Download Finkel Presentation - North American Brain Injury Society

Post Traumatic Headache
Alan G Finkel MD FAAN FAHS
Contractor supporting the Defense and Veteran
Brain Injury Center (DVBIC)
Womack Army Medical Center, Ft Bragg, NC
20SEP2013
Disclosures
• With regards to this talk the speaker has no financial conflicts to Disclose
• During the course of this talk I will mention off label use of medications
• THE ARE NO APPROVED DRUGS FOR CHRONIC POST TRAUMATIC HEADACHE
•
Other Affiliations
–
–
–
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President and CEO, The Carolina Headache Foundation, Chapel Hill , NC
Chair, PTH Section, American Headache Society
Director, Carolina Headache Institute , Chapel Hill, NC
Professor, University of North Carolina
•
The views, opinions and/or findings contained in this report are those of the author(s) and
should not be construed as an official Department of Defense or Veterans Affairs position,
policy or decision unless so designated by other documentation.
•
This research was funded by the Department of Defense, U.S. Army, Defense and Veterans
Brain Injury Center, in part through a contract with The Henry M. Jackson Foundation for the
Advancement of Military Medicine, Inc.
•
In the conduct of research where humans are the subjects, the investigator(s) adhered to the
policies regarding the protection of human subjects as prescribed by Code of Federal
Regulations (CFR) Title 45, Volume 1, Part 46; Title 32, Chapter 1, Part 219; and Title 21,
Chapter 1, Part 50 (Protection of Human Subjects).
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http://www.afhsc.mil/viewMSMR?file=2012/v19_n05.
pdf#Page=17
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Finkel AG, Headache 2010; 50: 1259 - 1261.
4
Growing Interest
Source: PubMed accessed 08122013
5
Traumatic Brain Injury (TBI)
6
The Surge?
# of Publications
70
60
50
40
30
# o f Publications
20
10
0
Source: PubMed accessed 08122013
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5. Headache attributed to head and/or
neck trauma
5.1 Acute post-traumatic headache
5.2 Chronic post-traumatic headache
5.3 Acute headache attributed to whiplash injury
5.4 Chronic headache attributed to whiplash injury
5.5 Headache attributed to traumatic intracranial
haematoma
5.6 Headache attributed to other head and/or neck
trauma
5.7 Post-craniotomy headache
©International Headache Society 2003/5
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5.2.2 Chronic post-traumatic headache
attributed to mild head injury
A. Headache, no typical characteristics known, fulfilling
criteria C and D
B. Head trauma with all the following:
1. either no loss of consciousness, or loss of
consciousness of <30 minutes’ duration
2. Glasgow Coma Scale (GCS) >13
3. symptoms and/or signs diagnostic of concussion
C. Headache develops within 7 days after head trauma
D. Headache persists for >3 months after head trauma
©International Headache Society 2003/5
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Primary or secondary headache?
Primary:
• no other causative disorder
©International Headache Society 2003/5
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Primary or secondary headache?
Secondary (i.e., caused by another disorder):
• new headache occurring in close temporal relation to
another disorder that is a known cause of headache
• Worsening of a pre-existing headache disorder
©International Headache Society 2003/5
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IS POST-TRAUMATIC HEADACHE (PTH)
DIFFERENT?
• Case control (n = 46)
• MVC: 52%; mild: 88%
PTH
CTT
M w/o A
Other
PCS
75%
21%
4%
48%
“natural”
population “40%”
57%
<12%
(cluster
<1%
• No cases of migraine with aura or cluster
• “Criteria” met by both groups
Haas, DC, Chronic post-traumatic headaches classified and compared with natural headaches,
Cephalalgia 1996; 16: 486 - 93
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Natural History of PTH
• Walker study (n=109) with moderate or
severe TBI at VA rehabilitation facilities;
mostly car accidents
Source: Walker 2005, Headache after moderate and severe TBI: A longitudinal analysis
13
Natural History of PTH
Acute: 38%
6 months: 36% (16% delayed)
Source: Figure 1 from Walker 2005
12 months: 35% (16% delayed)
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Natural History after Mod-Sev TBI
Hoffman JM, Lucas S, Dikmen S, Braden CA, Brown AW, Brunner R, Diaz-Arrastia R,
Walker WC, Watanabe TK, Bell KR. Natural history of headache after traumatic brain
injury. J Neurotrauma. 2011 Sep;28(9):1719-25.
