PREVIEW ONLY 28/08/2013. Andrew Ellis. Professor Michael J Fulham. This webinar will begin in the next few minutes

Transcription

1 This webinar will begin in the next few minutes Need technical support for this live event? Please call , then press 1 NOTE: You will be initially asked for the address associated with this webinar account Say I m a webinar attendee I don t have an account Andrew Ellis BSc (Ex. Sci), M. Phty Headache: Signs, Symptoms and Treatment World Health Webinars CEO World Health Webinars Host Musculoskeletal Physiotherapist Sydney CBD Presented by: Professor Michael J Fulham Neurologist Will commence LIVE from Melbourne, Australia at 8pm AEST Be sure to convert to your own time zone at Click red button to minimise Professor Michael J Fulham You will be muted during every webinar. Make as much noise as you like :) Dodgy computer speakers? Select Telephone and call in toll - FREE to hear the presentation Questions? We ll answer them all at the end Neurologist Clinical Director of Medical Imaging and Head of Department, Royal Prince Alfred Hospital Professor in Sydney Medical School and Adjunct Professor in the School of IT, Faculty of Engineering and Information Technologies, the University of Sydney Directed the PET (molecular imaging) program at RPA since his return to Australia in Published over 170 peer reviewed journal papers and book chapters; is a co-investigator for grants totalling > $7M since Need technical support? Please call , then press 1 You will need to tell them that you are a webinar attendee and do not have an account with Citrix. 1

2 Learning Objectives Headache classification Headache: Signs, Symptoms & Treatment Pathophysiology of headache A neurologist s approach to headache Investigations Worrying symptoms/signs (red flags) Treatment Headache Introduction common, can be disabling, economically costly complex set of These disorders notes with are marked a preview. heterogeneity neurologists tend to Slides see difficult are limited. cases most patients don t seek medical care or are managed by their GP mechanisms still being clarified: genes important familial clustering channelopathies? ion influx disturbs repolarisation specific brainstem areas involved in genesis Headache Classification Classification to improve understanding and aid clinical trials (uniform patient recruitment) Classification - I Classification - II Headache Classification Subcommittee of the International Headache Society nd edition. Cephalalgia, 24 (Suppl 1); Episodic Childhood periodic syndromes 1.4 Retinal migraine 3. Cluster headache and paroxysmal hemicrania 3.1 Cluster 3.2 Paroxysmal hemicrania 3.3 Short lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) 1.5 Complications of migraine 2

3 Classification - III 4. Miscellaneous headaches associated with a structural lesion 4.1 Primary stabbing headache 4.2 Primary These cough headache notes are a preview. 4.3 Primary exertional headache 4.4 Primary headache associated with sexual activity 4.5 Hypnic headache 4.6 Thunderclap 4.7 Hemicrania continua 4.8 New daily persistent headache (NDPH) Classification - IV 5.1 Acute post-traumatic headache 5.2 Chronic post-traumatic headache 5.5 Traumatic intracranial haematoma 5.6 Other head and/or neck trauma 5.7 Postcraniotomy headache Classification - V 6.2 Nontraumatic intracranial haemorrhage 6.3 Unruptured vascular malformations AVMs, dural fistulas 6.4 Arteritis e.g GCA 6.6 Cerebral venous thrombosis 6.7 Other intracranial disorders MELAS, CADASIL Classification - VI 7. Headache attributed to nonvascular intracranial disorders 7.1 High cerebrospinal fluid (CSF) pressure 7.2 Low CSF These pressure notes are a preview. 7.3 Inflammatory Slides disease are (noninfectious) limited. 7.4 Intracranial neoplasm 7.5 Intrathecal injections 7.6 Epileptic seizure 7.7 Chiari type 1 malformation 7.8 Syndrome of transient Headache and Neurological Deficits with CSF Lymphocytosis (HaNDL) 7.9 Other nonvascular intracranial disorders Classification - VII 8. Headache associated with substances or their withdrawal 8.1 Acute substance use or overuse 8.3 Substance withdrawal 9. Headache attributed to infection 9.1 Intracranial infection 9.2 Systemic infection 9.3 HIV/AIDS 6.4 Chronic post-infection headache Classification - VIII 10. Disorder of homeostasis 10.1 Hypoxia / hypercapnia 10.2 Dialysis 10.3 Hypertension 10.4 Hypothyroidism 10.5 Fasting 10.6 Cardiac cephalalgia 10.7 Other disorders of homeostasis 3

