Headaches. Mini Medical School. November 10, 2016 A. Laine Green MSc, MD FRCP(C) Assistant Professor Department of Medicine (Neurology)
Artist Agnes Cecile
Disclosures I have received an honorarium from and/or acted as a consultant for: Tribute Pharmaceuticals Cambia (diclofenac potassium for oral solution) Allergan Canada BOTOX (onabotulinumtoxina) Cartoon by Dan Wasserman US News & World Report
How do Neurologists Think??
4 questions Is the problem neurological? Where is the problem? Brain, brainstem, cerebellum, spinal cord, nerve root, peripheral nerve, muscle What is causing the problem? What are we going to do about it?
Additional 2 questions in Headache cases 2014-2015 8
How common are headaches Headaches are very common Tension Headache most common > 50% of the population Migraine - lifetime prevalence Female = 25% Male = 10% Gender preference Pre-puberty F > M Post-puberty F >>> M (3:1) Estrogen Exception Cluster Headache M > F 10% of the Population 9 has Migraine!!!!
Burden of Headache 10% of population have migraine Up to 4% have headache more than half the days of the month Direct medical costs $1,000,000,000/yr 12-15 million lost school or work days/year Indirect costs may be double the direct costs 2014-2015 10
Chronic Migraine 0.9% and 1.4% of the population 11,678 in Nova Scotia Less than 1/3 work full time 1 in 5 can t work Use a lot of resources Family MD, specialist visits, pain clinic visits, ERs $1,884 per patient per year $22 million a year to the Nova Scotia health care system
Invisible disease
2014-2015 13
Classification International Classification of Headache Disorders Over 300 types of headaches Two main types Primary Secondary trauma, vascular, substance, infection, psychiatric Subtypes Episodic Chronic 14
The Headaches Tension Migraine And related Cluster And other similar Secondary
Secondary Headaches Serious or ominous And not so
Diagnosis History Physical 2014-2015 17
History How long? Attacks or continuous frequency Details about the headache Details Details
Details Location Severity Quality Duration Recurrence Associated symptoms Nausea/Vomiting Face changes Warning Triggers Aggravating factors Activity Light Sound Smell Effect of sleep Menstrual cycle Pill effects Hormone replacement therapy
Details Sleep disorder Caffeine Head/neck injuries TMJD/Bruxism Brain infections Anxiety Depression Fibromyalgia Other pain Abuse history Other specialists Tests done to date Other medical problems Family history Smoking/alcohol Job FUNCTION
Details on Treatments
Concerning features Signs of infection Weight change Cancer HIV Other body systems Focal neurological deficits Thunderclap Headache Change in Headache Headaches that change with position Headaches that start with bending, lifting, coughing, sneezing Progressive vision loss
Tension Type Headache
Tension Type Headache (TTH) Most common primary headache May be not the most common you will see Also called Muscle contraction headaches Stress headaches Ordinary Essential 24
Tension Type Headache Last 30 minutes to 7 days Both sides of head Pressing or tightening quality Not throbbing Mild or Moderate intensity Not worse with routine activity No nausea No vomiting May be light sensitive May be sound sensitive 25
Migraine
Migraine Last 4-72 hours One side of head Throbbing Moderate or severe intensity Worse with routine activity Nausea and/or vomiting Light and sound sensitive May be smell sensitive
Migraine with Aura Headache as described before Aura before headache Sometimes with Sometimes without headache Usually a visual phenomenon Lasts 5-60 minutes Reversible Person goes back to normal Can be sensory Can be speech Very rarely weakness
Cortical Spreading Depression
Cluster
Cluster Headache Also known as Suicide Headache Uncommon 0.1% lifetime prevalence Onset 20-40 yrs Male >>> Female Risk heavy smoking Precipitants alcohol, histamine, nitroglycerin Coarse facial features Seasonal and clockwise periodicity Same time of year Same time of night (often within 90 mins of sleep onset)
Leonine Facial Features
Cluster Headache Last 15 minutes to 3 hours 45 60 minutes Up to 8 per day 1-2 most common Severe or Very severe pain in or around the eye One sided Red eye, tearing eye Runny congested nose Swollen eye Red face Muffled hearing Droopy eye lid Small pupil Don t like to be still!
Thunderclap Headache
Treatment
Contributing Factors Sleep disorders Sleep apnea TMJ and bruxism Anxiety or mood disorders Other pain disorders Other medical disorders Stressors Caffeine
Patient education Diagnosis Medications Trouble shooting Goal setting Patient Satisfaction = Reality Expectations Headache diary Absolutely essential Medication side effects Implications of disorder Migraine with aura in women doubles their stroke risk! Medication Overuse
Treatment Lifestyle Non pharmacologic Acute Treatments Preventative Treatments >4 headaches per month Removing/modifying things that are counter productive Follow up
Treatment Lifestyle Diet Well balanced, good choices, all food groups No skipping meals Exercise Stress reduction Trigger identification and avoidance Hydration with water Avoid caffeine Sleep hygiene
Non Drug Treatments Heat Cold Rest decrease environmental stimulus Acupuncture Massage Biofeedback Cognitive Behavior Therapy Other As long it is helpful As long as it is not harmful As long as poverty is not a side effect
Medications When you have a headache Help prevent headaches >4 headaches per month Less frequent Less severe Do nothing for an individual headache attack Transitional treatments
Medication Overuse To be avoided
Other Treatments
Nerve Blocks Injections of anesthetic +/- steroids
Botox Chronic Migraine
Non Invasive Nerve Stimulators
Invasive Nerve Stimulators
Challenges in Headache Treatment Triptans only specific medicine Medicines with other intended purposes Anti-Seizure Anti-depressants Blood pressure Alzheimer s Efficacy Side effects
Removal of Non-Helpful Things Caffeine Caffeine Caffeine Any acute medication being overused Appropriate limits
Vent Starbucks =12 cans coca cola =2 medium Tim Hortons
Headache is kind of a big deal!
Live as if you were to die tomorrow. Learn as if you were to live forever. -M.K. Gandhi