Chronic Daily HeadachesChronic Daily Headaches

David V. Lardizabal, M.D.David V. Lardizabal, M.D.Assistant Professor, Kirksville College of Assistant Professor, Kirksville College of

MedicineMedicine

ObjectivesObjectives

To learn the systematic approach in To learn the systematic approach in the diagnosis of chronic daily the diagnosis of chronic daily headachesheadaches

To present different cases of chronic To present different cases of chronic daily headachesdaily headaches

Basic Components of the HistoryBasic Components of the History OnsetOnset LocationLocation QualityQuality DurationDuration FrequencyFrequency Associated SymptomsAssociated Symptoms Triggers Triggers Relieving FactorsRelieving Factors Medication: dose/frequencyMedication: dose/frequency General and Neurologic ExaminationGeneral and Neurologic Examination

Case #1Case #1

A previously healthy 38 year old man A previously healthy 38 year old man presented with 4 month history of daily presented with 4 month history of daily headache. The headache began gradually headache. The headache began gradually and without provocation. The pain was and without provocation. The pain was continuous and became progressively continuous and became progressively more severe and disabling. The headache more severe and disabling. The headache was moderately intense holocranial was moderately intense holocranial pressure that lasted throughout the day pressure that lasted throughout the day and was not associated with and was not associated with gastrointestinal or autonomic symptoms.gastrointestinal or autonomic symptoms.

Case #1 continuedCase #1 continued He tried over-the-counter analgesics He tried over-the-counter analgesics

without relief prior to receiving without relief prior to receiving acetaminophen with codeine from his acetaminophen with codeine from his family physician. A prior neurological family physician. A prior neurological examination and non-enhanced MRI of the examination and non-enhanced MRI of the head were unremarkable. His alleviating head were unremarkable. His alleviating factors was “resting and relaxing” were factors was “resting and relaxing” were the only thing that helped. His headache the only thing that helped. His headache was improved when he is supine i.e. was improved when he is supine i.e. resting in bed, resting in the sofa, or mid-resting in bed, resting in the sofa, or mid-day naps. When he rises from bed, his day naps. When he rises from bed, his headache would invariably intensity.headache would invariably intensity.

Diagnosis?Diagnosis?

MRI brainWith ContrastCoronal View

Diagnosis?Diagnosis?

Benign Intracranial Hypotension

Case #2Case #2

15 year old boy has been having 15 year old boy has been having daily headaches for the past 6 daily headaches for the past 6 months. It is a constant pressure. months. It is a constant pressure. He has incontinence and difficulty in He has incontinence and difficulty in looking up. He has tried different looking up. He has tried different analgesics without relief. He wakes analgesics without relief. He wakes up in the morning vomiting. The up in the morning vomiting. The neurologic examination showed no neurologic examination showed no upgaze and papilledema.upgaze and papilledema.

Diagnosis?Diagnosis?

Diagnosis?Diagnosis?

Pineal Gland Tumor

Case #3Case #3

18 year old female had a minor head 18 year old female had a minor head trauma from an altercation. She has daily trauma from an altercation. She has daily headaches and posterior neck pain for 2 headaches and posterior neck pain for 2 weeks. She vomits daily. She has no weeks. She vomits daily. She has no nausea, light or sound sensitivity. Her nausea, light or sound sensitivity. Her neurological examination is normal. The neurological examination is normal. The CT scan was negative. She was told to CT scan was negative. She was told to have post-traumatic headache.have post-traumatic headache.

Diagnosis?Diagnosis?

Diagnosis?Diagnosis?

SUBDURAL HEMATOMA

Lesson Number 1Lesson Number 1

Secondary Headaches should be Secondary Headaches should be vigilantly investigated in daily vigilantly investigated in daily headache patients.headache patients.

Neurologic Examination is importantNeurologic Examination is important CT is not the diagnostic test of choiceCT is not the diagnostic test of choice MRI with/without contrast should be MRI with/without contrast should be

performed in new daily headaches.performed in new daily headaches.