15
What is the Diagnosis of Headache
after Head Injury?
16
What about mild TBI?
Lucas S, Hoffman JM, Bell KR, Dikmen S. A prospective study of prevalence
and characterization of headache following mild traumatic brain injury.
Cephalalgia. 2013 Aug 6
17
Risk Factor - AGE
Lucas S, et al. Cephalalgia. 2013 Aug 6
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Risk Factor - GENDER
Lucas S, et al. Cephalalgia. 2013 Aug 6
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Headache Diagnosis after Mild TBI
Lucas S, et al. Cephalalgia. 2013 Aug 6
20
Migraine With and Without Aura
• At least 2 attacks
• Lasts 4 – 72 hours
• Characteristics (2/4)
–
–
–
–
Unilateral
Throbbing
Moderate-severe intensity
Pain worsened by exertion (>95%)
• Associated symptoms (1/2)
– Nausea or vomiting
– Photophobia & phonophobia
ICHD Cephalalgia, Vol 24, Supp 1, 2004
21
Migraine Is:
• A “personal biology” with extremely high prevalence
– Associated with
•
•
•
•
Lower thresholds to light and sound
. Trigeminovascular activation
Dura Mater
C fiber Nociceptors
– Inflammation
•
•
•
•
CGRP
NKA
Substance P
Prostaglandins
• Termination by triptans
– 5HT 1B/D receptor agonists
– NSAIDs
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Migraine Is:
• A neurovascular disorder
– Cortical Spreading Depression leads to:
– Trigeminovascular activation
• Dura Mater
• C fiber Nociceptors
– Inflammation
•
•
•
•
CGRP
NKA
Substance P
Prostaglandins
• Termination by triptans
– 5HT 1B/D receptor agonists
– NSAIDs
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Headache in Civilian Population
• Migraine
– Males: 6%
– Females: 18%
– Proportion with aura: ~30%
• Chronic daily headache
– 3-4% of adult population
– 50% have chronic migraine
• ~0.5-1.0% with continuous headache
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Migraine Prevalence by Age and Sex
Rescaled
Women: Prevalence 18%
Men: Prevalence 6-7%
Source: Data analysis from study referenced in Stewart WF, Lipton RB, Liberman J. Variation in migraine
prevalence by race. Neurology 1996 Jul;47(1):52-59
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Prolonged TNC Stimulation May Lead
to Central Sensitization
• Over-stimulation of the TNC
• Repeated stimulations and activations may lead to
chronicification
• Chronic Migraine
– More than 15 days of headache (US = 8 or more migraine days)
– Affects 4% of the population
– Is the main type of headache seen in headache clinics
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GOALS OF PREVENTIVE TREATMENT
• Decrease attack frequency (by 50%), intensity
and duration
• Improve responsiveness to acute Rx
• Improve function and decrease disability
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WHEN TO USE PREVENTIVE MANAGEMENT
• Migraine significantly interferes with patient’s
daily routine, despite acute Rx
• Acute medications contraindicated,
ineffective, intolerable AEs or overused
• Frequent headache ( 2 attacks per week)
• Uncommon migraine conditions
• Patient preference
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PREVENTIVE MEDICATIONS:
DRUG CLASSES
First Line
• Anticonvulsants
– Topiramate
– Valproate
• Beta Blockers
– Metoprolol
– Propranolol
• Antidepressants
– Amitriptyline
• NSAIDs
– Naproxen
– Ibuprofen
Complimentary
• Herbal
– Petacites
• Minerals
– Magnesium
• Vitamin
– Riboflavin/B2
• Other
– CoQ10
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Special Populations
Youth and Adult Sports
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Do athletes get headaches?
