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HEADACHES
WESTERN CLINICAL SCIENCES
SIOM-SPRING 2012
Dr. Alex
HEADACHES:
WHERE ARE WE GOING WITH
THIS TODAY?
• We will discuss the most common types of
headaches, how to differentiate them, common
clinical characteristics, what is believed to cause
each type, and Western treatment options.
• We will review danger signs needing referral.
• We will review some physical exam components
that are helpful in evaluating a patient with
headache.
• We will briefly review commonly used
pharmaceuticals and herbals used in treating
and preventing headaches.
COMMON TYPES OF
HEADACHES
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MIGRAINE
TENSION-TYPE
CLUSTER
MEDICATION OVERUSE
– (AKA REBOUND HEADACHE)
• POST-TRAUMATIC
• SINUS
MIGRAINE HEADACHE
• 17% of women, 6% of men (3x more common in
women)
• Classically, presents as episodic unilateral
(70%) head pain with gradual onset, crescendo,
pulsating, mod-severe pain, dull, deep, steady,
aggravated by activity, associated with nausea,
vomiting, photophobia, phonophobia, may have
preceding aura, lasts 4-72 hrs.
• Migraine sufferers prefer to rest in a dark, quiet
place.
MIGRAINE HEADACHE
• Migraine can be with aura, without aura, or
migraine variants (ophthalmic, e.g.)
• What is an aura? A progressive neurologic
deficit or disturbance with subsequent complete
recovery typically before the onset of the
headache. Most auras resolve in less than an
hour. Usually the headache starts within an hour
of the aura resolving.
• Common auras: visual (zig-zags in visual field,
spots), loss of sensation in arm or face, speech
slurring, focal motor weakness. Can be
confused as a stroke or TIA.
MIGRAINE HEADACHE
• What causes migraines?
• Used to believe it was a “vascular headache”,
but now we understand more.
• Genetic component/threshold
• Neuronal dysfunction that initiates an event in
the brainstem that is self-propagating wave of
neuronal depolarization that spreads across the
cerebral cortex, causing “neurogenic
inflammation” of the meninges
• May involve serotonin as well as substance P
and vasoactive peptides
MIGRAINE HEADACHE
• TREATMENT OPTIONS:
– PREVENTIVE (LIFESTYLE)
– ABORTIVE
– PROPHYLACTIC
MIGRAINE HEADACHE
• MIGRAINE TRIGGERS:
– DIET: alcohol, chocolate, aged cheeses, MSG,
Nutrasweet, caffeine, nuts, nitrates, anything a
person is allergic or sensitive to
– HORMONES: menses (due to declining estrogen),
ovulation, progesterone (BCP)
– SENSORY STIMULI: strong light, odors, sounds,
flickering lights
– STRESS: let-down periods, times of intense activity,
loss or change (divorce, job change)
– ENVT CHANGE: weather, travel, seasons, altitude,
sleep patterns, dieting, skipping meals, irreg physical
activity, schedule changes
Headache diary
Reproduced with permission from Bristol-Myers Squibb Company. Copyright 2001 Bristol-Myers Squibb Company.
MIGRAINE HEADACHE
• PREVENTIVE TX:
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Avoid triggers
Regular exercise
Relaxation
Biofeedback
Massage
Physical therapy
Acupuncture
Chiropractic/osteopathic manipulations
Hypnosis
TENS (transcutaneous electrical nerve stimulator)
MIGRAINE HEADACHE
• ABORTIVE TREATMENT
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NSAIDs
Tylenol (caution: can cause rebound!)
