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Everything you wanted to know
about Headache but were afraid to
ask
SNOOPing around
Richard S. Sohn MD
Emeritus Professor of Neurology
Washington Universtity
Financial Disclosure,
Richard S. Sohn MD
Richard S Sohn MD has no potential or current
conflicts of interest.
Migraine is More Common than
Asthma & Diabetes Combined
Disease Prevalence in the US Population
12%
5%
6%
7%
1%
Rheumatoid
arthritis
Asthma
Diabetes
Osteoarthritis
Migraine
Data from the Centers for Disease Control and Prevention, US Census Bureau, and the Arthritis Foundation.
Patients Presenting to PCPs with Episodic
Headache Most Likely Have Migraine
n= 377 patients who returned diaries
3%
Episodic Tension
3%
Headache
Other
Migrainous
18%
Migraine
76%
Migraine/Migrainous is Common (94%);
Tension Headache is Rare
Newman et al. Poster presented at: The Diamond Headache Clinical Research and Educational Foundation Meeting;
July 16-20, 2002; Lake Buena Vista, Fla.
Goals
• Differentiate troublesome from dangerous
headaches
• Recognize common headache syndromes
• Effectively treat common headache
syndromes
User friendly IHS classification
• Divide 13 general headings into 2 major groups
• Primary headaches(benign headache disorders)
–
–
–
–
–
–
Migraine
Tension type
Cluster
Post traumatic
Medication overuse
Other benign headaches
• Secondary headaches(headaches caused by
another disease)
History and Physical
Red Flags
Migraine Diagnosis
YES
SNOOP
Diagnostic Tests
CT,MRI,LP,ESR
NO
Primary Headache Disorders



Migraine
Tension-Type Headache
Cluster Headache
Other Disorders

Silberstein SD et al. Wolff’s Headache and
Other Head Pain 2001:6-26
Secondary Headache Disorders
Worrisome Headache Red Flags
“SNOOP”
• Systemic symptoms (fever, weight loss) or
secondary risk factors (HIV, systemic cancer)
• Neurologic symptoms or abnormal signs
(confusion, impaired alertness or consciousness)
• Onset: sudden, abrupt, or split-second
• Older: new onset and progressive headache,
especially in middle-age > 50 (giant cell arteritis)
• Previous headache history: first headache or
different (change in attack frequency, severity or
clinical features)
Silberstein SD et al. Wolff’s Headache and Other Head Pain 2001:6-26
Some causes of secondary headache
•
•
•
•
•
•
Intracranial masses
Infection
Trauma
Hemorrhage
Inflammation
Meningeal infiltration
Headaches are not caused by
• Hypertension (except malignant )
• Allergy
• Refractive error
Studies
• If the headaches are chronic
• If the examinations are normal
• NO STUDIES ARE NEEDED
Patient Description
41-year-old female school teacher
Chief Complaint
Recurrent ‘sinus headaches’ that last 2 days
Character of Pain
Patient described pain as pressure sensation involving the maxillary sinus region;
no radiation of pain. Pain was moderate to severe ranging from 6-8 on a 1-10 scale.
