headache ppt
TRANSCRIPT
Origins of Pain in the Head
• Extra-cranial pain sensitive structures:– Sinuses– Eyes/orbits– Ears– Teeth– TMJ – Blood vessels– 5,7,9,10 cranial nerves carry pain from thes
strucure
• Intra-cranial pain sensitive structures:– Arteries of circle of willis and proximal dural
arteries,– Dural Venous sinuses,veins– Meninges– Dura
Classification of Headaches
• PRIMARY - NO structural or metabolic abnormality:
– Tension– Migraine– Cluster
• SECONDARY – structural or metabolic abnormality:– Extracranial: sinusitis, otitis media, glaucoma, TMJ ds– Inracranial: SAH, vasculitis, dissection, central vein thrombosis, tumor,
abscess, meningitis– Metabolic disorders: CO2 retention, CO poisoing
RED Flags
• New onset headache in a patient >50 y.o.• Sudden, worst headache of one’s life• Morning headache associated with N/V• Fever, weight loss• Worsens with valsalva maneuvers• Focal neurologic deficits, jaw claudication• Altered LOC• Hx of trauma, cancer or HIV
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
Part 1:The primary headaches
1. Migraine
2. Tension-type headache
3. Cluster headacheand other trigeminal autonomiccephalalgias
4. Other primary headaches
Primary Headache Types
Migraine Tension Cluster
Pain Description
Throbbing, moderate to
severe, worse w/exertion
Pressure, tightness, waxes and
wanes
Abrupt onset, deep,
continuous, excruciating,
explosive
Associated Symptoms
Photo/phono-phobia, n/v, aura
None Tearing, congestion, rhinorrhea,
pallor, sweating
Bajwa and Wootton. Up to Date 2007
Primary Headache Types
Migraine Tension Cluster
Location 60-70% unilateral
Bilateral Unilateral
Duration 4-72 hr Variable 0.5-3 hr, many per day
Patient Appearance
Resting in quiet dark
room; young female
Remains active or prefers to
rest
Remains active, prefers
hot shower, male, smoker
Bajwa and Wootton. Up to Date 2007
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
1. Migraine
1.1 Migraine without aura1.2 Migraine with aura1.3 Childhood periodic syndromes that are
commonly precursors of migraine1.4 Retinal migraine1.5 Complications of migraine1.6 Probable migraine
Pathophysiology
• Brainstem neuronal hyperexcitability
• Cortical spreading depression w/aura
• Abnormalities of 5-HT, CGRP, NE, DA, GABA, glutamate, NO, and endorphins
• Trigeminal Activation
Marcus, DA. Headache Simplified 2008.
Presymptomatic hyperexcitabilty increases brain stem response to triggers
Release of Neurotransmitters
(5-HT, NE, DA, GABA, Glutamate, NO, CGRP, Substance P, Estrogen)
Neurotransmitters activate the Trigeminal Nucleus
Dilation of Meningeal blood
vessels (Throbbing)
Activation of Area Postrema
(N/V)
Activation of Hypothalamus
(Hypersensitivity)
Activation of cervical trigeminal system (Muscle
spasm)Activation of Cortex and
Thalamus (Head pain)
Marcus, DA. Headache Simplified 2008.
