6/4/2018. Headache. Headaches. Headache. Migraine Headaches. Headache. Red Flag signs and symptoms. Imaging CT without contrast.

Transcription

1 Presented by M.D. Shepherd, M.D. OH MY ACHING HEAD! Estimated that one half of the adult population is affected by a headache disorder International Society Classification Primary : Tension s 40% of the population Migraine s 10-12% of the population Cluster s 1% of the population Secondary : Infection of head or neck Vascular + Non vascular intracranial Disorder Substance use or withdrawal s attributed to eyes, ears, nose, sinus, teeth s Red Flag signs and symptoms Focal neurologic signs Papilledema Neck stiffness An Immunocompromised status Sudden onset of the worst HA of my life Personality changes after trauma that worsens with exercise/ activiy Imaging CT without contrast CT should be performed before LP in all patients suspected Subarachnoid hemorrhage, regardless of findings or neurologic exam. CT for patient with sudden onset of severe headache (worst HA of life, maximal HA from initiation, Thundercap HA) Migraine s Imaging MRI with and without contrast Immunocompromised patient with a severe headache likely due to infection/abcess Estimation of million Americans suffer from Migraine s. The ratio of Women/Men is more than 2.5/1 1

2 Migraine A mnemonic POUND is an evidence based aid for migraine diagnosis P pulsatile quality of headache O One day (4-72 hours) U Unilateral location N Nausea or vomitting D Disabling intensity Probability of migraine is 92% in patients who report at least 4 of the 5 pound symptoms International Society Criteria For Migraine HA without aura: HA lasts 4-72 hours (untreated) HA has at least 2 of the following: Aggravated by (or avoidance )of Routine physical activity Moderate to severe intensity Pulsating quality Unilateral location During HA at least one of the following: Nausea and or vomiting Photophobia and phonophobia Hx of at least 5 prior attacks The above not attributed to another disorder Migraine with Aura Migraine Pathophysiology Recurrent HA with the features of migraine without aura Neurologic (focal) symptoms Scatomata, smell, taste, sensory changes Positive Sx: Bright spot, lines, shapes that can spread to a quadrant or hemifield of vision. Auditory-tinnitus, noise, music Somatosensory- burning, parasthesias Negative Sx: Loss of Motor function, vision, hearing, feeling Migraines headaches involve activation of the Trigeminovascular system from the Trigeminal ganlion to the upper cervical roots. This releases vascular neuropeptides including Substance P and others resulting in neurogenic inflammation and vasodilation. Migraine prodrome Migraine Triggers Bowel changes constipation Mood changes depression or euphoria Food cravings Neck stiffness Increased thirst and urination Yawning despite adequate sleep Postdrome-may feel drained or mild elation Caffeine especially withdrawal weekend HA Hormonal changes Ex: Menstral Migraines Specific foods Specific odors Stress Exercise too little or too much inconsistance Weather changes Sleeping in late other sleep disturbances Not eating- missing meals 2

3 Unusual Migraines Differential DX of Migraine Hemiplegic Migraine- mimics stroke with unilateral weakness but comes on slowly over minutes to an hour and lasts less than 24 hrs Occular Migraine-Migraine with loss of vision in one eye (for less than 1 hr) due to vasoconstriction Migraine equivalent or acephalgic migrainegets aura symptoms for less than a hour but without the headache Acute Glaucoma Acute or Chronic Sudural Hematoma Acute severe HTN B9 intracranial HTN (pseudotumor cerebri) Carbon Monoxide poisoning Carotid Dissection Cervical spondylosis Cluster HA Encephalitis Frontal sinusitis Greater Occipital Neuralgia Nonpharmacutical Tx of Migraines Regular sleep same time for bed and awake and adequate sleep Reduce Stress Avoid known food triggers Regular exercise Migraine HA Treatments Mild-Moderate HA Excedrin Migraine Acetamenophen/ASA/ Caffiene NSAIDS Moderate Severe HA Triptans May increase dose Trial of different Triptans Sumatripton/Naproxyn (Trexiamte) Dihydroergotamine Nasal spray (migraine) Consider Isometheptene Nasal Lidocaine Cluster Cluster s Cluster s Severe Unilateral or Orbital (nose and eye) Lasts minutes Often recur same time each day Accompanied by Autonomic Sx Runny nose Eyes red and watering Clusters can last for weeks/months Cluster s 1/1000 adults in the US Onset of Cluster HA age yrs More prevalent in men than women 4:3 ration May include a genetic component 3

4 Cluster Cluster Diagnostic Criteria Pain Quality severe, suicide HA Location Unilateral, temporal or periorbital Frequency 1 episode every day to 8 episodes per day Duration min (untreated) Associated Sxs: At least one Sx involving Eye, nose, or face and Restlessness or Agitation Episodic Cluster 6x more common than chronic cluster HA At least two cluster periods of at least one week but less than one year With remission for at least one month Chronic Cluster At least one cluster period lasting at least one year with no remission or remission for less than a month. Cluster s Triggers Vasodilators ETOH, NTG, histamine Tobacco exposure, HX of personal use or second hand exposure in childhood Treatment of Acute Cluster HA O2 100% via non-rebreather mask l/min for min. Triptan Sumatriptan 6mg S:C may repeat 1x in 1 hr Zolmitriptan 5mg Nasal spray may repeat x1 after 2 hours (or) Zolmitriptan 5mg orally max 10mg /day Lidocaine 10% solution 1ml applied with cotton swab bilaterally into nostrils Octreotide (Sanostain) 10mcg SC Ergotamine 2mg SL, may repeat every 30 min to max of 6mg/day Meds Adverse Effects Tension Type Sumatriptan: dizziness, fatique, nausea, parathesias, vomitting, chest pressure Sumatriptan Nasal spray: Bitter taste Zolmitriptan NS: bad taste, nasal cavity discomfort, somulent Oral Tabs: Asthenia, dizziness, chest heaviness/tightness, nausea, parathesia Lidocaine: Nasal congestion, unpleasant taste The most common form of HA Affects >40% of adult pop. Worldwide Women slightly more than men Nociceptors in pericranial myofascial tissues are likely the sources of the HA Individuals who experience tension type HA have increased sensitivity to pressure, electrical stimuli and thermal stimuli than normal population. 4