Headaches would begin and end gradually
Frequency
1-2 times per month
Symptoms
Patient complained about nasal congestion and runny nose. Patient denied any
visual disturbances, fever, or joint pain. Upon probing, patient stated that she often
felt sick to her stomach during her headaches and her headaches intensified when
she bent over
Headache Triggers
Barometric pressure changes, cold, sleep disturbance
Medical History
Headaches began in late teens without known precipitant and have recurred monthly
since onset
Family History
Mother is also a long-standing ‘sinus headache’ sufferer
Physical Exam
Normal
Test Results
Normal sinus CT scan
Past Treatments
Sinus surgery with no change in her headaches. Also multiple courses of
antibiotics. Decongestants seem to relieve pain slightly
Migraine Is Often Overlooked
Sinus headache is the most common
misdiagnosis
Symptoms include
• Dull ache located near the
nose
• Pressure over the sinus
cavities
• Thick, colored nasal discharge
• OTCs can sometimes relieve
the pain
Headache:
A Minor Criteria in AAO-HNS Sinusitis
•
Headache is a minor factor in the diagnosis of
rhinosinusitis, according to AAO-HNS*
• Minor factors
Major factors
- Purulence in nasal cavity on exam
- Headache
- Facial pain/pressure/congestion †
- Fever (chronic)
- Nasal obstruction/blockage/
discharge
- Halitosis
- Fever (in acute only)
- Dental pain
- Hyposmia/anosmia
- Cough
- Fatigue
- Ear pain/pressure/fullness
* American Academy of Otolaryngology-Head and Neck Surgery, also adopted by the American College of
Allergy and Immunology Lanza et al. Otolaryngol Head Neck Surg 1997.117(pt 2): S1-S7
† Facial pain/pressure alone does not constitute a suggestive history for rhinosinusitis in the absence of
another major nasal symptom or sign.
Sinus Features of Headache May Hide
the Presence of Migraine
Symptoms at Screen in 2424 subjects with Migraine (IHS 1.1/1.2)
98%
Moderate/Severe Pain
89%
85%
84%
82%
Pulsing/Throbbing
Worsened by Activity
Sinus Pressure
Sinus Pain
73%
79%
67%
63%
57%
Nausea
Photophobia
Phonophobia
Nasal Congestion
Unilateral
40%
38%
Rhinorrhea
Watery Eyes
29%
27%
25%
Aura
Itchy Nose
Vomiting
0%
Migraine Symptoms
20%
40%
Sinus Symptoms
60%
80%
Adapted from Schreiber et al. Poster presented at: American Headache Society Meeting; June 21-23, 2002.
Seattle, Wash. Data on file, GlaxoSmithKline.
100%
Migraine Can Be Triggered by Weather
% of Migraine Patients with Triggers
Physical Exertion
45%
Skipping Meals
45%
Weather Changes
(n = 69)
46%
Changes in Sleep
52%
Strong Odors
55%
Menstruation
68%
Stress
72%
0%
10%
Scharff et al. Headache 1995; 35:397-403
20%
30%
40%
50%
60%
70%
80%
Because Pain Can Be Felt in All Regions of
the Trigeminal Nerve, a Diagnosis of
Sinus Headache is Often Given
Cranial Parasympathetic Nervous System
Extends into the Sinus Cavities
and Tear Ducts
Migraine Pain Can Be Bilateral and
Nonthrobbing
• 41% of migraine patients
had bilateral pain
• 50% of the time, pain
was nonthrobbing
Lipton et al. Headache. 2001;41:646-657.
Pryse-Phillips et al. Can Med Assoc J. 1997;156(9):1273-1287.
Migraine Is Often Overlooked
• Tension headache is another common
misdiagnosis
• Symptoms include
– Dull steady ache
– Physical activity does not worsen pain
– Nausea, photo/phonophobia
are not usually present
– Vomiting never present
– Patients have likely tried OTCs and failed
Cady et al. Headache Free. 1993;36-38.
Stress is the Most Frequently Reported
Trigger of Migraine
% of Migraine Patients with Triggers
80%
72%
68%
70%
60%
55%
52%
50%
46%
45%
45%
40%
30%
20%
10%
0%
Stress
Menstruation
n = 69
Scharff et al., Headache 1995; 35:397-403
Strong Odors
Changes in
Sleep
Weather
Changes
Skipping Meals
Physical
Exertion
Patients with Migraine by IHS Criteria
Have Symptoms Commonly Associated with
Tension Headache
100%
87%
% of patients
80%
60%
59%
57%
51%
37%
40%
20%
0%
n =412
Stiffness/ Tightness in
Neck /Shoulders
Occipital/Cervical
Pain
Tenderness in neck
muscles
Patient Report of
Tension or Stress
Adapted from Smith, et al. Poster presented at American Headache Society, June 21-23,
2002, Seattle, Wash.
