10/19/12. Post-Traumatic Headache. Lawrence J. Horn, MD Disclosures. Speakers Bureau: Allergan, Inc.

Transcription

1 10/19/12 Post-Traumatic Headache Professor and Interim Chair, Department of PM&R Wayne State University School of Medicine Detroit, MI Medical Director Neuroscience Rehabilitation Institute of Michigan Detroit, MI Lawrence J. Horn, MD Disclosures Speakers Bureau: Allergan, Inc. 1

2 10/19/12 Learning Objective Review the clinical presentations of various post-traumatic headaches. Post-Traumatic Headache Most common physical complaint in patients who have had a traumatic brain injury (TBI) Present in mild TBI/concussion and severe TBI International Headache Society (IHS) classification has shortcomings There is no one type of post-traumatic headache (PTH) Limited repertoire of headache responses, regardless of nociceptor Treatment should be multifaceted Lucas S, et al. Cephalalgia. 2012;32(8): PMID: IHS Definition: Headache Attributed to Head and/or Neck Trauma 5.1 Acute PTH Acute PTH attributed to moderate or severe head injury Acute PTH attributed to mild head injury 5.2 Chronic PTH (> 3 months) And the list goes on. International Headache Society (IHS). IHS Classification ICHS-II _teil2/ _necktrauma.html. 2

3 Epidemiology of PTH: Civilian Of all people with TBI 30%-90% develop PTH Most show improvement in first 3-6 months Most do not convert from acute to chronic headache Of those with moderate to severe TBI More likely to develop chronic PTH 40%-50% have headache at 12 months Dominant phenotype now appears to be migraine Risk Factors Women Premorbid history of headache Lucas S, et al. Cephalalgia. 2012;32(8): PMID: Epidemiology: Military 20% deployment-related concussion 1/3 meet criteria for PTH 58% of these have post-traumatic migraine (PTM) Associated with post-traumatic stress disorder (PTSD) Health complaints in PTSD PTH more likely with mild TBI Associated with blast or blast-induced neurotrauma Type of headache not well defined Neurovascular and structural elements Lucas S, et al. Cephalalgia. 2012;32(8): PMID: Sources of Head Pain Dura and venous sinuses Skin, nerves, muscles, periosteum and cranial cavities of head and neck Cervical joints Cervical muscles Gladstone J. Headache. 2009;49(7): PMID:

4 Interconnectivity between the spinal nucleus and tract of cranial nerve V Schematic representation of interconnectivity between the spinal nucleus and tract of cranial nerve V upper three cervical roots and the occipital branch of the fifth cranial nerve through the Gasserian ganglion. Zasler N, et al. Brain Injury Medicine: Principles and Practice Theorized Mechanisms of Central Sensitization Immediate Late Zasler N, et al. Brain Injury Medicine: Principles and Practice. 2006: Clinical Evaluation of PTH History: Mechanism of injury Whiplash Blast Neurosurgery Severity Associated symptoms: aura, vomiting Degree of functional disability Presence of pending litigation Psychiatric history History of headache Gladstone J. Headache. 2009;49(7): PMID: Zafonte RD, et al. J Head Trauma Rehabil. 1999;14(1): PMID:

5 Clinical Evaluation of PTH Character: Dull, throbbing, sharp Onset: Precipitants, menses, time of day, time after injury Location: Unilateral, bilateral, occipital, at a scar Duration and frequency Exacerbation: Physical activity, touch, sleep, noise Relief: Medications (how much/often), rest Gladstone J. Headache. 2009;49(7): PMID: Zafonte RD, et al. J Head Trauma Rehabil. 1999;14(1): PMID: Physical Examination of Patient with PTH Observation: scars, craniectomy Neurologic exam Palpation of head and neck Include clicking in temporomandibular joint Myofascial trigger points Auscultation for bruits Gladstone J. Headache. 2009;49(7): PMID: Zafonte RD, et al. J Head Trauma Rehabil. 1999;14(1): PMID: IHS Classification: Primary Headaches Migraine Migraine without aura Migraine with aura Tension-type headaches Episodic tension-type headache (TTH) Chronic TTH Associated with disorder of pericranial muscles Unassociated with disorder of pericranial muscles Cluster headache and chronic paroxysmal hemicrania Miscellaneous headaches unassociated with structural lesion International Headache Society (IHS). IHS Classification ICHS-II _teil2/ _necktrauma.html. 5

