Headache Dr. Asghari Neurologist

Transcription

1 In the name of God Management of the Headache Dr. Asghari Neurologist

2 Overall Approach Chief Complaint of Headache Headache Alarms Evidence of serious headache disorder by history or physical exam no Diagnosis of Primary Headache Disorder yes Treatment yes Work-up to identify/exclude secondary headache etiology no Consider work-up for secondary headache

3 History Frontal, occipital, facial? Unilateral or bilateral? First or worst? Sudden onset or gradual? Aching or sharp, pulsatile or steady, shocklike or tightness? Worsening or improving? Previous similar headache? Time to reach to peak of the pain?

4 History Nausea, vomiting, altered consciousness, flushing, lacrimation, falling, neck stiffness, photophobia, phonophobia, dizziness, blurred vision, diplopia? Frequency? Missed work or school or sleep disturbance? Precipitating and aggravating factors such as trauma, exertion, noise, position, foods, drugs, weather, anxiety, and menstruation?

5 History Relieving factors such darkroom, position, pressing on scalp, and medications? Family history of headache? Head trauma? Is the patient taking any medications? Medical history (HTN, vasculitis, cancer, HIV )? Recent procedure (LP)? Change in medications?

6 Physical Exam Vital signs (fever, hypertension, pulse) Head and face (trauma, bruise, sinus tenderness, temporal tenderness, CSF rhinorrhea) Eyes (conjunctiva, cornea, raccoon eyes) Ears (OM, hemotympanum, Battle s sign) Mouth (dental abscess, TMJ tenderness ) Neck (pain, tenderness, rigidity, muscle spasm, Kernig s and Brudzinski s signs, carotid bruit) Skin (rash)

7 Physical Exam Neurological Level of consciousness Pupils, visual acuity and fields, eye movements Fundi and discs (papilledema, retinal hemorrhages) Reflexes and Babinski s sign Gait Any other focal neurological deficits (motor and sensory paralyses, Horner's syndrome, ataxia )

8 Headache Alarms Onset after age years Sudden onset New onset with risk factors for HIV or cancer Associated with systemic illness (fever, meningismus, rash, weight loss) Altered consciousness (confusion or delerium) Papilledema

9 Significant trauma Headache Alarms Abnormal neurological symptoms and examination Abnormal vital signs, e.g., Cushings reflex First/worst (severe) headache Associated seizures Major change on headache character for those with chronic recurrent headaches

10 Overall Approach Chief Complaint of Headache Headache Alarms Evidence of serious headache disorder by history or physical exam no Diagnosis of Primary Headache Disorder yes Treatment yes Work-up to identify/exclude secondary headache etiology no Consider work-up for secondary headache

11 Migraine (without aura) (IHS Criteria) Five or more lifetime headache attacks each of them lasting 4-72 hours if untreated or unsuccessfully treated and symptom-free between attacks

12 Migraine (without aura) (IHS Criteria) Pain characteristics (at least 2) Unilateral pain Pulsating quality Moderate to severe intensity Aggravation by walking stairs or similar routine physical activity Associated symptoms (at least 1) Nausea, vomiting, or both Photophobia or phonophobia H&P and diagnostic tests do not suggest underlying organic disease

13 Migraine (with aura) (IHS Criteria) Aura characteristics (At least 3 ) One or more fully reversible aura symptoms indicating focal cerebral cortical or brain stem dysfunction At least 1 aura symptom develops gradually over >4 minutes or 2 or more symptoms occur in succession No single aura symptom lasts > 60 minutes Headache begins within 60 minutes of aura onset

14 Migraine Management Pharmacotherapy Abortive therapy non-specific (milder attacks) Specific (moderate to severe attacks) Preventive therapy Non-pharmacological treatment Identification of triggers Meditation Relaxation training Psychotherapy

15 Migraine Abortive Treatment Should usually be started as early in the development of an attack as possible, to relieve the pain, nausea, and vomiting. Once the attack is fully developed, oral agents are almost always less effective because of decreased GI motility and poor absorption, if vomiting develops oral preparations are no longer appropriative. Match agent to headache intensity. Prescribe an adequate dose. Consider the route.

16 Non-specific drugs Migraine Abortive Treatment For many patients, a simple oral analgesic may be effective: NSAIDs Aspirin Acetaminophen Analgesic combinations with caffeine Butalbital Induction of sleep, control of nausea, simple analgesics, and other non-narcotic agents should be more widely used.

