Headache mee

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HeadacheHeadache

Diagnosis & ManagementDiagnosis & ManagementDr Dr SumeraSumera



Discomfort in the region of the cranialvault.

Headache is usually a benign symptombut occasionally it is the manifestationof a serious illness.



International Classification of International Classification of

headache Disordersheadache DisordersP art 1P art 1 Primary headache DisordersPrimary headache Disorders- - migrainemigraine

-- tensiontension ±±type headachetype headache

--cluster headache& other cluster headache& other trigeminal autonomic cephalgiastrigeminal autonomic cephalgias

P art 2P art 2 Secondary headache disordersSecondary headache disorders

P art 3P art 3 Cranial neuralgias, central and primary facial painCranial neuralgias, central and primary facial pain& other headaches& other headaches



SNOOPSNOOP- -TTRed flags for secondary headacheRed flags for secondary headache

F lagF lagSS ystemic symptom or ystemic symptom or SS econdary risk factorsecondary risk factors

NNeurological symptoms or abnormaleurological symptoms or abnormalsignssigns

OOnsetnset

OOlder lder

PP revious headache historyrevious headache history

TT riggered headacheriggered headache

Description/exampleDescription/exampleFever/weight loss or known cancer,Fever/weight loss or known cancer,

HIV,immunosuppression or HIV,immunosuppression or thrombotic riskthrombotic risk

Confusion ,drowsiness or persistentConfusion ,drowsiness or persistent

focal signs>1hr focal signs>1hr

³First and worst headache´ , sudden³First and worst headache´ , suddenor abrupt from sleep, or or abrupt from sleep, or progressively worsening.progressively worsening.

New and progressive >50 Consider New and progressive >50 Consider TATA

First headache or fundamentalFirst headache or fundamentalchange in characteristics of h/achange in characteristics of h/aBy valsalva /exertion or sexualBy valsalva /exertion or sexual

intercourseintercourse



Headache EvaluationHeadache Evaluation

History (duration, onset, frequency)History (duration, onset, frequency)Is there a family history of headache?Is there a family history of headache?Are there any known causes of headache?Are there any known causes of headache?

What is the typical location(s)?What is the typical location(s)?What does the pain feel like?What does the pain feel like?What makes it worse?What makes it worse?What makes it better?What makes it better?What are the results of past evaluations?What are the results of past evaluations?Are there associated symptoms? Exam findings?Are there associated symptoms? Exam findings?What is the patient¶s sex?What is the patient¶s sex?



M IGRAINEM IGRAINE

A diagnosis of migraine can be given to aA diagnosis of migraine can be given to a

patient presenting with episodic headachepatient presenting with episodic headache(�15 days per month) that interferes(�15 days per month) that interferessignificantly with their everyday activitiessignificantly with their everyday activities(work, housework, and leisure activities).(work, housework, and leisure activities).



Diagnostic criteria for migraine withoutDiagnostic criteria for migraine withoutauraaura

A ttacks lasting 4A ttacks lasting 4- -72hrs72hrs

At least two of theAt least two of thefollowing:following:

UnilateralUnilateralPulsatingPulsatingM oderate to severeM oderate to severeAggravated byAggravated byexerciseexercise

At least one of theAt least one of thefollowing:following:

NauseaNauseaPhotophobiaPhotophobia

PhonophobiaPhonophobia



Diagnostic criteria for migraine withDiagnostic criteria for migraine with

auraauraM igraine without auraM igraine without aura plusplus

One or more transient focal neurologicalOne or more transient focal neurologicalsigns:signs:- - visual/sensory/aphasic/motor visual/sensory/aphasic/motor GradualGradual development of aura symptomdevelopment of aura symptom

Aura lasts 4Aura lasts 4- -60 mins followed by or 60 mins followed by or accompanied by headache within 60 minsaccompanied by headache within 60 mins



Predisposing factors & triggersPredisposing factors & triggers

Family historyFamily historyh/o travel sicknessh/o travel sicknessh/o cyclical vomitingh/o cyclical vomitingin childhoodin childhoodStressStressM enstrual cycleM enstrual cycleM enopausalM enopausalHead & neck traumaHead & neck traumaStrenuous exerciseStrenuous exercise

Relaxation after Relaxation after stressstress- -´weekend´weekendmigraine´migraine´