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Sports and Headache
• General population = 1% (Rasmussen)
• Aerobic - cardio
• Type and extent of exercise
– Compression
• “swimmers’ goggle”
• “tight hat band”
– “weightlifters’ headache”
– trauma-triggered and post-traumatic
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Post-traumatic Headache
• 3.b. Headache arising from mechanisms that occur
during exertion - Trauma
– Not case controlled
– Resemble primary headache disorders
• “TTH is the most common”
– “footballers’ migraine”
– Cluster-like (case report)
– Worsening of a pre-existing primary headache
Kernick DP, Goadsby PJ; Royal College of General Practitioners; British Association for
the Study of Headache. Guidance for the management of headache in sport on behalf
of The Royal College of General Practitioners and The British Association for the Study
of Headache. Cephalalgia. 2011 Jan;31(1):106-11
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Differential and Evaluation
• Rule out secondary cause
– MRI
• Arnold-Chiari malformations
– Exertional – weight lifters
• SAH
• Arterial dissection
• Cardiac ischemia
– BP and ECG
– Blood screening including TSH and diabetes
• Consider: urinary catecholamines
Kernick DP, Goadsby PJ; Royal College of General Practitioners; British Association for the Study
of Headache. Guidance for the management of headache in sport on behalf of The Royal College
of General Practitioners and The British Association for the Study of Headache. Cephalalgia. 2011
Jan;31(1):106-11
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Treatment - Acute
McCrory P, Heywood J, Ugoni A. Open label study of intranasal sumatriptan
(Imigran) for footballer's headache. Br J Sports Med. 2005 Aug;39(8):552-4
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Treatment - preventive
• “no evidence base”
• Amitriptyline: Tyler GS, McNeely HE, Dick ML. Treatment of post-traumatic
headache with amitriptyline. Headache. 1980 Jul;20(4):213-6
–
–
–
–
–
N = 23
Age (mean) = 35.2
Time from injury = 29 weeks (3 – 77)
Injury type: Recreational (1); non-vehicular (2); vehicular (20)
13 /23 – excellent response
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Youth sports
• Is Universal
– 38 million
• Not including playground
– Risk factors
• Competition
– Male: Football
– Female: Soccer
• Female
• Prior concussion
– High school injuries
• > 90% report headache immediately after concussion
– most symptoms resolve within a week (83%).
•
1.5% symptoms > 1 month
• Professional level
– no specific reports
• ? symptomatic
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Headache prevalence after mild
and moderate-severe TBI
Blume HK, Vavilala MS, Jaffe KM, Koepsell TD, Wang J, Temkin N, Durbin D,
Dorsch A, Rivara FP. Headache after pediatric traumatic brain injury: a cohort
study. Pediatrics. 2012 Jan;129(1):e31-9
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Does Age or Gender Determine
Headache After TBI?
Blume HK, Vavilala MS, Jaffe KM, Koepsell TD, Wang J, Temkin N, Durbin D, Dorsch
A, Rivara FP. Headache after pediatric traumatic brain injury: a cohort study.
Pediatrics. 2012 Jan;129(1):e31-9
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Treatment of Youth Sports PTH
• Cognitive rest is controversial
• When is prescription medication indicated?
• Consensus recommendations
– Preventive
• Amitriptyline
• Topamax (duh?)
• Beta blockers
– Acute
•
•
•
•
Triptans are not as effective in adolescents and post-adolescents
NSAIDs
?Baclofen
Avoid opioids
• Behavioral changes should be addressed
– Biofeedback
40
http://www.cdc.gov/concussion/pdf/poster_Eng.pdf
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http://www.cdc.gov/concussion/pdf/poster_Eng.pdf
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Where are we now?
• Headache is a recognized sequelae of youth
sports concussion
– RTP guidelines are not specific if headache is the
only remaining symptom
• Is persistent headache:
– a cardinal sign?
– a predictive variable?
– a reason to remain out of play?
– a (new onset) PRIMARY headache?
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Special Populations
Military
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Medical Encounters for Migraine Active Duty Population
Source: Medical Surveillance Monthly Report (MSMR) Vol 19 No. 2 Feb 2012
45
46
Hoge et al, Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq. N Engl J
Med 2008;358:453-63.
47
Hoge et al, Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq. N Engl J
Med 2008;358:453-63.
