How to remove the headache of dealing with headaches. Dr. Stefan Schumacher Consultant Neurologist Salford Royal Hospital

Transcription

1 How to remove the headache of dealing with headaches Dr. Stefan Schumacher Consultant Neurologist Salford Royal Hospital

2 Case 30 y old woman Sudden headache Vomiting, dizziness, photophobia Recurrent migraines last 10 years Alert, neck stiffness, photophobia, no focal neurology Next step? Ceftriaxone, Aciclovir 5 h later : GCS 10 R hemiparesis DR STEFAN SCHUMACHER, PALL MALL MEDICAL 2

3 Investigations WCC mild increased, CRP 40 Rest Bloods NAD CT brain with GAD : NAD MR : NAD LP : NAD Transfer ICU Swinging fever Variable R hemiparesis DR STEFAN SCHUMACHER, PALL MALL MEDICAL 3

4 Differentials SAH CNS infection Sinus thrombosis Arterial dissection Cerebral vasculitis Hypertensive encephalopathy???? This lady completely recovered after 7 days! Diagnose??? DR STEFAN SCHUMACHER, PALL MALL MEDICAL 4

5 Migraine coma with hemiplegia First described by Charcot in 19th century Recurrent coma and hemiplegia Begins often in childhood or early adulthood Headache, fever, meningism, fluctuating consciousness levels Leucocytosis, occas. CSF cells increased Often family condition Pathophys.? Metabolic abnormality leading to transient neuronal dysfunction Prognosis good DR STEFAN SCHUMACHER, PALL MALL MEDICAL 5

6 Framework International Classification of Headache Disorders : primary syndromes Migraine Tension Type Cluster and other trigeminal autonomic cephalgias Other primary headaches DR STEFAN SCHUMACHER, PALL MALL MEDICAL 6

7 Framework... : secondary headache syndromes due to : Head and neck trauma Cranial or cervical vascular disorder Non-vascular intracranial disorder A substance or its withdrawal Infection Disorder cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures Psychiatric disorders DR STEFAN SCHUMACHER, PALL MALL MEDICAL 7

8 Key questions Periodicity Associated features Behaviour during headache Family history Current medication Social situation / stressors What the patient thinks DR STEFAN SCHUMACHER, PALL MALL MEDICAL 8

9 Migraine : long-lasting health issue UK : 190,000 migraine attacks every 24 hours Patients have an average of 13 attacks per year Costs may be for UK economy more than 2 billion pounds per year DR STEFAN SCHUMACHER, PALL MALL MEDICAL 9

10 Migraine Prodrome Aura Headache Associated features Frequency Triggers Hormones DR STEFAN SCHUMACHER, PALL MALL MEDICAL 10

11 Migraine : unusual subtypes Basilar-type Hemiplegic Childhood periodic Ophtalmoplegic Menstrual DR STEFAN SCHUMACHER, PALL MALL MEDICAL 11

12 Migraine : complications Medication overuse Chronic Status migrainous Persistent aura without infractation Migrainous infarctation Migraine triggers seizure DR STEFAN SCHUMACHER, PALL MALL MEDICAL 12

13 Headache : others Tension-type Trigeminal autonomic cephalgias Cluster headache Paroxysmal hemicrania Hemicrania continua SUNCT ( short-lasting unilateral neuralgiform headache with conjunctival injection and tearing ) Headache associated with coughing, sexual activity DR STEFAN SCHUMACHER, PALL MALL MEDICAL 13

14 New daily persistent headache Raised intracranial pressure Low cerebrospinal fluid volume Chronic meningoencephaltis Post brain insult DR STEFAN SCHUMACHER, PALL MALL MEDICAL 14

15 Secondary headache syndromes not to miss Giant cell (temporal) arteriitis Depression Cervicogenic DR STEFAN SCHUMACHER, PALL MALL MEDICAL 15

16 Migraine : preventative treatment Propanolol mg Others (Metoprolol,Atenolol,Timolol,Nadolol) Sodium Valproate mg/day Topiramate 100 mg/day Gabapentin up to 1800 / day Amitryptyline 25 mg Pizotifen (1,5-3 mg/day) Flunarizine 5-10 mg/day Methysergide up to 12 mg/day DR STEFAN SCHUMACHER, PALL MALL MEDICAL 16