Secondary Chronic Daily HeadachesSecondary Chronic Daily Headaches

Post-Traumatic HeadachePost-Traumatic Headache Cervical Spine DisordersCervical Spine Disorders Headaches associated with Vascular Headaches associated with Vascular

Disorders; AVM; arteritis including GCA, Disorders; AVM; arteritis including GCA, dissection, subdural hematomadissection, subdural hematoma

Headache associated with Non-Vascular Headache associated with Non-Vascular disorders (EBV, HIV, tumor)disorders (EBV, HIV, tumor)

TMJ, Sinus infections (sphenoid), Chronic TMJ, Sinus infections (sphenoid), Chronic CNS infectionsCNS infections

Intracranial Hypotension or hypertensionIntracranial Hypotension or hypertension

Primary Chronic Daily HeadachesPrimary Chronic Daily Headaches

Definition of CDHDefinition of CDH

> 15 or more headache days> 15 or more headache days > 3 or more months> 3 or more months

Chronic Daily HeadachesChronic Daily Headaches

Duration of head painDuration of head pain Autonomic FeaturesAutonomic Features Medication HistoryMedication History Neurologic ExaminationNeurologic Examination

Duration of the Head PainDuration of the Head Pain

More than 4 hoursMore than 4 hours Less than 4 hoursLess than 4 hours

Autonomic FeaturesAutonomic Features

Eyelid swellingEyelid swelling Ptosis “drooping”Ptosis “drooping” Miosis or MydriasisMiosis or Mydriasis Conjunctival injectionConjunctival injection Lacrimation “Tearing”Lacrimation “Tearing” Rhinorrhea “runny nose”Rhinorrhea “runny nose”

Medication HistoryMedication History

What are the medication used for abortive What are the medication used for abortive and/or prophylactic therapy?and/or prophylactic therapy?

What is the monthly consumption?What is the monthly consumption?

Case #4Case #4

23 year old woman presented for 23 year old woman presented for evaluation of intractable and evaluation of intractable and disabling daily headache of 6 months disabling daily headache of 6 months duration. Her headache began 3 duration. Her headache began 3 years ago, occurring one to 3 times years ago, occurring one to 3 times per month. Initially, her headache per month. Initially, her headache were left temporal in location and were left temporal in location and were severe and throbbing and were severe and throbbing and associated with prominent nausea associated with prominent nausea and photo- or phonophobia.and photo- or phonophobia.

Case #4 continuedCase #4 continued

Over the past 6 months, she has had a Over the past 6 months, she has had a moderate intensity, diffuse, daily, and moderate intensity, diffuse, daily, and continuous headache with only mild continuous headache with only mild photophobia and occasional nausea. To photophobia and occasional nausea. To allow herself to function at school, allow herself to function at school, throughout the past year, she escalated throughout the past year, she escalated her abortive medication use, initially using her abortive medication use, initially using 4 to 8 acetaminophen-aspirin-caffeine 4 to 8 acetaminophen-aspirin-caffeine tablets daily and in the past 6 months, 4 to tablets daily and in the past 6 months, 4 to 8 perscription acetaminophen-caffeine-8 perscription acetaminophen-caffeine-butalbital tablets daily.butalbital tablets daily.

Case #4 continuedCase #4 continued

Prophylactic therapy with tricyclic Prophylactic therapy with tricyclic antidepressant and anticonvulsant antidepressant and anticonvulsant was unhelpful. Her neurological was unhelpful. Her neurological examination and brain MRI were examination and brain MRI were normal.normal.

Case #4Case #4

Fulfills criteria for CDHFulfills criteria for CDH Normal MRI and examNormal MRI and exam Secondary causes excluded.Secondary causes excluded.

Diagnosis?Diagnosis?

Chronic Daily Headaches?Chronic Daily Headaches?

Lesson Number 3Lesson Number 3

Chronic Daily Headache is a SymptomChronic Daily Headache is a Symptom It is NOT a DiagnosisIt is NOT a Diagnosis

MigraineMigraine

Medication Overuse Headaches ( MOH)Medication Overuse Headaches ( MOH)

Medication Overuse Headaches (MOH)Medication Overuse Headaches (MOH)

Simple analgesics Simple analgesics • > 15 days for > 3 months> 15 days for > 3 months

Opiods, Ergotamines, Triptans or Opiods, Ergotamines, Triptans or Combination of medicationsCombination of medications• > 10 days/month > 3 months> 10 days/month > 3 months

Frequent/regular use 2-3 times per weekFrequent/regular use 2-3 times per week

Lesson Number 4Lesson Number 4

Medication Overuse Headaches Medication Overuse Headaches should be excluded or Treated before should be excluded or Treated before diagnosing Primary CDH disordersdiagnosing Primary CDH disorders

What are the Primary Chronic What are the Primary Chronic Daily Headache Disorders?Daily Headache Disorders?

