Classification of headaches

Transcription

1 Classification of headaches

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3 Pain sensitive structures Skin, subcutaneous tissue, periosteum, arteries, muscles, eye, ear, pharynx, sinuses, basal dura, nerves Extracranial structures: well localized pain Intracranial structures: diffuse pain Supratentorial origin: trigeminal distribution fronto-temporal region Infratentorial origin: occipital region

4 Classification of headaches Primary headaches OR Idiopathic headaches Secondary headaches OR Symptomatic headaches THE HEADACHE IS ITSELF THE DISEASE NO ORGANIC LESION IN THE BEACKGROUND TREAT THE HEADACHE! THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER UNDERLYING DISEASE TREAT THE UNDERLYING DISEASE!

5 SECONDARY, SYMPTOMATIC HEADACHES THE HEADACHE IS A SYMPTOM OF AN UNDERLYING DISEASE, e.g. Sinusitis Glaucoma Eye-strain Hypertension Fever Anaemia, hypoxia, hypercapnia, hypoglycaemia Temporal arteriitis Cervical spondylosis Meningitis, encephalitis Brain tumor, meningeal carcinomatosis Haemorrhagic stroke

6 Secondary headache disorders Headache attributed to... head and/or neck trauma cranial or cervical vascular disorder non-vascular intracranial disorder a substance or its withdrawal Infection disorder of homoeostasis disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures psychiatric disorder cranial neuralgias and central causes of facial pain

7 HISTORY AND EXAMINATIONS SHOULD CLARIFY IF THE PATIENT HAS PRIMARY OR SECONDARY HEADACHE IS THERE ANY URGENCY IN CASE OF PRIMARY HEADACHE ONLY THE HEADACHE ATTACKS SHOULD BE TREATED ( ATTACK THERAPY ), OR PROPHYLACTIC THERAPY IS ALSO NECESSARY ( PREVENTIVE THERAPY, INTERVAL THERAPY )

8 Primary, idiopathic headaches Tension type of headache Migraine Cluster headache Other, rare types of primary headaches

9 Differentiation of the primary headaches History!!! Aura sign Intensity 10 grades scale Localization Characteristics Does he/she work further? Influenced by physical activity? Accompanying signs Reaction to common pain killers

10 TENSION TYPE OF HEADACHE EPISODIC FORM USUALLY AFTER STRESS SITUATION; ANXIETY, DEPRESSION IS FREQUENT NO ACCOMPANYING SIGNS; IN SEVERE ATTACK PHOTO- OR PHONOPHOBIA MAY OCCUR EPISODIC TENSION TYPE OF HEADACHE; LESS THAN 15 DAYS/MONTH; PERIODICITY PROFILE DURATION: 30MIN-7DAYS; IN CHRONIC FORM, COULD BE CONSTANT, CONTINUOUS DULL, BORING PAIN; DIFFUSE OR BAND LIKE; PRESSING, STRAINING, NOT TOO SEVERE PHYSICAL ACTIVITY DOES NOT INCREASE THE INTENSITY CHRONIC TENSION TYPE OF HEADACHE; MORE THAN 15 DAYS/MONTH; PERIODICITY PROFILE JAN FEB MAR APR MAY MON TUE WED THU FRI

11 Treatment of tension type of headache Acute, episodic form: paracetamol, metamizol, NSAID, mg ASA, or noraminophenazon (common pain killers) Indication of prophylactic treatment: tension type of headache in at least 15 days per month

12 Prophylactic treatment of the chronic tension type of headache Tricyclic antidepressants (amitryptiline, clomipramine) Guidelines: Start with low dose (10-25 mg) and increase the dose if there is no beneficial effect after 1-2 weeks Maximal dose should not be more than 75 mg/day Change to other tricyclic antidepressant only after 6-8 weeks Ask the patient to use headache diary Use the tricyclic antidepressant for 6-9 months Decrease the dose gradually