Patients with one or
more TTH
characteristics
Percentage of Patients with Neck Pain
Neck Pain Can Occur in all Phases of Migraine
100%
75%
92%
61%
50%
41%
25%
0%
Prodrome
n=108
Headache
Postdrome
Phases of Migraine
Kaniecki et al. Poster presented at: 10th IHC; June 29-July 2, 2001; New York, NY.
In the Presence of Neck Pain
Tension Headache is Frequently Diagnosed
100%
82%
% of Patients
80%
60%
40%
20%
18%
0%
n=108
No
Yes
Previous Diagnosis of Tension Headache
Kaniecki et al. Poster presented at: 10th IHC; June 29-July 2, 2001; New York, NY.
Trigeminal Nucleus Caudalis Relays Pain
Signals to Higher-Order Neurons in
the Thalamus and Cortex
In Summary
Many facets of migraine
One Nerve Pathway, Multiple Symptoms,
Multiple Manifestations of Migraine
Nausea and Vomiting
• Nucleus and tractus solitarius are near by
Sinus and ETTH vs Migraine
“Sinus”
Tension
Migraine
Family history
No
No
Yes
Yes
Fever
Yes
No
No
No
Clear/None
Clear/None
Disabling
Colored
Colored
No
No
No
Yes
Yes
Menstrual
association
No
No
No
Yes
Yes
Nasal discharge
Migraine is usually
•
•
•
•
•
Moderate to severe
Unilateral
Throbbing
2 to 4 hours
Associated symptoms
– Nausea and vomiting
– Sensory hypersensitivity
Phases of a Migraine Attack
Pre-HA
Headache
Mild
Premonitory/
Prodrome
Aura
Moderate
to Severe
Headache
Time
Early Intervention
Post-HA
Postdrome
Acute Treatment, Patient Desires
90%
85%
80%
75%
70%
65%
60%
Complete
No
Pain Relief Recurrence
Rapid
Onset
No Side
Effects
Relief of
Associated
Symptoms
Principals of acute treatment
• Treat early
• Appropriate drug,dose, formulation
• Migraine specific agents
– Temporarily disabling headache(stratified care)
– No response to general agents
• Non-oral in patients with vomiting
• Offer rescue medication
• Guard against medication overuse
Pain-free Results with Sumatriptan
SUM40274/275
% of Patients Pain-free
Treating when pain was mild
70%
57%
60%
50%
*
50%
40%
30%
27%
*
20%
22%
10%
14%
0%
*
61%
*
68%
†
*
30%
29%
Placebo
Sumatriptan 50 mg
Sumatriptan 100 mg
0
Baseline
1 hour
2 hours
4 hours
Individual results may vary. If pain returns, a second dose may be taken after 2 hours.
*P< 0.001 vs placebo
†P<0.05 vs placebo
Winner et al. Platform Presented at: American Headache Society Meeting; June 21-23, 2002; Seattle, Wash.
Data on file, GlaxoSmithKline.
Benefits of early treatment
•
•
•
•
•
Early pain free response
Less recurrence
Prevents progression of the attack
Limits disability
Less need for multiple doses of medication
and rescue medication
• May prevent progression to chronic daily
headache
The eternal optimist, Migraine
Patients
• Its not really a migraine
• It will go away by itself
• My old medicine will work just fine
The eternal optimist, Migraine
Patients
• Its not really a migraine WRONG
• It will go away by itself WRONG
• My old medicine will work just fine
WRONG
Common triptan side effects
•
•
•
•
•
•
Tingling
Warmth
Flushing
Chest discomfort
Sleepiness
Dizziness
Triptan contraindications
• Hemiplegic or basilar migraine
• Uncontrolled hypertension
• Use of MAOi’s except
naratriptan,eletriptan,frovatripran and almotriptan
• Use within 24 hours of an ergot or other triptan
• Pregnancy category C
• Coronary disease and peripheral artery disease
suspected or confirmed
Indications for preventive
treatment
• Migraine significantly interferes with daily routine
despite acute treatment
• More than 3 headaches a month, or 2 a week
• Acute treatments fail, are contraindicated, or
produce unacceptable side effects
• Patient preference
• Hemiplegic or basilar migraine
• Migraine with prolonged aura
Nonpharmacologic strategies
•
•
•
•
•
•
Regular sleep and meals
Regular exercise
Hydration
Decaffination
Elimination of triggers
Supported by class A studies
– Relaxation training with or without thermal
biofeedback
– EMG biofeedback
– Cognitive behavioral therapy
Migraine preventive drugs
• Beta blockers
– propranolol*, timolol*, atenolol,metoprolol,nadolol
• Calcium channel blockers
– verapamil, flunarizine (not inUS) diltiazem
• Antidepressants
– amitriptyline, desipramine,nortriptyline, MAOi’s
• Antiepileptic drugs
– valproate*, topiramate*, zonisamide
• Memantine
• *=FDA approved for migraine prevention.
