headache in emergency condition

NNC CMUThe Northern Neuroscience Centre

Chiang Mai University

Primary Headache in Emergency Setting

Surat Tanprawate, MD, MSc(Lond.), FRCP(T)1, 2 1Division of Neurology, Department of Medicine

2The Northern Neuroscience Centre Chiang Mai University



Primary headache in ER• Diagnostic issue for common primary headache

• Identify primary headache disorder mimickers (migraine mimickers, TACs mimickers)

• Knowing the unusual presentation of primary headache (migraine)

• Successful management typical primary headache disorder

• Typical acute migraine and cluster headache attack

• Knowing the other primary headache that may present at ER

Diagnostic issue for primary headache in ER



Cause of Symptomatic Migraine

Cause Suggestive features

Vascular disorderCADASIL, MELAS, aneurysm, AVM, CAA, carotid dissection, TIA/Stroke, temporal arteritis systemic hypertension

Non-vascular disorderpineal cyst, neoplasm

Age of onset > 60

Progressive headache Sudden onset

Prolonged aura Atypical aura (eg.hemiparesis)

New headache features



No. age/sex Presenting symptoms Diagnosis

1 57 Y.O. PH like symptom,

numbness (response to Indomethacin)

Vertibral artery dissection with medullary

infarct

2 51 Y.O. CH like symptomArterio venous fistula after cavernous sinus

thrombosis

3 60 Y.O. PH like headache (response to Indomethacin)

Nasopharyngeal carcinoma with cervical carotid artery invasion

4 30 Y.O. CH like headache Pituitary tumor

5 63 Y.O. CH like headache Cavernous sinus meningioma

Case record of symptomatic TACs from CMU

- duration of headache - other abnormal neurological

examination - sign of pituitary dysfunction:

Galactorrhea, impotence, testicular atrophy

- persistent horner’s syndrome - Triggered by changing standing

sympathetic-parasympathetic

dysregulation



Migraine variant / with red flag signs

• “Crash migraine” (Evans et al. Headache 2007;Dodick DW JNNP 2002)

• “Nocturnal migraine”(Dexter JD Headache 1975)

• “New onset migraine in the elderly”(Evans et al. Headache 2002;Haan J Cephalalgia 2006)

• “Migraine related vertigo”

• “Acephalalgic migraine”

• “Migraine with prolonged aura”

• “Hemiplegic / migraine with brainstem aura”



Migraine complication that may present in ER

A seizure fulfilling diagnostic criteria for one type of epileptic attack occurs during or within 1 h after a migraine aura

The present attack in a patient with Migraine with aura is typical of previous attacks except that one or more aura symptoms persists for >60 minutes with neuro-imaging demonstrates ischemic infarction in a relevant area

Migrainous infarction

Migraine trigger seizure

Primary headache management in emergency setting


Chiang Mai UniversityMigraine Emergency

Character of Migraine at ER

• Attack refractory to usual treatment (42%)

• Severity of attack (13.5%)

• Severity of accompanying symptoms (25%)

• Aura disturbances (7.2%)

• First episode of headache (4.4%)

• Status migrainosus (8.4%) Rosanna Cerbo et al. J Headache Pain (2005) 6:287–289

Ideal medication

• high efficacy

• rapid onset

• low recurrence rate

• easy access route (IV)

• few adverse event



Targeting acute migraine medication

1. Directed contraction of dilated cranial extracerebral blood vessels

2. Suppression of neuropeptide release from peripheral nerve ending around blood vessels

3. Inhibition of impulse transmission centrally in the TNC

4. Presynaptic blockade of synaptic transmission between axon terminals of there peripheral trigeminovascular neutrons and cell bodies of there central counterparts

5-HT1B

5-HT1D

5-HT1F



Dopamine and Migraine attacksEvidence of Dopamine system and Migraine

• Increase alleles of DA D2 receptor (DRD2) gene in migraine with aura

• Biochemical studies: DA, HVA, DOPAC level (CSF, platelet, plasma)

• Drug trial in acute treatment (antidopaminergic agents)

• DA modulate trigeminovascular transmission

• Migraineous phenomena in dopaminergic agonist therapy

Mascia J and Shoenen. Cephalalgia 1998;18:174-182Akerman S, Goadsby PJ Cephalalgia, 2007, 27, 1308–1314