13 Prophylactic treatment of the chronic tension type of headache First choice of drug: amitryptiline (Teperin tabl, 25 mg) 1st week: 25 mg in the evening 2nd week: 50 mg in the evening 3rd week: 75 mg in the evening continuously Change to other drug (e.g. clomipramine) if there is no beneficial effect within 6 weeks

14 Common side effects of tricyclic antidepressants Anticholinergic side effects: Dry mouth Increased pulse rate Urinary retention (in prostate hyperplasia!!!) Increased intraocular pressure (glaucoma!!!) Sleepiness or hyperactivity Serotonine syndrome (do not use if the patient takes SSRI drug)

15 If the patient does not tolerate the TCA drugs, or cannot be administared because of danger of interaction Anxiolytics (e.g.: alprasolam, clonazepam ) + selective antidepressants (e.g. SSRI) Change of lifestyle Psychotherapy, psychological treatments, biofeedback, behavioral therapy, relaxation methods

16 CT?

17 MIGRAINE with aura classic migraine without aura common migraine with prolonged aura complicated migraine Aura H e a d a c h e Common M Classic M Complicated M

18 MIGRAINE AURA SIGNS IN 20% OF ATTACKS; USUALLY VISUAL AURA ZIG-ZAG LINES, BRIGHTING SPOTS ACCOMPANYING SIGNS: PHONOPHOBIA DURATION: 2-72 HOURS SEVERE PAIN; MOSTLY UNILATERAL; PULSATING; PHYSICAL ACTIVITY INCREASES THE INTENSITY PHOTOPHOBIA PERIODICITY PROFILE NAUSEA VOMITUS JAN FEB MAR APR MAY ALCOHOL, ANXIETY, VASODILATORS, COLD WIND, MENSTRUATION MAY PROVOKE

19 Migraine: epidemiology Life-time prevalence 10%-12% 1% chronic migraine (>15 days/months) Sex ratio 2.5 (f) to 1 (m); in childhood 1 to 1 Mean frequency 1.2/month Mean duration 24 h (untreated) 10% always with aura, >30% sometimes with aura 30% treated by physicians

20 Migraine: pathophysiology Genetic disposition, hormonal influence Activation of trigeminovascular system Braistem nuclei trigeminal nucleus vessels of dura neurovascular inflammation caused by neuropeptides (VIP, CRGP ) Neurovascular inflammation and dilation of intracranial vessels Spreading Depression as mechanism of aura

21 Migraine WITHOUT AURA Typical headache 2/4 Unilateral Severe Pulsating Physical activity aggravates Accompanying signs 1/2 Photophobia and phonophobia Nausea, or vomitus WITH AURA + VISUAL SENSORY MOTOR SPEECH DISTURBANCE before migraineous headache AURA SYMPTOMS USUALLY<1/2 HOUR LESS THAN 1 HOUR

22 30 MIGRAINE WITH AURA DURING AURA: VASOCONSTRICTION HYPOPERFUSION DURING HEADACHE VASODILATION HYPERPERFUSION BUT: AURA SYMPTOM IS NOT CONSEQUENCE OF VASOCONSTRICTION INDUCED HYPOPERFUSION CUASE OF THE AURA: SPREADING DEPRESSION. Depolarization wave that moves across the cortex at a rate of 3 5 mm/min, followed by prolonged nerve cell depression THE VASOCONSTRICTION AND HYPOPERFUSION ARE CONSEQUENCES OF THE SPREADING DEPRESSION SPREADING DEPRESSION AURA VASOCONSTRICTION, HYPOPERFUSION

23 IMPORTANT TO KNOW! MIGRAINE WITH AURA IS A RISK FACTOR FOR ISCHAEMIC STROKE THEREFORE PATIENTS SUFFERING FROM MIGRAINE WITH AURA SHOULD NOT SMOKE!!! SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!! THE PROPROTION OF PATENT FORAMEN OVALE IN PATIENTS WITH MIGRAINE WITH AURA IS ABOUT 50-55%! (IN THE POPULATION IS ABOUT 25%).

