41-year-old woman began having
migraine attacks at the age of 14, shortly
after her menarche. Triggers for these
attacks included her menses, ovulation,
and delaying a meal. One or two days
before her attacks she would feel fatigued
and yawn excessively. Before some of her
more severe episodes she would
experience an enlarging visual scotoma
with a shimmering edge lasting for 20 to 30
minutes, followed by a unilateral pounding
headache with nausea and sometimes
vomiting. If she was unsuccessful in
treating the attack, it might last 2 to 3 days
and she would have to lie in a dark, quiet
room. She has learned that treating as
soon as possible during a migraine offers
her the best chance of success. Her
mother had similar attacks as does one of
her two daughters. When her
obstetrician/gynecologist prescribed an
estrogen-containing oral contraceptive she
experienced an increase in the frequency
and severity of her migraine attacks
leading her to stop the medication.
Comment. This patient had the onset of
headaches near the time of her menarche.
Estrogen is known to stimulate nitric oxide
synthase, which results in higher nitric
oxide levels. She had other triggers
besides her menses and was aware of
them. She also had a prodrome of yawning
(a hypothalamic phenomenon that cannot
be ascribed to a vascular etiology, but
rather is dopaminergic). Sometimes she
would manifest a visual aura, presumably
due to cortical spreading depression
traveling across her occipital cortex. Her
attacks met ICHD-II criteria for migraine
with and without aura. She had learned
she would get a better result if she treated
early (before central sensitization could
occur). As is the case for many women,
additional estrogen given as an oral
contraceptive worsened her headache
tendency; this also often occurs with
hormone replacement therapy.
As with many other medical conditions,
headaches are more common in patients
with brain tumors if they have a preexisting
primary headache disorder. In 30% of
cases involving brain tumor, headache is a
major concern, but only 1% of these
individuals have headache as the sole
clinical manifestation of the tumor. In one
study, 5% of those presenting with a brain
tumor or another structural neurosurgical
disorder presented with headache, and
none had headache as the sole concern.1
Individuals with primary headache
syndromes commonly experience a
change in the preexisting headache, with
an increase in frequency, severity, and
duration of symptoms. Headaches
associated with a brain tumor usually
increase upon Valsalva maneuver and
exertion (although this also occurs
frequently with migraine). Headaches
associated with brain tumors may awaken
the individual from sleep, but this is also
IDIOPATHIC INTRACRANIAL
HYPERTENSION
• Same as brain tumor HA
• Imaging normal, may show empty
sella/flattening of globes etc
• LP pressure elevated.
• Rx with acetazolamide/weight loss etc.
• LP shunt
• Can lead to visual loss
OTHER HA DISORDERS
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Temporal arteritis
Chronic meningitis
Cluster
Ice pick
Hemicrania continua
Orthostatic HA (LP< POTS)
Exertional HA –cough/coital/cardiac
Sinus thrombosis/dissection
Posttraumatic
Sinus (don’t upset me…)
Pituitary apoplexy
Headache Management
• Headache (HA) affects 15 to 20% of women
and 5 to 10% of men.
• Migraine treatment falls into 3 categories:
PREVENTIVE; ABORTIVE; and SYMPTOMATIC.
• Preventive therapy should be offered to patients
that have a headache once a week or more. “Low
and slow” is the preferred method of starting all
these medications. It often takes 1 to 2 months to
see an effect. The effect being aimed for is a 50%
reduction in HA frequency and/or severity. Since
complete relief is not always a realistic goal, abortive
and symptomatic medications should also be made
available.
• The medications that enjoy the best statistical
support for efficacy are tricyclics, topiramate,
beta-blockers, and valproate. There is also
some evidence for Vitamin B2 and, to a
lesser extent, magnesium. The evidence for
verapamil and gabapentin is relatively poor.
We generally try to treat with medications that
may address co-morbidities. Valproate
should be avoided in women of childbearing
age as there is a high risk of spinal
dysraphism.
• Abortive treatments consist of the triptans and
DHE. The method and timing of delivery needs to
be very carefully considered (early for triptans,
parenteral if nausea/vomiting). DHE allegedly
works at any point in the course of the HA. They
may be more effective if taken with
metoclopramide and/or a NSAID. Triptans and
DHE are CONTRAINDICATED in patients with
CAD, history of CVA/TIA, PVD, or if there are
substantial risk factors for the same. Triptans and
ergotamines are also contraindicated in some
migraine types such as hemiplegic or basilar
migraine.
• Symptomatic agents include OTC analgesics,
caffeine, butalbital combinations, Compazine, etc.