17 Migraine Abortive Treatment Specific agents- Triptans (5-HT receptor agonists) Sumatriptan (Imitrex) Tablets (25mg, 50mg, 100mg) Injection (6mg) Nasal Spray (5mg, 20mg) Zolmitriptan (Zomig) Tablets (2.5mg, 5mg) Nasal Spray Rizatriptan (Maxalt) Tablets (5mg, 10mg) Naratriptan, Almotriptan, Frovotriptan, Eletriptan

18 Migraine Abortive Treatment Specific agents- Ergot alkaloids Ergotamine Tablets (1mg, 2mg) with and without caffeine 100mg Dihydroergotamine (DHE) Tablets(2.5mg) Injection(1mg/ml) Nasal spray(4mg/ml)

19 Migraine Abortive Treatment Specific treatment Drug Dose Route Ergot alkaloids Ergotamine..1-2 mg/d, max-6 mg/d Oral Dihydroergotamine mg.sc 5-HT receptor agonists Sumatriptan mg Oral 6 mg..sc Rizatriptan 10 mg Oral

20 Migraine Abortive Treatment Anti-nauseant drugs Metoclopramide 5-10 mg Oral/IV Promethazine mg Oral/IM Chlorpromazine mg Oral/IV Domperidone mg Oral

21 Migraine Abortive Treatment What to Do When Therapy Fails IV DHE/prochlorperazine or metoclopramide IV or IM droperidol/diphenhydramine versus lorazepam IV divalproex (Depacon) IM ketorolac (Toradol) Steroids IV chlorpromazine (Thorazine) Parenteral narcotics

22 Migraine Prophylactic Therapy Prophylactic medications are prescribed to prevent or reduce the number of attacks in patients who experience frequent migraines, typically three or more per month.

23 Migraine Prophylactic Therapy According to the US Headache Consortium Guidelines, indications for preventive treatment include: Patients who have very frequent headaches Attack duration is > 48 hours Headache severity is extreme Migraine attacks are accompanied by prolonged aura Unacceptable adverse effects from acute treatment Contraindication to acute treatment Migraine substantially interferes with the patient s daily routine, despite acute treatment Special circumstances such as hemiplegic migraine or attacks with a risk of permanent neurologic injury Patient preference

24 Specific agents: Migraine Prophylactic Therapy Beta blockers Propranolol, Atenolol TCAs Amytriptyline, Nortriptyline, Doxepin Calcium channel blockers Verapamil, Nifedipine Anticonvulsants Valproic acid, Topiramate, Zonisamide Serotonin agents Methysergide (antagonist)

25 Migraine Prophylactic Therapy Beta blockers Gold standard and established efficacy (in 55-93% of patients) and safety in migraine prophylaxis Propranolol ( mg/d) If satisfactory response is not obtained within 4-6 weeks, after reaching the maximal dose, therapy should be discontinued. Taper slowly to avoid rebound headache and adrenergic side effects. Atenolol ( mg/d) Timolol (20-40 mg/d) Metoprolol ( mg/d)

26 Migraine Prophylactic Therapy TCAs Antidepressant are believed to have a possible effect on noradrenaline and serotonin or possible analgesic effect. They are useful in the prevention of tension H/A too. Amitriptyline ( mg/d) Nortryptiline ( mg/d) Doxepin (10-75 mg/d)

27 Migraine Prophylactic Therapy Anticonvulsants These agents are probably the most promising for the preventive regimens currently available for migraine. Sodium valproate ( mg/d) Short latency to onset of therapeutic action Side effects: nausea, alopecia, weight gain, tremor, sedation Contraindicated in pregnancy Topiramate ( mg/d) Zonisamide ( mg/d)

28 Migraine Prophylactic Therapy Calcium channel blockers Calcium channel blockers are also used to decrease the frequency of migraine attacks. It is thought that calcium blockers play a role in vessel constriction by preventing spasm of arteries by inhibiting contraction of smooth muscle. Verapamil ( mg/d) Nifedipine ( mg/d)

29 Migraine Prophylactic Therapy Other drugs Methysergide (2-6 mg/d) has been proved to be an effective prophylactic agent for migraine although it has potential for producing serious complications. Cyproheptadine (4-16 mg/d) may be useful in some patients particularly in preventing attacks of perimenstrual migraine.