4 Classification - IX Classification - X 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures 11.1 Cranial bones 11.2 Neck 11.3 Eyes 11.4 Ears 11.5 Rhino-sinusitis 11.6 Teeth, jaws, and related structures 11.7 Temporo-mandibular joint (TMJ) dysfunction 11.8 Other 12. Headache attributed to psychiatric disorders 12.1 Somatization disorder 12.2 Psychotic disorder 13.1 Trigeminal neuralgia 13.2 Glossopharyngeal neuralgia 13.3 Nervus intermedius neuralgia 13.4 Superior laryngeal neuralgia 13.5 Naso-ciliary neuralgia 13.6 Supraorbital neuralgia 13.7 Other terminal branch neuralgias 13.8 Occipital neuralgia Classification - XI 13. Cranial neuralgias and central causes of facial pain cont d 13.9 Neck-tongue syndrome External compression Cold stimulus Constant pain caused by compression, irritation, or Full distortion notes available of cranial nerves after purchase or upper cervical from roots by structural lesions Optic neuritis Ocular diabetic neuropathy Herpes zoster Tolosa-Hunt syndrome Ophthalmoplegic migraine Central causes of facial pain Simpler Classification Primary and Secondary Primary headache no underlying structural lesion: Migraine Tension-type episodic and chronic Cluster (and related trigeminal/autonomic cephalgias) Neuralgias trigeminal, glossopharyngeal, post-herpetic Other icepick, exertional, sex Simpler Classification Primary vs Secondary Secondary headaches underlying structural lesion(s): Brain tumour Stroke / Aneurysm / dissection / vasculitis Meningitis/encephalitis Cervicogenic Pathophysiology of Headache Hydrocephalus etc 4

5 Pain generation in headache I Pain generation in headache II Pain Pain structures cerebral cortex, ependyma, choroid; much of dura and pia arachnoid; floor of middle cranial fossa, bone structures blood vessels proximal part of the cerebral / dural arteries, large veins, venous sinuses periosteum floor of the ant/middle cranial fossa near MCA, posterior fossa - facet joints, intervertebral discs, ligaments, tendons, nerve roots, muscle Pain generation in headache III Pain (nociceptive) pathways Cutaneous Innervation of the Head & Neck I Trigeminal These nerve notes (V) - tentorium, are a preview. anterior/middle fossae, major vessels and Slides sinuses are limited. C Full 1-3 notes - under available surface of tentorium, after purchase posterior fossa from trigeminocervical complex pons / medulla / upper cervical cord Vagus/glossopharyngeal small contribution in posterior fossa hence pain occasionally back of throat/ear Pain generation in headache IV Trigeminocervical complex the theory hereditary predisposition Ch19 and Ch1 in FHM; heterogeneous external environmental factors (light, red wine, stress ) afferent input internal factors (hormones) afferent input unstable trigeminocervical vascular reflex with a segmental defect in the pain control pathway uses inhibitory neurons on trigeminocervical complex (V and C1-3) 5

6 Pain generation in headache V the theory susceptibility (genetic) to increased neural activation voltage gated channels These (channelopathy) notes are a preview. ascending inputs from spinoreticulothalamic, spinothalamic tracts, cervical afferents descending influences from peri-aqueductal grey midbrain, locus coeruleus in pons to trigeminocervical complex locus coeruleus projects widely to cortex trigeminal activity releases various neuropeptides sterile inflammatory response in vessel various neuropeptides Migraine Migraine Fr origin derives from hemicrania (Gk) 40% bilateral, 40% unilateral, 20% start on 1 side and become generalised an episodic usually throbbing headache, usually accompanied by nausea, photophobia, phonophobia, which may be preceded by focal neurological symptoms ( ) prevalence about 16-17%; W/M 3:2 46% have a family history (parents and siblings); 55% if grandparents considered association with anxiety, depression and epilepsy precipitating factors too much / too little sleep; stress (define stress ); relaxation; hormones perimenstrual; bright lights; certain foods, red wine etc Migraine a lifelong disorder onset in puberty, settles in early adult life, returns with children then abates to return in later life examination normal investigations bright Slides objects are in limited. white matter in migraineurs; activation in brainstem in patients having migraine at time of headache 3 main groups: ( common migraine ) ( classical migraine ) ( migraine equivalent, migraine accompaniment ) 6 main groups with 14 additional sub-groups in ICHD-2 common migraine A. At least 5 attacks fulfilling B to D B. Headache lasting 4-72 hrs (untreated or unsuccessfully treated) C. Headache with at least 2 of: unilateral pulsating moderate/severe intensity aggravated by routine physical activity D. During headache, at least 1 of: nausea and / or vomiting photophobia and phonophobia E. Not attributable to another disorder / syndrome classical migraine A. At least 2 attacks fulfilling B to D B. Aura consisting of at least 1 of: fully reversible These visual notes symptoms are a (+ve preview. and/or ve features) fully reversible sensory symptoms (including +ve and/or ve features) fully reversible aphasic speech disturbance neurological symptoms usually develop over 2 5 mins and last < 60 mins - usually visual fortification spectra (+ve) can be followed by scotoma (-ve) may be premonitory symptoms elation, confusion, cravings, irritability 6