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
1.1 Migraine without auraA.At least 5 attacks fulfilling criteria B-DB.Headache attacks lasting 4-72 h (untreated or
unsuccessfully treated)C. Headache has 2 of the following characteristics:
1. unilateral location2.pulsating quality3.moderate or severe pain intensity4.aggravation by or causing avoidance of routine
physical activity (eg, walking, climbing stairs)D.During headache 1of the following:
1. nausea and/or vomiting2.photophobia and phonophobia
E.Not attributed to another disorder
1.1 Migraine without auraNotes
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1.1 Migraine without auraNotes
• If <5 attacks but criteria B-E otherwise met, code as1.6.1 Probable migraine without aura
• When attacks occur on 15 d/mo for >3 mo, code as1.1 Migraine without aura + 1.5.1 Chronic migraine
• Pulsating means varying with the heartbeat• In children:
– attacks may last 1-72 h– occipital headache requires caution
• In young children:– photophobia and/or phonophobiamay be inferred
from their behaviour
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‘Not attributed to another disorder’
Note
For all primary headaches, this criterion means:
• History and physical/neurological examinations do not suggest any of the disorders listed in groups 5-12, or history and/or physical/ neurological examinations do suggest such disorder but it is ruled out by appropriate investigations,or such disorder is present but headache does not occur for the first time in close temporal relation to the disorder
1.2 Migraine with aura
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1.2 Migraine with aura
1.2.1 Typical aura with migraine headache1.2.2 Typical aura with non-migraine headache1.2.3 Typical aura without headache1.2.4 Familial hemiplegicmigraine (FHM)1.2.5 Sporadic hemiplegicmigraine1.2.6 Basilar-type migraine
1.2 Migraine with aura
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1.2 Migraine with aura
A.At least 2 attacks fulfilling criterion B
B.Migraine aura fulfilling criteria B and C for one of the subforms 1.2.1-1.2.6
C. Not attributed to another disorder
1.2 Migraine with auraSubtypes new to classification
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1.2 Migraine with auraSubtypes new to classification
1.2.1 Typical aura with migraine headache
• most migraine auras are associated with headache fulfilling criteria for 1.1 Migraine without aura
1.2.2 Typical aura with non-migraine headache
1.2.3 Typical aura without headache
• migraine aura is sometimes associated with a headache that does not fulfil these criteria
• or occurs without headache
1.2.1 Typical aurawith migraine headache
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1.2.1 Typical aurawith migraine headache
A.At least 2 attacks fulfilling criteria B–DB.Aura consisting of 1of the following, but no motor
weakness:1. fully reversible visual symptoms including positive
and/or negative features2.fully reversible sensory symptoms including
positive and/or negative features3.fully reversible dysphasic speech disturbance
1.2.1 Typical aurawith migraine headache
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1.2.1 Typical aurawith migraine headache
C. At least two of the following:1. homonymous visual symptoms and/or unilateral
sensory symptoms2. at least one aura symptom develops gradually over
5 min and/or different aura symptoms occur in succession over 5 min
3. each symptom lasts 5 and 60 minD.Headache fulfilling criteria B-D for 1.1 Migraine
without aura begins during the aura or follows aura within 60 min
E.Not attributed to another disorder
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1.2.2 Typical aurawith non-migraine headache
As 1.2.1 except:D.Headache that does not fulfil criteria B-D for
1.1 Migraine without aura begins during the aura or follows aura within 60 min
1.2.3 Typical aurawithout headache
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1.2.3 Typical aurawithout headache
As 1.2.1 except:D.Headache does not occur during aura nor follow aura
within 60 min
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
1.2.4 Familial hemiplegicmigraine (FHM)
A.At least 2 attacks fulfilling criteria B and CB.Aura consisting of fully reversible motor weakness
and 1of:1. fully reversible visual symptoms including positive
and/or negative features2.fully reversible sensory symptoms including
positive and/or negative features3.fully reversible dysphasic speech disturbance
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
1.2.6 Basilar-type migraine
As 1.2.1 except:B.Aura consisting of 2 of the following fully reversible
symptoms, but no motor weakness:1. dysarthria; 2. vertigo; 3. tinnitus; 4. hypacusia;5. diplopia; 6. visual symptoms simultaneously in bothtemporal and nasal fields of both eyes; 7. ataxia;8.decreased level of consciousness;9.simultaneously bilateral paraesthesias
C. At least one of the following:1. at least one one aura symptom develops gradually over
5 min and/or different aura symptoms occur in succession over 5 min
2.each aura symptom lasts 5 and 60 min
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
1.3 Childhood periodic syndromes that are commonly
precursors of migraine
1.3.1 Cyclical vomiting1.3.2 Abdominal migraine1.3.3 Benign paroxysmal vertigo of childhood
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
1.3.2 Abdominal migraine
A.At least 5 attacks fulfilling criteria B-DB.Attacks of abdominal pain lasting 1-72 h C. Abdominal pain has all of the following
characteristics:1. midline location, periumbilical or poorly localised2.dull or “just sore” quality3. moderate or severe intensity
D.During abdominal pain 2 of the following:1. anorexia; 2. nausea; 3. vomiting; 4. pallor
E.Not attributed to another disorder
Types of Migraine Treatment
• Acute– Taken during an attack– Reduces pain, associated symptoms and disability
and stops progression• Preventive
– Taken daily for months to years– Reduces frequency, severity, and duration– Used in addition to acute treatments
.