Excedrin (Tylenol, aspirin, caffeine)
Triptans: (Imitrex, Maxalt, Amerge, Frova, Zomig)
migraine-specific medications that inhibit the release
of vasoactive peptides, promote vasoconstriction,
block pain pathways in the brainstem. Use early in
HA. Not used in patients with CAD, CVA, pregnancy,
uncontrolled HTN. Can cause chest pressure,
flushing, dizziness, paresthesias,
drowsiness/malaise). SC, PO, NS. $15-54/attack
– Anti-nausea meds
– Combos
MIGRAINE HEADACHE
• PROPHYLACTIC TREATMENT
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Calcium-channel blockers
Tricyclic antidepressants
Beta blockers
SSRIs
Anti-seizure medications: valproic acid (Dilantin),
topiramate (Topamax), gabapentin (Neurontin)
– Bo-Tox injections
– Magnesium 500mg/day
MIGRAINE HEADACHE
• OTHER PROPHYLACTIC
POSSIBILITIES
– Butterbur (75 mg/day): may cause GI upset
– CoEnzymeQ10 (100mg 3x/day)
– Feverfew
– Riboflavin (400 mg/day)
TENSION-TYPE HEADACHE
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Most common type of headache
Pressure/tightness all over head bilaterally (vice-grip)
Waxes and wanes over time in intensity
Duration is variable
Usually does not have associated migraine features
(N/V/light and sound sens/aura)
• We used to think this type of headache was due to
contraction/hypertonicity of muscles of head and skull. It
is now viewed as a migraine variant and has similar
pathophysiology to migraine but is more mild.
TENSION-TYPE HEADACHE
• Primary treatment includes stress
management, psychotherapy and support,
relaxation, biofeedback, Tylenol, aspirin,
and NSAIDs.
• If they occur frequently, suspect
medication overuse HA, discuss pain
management and coping skills, and
consider prophylactic meds (tricyclic
antidepressants).
CLUSTER HEADACHE
• Repetitive headaches that occur for weeks
to months at a time, followed by periods of
remission.
• Not common: <1% of population
• Men>Women
• Age onset 25-50 yo
CLUSTER HEADACHE
• Clinical features:
– Unilateral
– Begins suddenly without warning and reaches max
intensity in a few minutes
– Deep, excruciating, continuous, explosive
– Usu begins in or around the eye or temple
– Lasts 15 min-3 hours
– Ipsilateral tearing, eye redness, runny nose,
sweating, pallor. N/V may occur, photophobia on
affected side.
– Patient is usually pacing, restless due to pain
CLUSTER HEADACHE
• Episodic: 1-3 attacks/day over 6-12 weeks
followed by 6-12 months of remission
• Usually begin between 9pm-9am and tend
to recur at about the same time of day
each day.
• >50% of patients report alcohol as trigger
CLUSTER HEADACHE
• What causes cluster headaches???
• Vasodilation, extracerebral neuronal
dysfunction, hypothalamus, genetics,
tobacco, alcohol…
• How do we treat cluster headaches???
• 100% O2 (oxygen!), triptans can be used
• Prophylactic meds: Calcium channel
blockers, Lithium, prednisone, seizure
meds
MEDICATION OVERUSE
HEADACHE
• 1% of population (women>men)
• Most commonly involves Tylenol, Fiorinal
(butalbital-aspirin-caffeine), aspirin, but
can also involve NSAIDs, narcotics
• Continuous analgesic exposure causes
tolerance which results in miniwithdrawals
• Moral of the story: Acute medications
should be limited to <10 days/month!
POST-TRAUMATIC HEADACHE
• Usually begins within 7 days after a head
trauma
• Tension type headache character is the
most common
• Beware of danger signs for a intracranial
bleed (more to come on the danger signs)
SINUS HEADACHE
• Overdiagnosed!!! Migraine sufferers, cluster
headache patients can have stuffy nose, sinus
pressure/pain…
• Really need pussy discharge in nose to
diagnose. Facial pain/congestion/fullness, nasal
obstruction, fever, loss of smell to make the
diagnosis of a sinusitis-related headache.
• A true sinus headache is treated with nasal
irrigation, nasal sprays, antibiotics
SO HOW DO YOU TELL ONE
TYPE OF HEADACHE FROM
ANOTHER?
• 1. How often do you get severe/disabling
headaches? (sensitive for migraine)
• 2. How often do you get other (milder)
headaches?
