Headache Pain Generators

Transcription

1 Objectives 1. Define the major categories of headache. 2. Take a history directed at characterizing a headache pattern in an individual patient and identify the cause or triggers of the headache. 3. Understand the distinguishing features and patterns of migraine headache. 4. Know first line treatments for tension versus migraine headaches. 5. Recognize warning signs for secondary headache syndromes due to intracranial structural lesions or increased intracranial pressure. Pain Generators Extracranial Musculoskeletal (spine, muscle) Oral (dental) Ocular Ear Vascular: branches of extracranial carotid, e.g. temporal arteritis Intracranial Dural and pial sensory fibers Trigeminovascular pathways Intracranial: Dural and pial sensory fibers Primary Disorders 1. Migraine With or without aura 2. Tension-type 3. Trigeminal Autonomic Cephalgias

2 Secondary Disorders 1. Increased Intracranial Pressure headaches Mass lesions Idiopathic Intracranial Hypertension (IIH) 2. Vascular Inflammation example: Temporal Arteritis Thrombosis example: Cerebral Venous Thrombosis Sub-arachnoid hemorrhage ( worst headache of life ) 3. Cervicogenic (spine, nerve roots) 4. Temporal Mandibular Joint (TMJ) 5. Medication Overuse Primary or Secondary Chronic Daily Tension-type Medication Overuse Transformed Migraine New Daily Persistent Rule out Secondary Exam: History onset aura or warning? sudden (thunderclap) or gradual prior head or neck trauma previous attacks (progression of symptoms?) duration of attacks (< 3 hours, > 4 hours, continuous) frequency: days per month with headache Pain location (unilateral, bilateral, cervical, retroorbital, face or jaw) Radiation of pain? -associated symptoms nausea, vomiting photophobia, phonophobia conjunctival injection, rhinorrhea, diaphoresis Exam: History Triggers: sounds, smells, movements? Aggravating factors posture, cough, exertion, straining, neck or jaw movements severity effect on work and family activities Acute and preventive medications effectiveness, side effects Co-morbid medical or mental health conditions History of heart disease or stroke Visual disorders Family history of headache disorders for the first time OR change in pattern?

3 Exam: Physical Exam: Physical Screening neurologic examination general assessment of mental status cranial nerve examination fundoscopy, pupils, eye movements, visual fields, face sensory and motor for asymmetry and/or weakness assessment for unilateral limb weakness or dyscoordination, deep tendon reflex asymmetry assessment of gait, including heel-toe walking (tandem gait) Neck examination posture, range of motion, palpation for muscle tender points Check for cervical paraspinal muscle spasm, trapezius tender points HEENT examination: eyes, ears, jaw movements Palpate occiput Palpate temple Palpate muscles of mastication for tender points Listen for bruits: head, eyes, neck Blood pressure measurements check orthostatic BP The majority of patients with primary headache disorders have a normal neurological exam Tender points in neck, shoulders, and/or occiput can point to cervicogenic headache Red Flags for Secondary First or worst headache of life Abrupt-onset headache thunderclap headache Change in pattern, frequency, or severity of headaches s ALWAYS on the same side s refractory to treatment New onset headache after age 50 New onset headache with cancer, immunosuppression, or pregnancy Associated signs/symptoms: fever, stiff neck, papilledema, cognitive impairment with syncope or seizure triggered by exertion, valsalva maneuver, or sex Neurologic symptoms >1 hour Abnormal general or neurologic examination Neuroimaging is warranted Red Flags for Secondary Emergent (immediate attention): Thunderclap onset (fast, maximal pain) worst headache of my life Fever and meningismus Papilledema with focal signs or reduced level of consciousness Acute glaucoma Urgent (attention within hours to days) Papilledema without focal signs or reduced level of consciousness Relevant systemic illness Elderly patient: new headache with cognitive change