Case #5Case #5

A 50 year old female has been A 50 year old female has been complaining of right supraorbital complaining of right supraorbital pain for the past 1 year. The pain is pain for the past 1 year. The pain is brief, typically 15 minutes. It is brief, typically 15 minutes. It is stabbing, and electric-like. The stabbing, and electric-like. The attacks are sporadic and she can attacks are sporadic and she can have 5 to 40 exquisitely painful have 5 to 40 exquisitely painful episodes for 5 days every week. The episodes for 5 days every week. The neurologic examination is normal neurologic examination is normal and MRI brain is normal.and MRI brain is normal.

Case #5 ContinuedCase #5 Continued

Anticonvulsants failed.Anticonvulsants failed. Microvascular Decompression failedMicrovascular Decompression failed Gamma Knife Therapy failed.Gamma Knife Therapy failed. What was the presumptive diagnosis What was the presumptive diagnosis

in this case?in this case?

Case #5 continuedCase #5 continued

The patient had tearing, ptosis, and The patient had tearing, ptosis, and rhinorrhea on the same side of the rhinorrhea on the same side of the pain.pain.

Diagnosis?Diagnosis?

This is not Trigeminal NeuralgiaThis is not Trigeminal Neuralgia Trigeminal Autonomic CephalalgiaTrigeminal Autonomic Cephalalgia

• Chronic Paroxysmal HemicraniaChronic Paroxysmal Hemicrania

Case #6Case #6 50 year old woman. She has been having 50 year old woman. She has been having

right sided headache for the past 10 years. right sided headache for the past 10 years. It is a dull pain that last almost the whole It is a dull pain that last almost the whole day. She has no nausea, no photophobia, day. She has no nausea, no photophobia, no phonophobia, or vomiting. At times, no phonophobia, or vomiting. At times, there are “stabbing” pains just above the there are “stabbing” pains just above the eyebrow. She has tearing in the right eye eyebrow. She has tearing in the right eye and ptosis in these acute stabbing and ptosis in these acute stabbing headaches. She has tried “all the headaches. She has tried “all the headache medications made by man.” headache medications made by man.” Her examination and MRI, LP were normal.Her examination and MRI, LP were normal.

Lesson Number 5Lesson Number 5

The presence of autonomic features is an The presence of autonomic features is an important differentialimportant differential• Chronic Paroxysmal Hemicrania (< 4 hrs HA)Chronic Paroxysmal Hemicrania (< 4 hrs HA)• Hemicrania Continua (> 4 hours HA)Hemicrania Continua (> 4 hours HA)

Patients with CDH with autonomic features Patients with CDH with autonomic features should be therapeutically tried with should be therapeutically tried with IndomethacinIndomethacin

Primary VarietyPrimary Variety

Headache Duration < 4 hoursHeadache Duration < 4 hours• Cluster HeadacheCluster Headache• Chronic Paroxysmal Hemicrania Chronic Paroxysmal Hemicrania • SUNCTSUNCT• Hypnic HeadacheHypnic Headache

Criteria of Chronic ClusterCriteria of Chronic Cluster

Attacks occurs for more than 1 year Attacks occurs for more than 1 year without remission or with remission lasting without remission or with remission lasting less than 1 month.less than 1 month.

Frequency: one every second day to eight Frequency: one every second day to eight day.day.

Associated with one of:Associated with one of:• Lacrimation, nasal congestion, rhinorrhea, Lacrimation, nasal congestion, rhinorrhea,

forehead/facial sweating, miosis, eyelid edema, forehead/facial sweating, miosis, eyelid edema, conjunctival injection, sense of restlessness or conjunctival injection, sense of restlessness or agitation during headache.agitation during headache.

Hypnic HeadacheHypnic Headache

Attacks of pain may be unilateral/bilateral Attacks of pain may be unilateral/bilateral and always occur after falling asleep.and always occur after falling asleep.

15-180 minutes15-180 minutes 15 times per month15 times per month None or one of the following:None or one of the following:

• Nausea, photophobia, phonophobiaNausea, photophobia, phonophobia Not attributable to another disorderNot attributable to another disorder

SUNCTSUNCT

Short-Lasting Unilateral Neuralgiform Short-Lasting Unilateral Neuralgiform Headache with Conjunctival injection and Headache with Conjunctival injection and TearingTearing

At least 20 attacksAt least 20 attacks Unilateral moderately severe orbital or Unilateral moderately severe orbital or

temporal stabbing or throbbing pain temporal stabbing or throbbing pain lasting 10-120 secondslasting 10-120 seconds

Not attributable to another disorderNot attributable to another disorder At least one: nasal congestion, rhinorrhea, At least one: nasal congestion, rhinorrhea,

or eyelid edema.or eyelid edema.