• 3. How often do you take HA relievers or pain
pills? (med overuse? If uses meds>3 days/week
&/or have daily headaches)
• 4. Has there been any recent change in your
headaches? (ID pts with important secondary
causes)
•
SO HOW DO YOU TELL ONE
TYPE OF HEADACHE FROM
ANOTHER?
Historical clues: age at onset, aura?,
freq/intensity/duration, #HA days/mo, time and
mode of onset, quality of pain, location of pain,
radiation, associated symptoms, family history of
migraine, things that make HA better and worse,
effect of activity on HA, relationship with
food/alcohol, response to any prior Tx, visual
changes, recent trauma, recent changes in
sleep/exercise/diet, change in work/lifestyle,
change in meds/BCP, envtl factors, menses
OTHER CAUSES OF
HEADACHES
• Stress/anxiety/depression
• Cervical spine disease
• Intracerebral mass (cancer, noncancerous mass,
abscess, blood)
• Fever
• Vascular lesion (aneurysm, AVM)
• Acute hypertensive emergency
• Infection-meningitis, encephalitits
• Benign intracranial hypertension
• Glaucoma
• Metabolic disturbance (sugar, electrolytes)
HEADACHE DANGER SIGNS
• Sudden onset or severe persistent HA that
reaches max intensity within a few
seconds or minutes
• Absence of similar HAs in the past (“first”
or “worst headache of my life”)
• Worsening pattern of HA (mass, med
overuse, hematoma)
• Focal neurologic symptoms (mass, AVM)
• Fever assoc with HA
HEADACHE DANGER SIGNS
• Any change in mental status, personality,
fluctuation in level of consciousness.
• Rapid onset with strenuous exercise, esp
after minor trauma
• New HA in pts <5 yo or >50 yo
• New HA type in pt with cancer
• New HA type in pt with HIV
• HA during pregnancy
PHYSICAL EXAM
• BP/Pulse
• Neuro exam: getting up from seated
position, toes/heels walk, gait, Romberg,
motor, sensory, coordination, cranial
nerves.
• Danger signs on exam: meningismus,
focal neurologic signs, papilledema
• Almost all HA patients will have a normal
neuro exam
IMAGING
• It is a clinical decision as to which HA
patients a doctor will request a CT or MRI
of the head.
• In general, if a patient has a significant
change in the pattern, frequency, severity
of HA, progressive worsening, focal neuro
signs, HA causing awakening from sleep,
onset of HA >50 years old, HA after
trauma  CT of head.
BEFORE THIS GIVES YOU A
HEADACHE, LET’S TAKE A
BREAK
SEIZURE DISORDERS
WESTERN CLINICAL SCIENCES
SIOM-SPRING 2012
Dr. Alex
WHAT’S IN STORE…
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WHAT ARE SEIZURES?
WHAT CAUSES SEIZURES?
TYPES OF SEIZURES
HISTORICAL CLUES
DIAGNOSIS
TREATMENT
WHAT TO DO WHEN SOMEONE HAS A
SEIZURE
WHAT ARE SEIZURES?
– Uncoordinated electrical discharges in the cerebral
cortex
– Due to either the overactivity of excitatory
neurotransmitters or the underactivity of inhibitor
neurotransmitters
– Epilepsy is the term used to describe people who
have recurrent seizures for any of a number of
reasons. Over half of people with epilepsy, though,
have no known cause.
– Seizures are depicted in prehistoric cave paintings,
referred to by Hippocrates and in the Bible.
– 5-8/1000 people have seizure disorder
GENERAL SEIZURE TYPES
• Epileptic seizures have typical
neurophysiological changes which can be
identified on electroencephalogram
(EEG).
• Then there are nonepileptic seizures that
do not have these typical features and are
more likely to be due to an acute
metabolic change or hypoxemia.