Acute Treatment Principles
• Treat attacks rapidly and consistently
• Tailor treatment to the patient and the sx
• Minimize adverse events and cost
• Limit to 3 days per week or less
Antiemetics
• Prevent and treat nausea
• Improve GI motility
• Enhance absorption of other anti-migraine medications
• Limited RCT to support their use in migraine
Phenothiazines• Promethazine (Phenergan)
– Available PO, IM, PR– Dose = 25-50 mg Q6H PRN– Blocks dopamine and histamine receptors
• Prochlorperazine (Compazine)– Available PO, IM, IV, PR– Dose = 5-10 mg Q6H PRN– Blocks dopamine receptors
• SE = sedation, dizziness, dystonic rxn
Migraine Specific Medications
TriptansErgots
Acute Treatment - Triptans
Fast onset/short duration• Sumatriptan• Rizatriptan• Zomitriptan • Almotriptan• Eletriptan• Treximet (Suma + Naproxen)
Slow onset/long duration• Naratriptan• Frovatriptan
Acute Treatment - Triptans
• Reasonable first choice for patients with moderate to severe disability from migraines
• Limit use to 2-3 days per week
• Patients who fail one triptan often respond to another
• Do not use one triptan within 24 hours of another
Acute Treatment - Triptans
Mechanism of action• 5HT-1B/1D agonists• Inhibit release of CGRP & substance P• Inhibit activation of the trigeminal nerve• Inhibit vasodilation in the meninges
Precautions• Ischemic heart dz or stroke• High risk for CAD• Pregnancy• Hemiplegic or basilar migraine• Ergots• Use w/ SSRIs?
Johnston et al Drugs 2010Loder NEJM 2010
Triptan Side Effects
• Flushing, feeling or warmth• Chest pressure or heaviness• Throat tightness• Paresthesias• Dizziness, fatigue, drowsiness• Nausea• Intolerable taste with nasal formulations
Johnston et al Drugs 2010Loder NEJM 2010
Drug Tmax (h) T1/2 (h) Metabolism
Sumatriptan 50 &100 mg tablets
2.5 2 MAO-A
Sumatriptan 20 mg nasal 1 2
Sumatriptan 6 mg subQ 0.16-0.2 2
Zolmitriptan 2.5 mg tab 2 3 2D6 and MAO-A
Zolmitriptan 2.5 mg ODT 3.3 2.5-3
Zolmitriptan 5 mg nasal 4 2.82
Rizatriptan 10 mg tab 1.2 2 MAO-A
Rizatriptan 10 mg ODT 1.6-2.5 2
Naratriptan 2-3 5-6 P450, 50% unchanged
Almotriptan 1.4-3.8 3.2-3.7 MAO-A, 3A4, and 2D6
Frovatriptan 2-4 26 Mostly unchanged
Eletriptan 1-2 3.6-5.5 3A4
Triptan Comparison
Acute Treatment – Ergots
• Mechanism of Action– Constrict peripheral and cranial blood vessels– Bind to 5HT, NE, DA, alpha and beta receptors
• Contraindications and precautions– CAD or CVD (or high risk), uncontrolled HTN– Hemiplegic or basilar migraine– Pregnancy (category X) and breast feeding– Drugs metabolized by CYP3A4, triptans
Ergot Side Effects
• Nausea and vomiting (pre-treat with antiemetic)
• Coronary artery spasm, angina, MI
• Tingling, numbness, Dizziness
• Increased BP and HR
• “Ergotism”
Choosing Acute Rx
Early N/V• Nasal triptans• Sumatriptan SubQ• ODT triptans?