4 Red Flags for Secondary Less urgent (attention within days to few weeks, usually) Unexplained focal signs Atypical headaches (not consistent with migraine or tension-type Unusual headache precipitants Unusual aura symptoms Onset after age 50 y Aggravation by neck movement; abnormal neck examination (consider cervicogenic headache) Jaw symptoms; abnormal jaw examination (consider temporomandibular joint disease) General Practice Points Rule out secondary headache when diagnosing a primary headache disorder Migraine is the most common headache type in patients seeking medical care for headache Migraine is underdiagnosed and undertreated Consider migraine in patients with recurrent moderate or severe headaches and normal neurologic exam s that interfere with daily activities are more likely to be migraine, less likely tension type Medication overuse is a risk in patients using combination analgesics or frequent NSAID or acetaminophen General Practice Points General Practice Points management may require: Change in work or lifestyle (disability) Change in method of birth control (women) Consideration of effects of menstrual cycle (women) Change in environment Possible association with environmental factors Patient may be able to identify headache triggers through careful headache diary Common headache triggers Emotional stress Hormones (women) Skipping meals Weather Sleep disturbance Odors Neck pain Lights Caffeine, Alcohol, Smoking Heat Food Exercise/sexual activity

5 General Practice Points management includes: Consideration of the complexity of the medication plan Can the patient follow the schedule? Consideration of the side effects of the medications proposed for treatment Sedation, cognitive side effects Beneficial side effects, e.g mood stabilization, may make some medications more effective Consideration of the teratogenic potential of headache medications Always counsel patients and document counseling Considerations before and during pregnancy Diagnosing primary headache syndromes Patients with recurrent headache attacks and normal neurologic examination findings 1. Migraine with or without aura if at least 2 of: nausea (with or without vomiting) light sensitivity /sound sensitivity some of the attacks interfere with daily activities 2. Episodic tension-type headache if attacks are not associated with nausea, and at least 2 of: bilateral headache nonpulsating pain mild to moderate intensity headache is not worsened by activity Diagnosing primary headache syndromes Diagnosing primary headache syndromes Cluster headache or another trigeminal autonomic cephalalgia if all of the following criteria: Frequent Severe Brief (duration < 3 h) Unilateral Ipsilateral conjunctival injection, tearing, or restlessness during the attacks (ipsilateral ptosis or miosis on exam). Need Neurologist referral*** CHRONIC HEADACHES Patients with headache on 15 d/mo for > 3 months and with normal neurologic examination Chronic migraine if headaches meet migraine diagnostic criteria (above) or are quickly aborted by migraine-specific medications (triptans or ergots) on 8 d/mo Chronic migraine with medication overuse if the patient uses ergots, triptans, opioids, or combination analgesics on 10 d/mo or uses plain acetaminophen or NSAIDs on 15 d/mo Chronic migraine without medication overuse if patients do not have medication overuse

6 Diagnosing primary headache syndromes Diagnosing primary headache syndromes CHRONIC HEADACHES Patients with headache on 15 d/mo for > 3 months and with normal neurologic examination Chronic tension-type headache if headaches fit episodic tension-type diagnostic criteria (above), but > 15 d/mo for >3 months May have nausea but mild, not moderate or severe No more than one of photophobia, phonophobia, mild nausea Episodes last 30 min to few days Patients with continuous daily headache for > 3 mo with normal neurologic examination Hemicrania continua if the headache is strictly unilateral, is always on the same side of the head ptosis or miosis might be present on examination responds dramatically to indomethacin May refer to neurologist New daily persistent headache if the headache is unremitting since onset Evaluate for secondary headache Refer to neurologist Medication Overuse : Who is at risk? Diagnosing Medication Overuse Patient with an episodic headache disorder usually migraine or tension-type headache treated with frequent and excessive amounts of acute symptomatic medications present or develops upon awakening, and commonly occurs daily or nearly daily Patients with headache for > 15 days per month Use of triptans, ergots, combination analgesics, or opioid-containing medications 10 days per month Use of acetaminophen or NSAIDs 15 days per month Patients may have psychiatric co-morbidities depression and anxiety psychological and physical drug dependence Patients may have pain-related co-morbidities Orthopedic, musculoskeletal pain generators Taking multiple analgesics for different disorders