Change of habitChange of habit- -missedmissedmeals /sleepmeals /sleepBright lightsBright lightsLoud noiseLoud noise

SmellsSmells- -perfume /petrolperfume /petrolDietaryDietary---- <10%<10%



Acute M anagementAcute M anagement

ParacetamolParacetamolNSADIsNSADIs ±±orally /rectally/orally /rectally/imim

AntiAnti--emeticemetic//prokineticsprokineticsmetclopramidemetclopramide or or domperidonedomperidone- -orally/rectallyorally/rectally//imim// buccalbuccal mucosamucosa

CombinationsCombinations- -egegmigralevemigraleve/ /

Specific antiSpecific anti- -migrainemigrainetherapytherapy- - triptanstriptans

OpiateOpiate ± ±based and mixedbased and mixedanalgesics should beanalgesics should beavoided.avoided.



TriptansTriptans- -55--HT1 class 1B/1D agonistsHT1 class 1B/1D agonists

SumariptanSumariptanZolmitriptanZolmitriptanRizatriptanRizatriptanEletriptanEletriptanAlmotriptanAlmotriptanNaratriptanNaratriptan

FrovatriptanFrovatriptanConsider formulation eg s/c injection/nasal sprayConsider formulation eg s/c injection/nasal spray/wafer sublingual/wafer sublingual



M igraineM igraineWhich triptan?Which triptan?Compared with sumatriptan 100Compared with sumatriptan 100

triptantriptan 2hr relief 2hr relief SustainedSustainedP ain freeP ain free

consistencyconsistency tolerabilitytolerability

sumatriptansumatriptan5050 == == -- ++ZolmitriptanZolmitriptan2.52.5

== == == ==Rizatriptan 10Rizatriptan 10 ++ ++ ++ ==Eletriptan 40Eletriptan 40 == == == ==AlmotriptanAlmotriptan12.512.5

++ ++ ++ ++++NaratriptanNaratriptan2.52.5

-- -- -- ++++

frovatriptanfrovatriptan -- -- --



M anagement of migraineM anagement of migraine

L ifestyle modificationsL ifestyle modifications- -

Regular sleepRegular sleepRegular mealsRegular mealsModerate amount of exerciseModerate amount of exerciseDrink plenty of water Drink plenty of water L imit caffeine, alcohol and other drugsL imit caffeine, alcohol and other drugs

Reduce stressReduce stressStop cocpStop cocp



Acute managementAcute management- -principlesprinciples

Use correct doseUse correct doseUse correct formulationUse correct formulation

Stepped treatmentStepped treatment- -simple analgesiasimple analgesia- -combinationscombinations- -

triptanstriptans

Early interventionEarly interventionUse at least 3 times before judgingUse at least 3 times before judging

effectivenesseffectivenessUse a maximum of 2Use a maximum of 2- -3 days per week and3 days per week and8/month8/month



M igraineM igraine-- preventive therapiespreventive therapies

When to useWhen to useFrequent headaches >3Frequent headaches >3- -4/month4/month

M igraine significantly interferes withM igraine significantly interferes withpatient¶s daily life despite abortivepatient¶s daily life despite abortivetreatmenttreatment

Acute/abortive therapies contraAcute/abortive therapies contra- -indicated,indicated,ineffective, not tolerated or OVERUSEDineffective, not tolerated or OVERUSED



M igraineM igraine ±± preventive treatmentspreventive treatments

AntidepressantsAntidepressants- - tricyclictricyclic amitriptylineamitriptyline

BetablockersBetablockers- - propranololpropranolol LA 80LA 80--160mg160mg

AnticonvulsantsAnticonvulsants- - sodiumsodium valproatevalproate topiramatetopiramateSeretoninSeretonin antagonistsantagonists± ±pizotifenpizotifen; ; methylsgidemethylsgideCalcium channel antagonistsCalcium channel antagonists ± ± verapamilverapamil

AnticonvulsantsAnticonvulsants- - gabapentingabapentin; ; pregabalinpregabalin



M igraineM igraine ±±emerging therapiesemerging therapies

CGRP antagonists ³PANTS´CGRP antagonists ³PANTS´- -olcegepantolcegepantBotox injectionsBotox injections

Greater occipital nerve blocksGreater occipital nerve blocksOccipital nerve stimulationOccipital nerve stimulation

Closure of PFOClosure of PFO- - study failed to meet primary endpointstudy failed to meet primary endpoint



Hormones & migraineHormones & migraine

Until puberty boys=girlsUntil puberty boys=girlsYear of 1Year of 1 stst menses 15% women have 1menses 15% women have 1 stst

migrainemigraineFertile years women: men=3:!Fertile years women: men=3:!



