Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same?...

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Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Is All Headache Pain The Same? Same? Diagnostic and Treatment Diagnostic and Treatment Pearls Pearls Christy M. Jackson, MD Christy M. Jackson, MD Director, Director, Dalessio Dalessio Headache Center Headache Center Scripps Clinic Scripps Clinic International Classification of International Classification of Headache Disorders Headache Disorders Second Edition Jan 2004 Second Edition Jan 2004 4 Primary Headache 4 Primary Headache Categories Categories 8 Secondary Headache 8 Secondary Headache Categories Categories New New: Trigeminal : Trigeminal Autonomic Autonomic Cephalalgias Cephalalgias New New: Sub classification : Sub classification of TTH of TTH

Transcript of Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same?...

Page 1: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Is All Headache Pain The Is All Headache Pain The Same? Same?

Diagnostic and Treatment Diagnostic and Treatment PearlsPearls

Christy M. Jackson, MDChristy M. Jackson, MD

Director, Director, DalessioDalessio Headache CenterHeadache Center

Scripps ClinicScripps Clinic

International Classification of International Classification of Headache DisordersHeadache Disorders

Second Edition Jan 2004Second Edition Jan 2004

4 Primary Headache 4 Primary Headache CategoriesCategories

8 Secondary Headache 8 Secondary Headache CategoriesCategories

NewNew: Trigeminal : Trigeminal Autonomic Autonomic CephalalgiasCephalalgias

NewNew: Sub classification : Sub classification of TTHof TTH

Page 2: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

ICHDICHD--2 Primary Headaches2 Primary Headaches

Lipton, RB, et.al. Neurology 2004;63:427-435

ICDH ICDH --2 Secondary Headaches2 Secondary Headaches

Lipton, RB, et.al. Neurology 2004;63:427-435

Page 3: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Migraine PrevalenceMigraine Prevalence

Page 4: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

0

5

10

15

20

25

30

0 20 30 40 50 60 70 80 100

Age (Years)

On

e Y

ear

Per

iod

Pre

vale

nce

(%

)

Females

Males

Migraine Prevalence Peaks in the 25Migraine Prevalence Peaks in the 25--55 Age 55 Age Range for Both GendersRange for Both Genders

Consulting PatternsConsulting Patterns

Page 5: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

PCP/NonPCP/Non--specialists Lead the List of Healthcare specialists Lead the List of Healthcare Practitioners Consulted Prior to a Diagnosis of Practitioners Consulted Prior to a Diagnosis of

Migraine*Migraine*

9%

16%

24%

82%

Counseling

Alternative Medicine

HA Specialist

PCP/Non-specialist

*Categories Not Mutually Exclusive

Undiagnosed Migraine Sufferers Often Undiagnosed Migraine Sufferers Often Receive Other Medical DiagnosesReceive Other Medical Diagnoses

42%

32%

Sinus HA

Tension-type HA

Page 6: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Page 7: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Sheftell FD. Managing Acute Pain October 1996;40-47

Reference: 6. Ophoff, R.A. et al.: Familial hemiplegic migraine and episodic ataxia type-2 are caused bymutations in the Ca2+ channel gene CACNL1A4, Cell 87:543-552, November 1, 1996

Page 8: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Migraine Activity May Start in the Cortex with Migraine Activity May Start in the Cortex with Cortical Spreading DepressionCortical Spreading Depression

Welch M et al. Headache. 2005 Apr; 45 Suppl 1:S25-32. Van den Maagdenberg AM et al. Neuron. 2004;41:701-10.Lauritzen M. Brain. 1994;117:199–210.

Double click image to play video

Trigeminal Nerves Surrounding Trigeminal Nerves Surrounding MeningealMeningeal Blood Vessels are ActivatedBlood Vessels are Activated

Trigeminal nerve fibers in the Trigeminal nerve fibers in the meningealmeningeal blood vesselblood vessel

1

2 3

Bolay H et al. Nature Medicine. 2001;8:136-142. Williamson DJ, Hargreaves RJ. Microsc Res Tech. 2001;53:167-78.

Page 9: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

NeurochemicalNeurochemical Release leads to Release leads to NeurochemicalNeurochemical ProductionProduction

KininsKinins start the process leading to prostaglandin synthesisstart the process leading to prostaglandin synthesis

KininsKinins facilitate the production of facilitate the production of cyclooxygenasescyclooxygenases

CyclooxygenasesCyclooxygenases convert convert arachidonicarachidonic acid to prostaglandinsacid to prostaglandins

Woolf CJ. Ann Intern Med. 2004;140:441-451.

