11/10/2017. THE BRIDGE Course Objectives. THE BRIDGE Course Objectives

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1 THE BRIDGE Course Objectives Describe clinical characteristics associated with migraine diagnosis in adult and pediatric populations. Identify barriers and risk factors impacting the clinical course of migraine in adult and pediatric populations. Explain migraine prodrome, aura and headache pain as related to proposed pathophysiologic mechanisms. THE BRIDGE Course Objectives Explain use of acute treatment in an adult and pediatric population. Consider mechanism, appropriate patient selection, administration (timing and route) and potential misuse and/or overuse concerns. Describe preventative treatment strategies in adult and pediatric population. Consider comorbid medical complaints in appropriate medication selection and monitoring. 1

2 THE BRIDGE Course Objectives Describe use of nerve blocks, nerve stimulators and onabotulinumtoxin A in migraine management. Identify evidence-based behavioral and nonpharmacologic strategies useful in managing complex headache patients including post-traumatic headache, medication overuse, complex comorbid illness and childhood disability. Diagnosing Headache in Adults and Adolescents Lynda J. Krasenbaum, MSN, ANP-BC Associate Director New York Headache Center New York, New York Disclosures Allergan: Advisory Board/Promotional Speaker Amgen: Advisory Board TevaPharmaceutical Industries: Advisory Board/Promotional Speaker 2

3 Learning Objectives Understand the diagnostic challenges of headache disorders Learn to collect proper history and physical examination data for appropriate evaluation Identify Red Flags Atypical features Differentiate between Primary and Secondary headaches Determine when and which diagnostic testing is required for an evaluation The Undiagnosed and Underdiagnosed Approximately 36 million Americans suffer with migraines About half of these remain undiagnosed Majority of patients seeking evaluation have Primary Headaches, majority of these are migraine Secondary headaches are less common but cannot be missed 1. Lipton RB, et al. Neurology. 2007;68(5): U.S. Census Bureau, Population Division. Annual Estimates of the Resident Population for the United States. Regions, States, and Puerto Rico: April 1, 2000 to July 1, The Path to Diagnosis Obtain detailed history Perform focused neurological examination Consider all Primary and Secondary Headache disorders Watch for Red Flags Recognize comorbidities and co-existing conditions Assess disability 3

4 Detailed History Age of onset with headache description Frequency and Severity previous and current headaches Location Description Duration Description of Prodrome (which precedes the headache) Description of the Aura, if one exists Associated symptoms Behavior during the headache Trigger factors Rapaport & Sheftell (1996) Additional History Points Past and Current medications for any condition (including nonprescription, supplements, OCPs) Allergies Past and Current medical/surgical history Family history (include any with headaches) Habits (sleep, smoking, caffeine, alcohol and drug use, exercise) Menstrual history and hormonal influences Psychosocial Rapaport & Sheftell (1996) Coexisting Conditions Psychiatric conditions (depression, anxiety, panic attacks, bipolar, PTSD) Sleep disorders (apnea, insomnia, RLS, narcolepsy) Fatigue disorders (fibromyalgia, chronic fatigue syndrome) Inflammatory disorders (Lyme, Lupus, polymyalgia) Vascular disorders (stroke, Raynaud s, arteritis) Asthma IBS PCOS Epilepsy Mitral Valve Prolapse, PFO Orthostatic Hypotension, fainting Motion sickness 4

5 Physical Examination Points General Appearance Vital Signs BP/HR, Temp, BMI Vascular--heart, bruits, pulses Head and Neck--ROM, cervical muscle tenderness, occipital nerve region tenderness, extracranial nerves, TMJs, Temporal arteries (age 50+), Paranasal sinuses Mental Status Cranial Nerves Fundi Visual fields Ocular motility Facial sensation and symmetry Palate/tongue Motor Examination(including cerebellar exam and gait) Sensory Examination Deep Tendon Reflexes Rapaport & Sheftell (1996) Red Flags in History An acute headache vs. recurrent Sudden onset (thunderclap) Onset after age 50 Systemic signs (fever, myalgias, weight loss) Systemic disease (malignancy, AIDS) Change in headache pattern change in frequency/severity Neurological symptoms or abnormal neurological findings cognitive changes Red Flags on Examination Abnormal vital signs increased BP/HR or temp Change in higher intellectual functioning or cognition Alteration in level of consciousness Signs of meningeal irritation (Brudzinski s/kernig s sign) Papilledema swelling of optic nerve indicating elevated ICP Presence of focal neuro signs hemiparesis, hemisensory loss, ataxia or aphasia, signs of brain stem dysfunction, pathological reflexes Rapaport & Sheftell (1996) 5

6 AKA SNOOP S Systemic symptoms (fever, weight loss) or Secondary risk factors (HIV, cancer) N Neurological symptoms or signs (confusion) O Onset: sudden, abrupt O Older, greater than age 50 (giant cell arteritis) P Previous headache history (new or change in frequency, severity, pattern) DodickDW. Adv Stud Med. 2003;3: Red Flags in History/Exam SNOOP S Systemic symptoms (fever, weight loss) or Secondary risk factors (HIV, cancer) N Neurological symptoms or signs (confusion) O Onset: sudden, abrupt O Older, greater than age 50 (giant cell arteritis) P Previous headache history (new or change in frequency, severity, pattern) DodickDW. Adv Stud Med. 2003;3: Primary Headaches Tension Type episodic and chronic Cluster episodic and chronic Migraine episodic and chronic with and without aura 6