17 Migraine : symptomatic treatment Aspirin Ibuprofen Ergotamine Opiates Triptanes DR STEFAN SCHUMACHER, PALL MALL MEDICAL 17

18 Triptans Sumatriptane (Imigran) 25,50 and 100 mg 25mg supp mg nasal spray 6 mg subcut. Zolmitriptane (Zomig, AscoTop) 2,5+5 mg oral 2,5+5 mg nasal Naratriptan (Naramic) 2,5 mg oral Rizatriptan (Maxalt) 10 mg oral (incl. water form) Almotriptan (Almogran)12,5 mg oral Eletriptan (Relpax) 20 and 40 mg oral Frovatriptan (Migard) 2,5 mg oral DR STEFAN SCHUMACHER, PALL MALL MEDICAL 18

19 Triptanes : half-life (hours) Frovatriptan 26 hrs Naratriptan 6 hrs Eletriptan 4 hrs Almotriptan 3,5 hrs Zolmitriptan 2,5-3 hrs Rizatriptan 2-3 hrs Sumatriptan 2 hrs DR STEFAN SCHUMACHER, PALL MALL MEDICAL 19

20 General guidelines for Triptanes use Taking early!! In the very onset, not aura! Frequent drug treatment? Drug overuse headache Mx. 10 tbl. monthly (?) DR STEFAN SCHUMACHER, PALL MALL MEDICAL 20

21 Triptanes : contraindications Untreated arterial hypertension Coronary heart disease Raynaud s disease Ischaemic stroke Pregnancy Lactation Severe liver or renal failure DR STEFAN SCHUMACHER, PALL MALL MEDICAL 21

22 DR STEFAN SCHUMACHER, PALL MALL MEDICAL 22

23 DR STEFAN SCHUMACHER, PALL MALL MEDICAL 23

24 Subarachnoid haemorrhage Incidence : ~6-8 per 100,000 population Prevalence : 1.6% ~30% will die as a result of the initial bleed or its immediate complications ~~30% of the survivors will be severely disabled Once ruptured, risk of re-rupture is ~50% in the first 4 weeks, with a 50% mortality Importance of early diagnosis NOT EVERY ANEURYSM WILL RUPTURE DR STEFAN SCHUMACHER, PALL MALL MEDICAL 24

25 Subarachnoid haemorrhage Clinical presentation : worse ever headache, +/- focal deficits, decreased conscious levels, meningism 10-30% have more than one CT : first line of investigation If negative, requires lumbar puncture CT cerebral angiogram accurately identifies the aneurysm, If patient presents late, CT is negative or clinical history is in doubt, MRI & MR angiogram is used DR STEFAN SCHUMACHER, PALL MALL MEDICAL 25

26 Subdural haemorrhage Usually related to trauma May be acute or chronic Due to shear-strain forces, the bridging cortical veins may be torn Typically hyperdense crescentic rim over cerebral convexity Does not cross the dural attachment, eg. falx Convexity subdural bleed DR STEFAN SCHUMACHER, PALL MALL MEDICAL 26

27 Subdural haemorrhage Subacute SDH Acute-on-chronic SDH DR STEFAN SCHUMACHER, PALL MALL MEDICAL 27

28 Case 45 y old female No prior headache Healthy ( Colitis ulc.) Sudden thunderclap headache with nausea, vomiting, no improvement with strong analgetics CT head, Bloods, LP, Mr Brain NAD DR STEFAN SCHUMACHER, PALL MALL MEDICAL 28

29 Your diagnosis???

30 Axial T1 Axial T1 Sagittal T1 DR STEFAN SCHUMACHER, PALL MALL MEDICAL 30

31 Sinus venous thrombosis

32 Dural venous sinus thrombosis Important condition to exclude in those with predisposing factors No definite aetiology in 25% Venous infarction is typically subcortical and haemorrhagic, and does not conform to a vascular (arterial) territory Predisposing factors haematological disorders paraneoplastichypercoagulability pregnancy, puerperium, oral contraceptives dehydration esp in infants underlying inflammatory conditions, such as ulcerative colitis & Behcet s disease DR STEFAN SCHUMACHER, PALL MALL MEDICAL 32