Botulinum toxin
•
•
•
•
Preprogrammed
Follow the pain
Literature is controversial
Thought to work by uptake into proximal
neurons, blocking secondary transmission,
not by neuro-muscular blockade
Occipital nerve injection and/or
stimulation
• Thought to work by decreasing input to
trigeminal system by decreasing spinal
sensory input
• Literature is controversial
Tension Type Headache
Treatment
JAMA, 285:2216-2222, 2001
Migraine in association with
menses
• Attempts to define menstrually associated
migraine in the literature have included:
– Menstrually associated migraine (MAM)
• Occur at other phases of the cycle
• 60-70% of female migraine patients
– True menstrual migraine (TMM)
• Exclusively with menses
• 7-10% of female migraine patients
Which Hormone
Supplement
Progesterone
– Headaches on time
– Vaginal bleeding delayed
Estrogen
– Headache delayed or avoided
– Vaginal bleeding on time
Menstrual Migraine
Miniprophylaxis
• Start a day or two prior to menses
• Continue throughout the menstrual period
• To reduce or eliminate hormone induced
headaches
Menstrual Migraine
Miniprophylaxis
•
•
•
•
•
•
Naratriptan (Amerge®) 1 mg BID
Summatriptan (Imitrex®) 25 mg TID
Rizatriptan (Maxalt®) 10 mg BID
Zolmatriptan (Zomig®) 2.5 mg BID
Frovatripatn (Frova ®) 2.5 mg daily
EXPENSIVE
Menstrual Migraine
Miniprophylaxis
• NSAID’s
– Naproxyn 250 BID
– Ibuprofen 400 BID
– etc
• Cox II inhibitor
– Celebrex 100 mg daily
Menstrual Migraine
Miniprophylaxis
• Active oral contraceptive 28/28
• Estrogen supplement
– Estradiol patch 0.05 mg
– Estradiol oral 1mg
– Conjugated Equine Estrogen.625 mg
Daily Headaches
• Secondary
• Transformed Migraine or Tension type
– Medication overuse
– Additional diagnosis
• Medical
• Psychiatric
• New Onset Daily Headache
Worrisome Headache Red Flags
“SNOOP”
• Systemic symptoms (fever, weight loss) or
secondary risk factors (HIV, systemic cancer)
• Neurologic symptoms or abnormal signs
(confusion, impaired alertness or consciousness)
• Onset: sudden, abrupt, or split-second
• Older: new onset and progressive headache,
especially in middle-age > 50 (giant cell arteritis)
• Previous headache history: first headache or
different (change in attack frequency, severity or
clinical features)
Silberstein SD et al. Wolff’s Headache and Other Head Pain 2001:6-26
SNOOP present
• Yes
– Order appropriate studies
– Specific treatment
• No—Medication overuse likely
Characteristics of Mediation
Overuse Headache
•
•
•
•
Daily or nearly daily dull generalized headache
Aggravation by mild physical or mental activity
Waking with early morning headache
Depression, restlessness, nausea, forgetfulness,
aesthenia
• Medication withdrawal symptoms
• Ineffectiveness of migraine specific abortive
meds
• Ineffectiveness of preventive meds
Evidence of medication overuse
•
•
•
•
Use of multiple pain pills
Frequent calls for refills
Doctor shopping
Creative reasons for early refills
Medication Overuse Headache
Treatment
•
•
•
•
•
Stop all abortive medications
Teach proper symptomatic medication use
Teach non pharmacologic preventive measures
Start prophylactic medication
Reasonable expectations
Chronic Daily Headaches
• Are not always because of medication
overuse.