7 Diagnosing Medication Overuse All acute symptomatic medications used to treat headaches have the potential for causing MOH. Risk for MOH varies with medication Highest with Opioids butalbital-containing combination analgesics aspirin/acetaminophen/caffeine combinations Intermediate to high with triptans Lowest with nonsteroidal anti-inflammatory drugs MIGRAINE HEADACHES Epidemiology of Migraine Migraine Migraine is a common disorder: affects ~12% of the general population Female > Male 17 % of women each year 6 % of men each year Most common in those aged 30 to 39 Migraine tends to run in families. Migraine without aura is the most common type, ~75 % of cases Migraine is a spectrum of illness Episodic Migraine Chronic migraine Transformation may occur over months to years Hallmark of Migraine: Severe headache Usually with nausea and/or light and sound sensitivity Four phases of Migraine headaches 1. Premonitory symptoms: affective/vegetative symptoms 24 to 48 hours prior yawning, euphoria, depression, irritability, food cravings, constipation, neck stiffness 2. Aura: one or more focal neurological symptoms (25%) Postdrome: may feel drained/exhausted or elation/euphoria

8 Pathophysiology of Migraine Recurrent stimulation of central pain pathways causes neuronal dysfunction Brainstem trigeminal neurons become hyperexcitable. Leads to structural and functional changes which are both intracranial and extracranial. Cortical spreading depression: A wave of neuronal and glial depolarization spreads across the cortex Causes aura Activates trigeminal nerve afferents Alters blood brain barrier permeability Pathophysiology of Migraine Cortical spreading depression activation of pain sensitive trigeminal nerve afferents via: The release of pro-inflammatory mediators Transduction of the inflammatory signal to trigeminal nerve fibers in the meninges Prolonged activation of trigeminal pain fibers pain of migraine headaches. Migraine Aura: cortical spreading depression in areas of the brain where depolarization is not consciously perceived, e.g. cerebellum Pathophysiology of Migraine Typical distribution of migraine headache pain = anterior and posterior regions of head and upper neck Can be explained by convergence of the projections from the upper cervical nerve roots and the trigeminal nerve Pathophysiology of Migraine Stimulation of the trigeminal ganglion release of vasoactive neuropeptides Neurogenic Inflammation A sterile inflammatory response Vasodilation (calcitonin gene-related peptide) Plasma protein extravasation. Causes prolongation/intensification of the pain of migraine Neurogenic inflammation Sensitization Neurons become increasingly responsive to nociceptive and nonnociceptive stimulation Response thresholds decrease Response magnitude increases Spontaneous neuronal activity develops

9 Migraine Pathophysiology of Migraine Sensitization causes many clinical symptoms of migraine Throbbing quality of the pain Worsening of pain with coughing, bending, or sudden head movements Hyperalgesia (increased sensitivity to painful stimuli) Allodynia (pain produced by normally non-noxious stimulation). Genetic basis complex (additive effect of multiple genes), but frequent Familial hemiplegic migraine channelopathies Hemiplegic migraine more often sporadic Migraine Diagnostic Criteria with > 2 of: Unilateral location Pulsating quality Moderate or severe intensity Aggravation by or causing avoidance of routine physical activity During the headache at least one of: Nausea and/or vomiting Photophobia/phonophobia attacks last 4 to 72 hrs (untreated or successfully treated) At least 5 such attacks Migraine with Aura Diagnostic Criteria At least two migraine attacks in life time with: 1. One or more fully reversible auras: Visual (+/-) flickering light, loss vision Sensory (+/-) tingling, numbness Speech/language Motor (e.g. hemiplegia) Brainstem (e.g. vertigo, tinnitus, diplopia, ataxia) Retina (monocular scotoma or blindness) 2. At least one of: At least one aura symptom spreads gradually ( 5 minutes), and/or two or more symptoms occur in succession Each individual aura symptom lasts 5 to 60 minutes At least one aura symptom is unilateral The aura is accompanied, or followed within 60 minutes, by headache *International Classification of disorders, 3 rd edition *International Classification of disorders, 3 rd edition