EPILEPTIC SEIZURES
CAUSES
• Genetics
• Congenital brain
malformations
• Inborn errors of
metabolism
• High fevers
• Head trauma
• Brain tumors
• Stroke
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Intracranial infection
Cerebral degeneration
Drug withdrawal
Drug reactions
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NONEPILEPTIC PHYSIOLOGIC
SEIZURES
CAUSES
Hyperthyroid
Hypoglycemia
Hyperglycemia
Hyponatremia
Hypoxia
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Resp/cardiac arrest
Carbon monoxide
Drowning
Anesthesia
Syncope/fainting
• Uremia
• Transient ischemic
attack
• Cardiac arrythmias
TYPES OF SEIZURES
• Partial (only part of the cortex disrupted)
– Simple (consciousness not impaired)
– Complex (with impairment of consciousness)
• Generalized (begins affecting the whole
cortex at one time)
– Nonconvulsive: Absence
– Convulsive: Myoclonic, Clonic, Tonic, TonicClonic, Atonic
SIMPLE PARTIAL SEIZURES
• With motor symptoms
– Focal motor
– Phonatory
• With somatosensory
symptoms
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Visual
Auditory
Olfactory
Gustatory
Vertiginous
• With psychic symptoms
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Dysphasic
Cognitive
Déjà vu
Affective (fear)
Hallucinations
COMPLEX PARTIAL SEIZURES
• Most common type of seizure among adult
epileptics.
• Usually last < 3 minutes
• Person appears awake but not responsive
and has no memory of the seizure at all.
• Staring, grimacing, lip smacking, plucking
at clothes, gesturing, chewing, snapping
fingers, walking, running, undressing
GENERALIZED SEIZURES
• Nonconvulsive
– Absence: occurs almost exclusively in kids. Last 5-10
sec only. Staring and unresponsiveness, sometimes
some repetitive behaviors.
• Convulsive
– Myoclonic: sudden brief muscle contractions, singly
or in clusters. Frequently just the arms.
– Clonic: Rhythmic jerking of muscles, frequently
affecting arms, neck, face.
– Tonic: Muscle stiffening only
– Atonic: “drop attacks” sudden loss of muscle tone of
the legs  fall.
– Tonic-Clonic: gets all the attention, dramatic
GENERALIZED TONIC-CLONIC
SEIZURE
• Frequently preceeded by an aura, or technically
a simple partial seizure, when the seizure
begins and the person is still awake to notice
smell, visual symptoms, feelings.
• Then the seizure begins with a tonic phase (1020 sec): loss of consciousness, loss of posture,
flex arms, eyes deviate up, extend
back/neck/arms/legs, involuntary noises,
shallow resp (cyanosis), tremors begin…
• Clonic phase (30-90 sec): brief violent
generalized flexor contractions alternating with
progressively longer muscle relaxation.
GENERALIZED TONIC-CLONIC
SEIZURE
• During clonic phase, there may be cyanosis,
cheek or tongue biting (no tongue swallowing!),
salivation (may be bloody), loss of bladder or
bowel control, and then ends with a deep
inspiration and sustained muscle relaxation.
• After the seizure, there is a post-ictal period
during which the person may be confused, have
no memory, headache, muscles sore,
fatigue/exhaustion, embarrassment, trouble
talking, frustration or anger, weakness, fear,
depression, lonliness, nausea, thirst…
WHEN TALKING TO SOMEONE
ABOUT THEIR SEIZURES
• Most people know seizure triggers (lowers
threshold): strong emotions, loud music, flashing
lights, fever, menses, lack of sleep, stress,
intense exercise.
• Most true seizures will have some post-ictal
period.
• Medications
• Past medical history (head injury, Alzheimer’s,
stroke, intracranial infection, substance abuse)
• FamHx
SEIZURE DIAGNOSIS
• Made by history given by patient and
witnesses.
• Blood work done to rule out physiologic
causes
• EEG
• MRI to rule out other causes
SEIZURE TREATMENT
• Antiseizure medications are begun when it
is believed that the person is likely to
continue to have seizures.