Sensitive to SE• Naratriptan• Frovatriptan• Almotriptan
Recurrence• Nara, Frova, Almotriptan• Ergots• Triptan + NSAID
Rapid Onset• Sumatriptan SubQ• Nasal Triptans• DHE nasal or IM
Indications for a Preventive Agent• Migraine-related disability > 3d/month
• Migraines last over 48 hours
• Acute treatments are contraindicated, ineffective, or overused
• Migraines cause profound disability or prolonged aura
• Patient preference
Beta Blockers
• FDA approved for migraine prevention– Propranolol (Inderal) 60-240 mg PO once daily for ER or divided
BID or TID for IR– Timolol (Blocadren) 10-30 mg PO daily in 2 divided doses
• Limited evidence for migraine prevention– Nadolol (Corgard) 20-240 mg PO once daily– Atenolol (Tenormin) 50-150 mg PO daily or divided BID– Metoprolol (Lotensin, Toprol XL) 100-200 mg daily or divided
BID for IR formulation
Beta Blockers
Advantages• Thoroughly studied and widely used• Timolol (Blocadren) and propranolol (Inderal) are FDA approved• Good choice for patients with HTN, CAD, tremor, or anxiety
Disadvantages• Side effects = fatigue, dizziness, depression, exercise intolerance,
may worsen aura• Avoid in patients with severe asthma, depression, bradycardia,
Raynaud's, overt CHF
Calcium Channel Blockers
. Although the mechanism by which calcium channel antagonists affect migraine is not known,
. vasoconstriction , prevention of platelet aggregation and alterations in release and reuptake of serotonin.
. Several trials have indicated some benefit for verapamil and flunarizine In recurrent migraine.
. Verapamil in doses of 80 to 160 mg 3 times a day reduces the incidence of migraine with aura, but it is not as useful in migraine without aura.
Tricyclic Antidepressants
• Amitriptyline (Elavil) 10-200 mg nightly
• Nortriptyline (Pamelor) 10-150 mg nightly
• Desipramine (Norpramin) 25-200 mg nightly
• Imipramine (Tofranil) 10-200 mg nightly
• Doxepin (Sinequan) 10-200 mg nightly
Lower end of dosage range is usually effective for migraine prevention
Tricyclic Antidepressants
Advantages• Inexpensive• Once daily dosing• Good choice for patients with insomnia, neuropathy,
mood disorders, fibromyalgia
Disadvantages• None are FDA-approved• Side effects = sedation, weight gain, dry mouth, urinary
retention• Avoid in sz disorder, cardiac conduction abnormalities,
BPH
Other Antidepressants
• Efficacy not established in clinical trials– Best for fluoxetine (Prozac) 20 mg daily– Anectodal evidence for other SSRIs, trazodone,
mirtazapine, bupropion, venalfaxine, and duloxetine
• Migraines are more likely to be poorly controlled if mood disorders are untreated
NSAIDs• Long-acting agents taken on a scheduled basis have low risk
of causing MOH
• Consider for patients who:– Have other chronic pain conditions – Frequently use short-acting NSAID for acute treatment – Are at low risk for developing complications from daily NSAID
• Caution patients about exceeding maximum daily dose
• Limited evidence to support efficacy
NSAIDs
• Diclofenac 75 mg PO BID
• Naproxen 500 mg PO BID
• Meloxicam 7.5-15 mg PO daily
• Celecoxib 200 mg PO daily
• Aspirin 81-325 mg PO daily– May be especially helpful for reducing aura
Antiepileptic Drugs (AEDs)
• FDA approved for migraine prevention– Divalporex Sodium (Depakote)– Topiramate (Topamax)
• Limited evidence for migraine prevention– Gabapentin (Neurontin)– Lamotrigine (Lamictal)– Levetiracetam (Keppra)– Zonisamide (Zonegran)
Divalproex Sodium (Depakote)
• Increases GABA and stabilizes nerve membrane activation thresholds
• Dose = 500 - 1500 mg daily divided BID or TID– ER formulation allows for once daily dosing
• NNT = 2.8 to 4.2 (to ↓ migraine frequency 50%)
• Therapeutic plasma concentration = 50-100 mg/L
Divalproex Side Effects
Common/dose related• Tremor• Drowsiness• Nausea/vomiting• Easy bruising• Weight gain• Nystagmus
Rare/idiosyncratic• Hepatotoxicity• Pancreatitis• Alopecia• Thrombocytopenia• Agranulocytosis• Rash (SJS)• Suicidal behavior
Topiramate (Topamax) - MOA
• Not completely understood
• Blocks NMDA receptors
• Blocks voltage dependant sodium channels
• Enhances GABA
• Weakly inhibits carbonic anhydrase
.