10 Complicated Migraine Disorders Neurologic symptoms and/or signs with aura Neurologic symptoms and/or signs during headache or afterward Basilar migraine: symptoms referable to brainstem Vestibular migraine: prominent vertigo with or without headache Cause of episodic vertigo ( migrainous vertigo ) Hemiplegic migraine Triptans not used Familial hemiplegic migraine Migrainous headache with seizure: Migrainous epilepsy Refer these to a Neurologist!!! Migraine: Approach to Treatment Pay attention to lifestyle and specific migraine triggers Irregular or skipped meals Irregular or too little sleep Stressful lifestyle Excessive caffeine or alcohol consumption Lack of exercise Obesity 2 categories of Pharmacologic migraine treatment 1. Acute drug therapy for individual attacks 2. Prophylactic drug therapy (when indicated) to reduce attack frequency Evaluate and treat coexistent medical and psychiatric disorders Migraine: Approach to Treatment Migraine: Acute Treatment Encourage patients to participate actively in their treatment and to employ self-management principles: diaries available for smart phones and tables Self-monitoring to identify triggers and headache patterns When identified, manage migraine triggers effectively Plan daily activity to avoid triggering or exacerbating migraine Use non-pharmacologic approaches Relaxation techniques/stress management skills Cognitive behavioral therapy Sleep evaluation Acupuncture Adapted from Becker WJ Continuum 21:

11 Migraine: Acute Treatment Mild to moderate attack: Not associated with vomiting or severe nausea Simple analgesics (NSAIDs, acetaminophen) or combination analgesics are first choice agents Mild to moderate attacks associated with severe nausea or vomiting: oral or rectal anti-emetic drug in conjunction with simple or combination analgesics Migraine: Acute Treatment Moderate to severe attack: Oral migraine-specific agents are first-line oral triptans or combination of sumatriptan-naproxen Moderate to severe attack with vomiting or severe nausea: non oral migraine-specific medications subcutaneous sumatriptan nasal sumatriptan and zolmitriptan oral disintegrating tablets may be helpful non oral antiemetic agents parenteral agents in ER: ketorolac (NSAID), dihydroergotamine (vasoconstrictive) Migraine: Acute Treatment Adapted from Becker WJ Continuum 21: Migraine: Prophylactic Treatment Prophylactic medication when: Recurrent migraine attacks are causing considerable disability Frequency of acute medication use is approaching levels that place the patient at risk of medication overuse headache 10 days per month for triptans, ergots, opioids, and combination analgesics > 15 days per month for acetaminophen and NSAIDs Recurrent attacks with prolonged aura are occurring Complicated migraine (hemiplegic migraine, basilar-type migraine, etc) Contraindications to acute migraine medications are making symptomatic treatment of migraine attacks difficult

12 Migraine: Prophylactic Treatment Migraine: Prophylactic Treatment Adapted from Silberstein SD Continuum 21: Adapted from Silberstein SD Continuum 21: Migraine: Goals of Prophylactic Treatment Reduce attack frequency, severity, and duration Improve responsiveness to treatment of acute attacks Improve function and reduce disability Tension-type Ill-defined and heterogeneous headache syndrome Phenotype is non-specific Define by what it is NOT, rather than what it IS Three recognized sub-types Infrequent episodic (<1 per day per month) Frequent episodic (1-14 days per month) Chronic (>14 days per month) Pain is NOT localized and generally not severe Prevent progression or transformation of episodic migraine to chronic migraine No significant nausea, no vomiting, no photo/phonophobias Can be similar to milder episodic migraine or a secondary headache