24 Is there a relationship between aura and patent foramen ovale? Paradoxic emboli theory is not likely Shunting of venous blood to the arterial side could be the reason no breakdown of certain amines (5HT) in the lung! Comorbidity could be also an explanation. However, closure of patent foramen ovale decreases the frequency of migraine attacks. BUT! Migraine is a benign disease. Please do not indicate closure of patent foramen ovale just because of migraine with aura!

25 Therapy expectations of the patients No side effect Fast and effective analgetic effect Easy to use No return of headache Permanent effect Successful treatment: pain free after 2 hrs, or pain relief from severe to mild pain, no return of pain within 24 hours, good efficacy in 2 of 3 attacks

26 Treatment of migraine Attack treatment Prophylactic treatment Not specific Aspirin NSAID Antiemetics Paracetamol Noraminophenazon Specific Ergotamin Dihydroergotamin Selective 5-HT 1B/1D agonists (triptans) Beta-receptor blockers Ca-channel antagonists Antiepileptics Antidepressants

27 Treatment of migraine attack Try to sleep Antiemetics Analgetics Ergot derivatives Triptans

28 Treatment of migraine attack I. Antiemetics 1. Metoclopramid (Cerucal tabl 10 mg) mg per os 20 mg rectal 10 mg parenteral 2. Domperidon (Motilium tabl 10 mg) mg per os

29 Treatment of migraine attack II. Analgetics 1. ASA (Aspirin, Colfarit, etc) mg per os 500 mg parenteral (Aspisol i.v.) 2. Paracetamol (Rubophen, Panadol, etc) mg per os 3. NSAIDs Ibuprofen (Ibuprofen, Humaprofen, etc) mg per os Diclofenac (Voltaren, Cataflam etc)50 mg per os Naproxen (Naprosyn, Apranax) mg per os

30 Treatment of migraine attack III. Ergot derivatives 1. Ergotamin tartarate 2-4 mg per os, sublinguali or rectal 1 mg nasal spray 2. Dihydrergotamin (Neomigran) nasal spray no more available

31 Treatment of migraine attack IV. Combinations in Hungary Migpriv: lizin-acetylsalicilate + metoclopramid Quarelin: aminophenazon+coffein+drotaverin Kefalgin ergotamin tartarate+ atropin+coffein+aminophenazon

32 Treatment of migraine attack V. Triptans 1. Sumatriptan (Imigran 6 mg inj, 50 and 100 mg tabl, Imitrex nasal spray, supp, Glaxo) 6 mg sc with autoinjector mg per os, nasal spray 20 mg 2. Zolmitriptan (Zomig, Zeneca) 2,5 5 mg 3. Naratriptan (Naramig, Glaxo) 2,5 mg 4. Rizatriptan (Maxalt, MSD) 5 10 mg per os 5. Eletriptan (Relpax, Pfizer) mg per os 6. Frovatriptan (Smith-Kleine Beecham) 2,5 mg per os 7. Avitriptan (Bristol-Myers Squibb) mg 8. Alniditan (Janssen) 2 4 mg, nasal spray 40

33 Contraindications of triptans Ischemic heart disease, angina pectoris, myocardial infarction Ischemic stroke Not treated hypertension, arrhythmia Long-lasting aura Hemiplegic or basilar migraine

34 The ideal triptan Effective Rapid onset No recurrence Good consistency Different applications Good tolerability No interactions Cheap

35 Attack treatment in emergency Very severe migraine attack / status migrainosus: Triptan (sumatriptan 6 mg s.c.) Lysin-ASA 1,000 mg i.v. Antiemetics i.v. Steroids i.v.