30 Migraine Non-pharmacological treatment Migraine Triggers Foods Disturbed sleep pattern Hormonal changes Drugs Physical exertion Visual stimuli Auditory stimuli Olfactory stimuli Weather changes Hunger Psychological factors

31 Migraine Non-pharmacological treatment Trigger Management Is important in preventing migraine attacks To avoid stress and relax more. To reduce excessive caffeine intake. To stop smoking and reduce alcohol intake. To D/C drug known to cause H/A such as reserpine, indocid, theophylline, long acting nitrites, estrogens and OCP To avoid prolonged fasts and irregular sleeping habits To avoid foods containing nitrites, (hot dogs) & prepared foods containing MSG, etc (cheeses, red wine, chocolate, chicken liver, pork containing tyramine & phenylethylamine)

32 Duration 30 min to 7 days Tension Headache (IHS Criteria) Pain characteristics (at least 2) Pressing/tightening quality Mild to moderate severity Bilateral location No aggravation by routine physical activity Associate symptoms (Must have both) No vomiting No more than one of: nausea, photophobia, phonophobia H&P and diagnostic tests do not suggest underlying organic disease

33 Non-pharmacological Massage Meditation Biofeedback Tension Headache Treatment Pharmacological Acetaminophen Aspirin NSAIDs (Diclofenac, Ibuprofen, Naproxen) If above drugs alone fail, addition of combination analgesics may be effective (Caffeine, Butalbital) Prophylaxis for chronic type (>15 days/month) Amitriptyline ( mg/d) Nortryptiline ( mg/d) Doxepin (10-75 mg/d)

34 Cluster Headache (IHS Criteria) Duration 15 to 180 minutes untreated Pain characteristics Severe unilateral orbital, supraorbital, or temporal pain Associated symptoms (at least 1, ipsilateral to pain) Conjunctival injection, Lacrimation Nasal congestion, Rhinorrhea Forehead and facial swelling Miosis, Ptosis Eyelid Edema Frequency: between 1 every other day to 8/day

35 For the attacks Cluster Headache Treatment Inhalation of 10 L/min of 100% oxygene,10-15 minutes. Intranasal Lidocaine (sphenopalatine ganglion block) or Sumatriptan. Sumatriptan 6 mg SC shortens an attack to minutes.

36 Cluster Headache Treatment Prophylaxis until the bout is over Nocturnal attacks: single oral dose of Ergotamine (2 mg) at bedtime. Prednisone (60 mg/d) for 7 days, rapidly tapering up to 10 days. Ergotamine 1-2 times daily at times when attack is expected. Lithium ( mg/d) particularly effective in chronic form. Verapamil ( mg/d) Valproate ( mg/d) Topiramate ( mg/d)

37 Overall Approach Chief Complaint of Headache Headache Alarms Evidence of serious headache disorder by history or physical exam no Diagnosis of Primary Headache Disorder yes Treatment yes Work-up to identify or exclude secondary headache etiology no Consider work-up for secondary headache

38 Secondary Headaches Vascular (SAH, ICH, dissection, rarely stroke) Infectious (meningitis, sinusitis, post-herpetic neuralgia) Post-traumatic (post-concussion) Elevated ICP (mass, HTN, pseudotumor) Decreased ICP (post-lp) Inflammatory (temporal arteritis) Drug-related (nitrates, caffeine withdrawal) Systemic/metabolic disorders (hypercalcemia, anemia, renal failure, hypoxia or hypercapnia) Ophthalmologic (glaucoma, eye strain, ischemia)

39 Diagnostic Studies CT scan (mass lesion, ICH,SAH, tumor, abscess, AVM) MRI/MRA (mass lesion, dissection, AVM, aneurysm, venous thrombosis, vasculitis) Lumbar puncture (meningitis, SAH, intracranial hypertension) Angiography (aneurysm, AVM, venous thrombosis, dissection) Laboratory studies (CBC, ESR, serum glucose, electrolytes, drug screens)

40 Which patients require Neuroimaging? Headache and focal neurologic deficit Headache of sudden, rapid onset HIV and new headache First or worst headache of life New or different headache after age Increasing severity History of malignancy or immunosuppression Focal neurologic deficits or seizures

41 Indications for LP Suspected SAH in a patient with a normal head CT CT is 90 98% sensitive for acute SAH Sensitivity decreases over time Suspected meningitis LP without CT in patients with normal neuro exam including normal mental status and normal fundoscopic exam Suspected idiopathic intracranial hypertension Headache with papilledema Normal CT and MRI

42 Case 1 28 years old obese female presents with daily bad headaches, involve her entire head and feel like pressure. Several times this week she has lost her vision in both eyes for a period of seconds. Positive findings on the physical examination: Bilateral papilledema Left 6th cranial nerve palsy

43 Case 1 A noncontrast head CT was obtained which was normal. Lumbar puncture: Opening pressure 320 mm H 2 O, No cells, Normal protein and glucose. MRI and MRV were normal.