7 Tension-type headache Tension-type headache constant tight or pressing sensation, usually bilateral; usually episodic and then chronic; not associated with nausea or vomiting or neurological symptoms or signs; photophobia or phonophobia can be present but ; not aggravated by physical activity headache bilateral in 80-90% pain dull, persistent; undulates in intensity throughout the day; often described as a tightness or heaviness rather than a pain can be present on waking and also can awaken from sleep; relieved by alcohol cf. vascular headaches prevalence unclear episodic tension headache probably very common single event (30+%); chronic tension headache about 2% patients may have a number of different headaches (10-15% also have migraine) Tension-type headache tension-type headache a continuum of migraine 40% have a family history of headache women > men (2x) associated with stress Slides (definition are of limited. stress) anxiety and depression more common inability to cope with life s daily pressures Neurological examination but many patients have signs of muscle over-contraction teeth clenching, frowning, teeth grinding, abnormal posture of head and neck pain on palpation over scalp, sub-occipital muscles, TMJs some evidence for a primary failure in the central pain-control pathways Headache due to head / neck trauma Headache attributed to head and / or neck trauma Cervicogenic headache ICHD-2 related to severity of injury and acute or chronic (> 3 mths) Post-traumatic headache resembles: tension-type 85% cervicogenic 8% migraine 2.5% Difficult area mild head injury in 75% but in 25% of these headache persists at 4 yrs post injury physical (nature of injury facet joint?), psychological and medicolegal (litigation-compensation) aspects Sjaastad et al 1990 episodic unilateral headache lasting 3hrs to a week, recurring from 2 day to 2 month intervals arising from cervical spine women > men precipitated by neck movement sometimes with nausea, vomiting, photophobia (cf migraine) Revised 1998 to include: blocked by local anesthetic Lesion in the cervical spine capable of producing the headache pain resolves after 3 months after successful treatment 7

8 Chronic Headache Definition headache for more than 4 hours for > 15 days Difficult Main causes Transformed Full notes available migraine/chronic after migraines purchase from Hemicrania continua (indocid) Persistent idiopathic facial pain Non paroxysmal neuralgia New daily persistent headache A neurologist s approach to headache Patient History Careful history critical /takes time (taken not given) / balance between listening and leading Essentials: onset age / mode (warning symptoms elation; irritable; vague; yawning; cravings / aura / speed of onset (acute / subacute /chronic) frequency and duration (precision) relapses and remissions; days / hours characteristics location and radiation occipital / eye / frontal / neck uni- or bilateral Quality Patient History constant aching stabbing throbbing Associated symptoms nausea / vomiting photo- / phonophobia neurological visual scintillations / aphasia / vertigo /paraesthesia / Horner s syndrome etc scalp / neck tenderness Patient History Aggravating / relieving factors posture head movement coughing/sneezing (raised ICP) quiet / dark environment (migraine) analgesia (amount and type) Investigations Previous treatment - type / dose / duration of medications Other medications (drug related headache eg imdur, indocid) Family history General Health and social circumstances 8