TensionTension- -type headachetype headache

Featureless headacheFeatureless headacheOften tight band around head / bitemporalOften tight band around head / bitemporal

M ild nauseaM ild nauseaM ild to moderate intensityM ild to moderate intensityepisodicepisodic



Chronic daily headacheChronic daily headache

Headache present >15 days /month for atHeadache present >15 days /month for atleast 2 months.least 2 months.

Exclude ³red flag´Exclude ³red flag´

T hink analgesiaT hink analgesia ± ±overuse headacheoveruse headacheusually dull, generalised . Early morning worseningusually dull, generalised . Early morning worsening



M edication overuse headacheM edication overuse headacheclinical featuresclinical features

C hronic daily headache> 15days/mthC hronic daily headache> 15days/mthRegular intake for >3mthsRegular intake for >3mths

M ay differ depending on drug being overused:M ay differ depending on drug being overused:

TriptansTriptans- - daily migrainous headachedaily migrainous headachedevelops on using triptans for >/= 10days/mthdevelops on using triptans for >/= 10days/mth

AnalgesicsAnalgesics- - diffuse featureless headachediffuse featureless headacheOn using opiate or combination analgesics for > /= 10 days/monthOn using opiate or combination analgesics for > /= 10 days/month

On using simple analgesics for >/= 15 days /monthOn using simple analgesics for >/= 15 days /month



Cluster headacheCluster headache

Strictly unilateralStrictly unilateralIpsilateral autonomic symptomsIpsilateral autonomic symptoms ± ±at leastat least one of:one of:

conjunctival injection, nasal blockage, facialconjunctival injection, nasal blockage, facial

sweating, miosis,ptosissweating, miosis,ptosisBoutsBouts--typically 1/year lasting 6typically 1/year lasting 6- -12 weeks with12 weeks withdiscrete headaches 1discrete headaches 1- -8times /day each lasting8times /day each lasting3030--60 mins60 mins

Age 20Age 20- -40 M >F=7:140 M >F=7:1Headache severe/excrutiatingHeadache severe/excrutiating- - restless ³bangingrestless ³banginghead against wall´head against wall´



Cluster headachesCluster headaches- -abortiveabortivetreatmenttreatment

SubcutaneousSubcutaneous sumatriptansumatriptan 6mg6mgHigh dose/highHigh dose/high flowrateflowrate oxygenoxygen

IntranasalIntranasal triptanstriptans- - not so effectivenot so effective



Cluster headacheCluster headache- - preventivepreventivetreatmentstreatments

VerapamilVerapamil 240240--960mg/day ( ECG)960mg/day ( ECG)- -bradycardia,hypotension,arrythmias,constipation,fatigue,oedemabradycardia,hypotension,arrythmias,constipation,fatigue,oedema

LithiumLithium 400400--2000mg/day2000mg/day hypothyroidism,Diabetes insipidus, tremor,nausea, wthypothyroidism,Diabetes insipidus, tremor,nausea, wtgain ataxia drowsiness, confusion seizuregain ataxia drowsiness, confusion seizure

M ethylsergide 3M ethylsergide 3- -12mg/day12mg/day vascular constrictive phenomena, fibroticvascular constrictive phenomena, fibroticreactions ,muscle cramps, abdominal discomfort weight gain, mood changereactions ,muscle cramps, abdominal discomfort weight gain, mood change

T ransitional treatments:T ransitional treatments:High dose corticosteroidsHigh dose corticosteroids- - 1mg/kg ( up to 60mg daily for 51mg/kg ( up to 60mg daily for 5

days tapering over 2days tapering over 2- -3 weeks3 weeksrapid onset of rapid onset of action. Attack recurs once dose reduced. Initial addaction. Attack recurs once dose reduced. Initial add- -onon

until other preventatives are effectiveuntil other preventatives are effective



THANKYOUTHANKYOU

QUESTION?QUESTION?

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