44 Case 1 Diagnosis of idiopathic intracranial hypertension was made.

45 Pseudotumor Cerebri Syndrome defined by signs and symptoms of high ICP without apparent intracranial mass or hydrocephalus. Papilledema 100% Headache 94% Visual disturbance 80% Transient visual obscuration 68% 6 th cranial nerve palsy 38% Decreased visual acuity 30% Blindness 10% If the condition goes untreated, progressive visual loss can occur.

46 Treatment (Pseudotumor) The patient s headache improves after drawing of 30 cc of CSF. How should this patient be managed from this point? Correct predisposing factors Many patients respond to serial LP s Weight loss, referral to dietician Refer to optometrist for visual field and acuity testing Diamox 1-2 g divided bid-tid, Prednisone mg/day, or Lasix mg divided bid

47 Treatment (Pseudotumor) What about prognosis? 1/3 of patients have spontaneous remission of headache after the first LP. Course is usually self-limited (<1 year), but may recur. If visual loss progresses or acutely worsens despite medical therapy: Optic nerve fenestration (poor long-term success reported) LP or VP shunting (both also reported to have high failure rates over the long-run) Last resort is craniotomy and dural flap

48 Case 2 45 years old woman presents 2 days after the onset of a severe headache involves the entire head. The headache came on in and reached its maximum severity in about 3-5 minutes. One days after the onset her neck and shoulders seemed stiff. There is history of prior similar, but less intense headache 10 days ago. Examination is normal except for BP 170/85 and mild neck stiffness.

49 Subarachnoid Hemorrhage

50 Treatment (SAH) SAH with increased ICP: Bed rest If herniation is suspected, use osmotic agents. Ventriculostomy Consider seizure prophylaxis. Nimodipine (60mg q4h) for vasospasm, but avoid hypotension BP control as goal SBP <150 and DBP <90 or MAP <120 Intravascular volume expansion with crystalloid or colloid fluids. Stool softener Pain relieving

51 What is the next? Call neurosurgery. Treatment (SAH) Arrange for urgent 4-vessel cerebral angiogram (MRA has lower sensitivity). Angiography does have a 10-20% false negative rate, and therefore should be repeated in 1-2 weeks if LP is positive.

52 Treatment (SAH) What is the grade of the SAH? Hunt and Hess clinical grading of SAH 1 Mild headache or nuchal rigidity 2 Severe headache but non-focal exam 3 Lethargy, confusion, or mild deficit 4 Stupor or hemiparesis 5 Deep coma or posturing This grading system helps monitor the clinical course of SAH, but also guides management decisions and prognosis

53 Treatment (SAH) When should aneurysms be clipped? No clear difference exists in outcome with early (0-3 days) or late (11-14 days) surgical intervention; however, many centers favor early surgery in patients with low-grade SAH.

54 Cerebral angiography and neurosurgical aneurysm clipping were performed and patient was discharged in one week without residual deficit. Treatment (SAH)

55 Complications (SAH) What are the potential complications of SAH? Hydrocephalus, especially in the first 24 hours Rebleeding: 20% in the first 2 weeks (peaks at day 1) Hyponatremia Aspiration pneumonia Hypothalamic dysfunction, leading to excessive sympathetic outflow and sometimes cardiac ischemia

56 Case 3 19 years old female with severe, constant, headache associated with stiff neck. There was no response to Sumatriptan and other analgesics. She is now nauseated and vomiting in the ER. The patient admits to no medical problems but takes OCP. Examination revealed papilledema.

57 Case 3

58 SSS thrombosis Classic finding on non-contrast CT is the delta sign, a dense triangle (from hyperdense thrombus) within the superior sagital sinus. Contrast-enhanced CT can show the empty delta sign (i.e., empty triangle sign) in the superior sagital sinus.

59 Treatment (SSS Thrombosis) Investigate for causing factors. Start heparin, with eventual switch to warfarin. In a series of 42 patients, 36 had partial or complete venous sinus recanalization following heparin therapy. Can directly infuse thrombolytics by endovascular catheter for clot lysis if patient worsens clinically. Stop oral contraceptives. Symptomatic relief of headache and nausea. Continue anticoagulation for 3-6 months with follow up MRV before discontinuation.