• A trial off abortive meds is worth a try.
Cluster Headache
• More common in men
• Periorbital, sharp penetrating severe,
repetitive
• Dysautonomia
– Lacrimation
– Conjuntival injection
– Nasal congestion and rhinorhea
• Tend to pace
Cluster headache, Treatment
•
•
•
•
•
•
High flow oxygen
Triptans
DHE
Prednisone
Verapamil
Lithium
Giant cell (Temporal) arteritis
• Temporal artery often enlarged and tender
• Risks
– Stroke
– Blindness
• Association with polymyalgia rheumatica
– Stiff painful joints
– Anemia
– Jaw claudication
Giant cell arteritis, Diagnosis
• Elevated ESR
• Biopsy
– Long segment
– Skip areas
Giant cell arteritis, Treatment
• Prednisone
– Start as soon as possible because of risk of
stroke and blindness
– Biopsy will remain positive for several days on
prednisone
• Start 60 to 80 mg daily
• Titrate down depending upon ESR
HEAD TRAUMA
Remember the neck
Post-traumatic headache
• New headache following a head injury
– Structural?
– Post concussive syndrome ?
Worrisome Headache Red Flags
“SNOOP”
• Systemic symptoms (fever, weight loss) or
secondary risk factors (HIV, systemic cancer)
• Neurologic symptoms or abnormal signs
(confusion, impaired alertness or consciousness)
• Onset: sudden, abrupt, or split-second
• Older: new onset and progressive headache,
especially in middle-age > 50 (giant cell arteritis)
• Previous headache history: first headache or
different (change in attack frequency, severity or
clinical features)
Silberstein SD et al. Wolff’s Headache and Other Head Pain 2001:6-26
SNOOP present
• Yes
– Order appropriate studies
– Specific therapy
• No---Post concussive syndrome likely
Postconcussive
syndrome
•Dizziness
•Fatigue
•Irritability
•Poor concentration
•Poor memory
•Insomnia
•Personality change
•Poor stress tolerance
•Low mood
•Anxiety
•Trouble thinking
•Headache
Jason laRue
Post concussive syndrome
Pathophysiology
• Shear forces
– Axonal injury (role of DTI?)
– As likely with “minor” or “significant” injury
• Injury to nearby structures
– Neck
– Jaw
– Scalp
Post concussive syndrome
Prognosis
•
•
•
•
30 to 80% had headache at 3 mos
8 to 35% at one year
Approx 1/3 are unable to return to work
Older age, higher education, higher income
and higher socioeconomic standing are
good prognostic indicators
Combination of multiple studies
Post concussive syndrome
Treatment
All treatment is symptomatic
• Headache by type
– Migraine
– Tension type
• Mood
• Anxiety
Encourage activity and social interaction
The 2W rule
If you take ANYTHING for headache
relief 2 or more days a week for 2 weeks in
a row, call your doctor
Patient education: Key messages
• Migraine is a neurobiologic disorder
• Migraineurs have a reduced threshold for
headache
• Migraine has a genetic basis
• Migraine can be managed not cured
– Reasonable expectations
– Ongoing process
• Migraine should be categorized along with other
chronic conditions like asthma, diabetes, arthritis
and hypertension
Articles worth looking at
• S.D. Silberstein, et al. …Migraine prevention in
adults... Neurology:April 24, 2012 78:13371345
• Migraine Treatment Guidelines from The
Medical Letter • February 1, 2011 (Issue 102) p.
7
Now you should be able to:
• Differentiate troublesome from dangerous
headaches
• Recognize common headache syndromes
• Effectively treat common headache
syndromes
Questions?