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HEADACHES
CHRONIC HEADACHE
Determining Its quality,severity
,location,duration,and time course
as well as the conditions that
produce
,exacerbate or relieve it
Ausculation-Palpation
Quality of cephalic pain in most
patients is dull (not sharp localize)
Throbbing D.D
Waxing&Waning
The most Intense headaches :
SAH-Meningitis—Migraine-ClusterTic doulourex
LOCATION OF HEADACHE
Supratentorial SOL:Frontotemporal
Infratentorial SOL:Occipitonuchal
Ear pain :Referal
Vertex or Biparietal :Sphenoid or
ethmoid sinus disease or thrombosis of
SSS
MODE OF ONSET &DURATION
SAH:Abrup
Meningitis:Hours or days
Ophthalmodynia :A few seconds
Ice pick headache:Seconds
Classic migraine:early morning
Cluster:Nightly
SOL: Any time of day or night
IICP :Worse in morning
Tension headache :Persists for weeks
RELATION OF HEADACHE TO
CERTAIN BIOLOGIC EVENTS
Premenstural headache:Tension or
,
Migraine
Cervical spine disease:First movement
of the neck is painful
Eye strain headache
Alcohol-Exercise-Straining-Coughing-
MIGRAINE
CLINICAL FEATURES
90% <40 YEARS OLD
F >M
90% Familial History Positive
20% of Women
6% Men
MIGRAINE WITHOUT AURA
Prodormal Phase:
May awaken the subjects
May be unilateral
Lower half headache
Prefer dark &quiet room
Photophobia&phonophobia&osmopho
Nausea-vomiting(delayed)-diarrhea
Anorexia> Nausea
Blurred vision-LightheadednessEpistaxis-subconjunctival hemorrhage
Fever-PAT (rarely)
Peak of pain :30min to several hours
Frequency&severity is extremly variabl
Status migrainosus = Hospitalization
Chronic daily headache=Attack at less
than weekly
MIGRAIN WITH AURA
Aura=Transient
visual,sensory,motor,or language
disturbance
Headache is identical to common M
prodormal symptoms may be accured
Visual aura(most common) teichopsia
Homonymous field (white or colored)
Positive scotoma then negative scoto
Metamorphopsia
Photopsia--- Retinal migraine
Contralateral headache
Sensory aura(second most common)
Paresthesias(positive)numbness(neg)
Variable distibution 20-30min
DD:TIA-seizure
Language aura:dysphasia or aphasia
Alexia-agraphia-mild confusion
Weakness of the limbs or facial
Transient abdominal symptomsdisturbed mentation-dejavu
MIGRAINE AURA WITHOUT
HEADACHE
TREATMENT & MANAGEMENT
Reassurance-lack of cure
Normal CT or MRI
Avoidance of trigger factors(caffeinesmoking-alcohol-reserpine-OCPnifedipine-theophilline-estrogens)
Avoidance of fasting & insomnia
& tyramin
PHARMACOTHERAPY
Triptans : mechanisms : 5 HT1 B
agonists
5 HT1 D agonists have
beneficial effect on migraine
associated
symptoms
side effects :
Tingling
Flash sensations
Heaviness or pressure in neck or
chest
Contrandications : IHD , HTN , using ergo ,
peripheral vascular disease ,pregnancy ,
lactation , hemiplegic migraine,
Well tolerated : naratriptan almotriptan ,
Triptan +NSAIDS
Triptan + metoclopramide
Ergots : vasoconstrictors and vasodilators
5 –HT receptors agonists
oral –rectal –parenteral
dose : 2mg + caffeine repeat : after 1 hour
1-2 mg rectally+analgesic orally
10mg metoclopramide
Supp : chlorpromazine 25-100 mg or
prochlorperazine 25mg or supp :
acetaminophen
Caution in : HTN , peripheral vascular
disease
Contraindicated : IHD , pregnancy ,
prolonged aura
Subcutaneous and Intranasal Serotonin (5-HT) Agonists