9 Investigations Controversial good history and clinical examination (normal) sufficient increasing reliance on tests vs. taking a history and performing Full notes a clinical available exam after purchase from patient concern about underlying serious disorder first Case Histories MR brain excludes a structural lesion CT cervical spine if relevant history and clinical findings Case #1 : Carotid Dissection headache Case #1 : dissection of R internal carotid artery 45 M Qantas executive Onset of R sided throbbing headache, more severe than usual migraine, lasted 3 days rather than 1 and had an episode of word finding difficulty on 3 rd day that lasted 60 mins. Three months earlier had been held up in office in Buenos Aires; gun held to side of head for at least 4 hours until robbers left. FH sister has migraine; PMH migraine without aura unilateral headache with nausea; lasted for a day; occasionally would need to go home from work. Otherwise well. OE R handed; R Horner s syndrome no other focal neurological signs Investigations CTA, MR brain R L Case #2 : Cervicogenic headache 68 W retired RN; MVA 7 yrs ago, no loss of consciousness but neck pain for some mths afterwards infrequent throbbing, unilateral headache with visual scintillations and nausea; also tight discomfort in neck / occipital region; she feels it is related to neck movement, radiates to her R eye, no nausea; worse since March this year; present most days but worse when she moves her head quickly FH mother / elder sister migraine; PMH - lumbar back pain - treated with physio and facet joint injections and Pilates for a short time OE asymmetric, tilted to R, with restricted head movements both sides but more on left; no focal neurological signs; tender scalp on right and also at base of neck Investigations MR brain, CT cervical spine 9

10 Case #2 : degenerative changes in C1-C2, C4-C5, C6-C7 and also upper cervical facets joints Case #3 : tension-type headache 68 M retired carpenter; fell from a building site in his 30s neck and backache at the time; settled head and neck ache worse in past 5 years aching, tight discomfort, begins in the neck and radiates to vertex; starts in the morning and gets progressively worse through the day; not throbbing; exacerbated by noise and bright lights both sides, never unilateral; Full no associated notes available nausea / vomiting; after purchase no aura; can from last hours to days; had tried simple analgesics (now reliant on codeine forte), tryptanol, epilim, sandomigran, methysergide PMH former smoker, severe emphysema (headache worse with chest infections) OE miserable, complaining but no focal neurological signs Investigations MR brain, plain films cervical spine Case #3 : emphysema, undisplaced # of C2 Worrying Signs & Symptoms 10

11 Warning symptoms / signs (red flags) patient is unwell - fever, anorexia, weight loss, myalgia - giant cell arteritis (temporal arteritis), CNS infection, metastatic disease Other neurological symptoms/signs (cf migraine aura) - including stroke, dissection Full notes headache available not after my usual purchase headache, from worst headache I have ever had haemorrhage intracerebral / SAH Onset Headache worsened by (Valsalva) structural lesion in CSF pathways / CSF leak; Chiari malformation Headache worse on standing / lying intracranial hypotension and hypertension (raised ICP structural lesion) Treatment Treatment Accurate diagnosis Patient explanation mechanisms, triggers, drug actions Main areas for PT tension-type Slides are headaches, limited. neck pain / neck induced headache relaxation therapy physio including mobilisation - in patient with neck pain medications (other than analgesics) Therapy in migraine and other disorders not in scope interval and prophylactic Conclusions Headaches are heterogeneous disorders A careful history is essential Chronic headache is a difficult to manage Trigeminocervical complex plays an important role in the generation and perpetuation of headache Therapy is multi-faceted avoidance of precipitating factors stress relief relaxation, exercise physical therapy medications References Headache Classification Subcommittee of the International Headache Society nd edition. Cephalalgia, 24 (Suppl 1); Lance JW, Goadsy PJ. Mechanism and Management of Headache. 7 th Ed. Philadelphia, Elsevier; Silberstein SD, Lipton RB. Wolff s Slides Headache are and limited. other head pain. 8 th Ed. New York, Oxford University Press;2008. Goadsby PJ, Hargreaves Full notes R. Refractory available migraine after and chronic purchase migraine: Pathophysiological from mechanisms. Headache 2008; 48: Sjaastad O et al. Cervicogenic headache: Diagnostic criteria. Headache 1998; 38: Sjaastad O et al. Cervicogenic headache: Diagnostic criteria. Headache 1990; 30: Olesen J, Tfelt-Hansen, Welch KMA. The Headaches. 2 nd Ed. Philadelphia, LWW; Saper JR. Posttraumatic headache. A neurobehavioural disorder. Arch Neurol; 2000; 57: Drottning M et al. Cervicogenic headache after whiplash injury. Cephalalgia 2002; 22L Live Q & A With Michael Fulham 11

12 Coming up next week Facebook, Twitter, LinkedIn, Google + Live Q & A With Michael Fulham Thank you From Michael Fulham & World Health Webinars Australia 12