HeadachesAnne Mounsey M.D.Dept. of Family MedicineUniv. of Virginia School of Medicine

ObjectivesLearn how to distinguish life threatening headaches from benign headaches.Learn management of migraine and chronic tension headache.

Causes of headaches.1. Traction or dilatation of intracranial or extracranial arteries.2. Traction of large extracranial veins3. Compression, traction or inflammation of cranial and spinal nerves4. Spasm and trauma to cranial and cervical muscles.5. Meningeal irritation and raised intracranial pressure6. Disturbance of intracerebral serotonergic projections

Pathophysiology of pain management in migraine

Cortical spreading depression activates the trigeminal and parasympathetic systems which causes vasodilatation and release of neuropeptides that cause inflammation.Serotonin 5 HT receptors modulate the release of neurogenic peptides.

The goal of therapy is to prevent the neorogenic inflammation that occurs as a result of neuropeptide release. Triptans are 5 HT receptor agonists and block this release

Acute onset headacheSufficient evidence from retrospective and prospective studies to support the association of an acute sudden onset headache with a vascular event.Sudden onset headache is a red flag

Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache: Annals of Emerg Med 2002 (1):39.

Life Threatening causes of acute headaches.

Intracranial hemorrhageSubdural hemorrhageSubarachnoid hemorrhage.MeningitisHypertensive encephalopathy.

Temporal arteritis in patient over 50. Red flag is the first and the worst.

Subarachnoid hemorrhage:causes80% of non traumatic hemorrhages from ruptured saccular aneurysms.Other causes: AV malformations, neoplasms, blood dyscrasias.

Commonest ages 40-60 yrs.

Subarachnoid hemorrhage:risk factors.Estimated that 5% of population have a berry aneurysm.HTNSmoking and alcoholSympathomimetic drugsPolycystic kidney diseaseCoarctation of the aortaMarfans syndrome

Subarachnoid hemorrhage:useful signs and symptomsSudden onset of worst headache of life.Worse on exertion eg valsalva, exercise.75% of patients have nausea and vomiting.50% of patients have meningism. 25% of patients have neck stiffness.

Linn F et al: Prospective study of sentinel headache in aneurysmal subarachnoid hemorrhage, Lancet 344:590, 1994. Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage, J Neurosurg 25:219, 1966.

Subarachnoid hemorrhage (SAH) refers to extravasated blood in the subarachnoid space. The blood activates meningeal nociceptors, leading to diffuse occipital pain along with signs of meningismus. SAH accounts for up to 10% of all strokes and is the most common cause of sudden death from a stroke.[38] 20% of strokes are hemorrhagic, 80% are ischemic . Of the hemorrhagic strokes half are due to a subarachnoid hemorrahge and half due to intracerebral hemorrhage.Intracerebral hemorrhage is associated with HTN and AVM.

Risk factors for SDHAge, alcohol, anticoagulation or anti-platelet treatment.May be minimal trauma such as coughingThe signs and symptoms of brain compression may not appear until up to 2 weeks after the trauma..

Subdural hemorrhageDull, mild generalized head pain.Symptoms of chronic SDH may be subtle. Up to 50% have altered level of consciousness Headache is worse at night and same side as hematomaOn exam patient may have unilateral weakness and increased reflexes.

Hypertensive EncephalopathyAssociated with high blood pressure, nausea, vomiting and blurred visionUsually associated with blood pressures of 200/130.Headache diffuse and worse in the morning and subsides during the day.

Meningitis:useful signs and symptoms.The absence of fever, neck stiffness and altered mental status in a patient with a headache virtually eliminates the diagnosis of meningitis.In multiple studies the presence of neck stiffness on examination has a pooled sensitivity of 70%.

Does this adult patient have meningitis? Attia et al. JAMA 1999;281(2):175-181

Fever is the most sensitive and then neck stiffness.Sensitivity is the proportino of paeple with the disease who have a positive result.

Signs of Meningism.In a prospective study of young adult patients Kernigs sign had a sensitivity of 9% and a specificity of 100%.Brudzinskis sign has not been evaluated since the original report .

Uchihara T, Tsukagoshi H. Headache 1991;31:167-171.

Specificity is number of people without the disease who have a negative test result.

Can response to therapy aid diagnosis?No meta-analyses or RCTS to support or refute using response to therapy as an indicator of underlying pathology.Case reports exist of patients whose headaches have significantly improved with analgesia and then subsequently died from an intracranial hemorrhage.Bottom line: Level C recommendation that response to therapy should not be used as the sole diagnostic indicator of the etiology of the headache.

Case reports of patients presenting with headaches to the ER that have responded wel to ketoralac (toradol) and been discharged and then found dead at home secondary to intra cerebral hemorrhage, SAH,

Acute H/A: Factors in history associated with abnormality on neuroimaging.Headache waking patient up.Headache worsening with valsalva Subjective sensory disturbance.Rapidly increasing headache.