36 Strategy of treatment of migraine attacks Step care accross or within attacks 1: NSAID 2: ergot 3: triptan Stratified care do not go through all the steps, but drug can be chosen depending on the severity of the attack

37 Prophylactic treatment of migraine Indication: 2 or more attacks/month attacks At least one long (>4 days) attack or aura/month Start of prophyalactic treatment: gradually Duration of prophylactic treatment: 2-9 months Stop of prophylactic treatment: gradually, within 4 weeks Use headache diary INFORM THE PATIENT ABOUT THE PROPHYLACTIC TREATMENT!!!

38 Aims of prophylactic treatment of migraine To decrease the frequency of attacks To decrease the intensity of the pain To increase the efficacy of attack therapy

39 Prophylactic treatment of migraine Beta-receptor-blockers (propranolol) Calcium channel blockers (flunarizine) Antiepileptics (valproic acid) Tricyclic antidepressants (amitriptyline) Topiramate (Topamax) Serotonin antagonists NSAID Blood pressure Pulse rate Depression in the history? BMI Epilepsy? Essential tremor? Tension type of headache? Pregnancy?

40 Beta-receptor-blockers (propranolol 2x20-40 mg) Calcium channel blockers (flunarizine, 10 mg every evening) Side effects: provokes depression, increases appetite, cause sleepiness Tricyclic antidepressants (amitryptiline, mg every evening) Antiepileptics (valproic acid, 2x mg) Use: hypertension, tachycardia, essential tremor Do not use: hypotension, bradicardia, heart conduction disturbances, atshma Do not use: obesity, maior depression in the history Use: if tension type of headache is present besides migraine Do not use: see above Few side effects, but pregnancy should be avoided

41 Other prophylactic treatment of migraine Change of life-style Regular, not exhausting physical activities Cognitive behavioral therapy Regular sleeping Avoid the precipitating factors Acupuncture?

42 Migraine and pregnancy Migraine without aura in >70% of women less frequent or absent (prognostic factor: menstrual migraine) Significantly more manifestation of migraine with aura Acute treatment: paracetamol; NSAIDs in second trimenon Triptans not allowed Prophylaxis: magnesium, metoprolol, (fluoxetine)

43 Migraine in childhood I Prevalence 5% Sex ratio 1:1 (boys with good prognosis) Abdominal symptoms often predominant Characteristics of attacks as in adulthood except shorter duration of attacks Short sleep very effective

44 Migraine in childhood II 60 Acute treatment: First choice: ibuprofen 10 mg/kg Second choice: paracetamol 15 mg/kg Third choice: sumatriptan nasal spray mg Prophylaxis: Flunarizine 5-10 mg Propranolol 80 mg Non-drug therapy very effective

45 Complicated migraine Persisting aura signs even after the headache phase Ophthalmoplegic migraine Hemiplegic migraine

46 CLUSTER HEADACHE ACCOMPANYING SIGNS UNILATERAL SWEATING ALCOHOL, COLD WIND, VASODILATORS, ANXIETY, BUT ALSO SLEEP PROVOKE DURATION OF AN ATTACK: MINUTES; DURATION OF A CLUSTER PERIOD: 3-16 WEEKS REDISCH FACE NASAL CONGESTION, OR RUNNING OF NOSE FREQUENTLY AT NIGHT; UNILATERAL - AROUND THE EYE; THE PAIN IRRADIATES TO THE TEMPORAL REGION PERIODICITY PROFILE MON TUE WED THU CONJUNCTIVAL INJECTION; LACRIMATION, TEARING; PUPILLARY DISTURBANCE (ANISOCORIA, HORNER S SYNDROME)

47 CLUSTER HEADACHE Periodicity profile weeks

48 Treatment of cluster attack Oxygen:7 liters/min 100% oxigén for 15 minutes Effective in 75% of patients within 10 minutes Sumatiptan 6 mg s.c., mg per os Ergot derivatives (lot of side effects) Anaesthesia of the ipsilateral fossa sphenopalatina 1 ml 4% Xylocain nasal drop The head is turned back and to the ipsilateral side in 45 degree