Topiramate Dosing• Dose titration in clinical trials:
– Initial dose = 25 mg daily– Titrate by 25 mg every week– No consistent additional benefit seen in doses >100 mg
• Dose titration in U of U Headache Clinic– Initial dose = 12.5 mg at bedtime– Titrate by 12.5 mg every week– Goal of 50 mg BID– May eventually increase up to 100 mg BID in certain patients
Topiramate Side Effects
Common• Paresthesias• Cognitive problems• Fatigue• Weight loss• Dizziness• Nausea• Taste perversion
Rare or Serious• Metabolic acidosis• Depression• Nephrolithiasis• Glaucoma• Oligohydrosis• Suicidal behavior
Gabapentin (Neurontin)• Mechanism of action
– Enhances GABA activity– Binds to alpha-2-delta subunit of voltage gated calcium channels– Inhibits high-voltage-activated calcium currents– Result is decreased synaptic transmission
• Limited evidence from clinical trials for migraine prevention– NNT = 3 (50% reduction in migraine frequency)– Only 2 RCT, did not use typical migraine outcomes
Vikelis and Rapoport. CNS Drugs 2010.
Botulinum Toxin
• Recently FDA approved for chronic migraine• Dose = 155-195 units injected into muscles of
face, neck and head• Mecahnism of Action (purposed)
– Blocks release of Substance P and CGRPInhibits peripheral signals to CNS and blocks central sensitization
Dodick DW. Headache 2010.
Botulinum Toxin
• Efficacy– Botulinum Toxin superior to placebo in 2 large,
double blind, randomized, controlled trials– Botulinum Toxin similar to topiramate and
amitriptyline in small, shorter duration studies– Botulinum toxin = placebo for episodic migraine
• Side effects = muscle weakness, injection site pain, and “spread of toxin effect”
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
2. Tension-type headache
2.1 Infrequent episodic tension-type headache2.2 Frequent episodic tension-type headache2.3 Chronic tension-type headache2.4 Probable tension-type headache
Tension Type Headache• Occurs in up to 80% of the population
• Most patients treat with OTCs and do not seek medical attention
• Pathophysiology unclear– Theory of increased muscle tension is unproven
• Pain characteristics– Bandlike, bilateral– Extends form forehead to sides of temples– Involves posterior neck muscles in cape-like distribution
Acute Treatment (Episodic TTH)
• First line: OTC analgesics (APAP, NSAIDs)
• Second line: ASA+APAP+caffeine, butalbital containing products
• High risk of rebound headaches
• Limit acute treatment to 2-3 days per week
Preventive Treatment (Chronic TTH)
Non-Pharmacologic• Proper sleep hygiene• Stress management• Acupuncture• Biofeedback• Physical therapy
Pharmacologic• TCAs (best efficacy)• SSRIs (better tolerated)
**Consider for patients with >15 headaches per month**
3. Cluster headacheand other trigeminal autonomic
cephalalgias
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
3. Cluster headacheand other trigeminal autonomic
cephalalgias
3.1Cluster headache3.2Paroxysmal hemicrania3.3Short-lasting unilateral neuralgiform
headache attacks with conjunctival injection and tearing (SUNCT)
3.4Probabletrigeminal autonomic cephalalgia
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3.1 Cluster headacheA.At least 5 attacks fulfilling criteria B-DB.Severe or very severe unilateral orbital, supraorbital
and/or temporal pain lasting 15-180 min if untreatedC. Headache is accompanied by 1of the following:
1. ipsilateral conjunctival injection and/or lacrimation2.ipsilateral nasal congestion and/or rhinorrhoea3.ipsilateral eyelid oedema4.ipsilateral forehead and facial sweating5.ipsilateral miosis and/or ptosis6.a sense of restlessness or agitation
D. Attacks have a frequency from 1/2 d to 8/dE. Not attributed to another disorder
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3.1 Cluster headache
3.1.1 Episodic cluster headacheA. Attacks fulfilling criteria A-E for 3.1 Cluster
headacheB. At least two cluster periods lasting 7-365 d and
separated by pain-free remission periods of 1 mo
3.1.2 Chronic cluster headacheA. Attacks fulfilling criteria A-E for 3.1 Cluster
headacheB. Attacks recur over >1 y without remission periods
or with remission periods lasting <1 mo
Cluster Headache Abortive Treatment
• Inhalation of 100% oxygen up to 15 L/min
• Sumatriptan (Imitrex) 4-6mg subQ or 20 mg nasally
• Zolmitriptan (Zomig) 5-10 mg nasally or PO
• Dihdroergotamine (Migranal) 1 mg nasally up to 3 mg in 24 hours