33 Case Male, 30 y 10 days : sudden headache, depression, apathy Afebrile, GCS 15/15,MMSE 30/30 Hb 13, WBC slightly increased CRP 30 CT brain : NAD LP : Protein 0,8, cells : 15 (mainly Lymphocytes) Next day increasingly confused, plantars up. Temp 38,7, intermitt. unresponsive, restless, confused, R ptosis DR STEFAN SCHUMACHER, PALL MALL MEDICAL 33

34 Temporal lobe changes extending up to insula and subfrontal region, but sparing the basal ganglia; typically bilateral but asymmetric involvement DR STEFAN SCHUMACHER, PALL MALL MEDICAL 34

35 Encephalitis Meningitis is usually diagnosed clinically with confirmatory evidence on LP Many different types of viral encephalitis Herpes simplex type 1 encephalitis is the most common cause of fatal sporadic viral encephalitis (~90% of cases are in adults) Others : EBV, CMV, VZV Clinically present with non-specific symptoms of headache, confusion & disorientation DR STEFAN SCHUMACHER, PALL MALL MEDICAL 35

36 Useful websites British Association for the Study of Headaches (BASH) : International Headache Society : Migraine Action Association : Migraine Trust : Organisation for the Understnding of Cluster Headache : DR STEFAN SCHUMACHER, PALL MALL MEDICAL 36

37 NW Headache Final V Approved by GMMMG June Review date: June DR STEFAN SCHUMACHER, PALL MALL MEDICAL 37

38 Emergency Symptoms/signs Thunderclap onset Accelerated/Malignant hypertension Acute onset with papilloedema Acute onset with focal neurological signs Head trauma with raised ICP headache Photophobia + nuchal rigidity + fever +/-rash Reduced consciousness Acute red eye:?acute angle closure glaucoma New onset headache in: 3rd trimester pregnancy/early postpartum Significant head injury especially elderly patients, alcohol dependency, people on anticoagulants DR STEFAN SCHUMACHER, PALL MALL MEDICAL 38

39 Giant Cell arteritis Incidence 2/10,000 per year Consider with presentations of new headache in >50 year olds Many headaches respond to high dose steroids NB do not use response as the sole diagnostic factor. ESR can be normal in 10% - check CRP as well Symptoms may include: jaw/tongue claudication, visual disturbance, temporal artery: prominent, tender, diminished pulse; other cranial nerve palsies, limb claudication Urgent referral to: Rheumatology if diagnosis clear Neurology if headache or possibly GCA Ophthalmology if amaurosis fugax / visual loss / diplopia NOT migrainous auras DR STEFAN SCHUMACHER, PALL MALL MEDICAL 39

40 2WW - suspected cancer referral Headaches with features of raised intracranial pressure: Actively wakes a patient from sleep, but no migraine or cluster Precipitated by Valsalva manoeuvres i.e. cough, straining at stool Papilloedema Other symptoms of raised ICP headache including: HA present upon waking and easing once up ad worse when recumbent Pulse synchronous tinnitus Episodes of transient visual loss when changing posture e.g. upon standing Vomiting-significance should be judged in context as nausea and vomiting are features of migraine HA with new onset seizures HA with new or persistent neuro deficit Relevant history of malignancy (metast.?) Vomiting without other obvious cause DR STEFAN SCHUMACHER, PALL MALL MEDICAL 40

41 Red flags (for secondary headaches) HA rapidly increasing in severity and frequency despite approbiate treatment Undifferentiated HAS(not migraine/tension HA) of recent origin and present for > 8 weeks Recurrent HA triggered by exertion Orthostatic HA (HA in upright position,? low CSF pressure?) New onset HA in : > 50 y old (giant cell arteritis?) Immunosuppressed / HIV DR STEFAN SCHUMACHER, PALL MALL MEDICAL 41

42 Botox (NICE TA260) Between 31 and 39 injections i.m. around scalp and neck every 12 weeks Minimum treatment criteria : Chronic migraine i.e. > 15 HA days/month of which >8 are migraine for a minimum of 3 consecutive months Tried 3 different migraine preventatives at maximally tolerated doses for 3 months each not including Pizotifen Not overusing triptans, opiates or other analgetics DR STEFAN SCHUMACHER, PALL MALL MEDICAL 42

43 THANK YOU VERY MUCH