49 Prophylactic treatment of the episodic form of cluster headache Prednisolon Treatment: 1-5. days 40 mg days daily 30 mg days daily 20 mg days daily 15 mg days daily 10 mg days daily 5 mg nothing

50 Prophylactic treatment of the chronic form of cluster headache Lithium carbonate Daily mg Can be decreased after 2 weeks remission Control of serum level is necessary (0,4-0,8 mmol/l)

51 Differentiation between primary headaches Aura sign Intensity 10 grades scale Localization Characteristics Does he/she work further? Influenced by physical activity? Accompanying signs Reaction to common pain killers Duration History!!! Migraine Tension type h. Cluster h. Yes 8-9 Unil. Throbbing No Yes Yes No 2-72 hrs No 5-6 Band-like Pressing Yes No No Yes? No 10 Ocular Severe No No Yes! No ¼-3 hrs

52 Cluster headache and trigemino-autonomic cephalgias Trigemino-autonomic cephalgias (TAC) Cluster headache SUNCT-syndrome Paroxysmal hemicrania (Hemicrania continua)

53 71 Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing: SUNCT Rare neuralgiform pain around the eye Male predominance Conjunctival injection and lacrimation Duration: ¼-2 minutes, no refracter period 5-30 attacks / hour for days, weeks Symptom free periods (for months, years) interrupt the disease Treatment:??? lamotrigine Differential diagnosis: cluster headache, trigeminal neuralgia

54 Episodic paroxysmal hemicrania Duration: 2-30 minutes Usually more than 5x/day Indomethacine prevents the headache At least one vegetative sign (lacrimation, conjunctival injection, nasal congestion, running of nose, ptosis, miosis) Epizodic: from 7 days till one year, interrupted by more than 1 month pain free periods Chronic: longer than one year, or the remissions last less than 1 month

55 Hemicrania continua Duration > 3 months Unilateral, always the same side No pain-free period Moderate, sometimes severe in intensity At least one vegetative sign (lacrimation, conjunctival injection, nasal congestion, running of nose, ptosis, miosis) Indomethacin prevents the headache

56 Symptomatic, secondary headaches Secondary headaches OR Symptomatic headaches THE HEADACHE IS ON LY A SYMPTOM OF AN ANOTHER UNDERLYING DISEASE TREAT THE UNDERLYING DISEASE!

57 Symptomatic, secondary Tumor Progressing headache Neurological signs Nausea, vomitus (Epilepsy) Change of behaviour headaches Cerebral hemorrhage Sudden onset Neurological signs Nausea, vomitus (Epilepsy especially in case of sinus thrombosis) Inflammation (meningitis, encephalitis) Acute or subacute onset Fever, meningeal signs Neurological signs in case of encephalitis Progressing headache, confusion Epilepsy Diff. dg CT, MR CSF EEG

58 Headaches - urgency Urgency is necessary if: - previously the patient had no headache - change of characteristics of pain - headache after the fifth decade - headache with sudden onset - progressing headache - headache with neurological signs

59 Diagnostic procedures History! and examination X-ray EEG (meningitis, encephalitis, uraemia ) cerebral CT (tumor, stroke) cranial MR (tumor, vascular malformation, demyelinisation) Examination of CSF (inflammation, SAH) ENT, dentist, internist

60 Trigeminal neuralgia In middle or older ages Males:females ratio: 2:3 Incidence: 4-5/ /year Prevalance: 30/ V/2, V/3 V/1 rare (less than 5%) Right sided > left sided Usually no neurological sign In remission no complaint

61 Trigeminal neuralgia signs and symptoms Symptomatic or idiopathic (?) forms Severe, shooting, sharp pain (like a lightening) danger of suicide Sudden onset and end Short duration (usually ca. 5 sec., but might be repeated several hundreds times/day); always<2 min. Respects the territory of a trigeminal branch The pain paroxysm is followed by 2-3 min. refractory period Trigger points: not nociceptive stimuli, but touch may provoke Previous Dental or ENT treatment