• Drugs block the sodium or calcium
channels in the nerve cells to inhibit the
electrical activity that stimulates the
seizure. There are also medications used
that affect GABA metabolism (an inhibitory
neurotransmitter).
SEIZURE TREATMENT
• Seizure diary to discover triggers.
• Psychosocial issues related to loss of
independence, employment, insurance,
ability to drive, and self-esteem.
• In Washington state, you can drive if you
have not had a seizure for 6 months. The
doctor who makes the driving
recommendation is liable.
WHAT TO DO WHEN SOMEONE
HAS A SEIZURE
• It is very scary to see, but it is important to try to stay
calm.
• Protect the person from injury by removing harmful
objects from nearby
• Look for any ID/jewelry that identifies the person as an
epileptic.
• Cushion the head
• Aid in breathing by gently placing them on their sides
when seizure is done.
• Reassure calmly and tell them what just happened and
where they are.
• Stay with the person until the recovery is complete.
WHAT TO DO WHEN SOMEONE
HAS A SEIZURE
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DON’T…
Restrain the person in any way
Put anything in their mouths
Try to move the person
Give them any food or drink until fully
recovered
• Attempt to bring them around
• Yell at them or get angry with them
WHAT TO DO WHEN SOMEONE
HAS A SEIZURE
• CALL 911 IF….
• You think it may be the person’s first
seizure
• Seizure lasts more than 5 minutes
• One seizure follows another without
regaining consciousness between.
• The person is injured during the seizure.
• (It is OK if the person turns blue during the
seizure)
PERIPHERAL NEUROPATHY
PERIPHERAL NERVOUS
SYSTEM
• Everything except the brain and spinal
cord
• Takes messages from the brain out into
the body.
• Motor
• Sensory
• Autonomic (sweat glands, blood vesssels,
digestion, bowel and bladder, sexual
function)
NEUROPATHY
• Nonspecific term meaning damage to
nerves.
• Damage occurs due to lack of blood flow
and therefore lack of oxygen supply
• In the PNS, symptoms can be due to
damage of motor/sensory/autonomic
nerves causing a variety of symptoms.
• Symptoms usually begin gradually over
time
NEUROPATHY
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Pain
Numbness
Tingling
Weakness
Burning
Loss of feeling
Sensation that you are
wearing socks or gloves
• Nausea/vomiting
• Diarrhea or constipation
• Sharp/jabbing pain
• Electric pain
• Incontinence of bladder or
bowel
• Extreme sensitivity to light
touch
• Lack of coordination
• Sexual dysfunction
• Low blood pressure
• Sweating
NEUROPATHY-CAUSES
• Trauma/repetitive use
(carpel tunnel)
• Diabetes (50%)
• Alcoholism
• Vitamin deficiency
• HIV
• Autoimmune disease
• Hypothyroidism
• Medications (chemo,
HIV meds)
• Toxins (heavy metals)
• Genetics
NEUROPATHY-DIAGNOSIS
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Neurologic examination
Labs: vitamin levels, TSH
Nerve conduction study
Nerve biopsy
NEUROPATHY-TREATMENT
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Depends on the cause
Control sugars if from diabetes
Supplement vitamins if deficient
Treat autoimmune disease
Discontinue offending activity if due to
mechanical irritation
• Discontinue offending med or toxic
exposure
NEUROPATHY-TREATMENT
• Tylenol/NSAIDs/Aspirin for pain
• Anti-seizure medications (Neurontin,
carbamazapine, phenytoin) dizzy, drowsy
• Lidocaine patch
• Tricyclic antidepressants/SSRIs
• Codeine/narcotics
• TENS
• Biofeedback
• Acupuncture
• Hypnosis
• Relaxation Techniques
TENS
NEUROPATHY-COMPLICATIONS
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Foot ulcers/gangrene
N/V/bloating (gastroparesis)
Impotence
Incontinence of urine or stool
Hypotension
Sweating or lack of sweating
THAT’LL WRAP THIS UP!