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Post-Deployment Headache
• Headache / migraine is common during or
following deployment
• Complicates the interpretation of posttraumatic headache data in military
populations
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Headache in recently deployed
soldiers (all)
Source: Theeler et al, Prevalence and Impact of Migraine Among U.S. Army Soldiers deployed in support of
Operation Iraqi Freedom, Headache 2008; n=2726
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Headache Type
Source: Scher et al, Headache Disorders in Recently Deployed Soldiers With and Without
Traumatic Brain Injury, AAN Annual Meeting April 2010
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Frequency
Source: Scher et al (Finkel), Headache Disorders in Recently Deployed Soldiers With and Without
Traumatic Brain Injury, AAN Annual Meeting April 2010
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What Kind of Headaches Do
Soldiers Have After Mild TBI?
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Headache Characteristics per SM
All
Blast
Non-blast
# of Headaches (mean, range) 2.2 (1 – 3)
2.4 (2 – 3) 2 (1 – 3)
Continuous headache (n, %)
13 (92.9) 9 (81.8)
22 (88)
Finkel et al, Headache 2010
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Headache Onset
Continuous (22/25) vs Episodic %)
Finkel et al, Headache 2010
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Density
Finkel et al, Headache 2010
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Density: Continuous vs Episodic
Finkel et al, Headache 2010
57
Primary Headache Diagnosis (per SM)
Headache Diagnosis (ICHD).
MIGRAINE (some had more than one migraine type)
Migraine with aura (1.2)
N
15
5
Chronic tension-type headache (2.3)
12
Chronic cluster headache (3.1.2)
3
Chronic paroxysmal hemicrania (3.3.2)
1
Chronic SUNA (A3.3.2)
1
Primary stabbing headache (4.1)
4
Hemicrania
(4.7) 2010
Finkel etcontinua
al, Headache
2
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Secondary Headache Diagnosis
Headache attributed to low cerebrospinal fluid pressure (7.2)
1
Headache attributed to disorder of the neck (11.2)
1
Headache attributed to craniocervical dystonia (11.2.3)
1
Headache or facial pain attribute to temporomandibular joint
1
(TMJ) disorder (11.7)
Headache attributed to other disorder of cranium, neck eye, ears, 1
nose, etc. (11.8)
Symptomatic trigeminal neuralgia (13.1.2)
2
Finkel et al, Headache 2010
Supraorbital neuralgia (13.6)
1
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Observations: Headaches
• Injuries were more than 2 years ago
• Patients can describe multiple headaches
• Headache onset can occur after one week
– Continuous Headaches all start in less than one week
• Headaches may be superficial (“outside”) and focal
• Continuous Headaches are
– Less severe
– More aching and more neck pain
– Can have migraine features
• Episodic Headaches
– May start after one week
– Can be diagnosed using primary classification
Finkel AG, Yerry J, Scher A, Choi YS. Headaches in soldiers with mild traumatic brain
injury: findings and phenomenologic descriptions. Headache. 2012 Jun;52(6):957-65
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TREATING PTH
Based upon Diagnosis (sic)
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Differential and Evaluation
• Primary Headache
• Secondary Headache
– MRI
• Intracranial Hypotension
• Chiari Malformation (?)
– Diffuser Tensor Imaging (DTI) - ?
– Sleep Study
– Neuro-optometry
– Cervicogenic
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Amitriptyline?
Patil VK, St Andre JR, Crisan E, Smith BM, Evans CT, Steiner ML, Pape TL.
Prevalence and treatment of headaches in veterans with mild traumatic brain injury.
Headache. 2011 Jul-Aug;51(7):1112-21
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A Valiant Attempt
Erickson JC. Treatment outcomes of chronic post-traumatic headaches after mild head trauma in
US soldiers: an observational study. Headache. 2011 Jun;51(6):932-44
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A Losing Battle?
Cohen SP, et al. Headaches during war: Analysis of presentation, treatment, and
factors associated with outcome. Cephalalgia. 2011 Oct 18
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A Novel Drug: Prazosin
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Pathophysiology and Treatment
A Modest Proposal
67
Outside or Inside: Does this explain why mTBI
results in persistent headache?
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Intracranial origin of extracranial pain
“In this scenario, action potentials generated intracranially at the leptomeningeal pain
fibers spread antidromically to collaterals that terminate outside the cranium,
resulting in activation of neighboring somatic nociceptors through local release of
proinflammatory neuropeptides in both the dura and the scalp.