HEADACHE RESPONSE (%)*
DRUG
DOSE
(mg)
1 HR
2HR
4HR
RECURRENCE OF HEADACHE(%)'
Di hydros rgo la mine
Subcutaneous
1
57
73
85
18
Intranasal
2
46
47-61
56-70
14
Subcutaneous
6
70
75
83
35-40
Intranasal
20
55
60
NA
35-40
5
55
70
78
25
Sumatriptan
Zolmitriptan
Intranasal
Oral Serotonin (5-HT) Agonists
HEADACHE RESPONSE (%)'
DOSE (mg)
1 HR
2HR
4 HR
RECURRENCE OF HEADACHE (%)
Almotriptan
12.5
35
57
NA
23
Eletriptan
20.0
20
49
NA
30
40.0
30
60
NA
22
Frovatriptan
2.5
NA
42
61
10-25
Naratriptan
1.0
19
42
51
17-38
25
21
48
67
5.0
30
60
NA
10-0
37
67-77
NA
25
NA
52
68
50
NA
50
70
100
NA
56
75
2.5
38
64
75
5.0
44
66
77
DRUG
Rizatriptan
Sumatriptan
Zolrmitriptan
30-35
35-40
31
Serotonin (5-HT) Agonists Used in Acute Migraine Treatment
MAY REPEAT
DOSES
MAXIMUM
DOSE
DRUG
ROUTE(S)
DOSE
IF HEADACHE
RECURS
PER 24 HR
Dihydroergotamine
IV
0.5, 1.0 mg
1 hr
3mg
(DHE-45)
IM
0.5, 1.0mg
1 hr
3mg
sc
0.5, I.Omg
1 hr
3mg
(Migranal)
Nasal spray
2mg
(0.5mg/spray
)one spray in
3mg
each nostril, repeal in
15 min
Almotriptan (Axert)
Oral
12.5mg
2hr
25 mg
Eletriptan
(Replax)
Frovatrrptan
(Frova)
Naratriptan
(Amerge)
Rizatriptan
(Maxalt)
Oral
Oral
2.5mg
1 mg, 2.5mg*
Oral
Oral
Oral
Sumatriptan
(Imitrex)
Zolmitriplan
(Zomig)
20, 40 mg
5mg, lOmg'
25mg, 50mg,
100mg
2hr
80mg
2hr
7.5 mg
4 hr
5mg
2hr
30 mg
2hr
300 mg
2hr
12mg
SC
6mg
Intranasal
5 mg, 20 mg*
Oral
2.5mg*, 5mg
2hr
Intranasal
5mg
2hr
40 mg
10 mg
10mg
Nonhormonal Prophylaxis for Menstrual Migraine
CYCLIC (PERIMENSTURAL) DAYS -3THROUGH +3
Nonsteroidal anti-inflammatory drugs
Naproxen sodium 550 mg bid
Mefenamic acid 250 mg tid
Ketoprofen 75mg tid Triptans and ergots
Sumatriptan 25mg tid
Naratriptan 1.0 mg tid or 2.5 mg bid
Frovatriptan 2.5 mg once daily
Zolmitriptan 2.5mg bid
Ergotamine tartrate + caffeine (Wigraine) 1 mg qhs or
bid
Dihydroergotamine 0.5-1.0mg (SC, IM, or intranasal)
bid
NONCYCLIC (THROUGHOUT CYCLE)
Tricyclic antidepressants
Nortriptyline or amitriptyline 10-150 mg qhs
Beta-blocker
Propranolol or nadotlol 40-240 mg daily
Calcium-channel blocker
Verapamil 240-480mg daily Anticonvulsant
Divalproex 250-500 mg bid
Topamax 75mgqhs to 100mg bid Dopamine
agonists
Bromocriptine2.5-5.0mg tid Other
Magnesium 360-600mg daily
PROPHYLACTIC TREATMENT
Beta blockers :Propranolol 80240mg/d for 2-3months
side effects (lethargy –depression
-hypotension-bradycardia impotence-insomnia-nightmare)Group* C
Timolol - Nadolol- AtenololMotoprolol
Antidepressants :
Amitriptyline :
effect :blockade of noradrenaline uptake
inhibition of serotonin re uptake
unknown
Side effects : morning drowsiness ,
dryness of the mouth , weight gain,
tachycardia ,vertigo , constipation ,
B.M depression
Group :D
duration: 3months
Phenelzine (MAOI) :
drug interactions : sympathomimetics ,
anticholinergic , TCA ,
oppioids ( meperidine )
Side effects : HTN , hallucinations ,
retention of urine , agitation
Calcium channel blockers :
mechanism : unknown , vasoconstriction ,
prevention of platelet aggregation
,alteration in release and reuptake of
serotonin.
Verapamil : 80-160mg TDS ,effective in
classic migraine Side effects: vertigo
,constipation ,HF bradycardia ,V.F: half
life:2.8-4.7h form:tab:40-80mg FC
tab:240mg ing:5mg / 2mg
metabolism :liver excretion :kidney
group :C ,
flunarizine? nimodipine? Diltiazem?
Anticonvulsants : mechanisms: unknown