13 Tension-type Most common primary or secondary headache type Estimated mean lifetime prevalence in adults is 46% Prevalence for Chronic TTH is 2-3% 40% of TTH patients report a family history of headache Peak prevalence between years of age Socioeconomic impact of TTH greater than that of migraine Co-morbid with major depression, anxiety disorder, TMJ, C- spine disc and spondylotic disorders Generators: pericranial myofascial factors (episodic TTH) and central nociceptive pathways (chronic TTH) Persistent activation of trigger points Peripheral nociceptor sensitization Eventual second-order neurons sensitized in the spinal trigeminal nucleus (pain thresholds decreased) Acute Medications for Tensiontype Acetaminophen Aspirin Ibuprofen Naproxen sodium Diclofenac Caffeine 500mg to 1000mg 500mg to 1000mg 200mg to 800mg 375 to 550 mg 12.5mg to 100mg 65mg to 200mg Monitor for medication overuse Guidelines from the European Federation of Neurological Societies. See Kaniecki, RG Continuum 18: Prophylactic Medications for Tension-type Amitriptyline Nortriptyline Mirtazapine Venlafaxine mg per day mg per day 30mg per day 150 mg per day For patients with 2 3 headache days per week Guidelines from the European Federation of Neurological Societies. See Kaniecki, RG Continuum 18: and Becker et al Can Fam Phys 61: Non-Pharmacologic Management of Tension-type Lifestyle and physical approaches Regular sleep and meal schedules Exercise and physical therapy Cervical muscle stretching Passive physical manipulations Behavioral therapies Relaxation techniques EMG-guided biofeedback Cognitive-behavioral therapy Acupuncture

14 Trigeminal Autonomic Cephalgias Unilateral headaches Spectrum from short-lived but recurrent to chronic Associated with one or more cranial autonomic symptoms Ptosis Conjunctival injection Lacrimation Nasal congestion or rhinorrea Cluster SUNCT: short, unilateral, neuralgiform, conjunctival, tearing SUNA: short, unilateral, cranial autonomic Trigeminal Autonomic Cephalgias Paroxysmal hemicrania Hemicrania continua Adapted from Newman LC Continuum 21: Features of the Trigeminal Autonomic Cephalgias Pathophysiology of the Trigeminal Autonomic Cephalgias Adapted from Newman LC Continuum 21: Common pathophysiology Ipsilateral activation of the hypothalamus: Cluster headache SUNCT Contralateral activation of the hypothalamus: Paroxysmal hemicrania Hemicrania continua Trigeminovascular pathway: ipsilateral pain V1 branch (ophthalmic) activated Elevated levels of calcitonin gene-related peptide (CGRP) Cranial autonomic pathways: autonomic features Descending input from hypothalamus, release of vasoactive intestinal polypeptide (VIP)

15 Features of the Trigeminal Autonomic Cephalgias Cluster Most common TAC, but uncommon overall (0.1%) Severe, unilateral orbital, supraorbital, and/or temporal; pain lasts minutes (untreated) At least one autonomic symptom in face or ear OR a sense of restlessness or agitation with headache Attack frequency between one every other day and eight per day more than half the time during a cluster TAC headaches can be distinguished by treatment responses Adapted from Newman LC Continuum 21: Episodic: headaches in bouts from 7 days to 1 year separated by pain-free intervals of at least 1 month Chronic: attacks for more than 1 year without remission or remission < 1 month Cluster Treatment Options Cluster Treatment Options Adapted from Newman LC Continuum 21: Adapted from Newman LC Continuum 21:

16 Cluster Treatment Options Adapted from Newman LC Continuum 21: Final Points is among the most common medical complaints. Episodic tension-type headache is the most frequent headache type in population-based studies Migraine is the most common diagnosis in patients presenting to primary care physicians with headache Sinus headache is often self-diagnosed by patients, but many patients presenting with sinus headache turn out to have migraine Hypertension can cause headaches in hypertensive emergencies, but not with typical migraine or tension headaches. References Available in PubMed Aurora SK et al Chronic Migraine: An Update on Physiology, Imaging, and the Mechanism of Action of Two Available Pharmacologic Therapies. January 2017: Becker WJ Acute migraine treatment. Continuum 21: Becker WJ et al Guideline for primary care management of headache in adults. Can Fam Physician 61: Bendtsen L et al Muscles and their role in episodic tension-type headache: implications for treatment. Eur J Pain 20: Kaniecki RG Tension-type headache. Continuum 18: Levin M Approach to the workup and management of headache in the emergency department and inpatient settings. Semin Neurol 35: Newman LC Trigeminal autonomic cephalgias. Continuum 21: Silberstein SD Preventive migraine treatment. Continuum 21: