headache case seminar_rcpt

8/17/2019 Headache Case Seminar_RCPT

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NNC CMU

The Northern Neuroscience CentreChiang Mai University

Headache Clinical Case Seminar

“COME ACROSS THE DIAGNOSTIC PITFALL”

Surat Tanprawate, M.D., MSc(Lond.), F.R.C.P(T)CMU Headache Study Group,

The Northern Neuroscience Centre/Division of Neurology

Faculty of Medicine, Chaing Mai University

RCPT 2016 PATTAYA


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Headache adventure


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NNC CMUThe Northern Neuroscience Centre

Chiang Mai University

What is your diagnosis?

A. Vestibular migraine

B. Migraine with brainstem aura

C. Migraine with BPPV

D. Headache attributed to brainstem TIA


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Feature suggest

serious secondary

headache

“Red flag sign”

Feature suggest

primary

headache

“Blue flag sign”

Grouping

“Clinical headache syndrome”

“Headache in Special Circumstances”

Feature suggest

other secondary

headache

“Yellow flag sign”

Diagnosis

Primary headache vs Secondary headache vs Cranial neuralgia

Hx taking and PE


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Age > 50 (first onset) Healthy young age Side locked headache

Headache after trauma/neck

injury

Temporal profiles: chronic,

episodic, complete wax and

wane

Morning headache

Abnormal neurological exam;

including papilledema,sti"ness of neck

Character: non-fixed/

alternated site or mildbilateral

Headache non-response to

medication

Temporal profiles: sudden

severe, worsening headache

Specific triggers: internal

(sleep, anxiety, menstruation),

external (environment)

Headache with TACs

characters

Concurrent events:pregnancy,

immunocompromise,

systemic symptome

Headache response to

migraine specific medication

Provoking activity: exercise,

cough, wake up from sleep,

postural headache etc.


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Headache with vestibular symptoms• Primary headache disorder

• Vestibular migraine

• Migraine with brainstem aura

• Hemiplegic migraine

• Primary headache with Neuro-otologic disorder (BPPV/ Menneire’s disease/etc)

• Secondary headache disorder - brainstem lesion esp.

TIA

Grouping

“Clinical headache syndrome”


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New diagnostic criteria of Vestibular migraine

(A1.1.6) : ICHD-III Beta version 2013 A. At least five episodes fulfilling criteria C and D

B. A current or past history of 1.1 Migraine without aura or 1.2 Migraine with aura

C. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72

hours

D. At least 50% of episodes are associated with at least one of the following three migrainous

features:

1. headache with at least two of the following four characteristics: unilateral location,

pulsating quality, moderate or severe intensity, aggravation by routine physical activity

2. Photophobia/phonophobia

3. Visual aura

E. Not better accounted for by another ICHD-III diagnosis or by another vestibular disorder

ICHD-III Beta 2013


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Vestibular symptoms in vestibular migraine (defined by Barany Society)

Vertigino/dizziness character Vertigo duration

a) spontaneous vertigo:

(i) internal vertigo (a false sensation of self-

motion)(ii) external vertigo (a false sensation that the

visual surround is spinning or flowing)

b) positional vertigo, occurring after a

change of head position

c) visually induced vertigo, triggered by a

complex or large moving visual stimulus; d) head motion-induced vertigo, occurring

during head motion

e) head motion-induced dizziness with

nausea (dizziness is characterized by a

sensation of disturbed spatial orientation

10% seconds

30% lasting minutes

30% hours

30% several days

Stolte B, Holle D et al. Cephalalgia. 2015 Mar;35(3):262-70


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Mechanisms involved in the pathophysiology of

vestibular migraineInherited brain excitability Trigemino-vascular reflex

Thalamo-

cortical

processing

Amygdala

Insula

Emotional

response

Spatial

memory

changes

Cognitive/

perceptive

changes

Cochlea/vestibular hypersentitivity

Vestibular dysfunction

Sensorimotor response: eye, head, gait

Trigeminal pain pathway

activation

Vasodilation of inner ear

blood vessels

CGRP-Substance P-Neurokinin A

Espinosa Sanchez JM et

al. Front in Neurol2015;6(12): 1-6


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Migraine with brainstem aura

Vestibular migraine


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Vestibular migraine treatment• Few studies• acute; zolmitriptan

• anti-vertigo agent: promethazine, dimemhydrinate,meclozine

• prophylactic;

• nortriptylline, verapamil, metoprolol, topiramate,flunarizine, valproic acid, lamotrigine

• CAI: acetazolamine


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A case example of migraine with brain stem aura

A patient with recurrent headache for 2 years with

associated neurological symptoms


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Practical point in migraine diagnosis

Typical migraine

- migraine without aura- migraine with typical aura(Typical aura: duration: 5-60 minutes,

visual symptoms, sensory symptoms

+/- speech symptoms, occurs in

succession , gradual onset, and slow

progression)

Atypical migraine

- migraine atypical aura (brainstem aura,hemiplegic aura, prolonged aura)

- aura without headache (late-life

migraine accompaniments)

- migraine complication: migralepsy,

migraine infarct


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S.D. Silberstein, et al. Neurology 2012;78;1337

AAN/AHS 2012

Flunarizine is available in EU

Treatment guideline in episodic migraine in adults


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Pascual J, Caminero AB et al. Headache 2004;44:1024-1028

Treatment disturbing aura inmigraine with Lamotrigine


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Case seminar-2An 65 years old man with dull aching,

diffuse

headache triggered by stressfor 1 month. He has been diagnosed as

TTH and treated with simple analgesic ,

but no improvement

He noted that chaining position to

upright also trigger headache

PE: normal


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Just a TTH?

In context of bilateral,

mild to moderate

diffuse/temporal

headache without

significant other features

Tension-type headache

TTH mimicker

TTH with co-morbidities


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Tension-type like headache• Chronic transform migraine

• Medication overused

headache

• Headache attributed to a

substance or its withdrawal

• Mild intracranial

hypertension/intracranial

hypotension

• Diffuse incracranial

disorder

• Headache attributed to

disorder of homeostasis

• Hypoxia/hypercapnia,aeroplane travel, sleep

apnea headache, arterial

hypertension,

hypothyroidism, fasting


cervical dystonia


psychiatric disorder


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What should we ask when we see TTH like

headache without localising neuro-signs?

• The history of chronic migraine (to identifytransform migraine)

• Trigger factor (to identify CSF disorder, diffuseintracranial lesion, posterior fossa lesion, dystonia)

• Systemic symptoms (to identify systemic illness)

• Time (to identify OSA)

• Blood pressure (to identify systemic hypertension)


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Miguel Gus, Flavio Danni et al. Arch Intern Med 2001;161:252-255

76 HT patients with ambulatory BP monitoring

between headache vs non-headache patients

HT and Headache


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Headache and HT• Mild (140-159/90-99 mgHg) to moderate (160-179/100-109 mmHg)

chronic arterial HT does not appear to cause headache

• Abrupt elevation of arterial BP is responsible for headache ratherthan absolute value

• Major causes of HT attributed headache

• Pheochromocytoma

• HT crisis with/without encephalopathy

• Pre-eclampsia and eclampsia

• Acute pressure response to an exogenous agent

Assarzadegan F, Asodollahi M et al. Ir J neurol 2013; 12(3): 106-110

Cephalalgia 2014 ICHD-III beta

Th N th N i C t


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NNC CMU

The Northern Neuroscience CentreChiang Mai University

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