Sodium channel inhibition, GABA
Na-valproate :dose: 500-1750mg/d
Side effects: sedation , dizziness, appetite,
LFT, hair loss, BT,
Group :D Form :tab 200-500mg 
syrup 200mg /5cc HL :6-16 h 
Gabapentin : relative well tolerated

side effects : dizziness ,sedation ,depression
, ataxia , fatigue , leukopenia
dose:900-2400mg/d
cap: 100- 300-400
mg HL:5-7h contraindication <12 years
group:C
Topiramate : mechanisms : Ca channel blocker ,
GABA
Dose : 15-25 mg/d
75-200 mg/d Form:
tab : 25-50-100-200 mg
Side effects : sedation cognitive problems ,
paresthesia , weight loss, ataxia ,
depression
Group :C
HL : 21h excretion: kidney



Serotonergic agents : 
1)methysergide 
Side effects: retroperitoneal fibrosis
1/1000 pulmonary and heart valve
fibrosis ,nausea, leg pain, abdominal
cramp ,agitation, hallucination
6 months after 4 weeks stop restart U/A
+ Cr . CT or MRI of abdomen ,CXR
Dose: 2mg /d 7-10 days 6-8mg/d
2) Cyproheptadine : antibradykinin,
antiplatelet aggregation, serotonin
antagonist ,minor role in adults
Side effects: weight gain drowsiness
group: B tab: 4mg
breast feeding contraiadicoted

Riboflavin dose: 400mg/d
Group :A
Mg supplementation : dose : 600 mg/d
Side effects : diarrhea, DTR ,
hypotension , cardiac block ,
respiratory paralysis .
Contraindication : heart block
vial : 10-20 -50 %
Group : D
HL : 0.5 -4 h
Aspirin : 325 mg
NSAIDS : 

Botulinum : release of proinflammatory
and vasodilating neuropeptide block
glutamate
of
Dose : 100 units beginning of effect after 710 days persists to 3 months
Imipramine-Desipramine-Nortriptyline

Fluoxetine&Sertraline ?

STATUS MIGRAINOSUS
Fluid replecement-Correction of
electrolyte imbalance-- Suppression
of vomiting
DHE&Antiemetics TID
Dexamethasone or Prednisolone
20 mg QID --- taper 2-3 days
Tention Type Headache The most
common almost always mild-rare
CCTH
Criteria for diagnosis : lasts from 30
min to a week and has 2 or more
fallowing 1)bilateral 2)pressure
nonpulsatile3)mild to moderate
4)not aggravated by routin activity
TTH unassociated with nausea and vomiting
can have photophobia or phonophobia but not
both—tension and stress are associated
Treatment : NSAIDS- butalbital +analgesics
Preventive therapy: TCA-mirtazapine-topiramatevenlafaxine-tizanidine -botulinium toxin
SSRIs not effective
CLUSTER HEADACHE
Episodic type:1-3 attack of periorbital pain
each day for 4-8 weeks- pain free interval
one year
Chronic form :attacks are similar
there are no sustained remission
M/F=8/1 no hereditary prevalence =69/100000
Age= 20-50y
Clinical features : periorbital( temporal or
maxillary) pain without warning reach
crescendo 5min-sever and deep-nonflactuating
rarely pulsatile-strictly unilateral usually same
side-lasts 30 min to 2 hours-homolateral
lacrimation,red eye, nasal stuffiness and ptosis
nausea is uncommon-alcohol provokes attack
in 70% on-off vulnerability to alcohol is
pathognomonic
Treatment :the most satisfactory treatment is
prevention”
lithium 600-900 mg/d particulary chronic form
prednisone 10days ;beginning 60 mg daily for
7days and rapidly tapering
melatonin9 mg HS occasionally
ergotamine 1mg is most effective when given
1-2hours before a single nocturnal attack
……..Treatment:
occipital nerve stimulation-hypothalamic S
Treatment of attack : oxygen inhalation
10 lit/min for 15 min – intranasal lidocaine
4%topical or 2%viscous-sumatriptan 6mg
shorten attack 10-15 min