Acute migraine therapy ER

• Dopamine antagonists

• Prochlorperazine, chlorpromazine iv

• Metoclopramide iv

• Haloperidol, droperidol iv

• Sumatriptan sc

• Opioids (meperidine, morphine, tramadol)

• Dexamethasone iv

• Sodium valproate iv

• Magnesium sulfate iv

• Lidocaine intranasal



AHRQ Effective Health Care Review “Helping Clinician Make Better Treatment Choices”

AHRQ:The Agency for Healthcare Research and Quality

1. Ability to achieve pain-free status

Neuroleptics, NSAIDs, and Sumatriptan improve the likelihood of achieving pain-free at various time point after administration - Sumatriptan at 30-120 mins (RR = 4.73) - Neuroleptics (prochlorperazine, chlorpromazine, droperidol) at 60 mins (RR = 3.38) - NSAIDs at 60-120 mins (RR = 2.74)

2. Ability to provide significant headache relief (complete or partial)Neuroleptics and sumatriptan provide significant headache relief at various time points after administration - Neuroleptics (haloperidol, chlorpromazine, prochlorperazine, droperidol) at 60 mins (RR = 2.69) - Sumatriptan at 60 mins (RR = 3.03)




3. Ability to reduce pain intensityPain intensity measurements at time points after administration are reported on a 100-point visual analog scale (in mm). - Neuroleptics (chlorpromazine, haloperidol, prochlorperazine) at 30 mins to 4 hrs (MD = -46.59) - Metoclopaminde at 30-60 mins (MD = -21.88) - Opioids (meperidine, nalbuphine, tramadol) at 45-60 mins (MD = -16.73) - Sumatriptan at 30 mins (MD = -15.45) Neuroleptics (chlorpromazine) reduce pain intensity more than metochopramide (MD = 16.45)

4. Ability to prevent recurrence

Dexamethasone plus standard abortive therapy are less likely to report recurrence of pain or headache up to 72 hours (RR = 0.68; 95% CI, 0.49 to 0.96).




5. Adverse event

>> akathisia after treatment with a neuroleptic agent or metoclopramide are about 10 times greater than with placebo.

>> The risk of sedation is common after treatment with metoclopramide or prochlorperazine (17% for both).

>> The most common adverse effects from dihydroergotamine include pain or swelling at the injection site, intravenous site irritation, sedation, digestive issues, nausea or vomiting, and chest symptoms (palpitations, arrhythmia, or irregular heartbeat).

AHRQ Effective Health Care Review “Helping Clinician Make Better Treatment Choices”



Dexamethasone IV in ER setting

“IV Dexamethasone provides a reasonable option for managing resistant, severe, recurrent or prolonged migraine attacks in the ED”

Woldeamanuel TW et al. Cephalalgia 2015, Vol. 35(11) 996–1024

14 studies (56%) used IV Dexamethasone



Drug showed weak evidence, but may be used

• Magnesium sulfate IV

• Sodium valproate IV



A RCT of MgSO4 (2g iv) vs Metoclopamide (10mg iv) vs Placebo in acute migraine attacks in ER

VAS scores at 15 and 30 min of treatment. Changes were significant at 30 min in all groups (P < 0.000), but the difference

between groups was not significant at either 15 or 30 min.Cete Y, et al. Cephalalgia 2005; 25:199–204

120 migraine patients

––– Metoclopramide –-–– magnesium - - - - placebo.



Occipital nerve block(ONB) in acute and transitional therapy in migraine

Levin M. Neurotherapeutics. 2010 Apr;7(2):197-203.

Reference n Intervention Results Study design

Gawel and Rothbart 97 A single or repeated GON block(s) using lidocaine and methylprednisolone

Headache improvement in 54% of subjects for up to 6 months

Retrospective

Caputi and Firetto 27 Repeated GON and SON blocks using bupivacaine

Headache improvement in 85% of subjects for up to 6 months

Retrospective

Bovim and Sand 14 A single GON block with or without SON block using lidocaine and epinephrine

Head pain reduction in 6% of subjects at 30 minutes

Retrospective

Ashkenazi and Young 19 A single GON block using lidocaine and trianmcinolone, and TTP using lidocaine

A significant decrease in head pain in 90% of subjects

Prospective, non-controlled

• *Pain reduction after GONB as soon as 3 minutes and remained about 6 months



Occipital nerve block(ONB) in acute migraine• Local aesthetics reversibly bind to the voltage-gated Na+ channels,

block Na+ influx, and thus block action potential and nerve conduction

Levin M. Neurotherapeutics. 2010 Apr;7(2):197-203.