Primary CDHPrimary CDH

Headache Duration > 4 hoursHeadache Duration > 4 hours• Chronic MigraineChronic Migraine• Chronic Tension-Type HeadacheChronic Tension-Type Headache• New Daily Persistent HeadacheNew Daily Persistent Headache• Hemicrania Continua (indomethacin Hemicrania Continua (indomethacin

responsive)responsive)

Chronic Migraine (CM)Chronic Migraine (CM)

““transformed migraine”transformed migraine” Migraine without aura with CDH features in Migraine without aura with CDH features in

the absence of medication overuse.the absence of medication overuse. When CM is associated with medication When CM is associated with medication

oversue, only a diagnosis of probable oversue, only a diagnosis of probable Chronic mgraine and probable MOH.Chronic mgraine and probable MOH.

Only after withdrawal of overused Only after withdrawal of overused medications and the persistence of medications and the persistence of migraine on more than 15 days per month migraine on more than 15 days per month can a diagnosis of CM be made.can a diagnosis of CM be made.

Chronic Tension-Type HAChronic Tension-Type HA Fulfills CDH definitionFulfills CDH definition At least 2 of of the pain characteristicsAt least 2 of of the pain characteristics

• Pressing/tightening qualityPressing/tightening quality• Mild to moderate severityMild to moderate severity• Bilateral locationBilateral location• No aggravation by walking stairs or similar No aggravation by walking stairs or similar

routine physical activityroutine physical activity Historyof episodic TT HAHistoryof episodic TT HA No vomiting, no more than one: nausea, No vomiting, no more than one: nausea,

photophobiaphotophobia Does not meet criteria for NDPH or HCDoes not meet criteria for NDPH or HC

New Daily Persistent HeadacheNew Daily Persistent Headache

Abrupt development (< 3 days) of Abrupt development (< 3 days) of headache that does not remit. headache that does not remit.

SummarySummary

Chronic Daily Headache should be Chronic Daily Headache should be approached in a systematic mannerapproached in a systematic manner

Secondary HA should be excludedSecondary HA should be excluded It must fulfill CDH definitionIt must fulfill CDH definition Do no over-medicate patients or Do no over-medicate patients or

educate them in avoiding educate them in avoiding overmedicationovermedication

Always remember the associated Always remember the associated symptoms; not just the painsymptoms; not just the pain

Thank YouThank You

DIHYDROERGOTAMINE PROTOCOLDIHYDROERGOTAMINE PROTOCOL

Metoclopramide 10 mg I.V.DHE 0.25 or 0.5 mg I.V. (2-3 min.)

Nausea

NO DHE for 8 hours

DHE 0.3 or 0.4 mg + 10 mg metoclopramide IV q8H for 3 days

Nausea No Nausea

DHE 0.75 mg q8H I.V. q8H x 3 daysMetoclopramide 10 mg

DHE 1.0 mg q8H I.V. x 3 days Metoclopramide 10 mg

DIHYDROERGOTAMINE PROTOCOLDIHYDROERGOTAMINE PROTOCOL

Metoclopramide 10 mg I.V.DHE 0.25 or 0.5 mg I.V. (2-3 min.)

Head Pain; No Nausea

DHE 0.5 mg IV in one hour (metoclopramide)

Nausea No Nausea

DHE 0.75 mg q8H I.V. q8H x 3 daysMetoclopramide 10 mg

DHE 1.0 mg q8H I.V. x 3 days Metoclopramide 10 mg

DIHYDROERGOTAMINE PROTOCOLDIHYDROERGOTAMINE PROTOCOL

Metoclopramide 10 mg I.V.DHE 0.25 or 0.5 mg I.V. (2-3 min.)

No Head Pain; No Nausea

DHE 0.5 mg + Metoclopramide 10 mg IV q8H x 3 days

Nausea No Nausea

DHE 0.75 mg q8H I.V. q8H x 3 daysMetoclopramide 10 mg

DHE 1.0 mg q8H I.V. x 3 days Metoclopramide 10 mg