62 Trigeminal neuralgia Idiopathic: 20 years ago: 90%. Symptomatic Pons (MS), cerebello-pontine angle, pyramid Mandibula, teeth, sinuses. Microvascular compression and local demyelinization

63 Trigeminal neuralgia - therapy Baclofen (GABA-B rec agonist), NNT:1,4 Carbamazepine (Na-channel), NNT:1,4-1,7 Lamotrigin (Na channel ), NNT:2,1 Gabapentin, (Ca channel ), NNT: 3,2-3,8 Phenytoin, Valproic acid, Clonazepam, Lidocain, Start wit low dose, increase after 2-3 days till the effective dose, or intolerable side effects, or maximal dose -- tolerance Spontaneous remission is not rare

64 Conservative treatment or surgery Success of medicine therapy Side effect of medicine therapy Risk of surgery 80

65 Glossopharyngeal neuralgia 100x less frequent than the trigeminal neuralgia Localization of pain: pharynx, Eustachian tube, middle ear Provoke: swallowing, yawning, laughing, chewing Cause: microvascular compression, elongated styloid process, tumor of cerebello-pontin angle, tumor of base of skull, nasopharyngeal cc., peritonsillar abscess

66 Postherpetic neuralgias Herpes zoster ophthalmicus Herpes zoster infection of the Gasserian ggl. Eruptions usually in V/1 region Eruptions occur 4-5 days after severe pain of V/1 Long-lasting, burning pain, superimposed by attacks of pain Treatment: acyclovir in acute phase Treatment of neuralgia: carbamazepine, phenytoin, TCA,

67 Facial pains Tolosa-Hunt syndrome (ophthalmoplegia dolorosa) granulomatose inflammation in cavernous sinus, superior orbital fissure Treatment: steroid Gradenigo s syndrome: otitis media inflammation of apex of petrous bone lesion of ipsilateral abducent nerve and facial pain around the ear and forehead

68 Atypical facial pain Frequently after dental treatment No dental cause Signs are not typical for trigeminal neuralgia Continuous, not severe pain Treatment = treatment of chronic tension type of headache

69 Posttraumatic headache Similar to the tension type of headache Preceding head trauma Frequently not immediately after the traume Treatment = treatment of chronic tension type of headache

70 Headache of cervical origin Cervical pain radiating to the occipital region Head movement provokes the pain Lidocain infiltration NSAID: mg indomethacin, mg piroxicam (Hotemin, Feldene), muscle relaxants, etc Other methods (physiotherapy, TENS) Surgical methods (CV-CVII fusion of vertebrae)

71 Arteriitis temporalis Arteriitis temporalis (age>50y, We>50 mm/h) Autoimmune disease, granulomatose inflammation of branches of ECA Unilateral headache Pulsating pain, more severe at night Larger STA 1/3 jaw claudication inflammation of internal maxillary artery Weakness, loss of appetite, low fever, Danger of thrombosis of ophthalmic or ciliary artery!!! Amaurosis fugax may precede the blindness Treatment: steroid mg methylprednisolone decrease the dose after 1-2 weeks to 10 mg!!! Diagnosis: STA biopsy. BUT Start the steroid before results of biopsy!!! We, pain decrease

72 Carotid dissection After neck trauma, extensive neck turning, or spontaneous Neck pain, headache Horner s syndrome Lower ranial nerve lesion Stroke Diagnosis: carotid duplex, MRI-T1

73 Headaches, provoked by medicines Addiction to pain killers ergotamine, coffein, barbiturates, ASA When the effect of the pain killer decreases, the headache increases Stop the drugs, if necessary start indomethacine or carbamazepine Vasodilators Nitrates Dipyridamol