Inflammation Activates Pain Receptors Inflammation Activates Pain Receptors Leading to Pain TransmissionLeading to Pain Transmission

Inflammation and Inflammation and vasodilationvasodilation sensitize peripheral sensitize peripheral meningealmeningealpain receptors and lead to pain transmissionpain receptors and lead to pain transmission

Pain Receptors transmit signals to the trigeminal ganglion and Pain Receptors transmit signals to the trigeminal ganglion and the TNCthe TNC

When the TNC transmits pain signals to thalamus & cerebral When the TNC transmits pain signals to thalamus & cerebral cortex, the patient first feels paincortex, the patient first feels pain

Silberstein SD. Cephalalgia. 2004; 24(suppl 2):2-7. Bolay H et al. Nature Medicine. 2002;8:136-142Goadsby PJ et al eds. Pathophysiology of Headache in Wolff’s Headache and Other Pain. 7th ed. Oxford: Oxford University Press; 2001:62.Hargreaves RJ, Shepheard SL. Can J Neurol Sci. 1999;26(suppl3):S12-19

Page 10: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Page 11: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Integrative Approaches to Integrative Approaches to Headache ManagementHeadache Management

Evidence Based usage of supplementsEvidence Based usage of supplements RiboflavinRiboflavin

MagnesiumMagnesium

PetadolaxPetadolax

Coenzyme Q10Coenzyme Q10

BiofeedbackBiofeedback

AcupunctureAcupuncture

Physical TherapyPhysical Therapy

Page 12: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Lipton & Stewart. Cephalalgia. 1997;17(18):53-59

Page 13: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Acute Management

Mostly migraine cases, some cluster

Outpatient vs Inpatient strategies

Infusion Centers will obviate the need for UCC or ER evaluation

Outpatient Strategies

Status Migrainosis

Intractable Cluster

Severe Muscle Contraction Pain

Trigeminal Neuralgia

Page 14: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Status Migrainosis

Classical definition is unremitting migraine for more than 72 hours

Prednisone taper of 60 mg initially with 5 or 10 day taper

Toradol injection, nasal spray or tablets Triptan injectable if not tried already with

antinauseant Occipital Nerve Block Infusion center or admission

New Options for Migraine New Options for Migraine TreatmentTreatment

CalcitoninCalcitonin Gene Receptor Protein (CGRP) Gene Receptor Protein (CGRP) Inhibitor Inhibitor –– TelcagepantTelcagepant

Occipital Nerve StimulationOccipital Nerve Stimulation

SumatriptanSumatriptan Air InjectorAir Injector

SumatriptanSumatriptan patchpatch

ToradolToradol nasal spray nasal spray -- SprixSprix

DHE Inhalation ApparatusDHE Inhalation Apparatus--LevadexLevadex

Page 15: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Page 16: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

New Options for Migraine Prophylaxis

Namenda

Savella

Botulinum Toxin 155-195 units every 3 months

Hypotheses:MechanismsHypotheses:Mechanisms of of Botox A in HeadacheBotox A in Headache

May reduce May reduce pericranialpericranial muscular tension and muscular tension and contractionscontractions

May directly affect sensory nerves May directly affect sensory nerves –– possibly possibly reducing reducing neuropeptideneuropeptide release release

Page 17: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Dosing of BTX-A in Headache FDA recommendations for 155FDA recommendations for 155--190 units Botox A190 units Botox A

Fixed site of 31 standard sites usedFixed site of 31 standard sites used

Every 12 weeksEvery 12 weeks

Fixed-SiteFollow-the-Pain

Page 18: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Page 19: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Page 20: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Cluster Headache TreatmentCluster Headache Treatment

Acute TherapyAcute Therapy High Flow High Flow

OxygenOxygen

TriptanTriptan

DHEDHE

Suppressant Suppressant TherapyTherapy SteroidsSteroids

IndomethacinIndomethacin

Ca Channel BlockerCa Channel Blocker

LithiumLithium

TopiramateTopiramate

WarfarinWarfarin

**WarfarinWarfarin for Refractory Cluster Headache, for Refractory Cluster Headache,

Hakim, S Headache 51:5, 713Hakim, S Headache 51:5, 713

Page 21: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Tension Type Headache TreatmentTension Type Headache Treatment