7 Long vs. Short Duration Headache Duration > 4 Hours Chronic migraine (transformed migraine) Chronic tension-type headache New daily persistent headache Hemicrania continua Headache Duration < 4 Hours Cluster headache Paroxysmal hemicranias Hypnic headache Idiopathic stabbing headache Adapted from Silberstein SD, et al. Neurology.1996 Tension-Type Headaches General Symptoms: Dull steady ache / band-like distribution Physical activity does not worsen pain Nausea, photo/phonophobiaare not usually present Vomiting never present Treatment: ACUTE: Usually simple analgesics; Acetaminophen/ASA CHRONIC: NSAIDS; biofeedback; may use prophylaxis (tricyclics, etc.) if >15 days per month Cady et al. Headache Free. 1993; Cluster Headaches Attacks: 1-8 per day lasting min Unilateral, periorbital / retroorbital Stabbing and unbearable Conjunctival injection, lacrimation, nasal congestion, rhinorrhea Acute Treatment: Inhaled O 2 >10 L/min x 10-15min Sumatriptan6mg injsc Prophylaxis: verapamil, valproicacid, lithium, prednisone*, occipital nerve blocks* 7

8 Typical Migraine Often one-sided headache Nausea, vomiting Light, sound and smell sensitivity Pain worse with movement Lasts 4-72 hours Aura may precede or accompany headache The Typical Migraine Attack Intensity of Symptoms or Phases Associated Features Prodrome Aura Headache Postdrome Time Migraine w/o aura ICHD-3 β A. At least 5 attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) C. Headache has at least 2 of the following 4 characteristics Unilateral location Pulsating quality Moderate or severe pain intensity Aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs) D. During headache at least 1 of the following: Nausea and/or vomiting Photophobia and phonophobia E. Not better accounted for by another ICHD-3 diagnosis ICHD-3 (beta). Cephalalgia. 2013;33:

9 Migraine w/ aura ICHD-3 β A. At least 2 attacks fulfilling criteria B and C B. 1 or more of the following fully reversible aura sx: 1. Visual 4. motor 2. Sensory 5. brainstem 3. Speech and/or language 6. retinal C. At least 2 of the following 4 characteristics: At least 1 aura sxspreads gradually over 5 min, and/or 2 or more sxoccur in succession Each individual aura symptom lasts 5-60min At least 1 aura sxis unilateral The aura is accompanied, or followed within 60min, by headache D. Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been excluded ICHD-3 (beta). Cephalalgia. 2013;33: Chronic Migraine (CM) ICHD-3 β A. Headache (tension-type-like and/or migraine-like on 15 days per month for >3months and fulfilling criteria B and C B. Occurring in a patient who has had at least five attacks fulfilling criteria B-D for 1.1 Migraine without aura and/or criteria B and C for 1.2 Migraine with aura C. On 8 days per month for >3months, fulfilling any of the following: Criteria C and D for 1.1 Migraine without aura Criteria B and C for 1.2 Migraine with aura Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative D. Not better accounted for by another ICHD-3 diagnosis ICHD-3 (beta). Cephalalgia. 2013;33: Secondary Headaches Increased Intracranial Pressure Brain Tumor Intracranial Hematoma Epidural, Subdural, Intracerebral, Subarachnoid Hemorrhage Arteriovenous malformation (AVM) Cerebral Ischemia Cerebral vein and cavernous sinus thrombosis Pseudotumor Cerebri (Idiopathic Intracranial Hypertension) Acute Angle Closure Glaucoma Internal Carotid Artery Dissection Meningitis Severe Hypertension Headache of Anemia Trigeminal Neuralgia (Tic Douloureux) Fever and Headache Lyme Disease Post-Seizure Headache Headache related to Hypoxia Sexual Headache (Orgasmic or Coital) Post Traumatic Headache Hypoglycemia and Headache Endocrine causes of Headache Giant Cell Arteritis (Temporal Arteritis) Painful Ophthalmoplegia (Tolosa-Hunt) Sinus Headache/Sinusitis Eye Strain Headache Dental Disease TMJ Disorder Allergy and Headache Post ECT Headache Ice Cream Headache Rapaport & Sheftell(1996) 9

10 Diagnostic Testing Head CT severe or sudden headache More accurate in detecting acute SAH or focal bleeding Without contrast to detect blood With contrast to uncover tumors, AVM, other lesions MRI brain chronic headache With contrast tumors, MS, vertigo/tinnitus, pituitary adenomas Without contrast Chiari Malformations Diagnostic Testing MRA brain Arterial Dissection, AVM, Aneurysm MRV brain Venous Sinus Thrombosis Lumbar Puncture Subarachnoid Hemorrhage, High/Low Pressure headache, Meningitis, Pseudotumor Cerebri, other CSF pathology Labs to evaluate for systemic illness, nutritional deficiencies Summary Knowledge of the differences between Primary and Secondary headaches is key Must obtain thorough history and exam Be aware of warning signs and symptoms Distinguish between episodic and chronic headache conditions Majority of patients have primary headaches and the majority of those are migraine 10

11 Thank you for your attention! 11