Headache – practical scenario
-
Upload
webzforu -
Category
Health & Medicine
-
view
764 -
download
0
Transcript of Headache – practical scenario
![Page 1: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/1.jpg)
Headache – Practical ScenarioDr. Thomas Mathew
MD,DNB,DM(Neurology)Associate Professor
Department of NeurologySt.John’s Medical College and Hospital
Bangalore-560034
![Page 2: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/2.jpg)
Case 1
![Page 3: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/3.jpg)
On history…• 24 year old lady
• Episodic vertigo lasting 30 minutes
• 1-2/ week for the past 2 years
• No history of tinnitus/deafness
• No history of loss of consciousness
![Page 4: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/4.jpg)
On examination…
• No focal neurological deficits
• Fundus normal
![Page 5: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/5.jpg)
What will you ask next ?
![Page 6: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/6.jpg)
Options are…
A. Postural variationB. Head traumaC. Alcohol intakeD. History of headache
![Page 7: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/7.jpg)
Diagnosis
Migraine related vertigo
![Page 8: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/8.jpg)
How will you manage ?
Options are…A. CinnarizineB. ProchlorperazineC. BetahistineD. None of the above
![Page 9: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/9.jpg)
What you should do ?
• Flunarizine
• Topiramate
• Betablockers
• Amitriptyline
• Valproate
![Page 10: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/10.jpg)
Flunarizine – Practical Scenario
Prof. A.V. SRINIVASAN,MD, DM, Ph.D,DSc(HON) F.A.A.N, F.I.A.N.
Emeritus Professor The Tamilnadu Dr. M.G.R. Medical University
Former HeadInstitute of Neurology, Madras Medical College
Adjunct Prof. IIT Madras
Prof. A.V. SRINIVASAN,MD, DM, Ph.D,DSc(HON) F.A.A.N, F.I.A.N.
Emeritus Professor The Tamilnadu Dr. M.G.R. Medical University
Former HeadInstitute of Neurology, Madras Medical College
Adjunct Prof. IIT Madras
![Page 11: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/11.jpg)
Flunarizine: Indications
• Prophylaxis of migraine• Symptomatic treatment of dizziness• (Peripheral vascular disease)• (Alternating hemiplegia)• (Epilepsy adjuvant)
![Page 12: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/12.jpg)
Contra-indications
• Parkinson’s disease• History of EP syndromes• History of depression• Breast feeding• (Pregnancy)Caution• Elderly• Hepatic disease
![Page 13: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/13.jpg)
Adverse effects
• Weight gain• Sedation• Depression• EP syndrome (de Melo-Souza syndrome)• Headache/insomnia/asthenia/GI
![Page 14: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/14.jpg)
Interactions
• Alcohol• Hypnotics /tranquilizers• COC• Anticholinergics• Anticonvulsants
![Page 15: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/15.jpg)
HC Deiner et alCephalalgia 2002;22:209-221
• 808 patients• Double blind 16 week treatment phase• Flunarizine 10mg(5days/week) v Flunarizine
5mg v Propranolol 160mg• Responders (50% reduction) 5mg:46%. 10mg:53%. Propranolol:48%• Drop out due to adverse effects5mg:16.7%. 10mg: 19.3%. Propranolol:16.7%
![Page 16: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/16.jpg)
M. ThomasHeadache 31:613-615, 1991
• India• 29 patients (14 dropped out)• 6months double blind crossover• 10mg v placebo• No decrease in migraine frequency• Reduced duration and severity
![Page 17: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/17.jpg)
Experience of use
• Reduce if excessive daytime drowsiness• Watch for mood change• Use 5-15mg• Very useful even for refractory patients/prolonged
aura/hemiplegic aura/severe migrainous vertigo
![Page 18: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/18.jpg)
![Page 19: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/19.jpg)
Headache – Practical ScenarioDr. Thomas Mathew
MD,DNB,DM(Neurology)Associate Professor
Department of NeurologySt.John’s Medical College and Hospital
Bangalore-560034
![Page 20: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/20.jpg)
Case 2
![Page 21: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/21.jpg)
On history…• 28 year old
• Episodic headaches
• 12 hours• 4-5/week
• Severe/throbbing/worsens with exertion
![Page 22: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/22.jpg)
On History…
• Photo/phonophobia/vomiting
• Family history of headache present
• Feels like crying/sad/thought of even suicide
• Takes vasograine 4-5/week
![Page 23: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/23.jpg)
On examination…
• Obese . BP 130/90 mm of Hg
• BMI >35
• No deficits
• Fundus normal
![Page 24: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/24.jpg)
What is the drug of choice?
A. FlunarizineB. BetablockerC. AmitriptylineD. ValproateE. Topiramate
![Page 25: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/25.jpg)
Patient was started on topiramate
• 25 mg per day
![Page 26: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/26.jpg)
What else you will advise ?
![Page 27: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/27.jpg)
Options are…
A. Stop vasograine abuse
B. Identify precipitating factors
C. Life style modification
D. All the above
![Page 28: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/28.jpg)
Patient comes back after 1 week of Topiramate
• “ I can’t see clearly from today morning”
![Page 29: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/29.jpg)
What will you do ?
![Page 30: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/30.jpg)
Options are…
A. Fundus examination
B. Urgent ophthalmological consult
C. Check Intraocular pressure
D. IV mannitol
E. All the above
![Page 31: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/31.jpg)
Diagnosis
Topiramate induced acute angle closure glaucoma
![Page 32: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/32.jpg)
Thank you
![Page 33: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/33.jpg)
Practice Patterns in Headache Management
E- Voting Module
![Page 34: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/34.jpg)
When would you initiate prophylaxis for migraine?
A. Patients with 4 or 5 migraine days per month with normal functioning
B. 3 migraine days with some impairment C. 2 migraine days with severe impairmentD. Any one of the above
![Page 35: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/35.jpg)
What can be the duration of therapeutic trial for a migraine prophylactic drug?
A. Less than 1 weekB. 2-4 weeksC. 2- 6 monthsD. 4-6 weeks
![Page 36: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/36.jpg)
What are the ‘red flags’ in headache history?
A. New headache onset in an older patient B. Rapid onset of headacheC. Systemic Symptoms such as fever or weight
lossD. All of the above
![Page 37: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/37.jpg)
Which channels are blocked by Flunarizine?
A. Calcium channelsB. Sodium channelsC. BothD. None of the above
![Page 38: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/38.jpg)
What is the typical characteristic of migraine headache?
A. Pulsating, throbbingB. Pressing, tightening but not pulsatingC. Boring, searingD. None of the above
![Page 39: Headache – practical scenario](https://reader033.fdocuments.in/reader033/viewer/2022052307/554f318eb4c905cd048b4a62/html5/thumbnails/39.jpg)
Thank you