5 ICHD-2 Infrequent Tension HA Diagnostic Criteria for Episodic Tension Type s-frequent or Infrequent Frequent: At least 10 episodes occurring on more than one, but fewer than 15 days/mo. for at least 3 months and meeting all the criteria for infrequent episodic tension type headaches At least 10 episodes- occurring fewer than 7 days per month, on average (fewer than 12 days/year) and fulfilling the following criteria: HA lasts 30min 7 days HA has at least 2 of the following features: Bilateral location Pressing or squeezing (non pulsating) Mild or Moderate intensity Not aggravated by routine physical activity like walking or climbing stairs. No nausea or vomiting, either photophobia or phonophobia HA not attributed to another disorder Episodic Tension Type Individuals who meet this ICHDD-2 criteria for Tension type headaches and have normal neurologic exams require NO additional testing or neuroimaging. Abortive Therapies Acetamenophen NSAIDs Tramadol Triptans Occipital block Prophylactic Therapy Chronic Daily HA Amitriptyline: reduces frequency of HA by more than 50% of pain in 46% of 16 wks Tizanidine: 55% reduction in days with severe HA (placebo 21%) and 35% reduction in severity (placebo 20%) and 35% reduction in duration (placebo 9%) Propanolol Valproate (Depokote) Botox: reduces # of HA /mo by 2-3 Defined as the presence of a HA on 15 days or more per month for at least 3 months Most common types of chronic daily headaches are Chronic Tension- type Chronic Migraine Consider discogenic cause of 5

6 Chronic Daily HA All patients should be asked about medication overuse Patients who overuse medication for abortive therapy should be encouraged to stop the medication entirely and consider prophylaxis treatment Treatments/Chronic Daily HA Biofeedback and relaxation techniques Can decrease frequency and severity Cognitive behavioral therapy Individual or group Amitriptyline: decreases frequency & severity SSRI: No proven benefit Tizanidine (zanaflex) some benefit both migraine and chronic tension Gabapentin: increases # of HA free days Valproate (Depokate) decreases rate of HA by 50% Topiramate (topamax) decreases rate of HA by 50% Propranalol reduces frequency of migraines Types of Chronic Daily HA Type of Chronic Daily HA Hypnic: Develops during sleep No autonomic Sx Must have 2 of 3 criteria Occurs more than 15 times/mo Lasts longer than 15 minutes after awakening Onset after age 50 year of age Primary Cough Generalize pain with onset from cough or valsalva; lasts one second to 30 minutes Primary Exertional Pulsating pain lasts 5-48 min brought on by physical exertion R/O secondary cause Primary stabbing headache: Treatment and localized status of pain, felt over orbit, temporal, parital area. Paroxismal Hemcrania: severe unilateral, orbital, supraorbital or temporal. Lasts 2-30min accompanied by ipsilateral symptoms consistant with Cluster headache. More than 5 attacks per day more than ½ the time. Prevented by Indomethacin unlike Cluster headache Thunderclap s Severe headaches that peak within 60 seconds Some start to take after an hour Some can last more than an week Can occur anywhere in the head Can be associated with nausea vomiting or los of conciousness Causes of Thunderclap HA Aneurysm Rupture of blood vessel in the brain Blood clot in the brain Arterial or venous internal tear, Carotid or vertebral artery CSF leak tear around spinal nerve Pituitary bleed or ischemia Severe Intracerebral HTN Meningitis/ Encephalitis These are emergencies 6

7 Testing for Thunderclap HA Case In ER CT with and without dye LP MRI 30 yo woman is seeking treatment for her headaches. She has had HA s since she was 14 yo but now they are more frequent. She has a headache almost daily making it difficult to concentrate at work. The headaches are rightsided and associated with blurred vision and nausea. Oral Sumatriptan used to effectively treat the headache once it starte, but it no longer helps even though she uses it nearly every day now. Her vitals and appearance are normal and the neurologic exam is also normal. What would be a good next step in treatment? Case Treatments Bibliography May choose more than one 1.Indomethacin 2.SSRI 3.Cognative tx and Topamax 4.Elimination of Sumatrystan Hainer BL, Matheson EM. Approach to Acute in Adults. Am Fam Physician may 15:87 (10): Yancey J, Sheridan R, Koren K. Chronic Daily : Diagnosis and Management. Am Fam Physician April 15:89(8): Weaver-Agostoni J. Cluster. Am Fam Physician July 15:88(2): Gilmore B, Michael M. Treatment of Acute Migraine. Am Fam Physician Feb 1:83(3): Up To Date 7