Acute:Acute: NSAIDSNSAIDSTramadolTramadolLocal heat/coldLocal heat/coldValiumValium

Preventive:Preventive: TCATCANSAIDSNSAIDSPhysical TherapyPhysical TherapyTMJ analysis TMJ analysis ––

consider Botox for consider Botox for massetermasseterdystoniadystonia

Page 22: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

CervicogenicCervicogenic HeadacheHeadache

Side Locked, older population or in history of Side Locked, older population or in history of traumatrauma

Originates at base of skull and travels up over Originates at base of skull and travels up over scalp to eyescalp to eye

May become May become pulsatilepulsatile

Does not meet criteria for migraineDoes not meet criteria for migraine

Responds to occipital nerve blocks, Responds to occipital nerve blocks, indomethacinindomethacin

Characteristics of Medication Overuse Headache

Diffuse, bilateral headache every day, aggravated by physical or mental exertion

Waking with early morning headache

Restlessness, nausea, forgetfulness, depression

Medication withdrawal symptoms when meds missed

Tolerance to abortive medications

Lack of efficacy in many preventive medications

Page 23: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Infusion Center

Added to the Dalessio Headache Center this year

Locations at TP, RB and CV

Entry requires eval by one of our MDs or NPs

Same day infusion of a cocktail of options

Infusion Cocktail

IV fluids

IV Magnesium one gram

IV Valproic Acid 500mg

IV Decadron 10 mg

IV Compazine or Reglan

IV Toradol 30-60 mg

Page 24: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Inpatient Strategies

Medication Overuse Headache largely vs Status Migrainosis

DHE Protocol

IV Reglan

IV Steroids, especially if triptan withdrawal

Clonidine if indicated for opiate withdrawal

Phenobarbitol if indicated for butalbitalwithdrawal

DHE Protocol

Initial test dose of 0.5 mg IV with Reglan as premedication for nausea

Follow up dosing of 0.2-1.0 mg every 8 hours for 2-3 days

As outpatient, patient will continue DHE as a subcutaneous injection three times daily for one week, then taper over 3 weeks

Page 25: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Patient Presentation

35 year old female

Presents to office after having been seen in Urgent Care twice in past week for headache, treated and sent home

CT Brain normal, LP with WBC of 10, otherwise normal

BP: 134/80, HR 80, AF, Weight 150, Height 5’6”

History

No prior history of recurrent headache episodes

No family history of headache

Mild postural and exertional component to pain

Global, non pulsatile with no features of photo or phonophobia

Page 26: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Differential Diagnoses Secondary Headache Meningitis/Encephalitis PseudotumorMass lesionAneurysm SubduralVasculitisMedication reactionChiari IOther

Primary HeadacheNew Onset Daily Persistent HeadacheMedication Overuse Headache

Work Up

ImagingMRI/MRA Brain

Laboratory testingCBC

Chemistry panel

ESR, CRP, ANA, RPR

PTT

Page 27: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

MRI Brain

Cortical Infarct

Gyral enhancement

Clinical Update

MRI tech tells nurse patient had shaking of her left arm during MRI

Page 28: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Next Step: What is the definitive test?

Carotid Ultrasound

MRV

Brain Biopsy

EEG

MRV Images

Page 29: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

CT scan

Cerebral Venous ThrombosisMain Neurologic Signs

and SymptomsHeadache 89%

Papilledema 28%

Generalized seizures 30%

Focal seizures 20%

Mental Status disorder 30%

Mean age 39 years

3:1 female to male ratio

Page 30: Is All Headache Pain The Same? Diagnostic and Treatment Pearls · Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD Is All Headache Pain The Same?

Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD

Evaluation CT Brain less sensitive

MRI Brain is best noninvasive tool

MRV is widely used in place of conventional angiography

CSF exam useful if meningitis/encephalitis is expectedMay also be therapeutic if elevated ICP present

LabsCBC, ESR,ANA,PTT, procoagulant workup (Pro C,

S, Antithrombin III, Factor V Leiden, Antiphospholipid Ab, Lupus Anticoagulant)

Management Anticoagulation with heparin should be started as

soon as possible Safe, even in the case of hemorrhagic conversions of

bland venous infarcts PTT maintained at 2x control until headache

resolves, focal deficits stabilize and mental status normalizes

Local thrombolysis may be necessaryMaintenance on warfarin 3-6 months or indefinitely

if procoagulant state found Seizure management ICP management with acetazolamide, diuretics