• It must be remembered that frequent use of any of
the abortive and symptomatic agents can be
responsible for causing drug rebound headache
syndromes (DRHA). Even 6 Tylenol a week has
been reported to cause DRHA. Opiates cause
headaches to become more frequent and to more
rapidly develop allodynia. If a patient has daily or
near daily HA, a very careful inquiry into OTC
medication use and caffeine consumption must be
made.
• One of the most common referrals we
receive is for CDHA. The treatment of this
condition is detoxification (usually a slow
taper of medication).
• Early and aggressive prophylactic
treatment of HA is very important in terms
of decreasing the morbidity of this
disorder.
• Botox
Upcoming/New treatments
• CGRP: infusion of this precipitates a
migraine attack
• CGRP antagonists
• CGRP monoclonal antibodies
• TMS
• Cefaly Headband
• Local anesthetic - sphenopalatine
Indications for Behavioral and Physical Treatments
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•
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(a) patient preference for nonpharmacological interventions;
(b) poor tolerance for specific pharmacological treatments;
(c) medical contraindications for specific pharmacological treatments;
(d) insufficient or no response to pharmacological treatment;
(e) pregnancy, planned pregnancy, or nursing;
(f) history of long-term, frequent, or excessive use of analgesic or acute medications that can
aggravate headache problems (or lead to decreased responsiveness to other
pharmacotherapies);
•
g) significant stress or deficient stress-coping skills
.
Behavioral and Physical Treatment Goals
• reduced frequency and severity of headache,
• reduced headache-related disability,
• reduced reliance on poorly tolerated or unwanted
pharmacotherapies,
• enhanced personal control of migraine,
• reduced headache-related distress and psychological symptoms.
Behavioral Treatments
• Relaxation training, biofeedback training, cognitive-behavioral (or
stress-management) therapy, hypnosis, and various combinations of
these interventions.
• control muscle tension and those that teach patients to use mental
relaxation and/or visual imagery
• standard thermal (hand-warming) and electromyographic (EMG)
biofeedback training.
• psychotherapeutic intervention that had as its primary goal to teach
skills for identifying and controlling stress and minimizing the effects
of stress.
Results of Behavioral Training
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Relaxation training 32% reduction
Hypnotherapy effective vs prochlorperazine
Thermal biofeedback 37% improvement
Thermal biofeedback plus relaxation 33% reduciton
EMG biofeedback therapy 40%
Cognitive-behavioral training and thermal biofeedback 38%
Physical Treatments
• Acupuncture: no clear data to support this
• TENS: little support
• Occlusal adjustment: not superior to sham
• Cervical manipulation: little support for chronic headache; improved
frequency severity and disability but not duration
Other Non-pharmacologic Treatments
• Hyperbaric O2 – very successful for acute migraine
Headache Questionnaire
How long have you had headaches?
2. How often do your headaches occur?
_____Daily____Weekly_____Days a week______Days a month
3. How long do your headaches usually last?
4. How long does it take from the onset of the headache (the first clear
warning that it is going to occur) to its maximum intensity?
5. Are there any triggers for your headaches such as foods (chocolate,
nuts, peanut butter, smells, tobacco smoke, red wine, MSG, cured
meats, Nutrasweet), activities (exercise or exertion), menstrual cycle,
lack of sleep, missed meals, heat or bright light?
6.Are your headaches:
A) Steady
B) Squeezing
C) Throbbing
D) Sharp E) Stabbing
7. Are your headaches in any specific area of your head?
A) One-sided B) Back of head C) Band Like
D) Behind the
eyes
E) Forehead
F) Other
8. Do you have any warning symptoms before your headache :
A) Flashing Lights
B) Numbness or weakness of part of the body?
C) Dizziness
D) Difficulty speaking
E) Visual loss
F) Other
9. Are there other symptoms that accompany your headaches?
A) Nausea or vomiting
B) Sensitivity to light
C) Sensitivity to
sound
D) Passing out
E) Loss of or blurring of vision
10.Do your headaches keep you awake?
_____Do your headaches wake you up?
_____Get worse with activity?
11. Does anything help your headache?
12. Does anyone else in your family have headaches? If so, Who?
13. Have you ever had a CT or MRI of your head? YES or NO
14. Have you ever taken any of these medications?
Now
Amitriptyline/Elavil
Nortriptyline/Pamelor
lnderal/Propanolol
Depakote
Verapamil/Cardizem
lmitrex/Maxalt/Zomig
Ergotamine
DHE-45/Migranal
Fioricet/Fiorinal/Butalbital
Sansert
Topamax
Amerge
Tylenol/Ibuprofen/Alieve
Ever
Any Help?
Side Effects
15. How often do you take Tylenol, aspirin, Excedrin or other over-thecounter preparations?
16. How much caffeinated coffee/tea/soda do you drink?
17. Describe your typical sleep habits.