HEADACHE Transient discomfort, chronic nuisance, or looming disaster?

Transcription

1 HEADACHE Transient discomfort, chronic nuisance, or looming disaster? Hussien H. Rizk, MD Cairo University Medical School ١

2 Headache Second most common o symptom (after pain) Migraine alone afflicts 12 16% of individuals Rasmussen et al. J Clin Epidemiol 1991; 44:1147 Tension type headache is more common Migraine causes 150 million lost work d/y & 329,000 lost school d/y in US. Stewart et L. JAMA 1992; 267:64 Major cause of analgesic overuse & adverse effects. Most frequent cause that leads patients & physicians to suspect HTN ٢

3 EPIDEMIOLOGY AND CLASSIFICATION 90% of all benign headaches fall under 3 categories: Migraine (45 85%) Tension type headache (up to 38%) Cluster headache (0.1 1%) Headache due to common systemic disorders (fever, sinusitis, & acute hypertension) Schwartz et al. JAMA 1998; 279:381. Bigal et al. Headache 2000; 40:241. Dowson et al. Cephalalgia 2002; 22:590. Bahra & Goadsby Neurology 2002; 58:354 Bahra, & Goadsby. Neurology 2002; 58:354. Headache Classification Committee: International Headache Society. International Classification of Headache Disorders. Cephalalgia 2004; 24:1. ٣

4 Headache Type Lifetime Prevalence Primary Headache Lifetime Prevalence Tension-type 78% Migraine 16% Secondary Headache Fasting 19% Sinus/nasal disorder 15% Head injury 4% Non-vascular intracranial disorder (including brain tumor) 0.50% ٤

5 Age & gender differences in migraine incidence ٥

6 Age & gender differences in migraine prevalence ٦

7 SYMPTOM LOCATION Which headache is that? MIGRAINE TENSION CLUSTER Unilateral in 60 70%; Bilateral, always Always unilateral, bifrontal or global in usually begins around 30% the eye or temple DURATION 4 72 H Variable 30 min. 3 H APPEARANCE Rest, dark, quiet Restful or active active ASSOCIATED SYMPTOMS Nausea, vomiting, visual aura, motor or speech deficit, photo & phonophobia None Ipsilateral lacrimation, rhinorrhea, pallor, sweating, focal deficit, Horner's syndrome CHARACTERISTICS Gradual, crescendo; pulsating; moderate to severe; aggravated by physical activity Pressure or tightness which waxes and wanes Begins quickly, peak in minutes; deep, continuous, excruciating, & explosive in quality ٧

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10 HEADACHE TRIGGERS Diet Alcohol Chocolate Aged cheeses Monosodium glutamate Aspartame Caffeine Nuts Nitrites, Nitrates Hormones Menses / Ovulation Hormone replacement Sensory stimuli Strong / flickering light Odors Sounds, noise Stress Let down periods Times of intense activity Loss (death, separation, divorce, job change) Moving Crisis Changed environment Weather Travel (time zones) Seasons / Altitude Schedule changes Sleeping patterns Dieting /Skipping meals Irregular physical activity ١٠

11 Evaluation: History Age at onset Aura and prodrome Intensity, duration # of headache d/m Time & mode of onset Quality, site, & radiation i Associated symptoms FH of migraine Precipitating & relieving Effect of activity on pain Relation to food/alcohol Response to previous Rx. Recent change in vision Recent ttrauma Recent change in sleep, exercise, weight, or diet State of general health Change in work or lifestyle Rx of birth control Environmental factors Effects of menstrual cycle & exogenous hormones ١١

12 Patient questionnaire ١٢

13 Danger signals Sudden onset or severe persistent headache reaching peak in few sec or min: Suspect subarachnoid hemorrhage. Cluster headache may be confused witha serious headache, since pain can reach peak within min. However, cluster headache is transient (usually <1 2 H) and is associated with ipsilateral autonomic signs (tearing or rhinorrhea) h ١٣

14 Danger signals The "first" or "worst" headache of my life: intracranial hemorrhage or CNS infection. A worsening pattern: mass lesion, subdural hematoma, or medication overuse headache. Focal neurologic symptoms other than typical visual or sensory aura: mass lesion, arteriovenous malformation, or collagen vascular disease. ١٤

15 Circumstances suggest etiology Rapid onset of exertional headache, especially with minortrauma: carotid dissection or intracranial hemorrhage. Head pain that spreads into the lower neck and between the shoulders: meningeal irritation [infection or blood] New headache < 5 or > 50 y. New headache type with cancer: metastasis. New headache type with Lyme : meningoencephalitis. New headache type with HIV: infection or tumor. Headache during pregnancy or postpartum: venous sinus thrombosis, carotid dissection, and pituitary apoplexy. ١٥