6 Clinical Classification System PTH 1 Musculoskeletal PTH TTH (tension-type headache) Myofascial Cervicogenic PTH Craniomandibular PTH PTM/probable migraine Neuralgias/neuritic Certain cranial neuralgias Theeler BJ, et al. Cephalalgia. 2012;32(8): PMID: Clinical Classification System PTH 2 PTH from intracranial abnormalities Intracranial pressure (ICP), including tension pneumocephalus ICP Syndrome of the trephined (postcraniectomy headache) Carotid cavernous fistula Cavernous sinus or intracranial sinus thrombosis Carotid dissection Theeler BJ, et al. Cephalalgia. 2012;32(8): PMID: Clinical Classification System PTH 2 Other Medication overuse headache (MOH) Dysautonomic Blast Sinus Theeler BJ, et al. Cephalalgia. 2012;32(8): PMID:

7 Musculoskeletal Headache Classic tension headache (?) Myofascial-pain related headache Cervicogenic headache Craniomandibular syndrome Jull G, et al. Cephalalgia. 2007;27(7): PMID: Tension Headache Bilateral head pain Pressing quality (like a tight hat) Mild to moderate intensity May have peri-cranial tenderness Not associated with: Nausea/vomiting Aura Sensitivity to light or sound Exacerbation by physical activity May be confused with Migraine without aura Medication overuse headache Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S PMID: Pathophysiology of TTH Pericranial and cervical Injury produces peripheral activation of nociceptors Peripheral and central sensitization (chronic TTH) Antidromic release of pain mediators Substance P Bradykinin CGRP Heightened pain sensitivity peripherally Neutral stimuli perceived as painful Development of trigger points TTH=tension-type headache Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S PMID:

8 Central Sensitization Overlap of receptive fields from C 1 C 4 muscles and trigeminal nucleus caudalis Trapezius Suboccipital Sternocleidomastoid Temporalis Masseter Jensen R. Cephalagia. 2001;21(7): PMID: Myofascial Pain: Part of TTH? Commonly injured muscles of head and neck Trigger points (with associated increased allogenic substances) Radiation of pain in characteristic distribution Autonomic dysfunction May cause unilateral or bilateral headache Jensen R. Cephalagia. 2001;21(7): PMID: TTH=tension-type headache Muscular Reaction to Whiplash Injury Center, Sternocleidomastoid muscle, (SCM) extension to upper half of cervical spine and flexor to lower half. Right, Hyperextension, the SCM is completely an extension and shorter than in neutral. Left, In flexion, the SCM is completely flexor and shorter than in neutral and hyperextension. This rapid movement overstretches muscle and causes a reflex inhibition and muscle strain. Cailliet R. Neck and Arm Pain. 2 nd ed

9 Referred Pain Patterns Sternocleidomastoid Muscle Sternal (superficial) division Clavicular (deep) division Travell JG, Simons DG. Sternocleidomastoid muscle. In: Travell & Simons Myofascial Pain and Dysfunction: The Trigger Point Manual Referred Pain Patterns Splenius Capitis and Splenius Cervicis Muscles Travell JG, e. Splenius capitis and splenius cervicis muscles. In: Travell & Simons Myofascial Pain and Dysfunction: The Trigger Point Manual Referred Pain Patterns Trapezius muscle Referred pain pattern and location (Xs) of trigger point 1 in the upper trapezius muscle. Solid red shows the essential referred pain zone; stippling maps the spillover zone. Travell JG, Simons DG. Trapezius muscle. In: Travell & Simons Myofascial Pain and Dysfunction: The Trigger Point Manual

10 Treatment of TTH Prevent Conversion of Acute Chronic Nonsteroidal anti-inflammatory drugs (NSAIDs) Prophylaxis Tricyclic antidepressant (TCA)* Topiramate?* Botulinum toxin?* Acupuncture? Behavioral strategies Biofeedback Correct sleep disturbances *This is not an FDA-approved use for this agent Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S406-S412. PMID: Treatment of Myofascial Pain Apply cold and stretch Apply moist heat and stretch Perform needling: dry or with local anesthetic agent Conduct strengthening program Avoid certain postures Borg-Stein J, et al. Arch Phys Med Rehabil 2002;83(3 Suppl 1):S40-47, S PMID: Migraine: Trigemino-Neurovascular Headache 10