However the absence of these does not rule out positive findings on neuroimaging.

Annals of Emergency Medicine: Vol 39:1:Jan 2002.

Loss of headache free period. Above findings increase the probability of abnormal findings on neuroimaging but have very wide confidence intervals

Clinical Policy of the ACEP for management of patients presenting with acute onset headache.Level B recommendations:Patients with headache and abnormal neuro exam should undergo an emergent non contrast CT.Patients presenting with an acute sudden onset headache should be considered for an emergent CT scan.HIV patients with a new headache should have urgent neuroimaging

Emergent means done at once to exclude life threstening condition. Urgent means arranged prior to disharge. HIV patinets have high incidence of space occupying lesions.

Clinical Policy of ACEP cont.Level C recommendation: Patients over 50 with a new headache should be considered for urgent neuroimaging.Emergent means done immediatelyUrgent means scan appointment is arranged prior to discharge and included in disposition.

Annals of Emergency Medicine: Vol 39:1:Jan 2002.

Migraine: IHS criteria5 attacks ofHeadache lasting 4-72 hours.Must be associated with nausea or vomiting or photophobia and phonophobiaMust have 2 of the following

UnilateralPulsatingModerately severe.Aggravated by physical activity

Sinus H/A vs. MigraineSummit study.Prospective multi center observational study of 2,991 patient with self diagnosed or physician diagnosed sinus headache. Using the IHS migraine criteria 80% of them had migraine.

Schreiber CP, et al. Archives of Internal Medicine. In publication

To diagnose sinus headache must have purulent discharge on suction or spontaneous and simultaneous onset of headache and sinusitis and abnormal xray, CT or transillumination.

Phases of migrainePremonition: eg hunger, energy surges, irritability.Prodrome: aura.Headache phasePostdrome.

Migraine Treatment

DrugLevel of EvidenceTylenolB NSAIDSATriptansAFiorinal AMidrinBOpiatesADHEBSteroidsC

NSAIDS, A for ibuprofen, B for naproxen. A for aspirin.Dihydroergotamine is S/C or a spray.More side effects than triptans.all triptans are A.

TriptansMeta-analysis of 53 studies showed all the oral triptans are effective and well tolerated.Rizatriptan 10mg, eletriptan 80mg amd almotriptan 12.5 mg were the most effective.40-80% two hour headache response.Give as early as possible in migraine attack.Nasal spray or S/C injection may be more effective.

Oral triptans in acute migraine:a meta-analysis of 53 trials. Ferrari MD. Lancet. 358 (9294):1668-75. 2001 Nov 17.

Treat early. Higher dose more effective. Nasal spray and SC more effective. For mild h/a 75% pain free at 2 hrs. for severe 50%. Try different triptans. Combine with NSAID

Percentage of patients with two hour headache response for each treatment ((bars are 95% confidence interval of the percentage)

NNT for headache response at 2 hours

Consider prevention when:US Headache consortium guidelines.Interferes with patients daily routine.>2/weekAcute medications ineffective or contraindicated.Presence of uncommon migraine conditionsHemiplegic migraineBasilar migraineMigraine with prolonged aura.

Migraine Prevention

DrugEvidenceValproateAAmitriptylineAPropranololAProzacBRiboflavinBGabapentinBACEBAspirinBClonidineBVerapamilB

Episodic Tension Type Headache.IHS CriteriaTension type headaches < 15 per month.Lasts 30 mins to 7 daysNo nausea or vomitingNo photophobia and phonophobia (1 ok)Headache has at least 2 of the following criteria:

pressing/tighteningBilateralMild-moderateNot aggravated by physical activity.

75% of patinets with migraine have neck pain.

Causes of TTHSome evidence that like migraine caused by serotonin imbalance but to a lesser extent than migraine.This would indicate that similar treatments would work.

Some evidence that TTH in migraneurs is a lesser version of their migraine. So triptans may work.

Treatment of TTHSimple analgesia:ibuprofen is more effective than acetaminophen.Combine analgesics with a sedating anit-histamine eg diphenhydramine.Limit treatment to 2 days a week to prevent rebound headaches.

Amitriptyline up to 100mg qd or nortriptyline up to 75mg qd . Tizanidine is an alpha2 adrenergic agonist that inhibits the release of norepinephrine. Increase dose of NSAIDA to max. Limit teartment to 2 days a week to avoid rebound. Can use ssris and TCAs for prevention.

Chronic Daily HeadacheAffects 4-5% of the population.Definiton: head pain for at least 4 hours for more than 15 days/month.Often develops from an episodic headache disorder either migraine or episodic tension type headacheIncludes chronic tension type headache(CTTH) and chronic daily migraine

Chronic tension type headache is the most common. Patients with chronic daily migraine have a past history of episodic migraine. Typically as the headaches come more frequently the associateds ymptoms of photophobia, phonophobia. Nausea and vomiting become less severe and less frequent.