2 cm.below

2 cm.lateral

2% Lidocaine 1.5 cc./side



Occipital nerve block in migraine - a case study

Pt.NO.Visual analog scale

(VAS) Occipital

tenderness Allodynia HIT-6 scale

Before 5 min 2nd 3rd Before 5 min 2nd 3rd Before 5 min 2nd 3rd Before 2nd 3rd

1 7 4 7 6 N N N N P N N N 60 64 60

2 5 3 5 5 N N N N N N N N 58 52 56

3 0 0 7 6 P N N N P N N P 60 40 60

4 8 4 3 3 P N N N N N N N 78 75 68

5 6 0 6 8 N N N N N N N N 60 36 66

6 5 0 5 5 P N N N N N N N 54 60 62Dollaporn & Surat Chiang Mai Headache Clinic2013

Cochrane review 2009

Hyperbaric oxygen in migraine attack



Other primary headache that may present at ED

Cluster headache Hypnic headache

Primary exercise/cough Primary thunderclap headache

Primary headache associated with sexual activity



Cluster headache acute therapy EFNS recommendation (2006)

European Journal of Neurology 2006, 13: 1066–1077

Knowing the other primary headache that may present at ER

Hypnic headachePrimary thunderclap headacheHeadache associated with sexual activity



Hypnic headache (HH)

• Described by Raskin (1988)

• Previous terms: “curious sleep-related headache syndrome”, “alarm clock headache”

• Secondary hypnic headache case reports: obstructive sleep apnea, posterior fossa meningioma, pontine infarct, nocturnal arterial hypertension, pituitary macroadenoma, transient HH syndrome after lithium withdrawal

Caminero et al. Cephalalgia 30(9) 1137–1139



Clinical findings in patients with hypnic headache (n=96)

Dodick DW et al. Cephalalgia 1998;18:152–156.



Acute treatment used for hypnic headache attacks

Treatment Number of patients

Efficacy Response rate (A+B/n, %)None Partial Good

Caffeine 19 3 1 15 84

Caffeine containing analgesics 10 4 1 5 60

ASA 9 3 5 1 66

Triptan 34 29 0 5 14

NSAIDs 38 34 0 4 10

Acetaminophen 15 12 2 1 20

Oxygen inhalation 8 7 0 1 12.5

Ergotamine derivative 5 2 2 1 60

Liang JF, Wang SJ. Cephalalgia 2014,34(10) 795–805

Acute and Preventive treatment options for HH



Primary Headache associated with sexual activities (HSA)

• First described in 1974 (prevalence 1%)

• 2 types

• type 1: Preorgasmic headache-dull ache in the head and neck with awareness of neck a/r jaw muscle contraction

• type 2: Orgasmic headache-sudden severe (“explosive”) -> 25% severe pain continue >2 hrs to 24 hrs

• SAH need to be excluded in every cases



Management at ED• acute treatment after the onset

• NSAIDs (paracetamol, ASA, diclofenac, ibuprofen) - no benefit

• short-term prophylaxis

• Indomethacin 25-100 mg given 30-60 min prior to sexual activity

• long-term prophylaxis

• Propranolol (60-240 mg), metoprolol, atenolol, ditiazem

Free A, Ever S. Practical Neurology 2005;5:350–355



Primary thunderclap headache (PTCH)• “Thunderclap headache” described by Raskin(1986) for sudden

headache caused by cerebral aneurysm

• “Thunderclap headache”: severe head pain of sudden onset, reaching maximum intensity in <1 min lasting from 1 h to 10 days

• Secondary thunderclap headache

• SAH, CVST, pituitary apoplexy, SIH, reversibel vasoconstriction syndrome, myocardial infarction, pheochromocytoma, hypertensive encephalopathy, obstructive hydrocephalus, carotid dissection, retroclival hematoma

Dodick DW. Headache 2002 42:309–315



Management• Usually self limited in 2 months

• Acute therapy - no

• Preventive therapy - Nimodipine, Gabapentin

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13th the Northern Neuroscience Center Conference (NNCC) 29-30 Jan 2016

Chiang Mai, Thailand

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