• Prednisone 40-100 mg burst and taper
Bajwa and Wootton. Up to Date 2007
Cluster Headache Prevention• Verapamil 120-360 mg PO daily
• Lithium 300 mg PO BID to TID
• Divalproex 500-1500 mg PO daily to BID
• Topiramate 50-200 mg PO divided BID
• Prednisone 40-100 mg burst and taper
• Melatonin 3 mg PO QPM
Bajwa and Wootton. Up to Date 2007
The Headache Diary
• Pain score
• Characteristics of the pain
• Associated symptoms
• Acute treatments used and response
• Triggers
The Headache Diary• Makes the patient responsible for their disease
• Aids in diagnosis and differentiating between headache types
• Assesses efficacy of acute and preventive treatment
• Identifies triggers
• Minimizes recall bias
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
3.2 Paroxysmal hemicraniaA.At least 20 attacks fulfilling criteria B-DB.Attacks of severe unilateral orbital, supraorbital or
temporal pain lasting 2-30 minC. Headache is accompanied by 1of the following:
1. ipsilateral conjunctival injection and/or lacrimation2.ipsilateral nasal congestion and/or rhinorrhoea3.ipsilateral eyelid oedema4.ipsilateral forehead and facial sweating5.ipsilateral miosis and/or ptosis
D.Attacks have a frequency >5/d for > half of the time, although periods with lower frequency may occur
E.Attacks are prevented completely by therapeutic doses of indomethacin
F. Not attributed to another disorder
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
4. Other primary headaches
4.1 Primary stabbing headache4.2 Primary cough headache4.3 Primary exertional headache4.4 Primary headache associated with sexual
activity4.5 Hypnicheadache4.6 Primary thunderclap headache4.7 Hemicraniacontinua4.8 New daily-persistent headache (NDPH)
4.5 Hypnic headache New entrant to classification
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
4.5 Hypnic headacheNew entrant to classification
A.Dull headache fulfilling criteria B-DB.Develops only during sleep, and awakens patientC. At least two of the following characteristics:
1. occurs >15 times/mo2. lasts 15 min after waking3.first occurs after age of 50 y
D.No autonomic symptoms and no more than one of nausea, photophobia or phonophobia
E.Not attributed to another disorder
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
4.6 Primary thunderclap headache
A.Severe head pain fulfilling criteria B and CB.Both of the following characteristics:
1. sudden onset, reaching maximum intensity in <1 min2.lasting from 1 h to 10 d
C. Does not recur regularly over subsequent weeks or months
D.Not attributed to another disorder
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
4.7 Hemicrania continuaNew entrant to classification
A.Headache for >3 mo fulfilling criteria B-DB.All of the following characteristics:
1. unilateral pain without side-shift2.daily and continuous, without pain-free periods3.moderate intensity, with exacerbations of severe pain
C. At least one of the following autonomic features occurs during exacerbations, ipsilateral to the pain:1. conjunctival injection and/or lacrimation2.nasal congestion and/or rhinorrhoea3.ptosis and/or miosis
D.Complete response to therapeutic doses of indomethacinE.Not attributed to another disorder
4.8 New daily-persistent headache New entrant to classification
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4.8 New daily-persistent headache New entrant to classification
A.Headache for >3 mo fulfilling criteria B-DB.Headache is daily and unremitting from onset or from
<3 d from onsetC. At least two of the following pain characteristics:
1. bilateral location2.pressing/ tightening (non-pulsating) quality3.mild or moderate intensity4.not aggravated by routine physical activity
D.Both of thefollowing:1. not >1 of photophobia, phonophobiaor mild nausea2.neither moderate or severe nausea nor vomiting
E.Not attributed to another disorder
Disorder Demographic Clinical Features Recommended Treatments
Chronic migraineFemale/male, 3 : 1 Prevalence 2%
Headache ≥15 days per month for >3 mo, of which ≥8 days meet ICHD-II criteria for migraine without aura or relief with triptan or ergot
Topiramate, divalproex sodium, amitriptyline
Chronic tension-type headacheEqual sex ratio Prevalence 2%Mild-moderate severity; no migrainous symptoms; bilateral, nonthrobbing
Amitriptyline
New daily persistent headache Female > male
Bilateral, persistent, moderately severe; may be preceded by viral infection; may resemble migraine or tension-type headache