This concept would be consistent with extracranial perivascular edema observed in
some patients undergoing amigraine attack (Graham and Wolff, 1938; Wolff et al.,
1953). This scenario may explain the perception of “imploding headache” (i.e.,
perception of pain on the outside of the skull; Jakubowski et al., 2006) in migraine
triggered by intracranial events, such as aura.
Finally, the presence of CGRP fibers in calvarial sutures, endosteum, and periosteum in
the present study may constitute a neural substrate for the perception of deformed,
crushed, or broken skull during migraine.” (my emphasis)
Kosaras B, Jakubowski M, Kainz V, Burstein R. Sensory innervation of the calvarial
bones of the mouse. J Comp Neurol. 2009 Jul 20;515(3):331-48
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Extracranial origin of intracranial pain
“In this scenario, action potentials generated at
extracranial collaterals of meningeal pain fibers spread
antidromically to collaterals that terminate inside the
cranium, resulting in local release of proinflammatory
neuropeptides and activation of neighboring meningeal
nociceptors. This scenario may explain the induction of
migraine headache by extracranial triggers, such as
tenderness of scalp muscles, or minor head trauma
affecting the periosteum.” (emphasis mine)
Kosaras B, Jakubowski M, Kainz V, Burstein R. Sensory innervation of the calvarial
bones of the mouse. J Comp Neurol. 2009 Jul 20;515(3):331-48
70
Central or Peripheral?
Jakubowski M, et al. Exploding vs. imploding headache in migraine prophylaxis
with Botulinum Toxin A. Pain. 2006 Dec 5;125(3):286-95
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Central or Peripheral?
• Patients randomized on basis of:
– Exploding: INSIDE OUT
• Feels like the head is too small for the brain
• A feeling of something trying to escape from inside the
head
– Imploding: OUTSIDE IN
• Like a vice
• Imploding description predicted a better outcome to
Onabotulinum Toxin A treatment for Chronic
Migraine
Jakubowski M, et al. Exploding vs. imploding headache in migraine prophylaxis
with Botulinum Toxin A. Pain. 2006 Dec 5;125(3):286-95
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Onabotulinum Toxin A (OBA) for the
Treatment of Chronic Post-Traumatic
Headache in Service Members with
a History of Mild Traumatic Brain
Injury
Yerry, Finkel, et al: Presented at the
International Headache Congress, JUN2013
Boston, MA
73
Demographics (n = 64)
Age
Gender (M:F)
Prior history of migraine (%)
31.3 + 7.5 (20 – 50)
ns
63 : 1
ns
7 (10.9)
p = 0.045*
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Conclusions for the Study
 Outcomes were not influenced by
 PTSD
 Headache Days per month
 Patients with non-continuous headache but daily headache
did better if a second continuous headache was no present
 Outcomes WERE influenced by




History of headache prior to injury (negative)
Number of treatments
Time between injury and first treatment with OBA
Continuous Headache
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TREATMENT
• The Bad News
– No completed treatment trials
– PTSD and other PCS
• Co-morbidity or concurrency
• The Good News
– Treating the primary phenomenology works (sometimes)
• Migraine type
– Formulary based including Chronic Migraine (?)Tension type
– Continuous headache?
• Focal or nummular types
• The outside and the inside
• The exploding and imploding
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Finally: What is it?
TBI vs PTSD
mTBI vs
MUS*
Headache
*MEDICALLY UNEXPLAINED (ABLE) SYMPTOMS
77
Conclusions
• Post Traumatic Headache is complex
– Different populations
– Primary and secondary headaches may coexist
• Classification remains a challenge
– Does the “boo-boo” matter?
• Migraine and Chronic Migraine are the most common types
– Will imaging show changes similar to non-traumatic migraine?
• The 7 Day Rule may require revision
– Do Headache Types “Mature”?
• Treatment is slowly improving
• Using drugs and treatments for Migraine and Chronic Migraine appear
to have some promise
78
Thank you for your attention
The views, opinions and/or findings contained in this report are those of
the author(s) and should not be construed as an official Department of
Defense or Veterans Affairs position, policy or decision unless so
designated by other documentation.
79