Chronic Tension Type Headache.Develops from episodic tension type headachesThe most common form of CDH.Familial tendency.Medication rebound headache may be a factor in the transformation of episodic headache to CDH.

Chronic Tension Type HeadacheAffect women more than menMost common in middle ageStress is often a triggerAverage duration is 4-13 hours.

When see a patinet with CDH ask what their has were like before they became constant ie did they have episodic has before.ask about analgesic use.

Treatment of CTTH.Treating each headache increases the frequency and severity of the headaches.Reserve medications for worse than usual headache.Expert opinion: treat 2 headaches a week.

Frequent headache sufferers are at risk of developing analgesic overuse or drug rebound headaches. Expert opinion: limit headache medication to 2 days per week.

Prevention of CTTHTricyclic antidepressants.Stress managementTizanidineSSRIs:prozacAnticonvulsants:gabapentin and topiramate.Acupuncture

Rebound Headaches. IHS criteria.Headache for 15 days/month with at least one of the following characteristics and 2,3 and 4.

BilateralPressing/tight non pulsating qualityMild/moderate intensitySimple analgesic use >15 days a month for 3 monthsHeadache has increased during analgesic useHeadache resolves or reverts to previous pattern within 2 months after discontinuation of analgesia.

Rebound headachesMost significant factor in their development is the lack of awareness by physicians and patients. Prevention better than cureTriptans, all analgesics and ergotamines have been associated with medication rebound headaches.

Most significant factor in their development is the lack of awareness by physicians and patients.

Rebound headachesIf patient is unable to tolerate abrupt cessation of medication may need to titrate down over 2 weeks.May need inpatient treatment to successfully withdrawVarious regimes including tizanidine, daily triptans, steroids and parenteral DHE have been used.

Most significant factor in their development is the lack of awareness by physicians and patients.

The goal of therapy is to prevent the neorogenic inflammation that occurs as a result of neuropeptide release. Triptans are 5 HT receptor agonists and block this releaseTemporal arteritis in patient over 50. Red flag is the first and the worst.Subarachnoid hemorrhage (SAH) refers to extravasated blood in the subarachnoid space. The blood activates meningeal nociceptors, leading to diffuse occipital pain along with signs of meningismus. SAH accounts for up to 10% of all strokes and is the most common cause of sudden death from a stroke.[38] 20% of strokes are hemorrhagic, 80% are ischemic . Of the hemorrhagic strokes half are due to a subarachnoid hemorrahge and half due to intracerebral hemorrhage.Intracerebral hemorrhage is associated with HTN and AVM.Fever is the most sensitive and then neck stiffness.Sensitivity is the proportino of paeple with the disease who have a positive result.Specificity is number of people without the disease who have a negative test result.Case reports of patients presenting with headaches to the ER that have responded wel to ketoralac (toradol) and been discharged and then found dead at home secondary to intra cerebral hemorrhage, SAH,Loss of headache free period. Above findings increase the probability of abnormal findings on neuroimaging but have very wide confidence intervalsEmergent means done at once to exclude life threstening condition. Urgent means arranged prior to disharge. HIV patinets have high incidence of space occupying lesions.To diagnose sinus headache must have purulent discharge on suction or spontaneous and simultaneous onset of headache and sinusitis and abnormal xray, CT or transillumination.NSAIDS, A for ibuprofen, B for naproxen. A for aspirin.Dihydroergotamine is S/C or a spray.More side effects than triptans.all triptans are A.Treat early. Higher dose more effective. Nasal spray and SC more effective. For mild h/a 75% pain free at 2 hrs. for severe 50%. Try different triptans. Combine with NSAID75% of patinets with migraine have neck pain.Some evidence that TTH in migraneurs is a lesser version of their migraine. So triptans may work.Amitriptyline up to 100mg qd or nortriptyline up to 75mg qd . Tizanidine is an alpha2 adrenergic agonist that inhibits the release of norepinephrine. Increase dose of NSAIDA to max. Limit teartment to 2 days a week to avoid rebound. Can use ssris and TCAs for prevention.Chronic tension type headache is the most common. Patients with chronic daily migraine have a past history of episodic migraine. Typically as the headaches come more frequently the associateds ymptoms of photophobia, phonophobia. Nausea and vomiting become less severe and less frequent.When see a patinet with CDH ask what their has were like before they became constant ie did they have episodic has before.ask about analgesic use.Frequent headache sufferers are at risk of developing analgesic overuse or drug rebound headaches. Expert opinion: limit headache medication to 2 days per week.Most significant factor in their development is the lack of awareness by physicians and patients.Most significant factor in their development is the lack of awareness by physicians and patients.