11 Migraine Clinical Presentation Episodic attacks of headaches Throbbing (lasts 4-72 hours) Unilateral (up to 40% become bilateral) Worse with coughing, bending, physical exertion Photophobia, phonophobia Associated autonomic disturbances Nausea, vomiting, anorexia With or without an aura Usually visual Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S PMID: Migraine Treatment Migraine treatment Prophylaxis Acute Episodes Beta-blockers Nonspecific Treatments Specific Treatments Ca Channel Blockers NSAIDs Antiemetics Triptans Dihydroergotamine Tricyclic Antidepressants Anticonvulsants Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S PMID: Other PTM Treatments Sphenopalatine block Used in past for cluster headache Parasympathetics to face and meninges Therapy to musculoskeletal component Heat, stretch, massage Naturopathic Butterbar Feverfew Lucas S. Phys Med Rehabil. 2011;3(10 Suppl 2):S PMID:

12 Neuralgia/Neuroma Neuroma Injury to skin, muscle, or periosteum Small nerve trapped in scar Greater (GON) or lessor occipital nerve (LON) injury May radiate to ipsilateral eye Supraorbital nerve injury Pain Sharp, tingling Localized (neuroma) or territory of major scalp nerve Can be elicited on palpation Ducic I, et al. Plast Reconstruct Surg. 2008;121(6): PMID: Schankin CJ, et al. Cephalalgia. 2009;29(7): PMID: Neuralgia/Neuroma Panskey B, House EL. Review of Gross Anatomy. Second Edition.1969 Dermatomal Distribution of Occipital Nerves Cailliet R. Neck and Arm Pain. 2 nd ed

13 Treatment: Neuroma Modalities: cold Topical anesthetic agents NSAID Tricyclic antidepressant agent* Serotonin norepinephrine reuptake inhibitor* Gabapentin* or pregabalin* Injection with local anesthetic ± steroid Surgery *This is not an FDA-approved use for this agent Schankin CJ, et al. Cephalalgia. 2009;29(7): PMID: Treatment: Neuralgia (GON, LON) Myofascial release of associated muscles and upper cervical segment Topical anesthetic agents NSAID Tricyclic antidepressant agent* Selective norepinephrine reuptake inhibitor* Gabapentin* or pregabalin* Injection with local anesthetic agent ± steroid Cryo- or radiofrequency ablation Neuromodulation: occipital nerve stimulator *This is not an FDA-approved use for this agent GON = greater occipital nerve; LON = lesser occipital nerve Ducic I, Larson EE. Plast Reconstruct Surg. 2008;121(6): PMID: PTH with Intracranial Pathology Intracranial pressure (ICP) abnormalities ICP Hydrocephalus Tension pneumocephalus ICP Cerebrospinal fluid (CSF) leak Syndrome of the trephined Carotid-cavernous fistula Cavernous sinus thrombosis Carotid artery dissection Meningitis Ramirez-Lassepas M, et al. Arch Neurol. 1997;54(12): PMID:

14 Syndrome of the Trephined Etiology Complication of craniotomy Impaired cerebral blood flow Symptoms Apathy Cognitive dysfunction Gait abnormality Headaches Hemiparesis Midbrain syndrome ± Orthostatic component Tremor Treatment Cranioplasty Joseph V, et al. J Neurosurg. 2009;111(4): PMID: Controversies in PTH: Prognosis Tied to resolution of post-concussive syndrome in mild TBI Of patients with moderate to severe TBI, 40%-50% have persistent headaches Mixed evidence for an effect of litigation on persistence PTSD? Pre-injury history or genetic predisposition Psychological and social factors Gladstone J. Headache. 2009;49(7): PMID: Clinical Connections Most common headache is migraine or migraine-like Need to treat musculoskeletal or tension headache component regarding of clinical classification Remember to palpate the head and neck, you find what you look for 14

15 10/19/12 Co-sponsored by Save the Date! 6th Annual Chair Summit September 26-28, 2013 Westin Tampa Harbour Island Tampa, Florida Check out for the most recent information on Chair Summit Registration will be open soon. See you in Tampa! 15