16 Intracranial infection Meningitis Bacterial Fungal Viral Lymphocytic Encephalitis Brain abscess Subdural empyema Headache with fever Systemic infection Bacterial infection Viral infection HIV/AIDS Other systemic infection Other causes Familial hemiplegic migraine Pituitary apoplexy Rhinosinusitis i iti Subarachnoid hge ١٦

17 HYPERTENSION RELATED HEADACHE It is a common belief that hypertension can cause headaches. This is true in hypertensive emergencies It is not true for migraine or tension headache. Physicians' Health Study [22,701 male physicians y]: no difference in % of men with HTN in the migraine and non migraine groups. Buring et al. Arch Neurol 1995; 52:129. Prospective Norway study [22,685] : high BP is associated with a reduced risk of non migrainous headache. Hagen et al. J Neurol Neurosurg Psychiatry 2002; 72:463. ١٧

18 HYPERTENSION RELATED HEADACHE Meta analysis [95 RCT] of anti HT Rx with 4 classes: Pts on any active treatment had significantly less headache than placebo Headache prevalence significantly reduced in each of the 4 classes of drugs compared individually with placebo. Law et al. Circulation 2005; 112:2301 ١٨

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21 Approach to headache with high B P Hypertensive urgency Yes Rx. antihypertensive No BP 200/120 Danger symptoms/signs? Frequent BP readings in the headache-free state Yes No Yes No Rx. Rx. antihypertensive Imaging / Lab Paracetamol Aspirin [R/O ICH] Metoclopramide Non-barbiturate sedative SSRI ٢١

22 Diagnostic algorithm ٢٢

23 Now, Analyze this 36 YOW. Long hx of migraine. Headache almost daily last year. Severe & incapacitating 2/w. Rx. 6 8 tab combination of ASA, paracetamol, & caffeine per day, minimal relief. No fever, weight, loss, diplopia, or tinnitus. Headache not exacerbated by a Valsalva maneuver or positional change. ٢٣

24 Risk factors : Chronic daily headache Obesity Hx. of frequent headache (>1/w) Over 50% have sleep & mood disorders d Exclude secondary headache, Ex. Imaging Common primary causes: caffeine consumption Transformed migraine overuse (>10 d/m) of Medication overuse acute headache Scher et al. Pain 2003;106:81 medications Wang et al. Neurology 2000;54:314 Zwart et al. Neurology 2003;61:160 ٢٤

25 Examination BP & pulse Bruit at neck, eyes, and head Palpate head, neck, and shoulder regions Temporal and neck arteries Spine and neck muscles Functional neurologic examination: getting up from seated position without support walking on tiptoes and heels cranial nerve, fundoscopy and otoscopy tandemgait and Romberg test symmetry on motor, sensory, reflex and cerebellar (coordination) tests. ٢٥

26 Danger signals Neck stiffness Papilledema Focal neurologic signs ٢٦

27 Indications for imaging: Definite Acute onset or Non acute headache and positive neurologic finding Headache with head, neck or eye bruit. No specific recommendation regarding the relative sensitivity of MRI compared with CT. Silberstein & Rosenberg. Neurology 2000; 54:1553. Full text of guidelines : ٢٧

28 Indications for imaging: less solid Recent significant change in pattern, frequency or severity. Progressive worsening despite Rx Focal neurologic symptoms without objective signs Onset with exertion, cough, or sexual activity Onset after age 40 years Kumar & Cooney. Med Clin N Am 1995; 79:261 Non migrainous featureless headache (2% chance to detect a treatable cause) Goadsby. BMJ 2004; 329:469. ٢٨

29 Migraine treatment algorithm ٢٩

30 Treatment of chronic daily headache ٣٠

31 Preventive Medications Used for Transformed Migraine or Medication-Overuse Headache ٣١

32 Summary Tension headache is common in the community Migraine is most common Dx in pts presenting to primary care with headache. h Evaluation of headache: Rule out serious underlying pathology Determine the type of primary headache using history as the primary diagnostic tool. Symptoms may overlap: migraine vs. tension headache OR migraine vs. 2ry headache (e.g. sinus). Imaging is not necessary in the majority of pts. Primary Chronic daily headache can be due to transformed migraine or medication overuse Imaging (usually CT ) is warranted in certain pts. ٣٢