Amitriptyline
Hemicrania continua Female > male
Rare; unilateral, constant, exacerbations of severe headache, cranial autonomic symptoms, and ice-pick pain; responsive to indomethacin by definition
Indomethacin
Primary Chronic Daily Headache Disorders of Long-Duration (>4 h)
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
Diagnostic criteriafor secondary headaches
A.Headache with one (or more) of the following [listed] characteristics and fulfilling criteria C and D
B.Another disorder known to be able to cause headache has been demonstrated
C. Headache occurs in close temporal relation to the other disorder and/or there is other evidence of a causal relationship
D.Headache is greatly reduced or resolves within 3 mo (shorter for some disorders) after successful treatment or spontaneous remission of the causative disorder
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
6. Headache attributed to cranial or cervical vascular disorder
6.1 Headache attributed to ischaemicstroke or transient ischaemic attack
6.2 Headache attributed to non-traumatic intracranialhaemorrhage
6.3 Headache attributed to unruptured vascular malformation
6.4 Headache attributed to arteritis6.5 Carotid or vertebral artery pain6.6 Headache attributed to cerebral venous thrombosis 6.7 Headache attributed to other intracranial vascular
disorder
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
6.4.1 Headache attributed to giant cell arteritis
A. Any new persisting headache fulfilling criteria C and D
B.At least one of the following:1. swollen tender scalp artery with elevated
erythrocyte sedimentation rate (ESR) and/orC reactive protein (CRP)
2.temporal artery biopsy demonstrating giant cellarteritis
C. Headache develops in close temporal relation to other symptoms and signs of giant cell arteritis
D.Headache resolves or greatly improves within 3 d of high-dose steroid treatment
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
6.7.1 CADASI L
A.Attacks of migraine with aura, with or without other neurological signs
B.Typical white matter changes on MRI T2WIC. Diagnostic confirmation from skin biopsy evidence or
genetic testing (Notch 3 mutations)
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
7.4.2 Headache attributed directly to neoplasm
A.Headache with 1of the following characteristics and fulfilling criteria C and D:1. progressive2.localised3.worse in the morning4.aggravated by coughing or bending forward
B. Intracranial neoplasm shown by imagingC. Headache develops in temporal (and usually spatial)
relation to the neoplasmD.Headache resolves within 7 d after surgical removal
or volume-reduction of neoplasm or treatment with corticosteroids
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
9.1 Headache attributed tointracranial infection
9.1.1 Headache attributed to bacterial meningitis
9.1.2 Headache attributed to lymphocyticmeningitis
9.1.3 Headache attributed to encephalitis
9.1.4 Headache attributed to brain abscess
9.1.5 Headache attributed to subdural empyema
9.1.1 Headache attributed to bacterial meningitis
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
9.1.1 Headache attributed tobacterial meningitis
A.Headache with 1of the following characteristics and fulfilling criteria C and D:1. diffuse pain2.intensity increasing to severe3.associated with nausea, photophobia and/or
phonophobiaB.Evidence of bacterial meningitis from examination of CSFC. Headache develops during the meningitisD.One or other of the following:
1. headache resolves within 3 mo after relief from meningitis
2.headache persists but 3 mo have not yet passed since relief from meningitis
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
9.1.1 Headache attributed tobacterial meningitis
Notes
• Criterion D does not relate to evidence of causation• Causation is established by onset during diagnosed
bacterial meningitis, whilst it is well recognised that this headache often persists
• When this occurs, 9.4.1 Chronic post-bacterial meningitis headache is diagnosed
• Criterion D2 allows a default diagnosis within 3 mo, before it is known whether headache will resolve or persist
©International Headache Society 2003/4ICHD-I I . Cephalalgia 2004; 24 (Suppl 1)
9.2 Headache attributed to systemic infection
A.Headache with 1of the following characteristics and fulfilling criteria C and D:1. diffusepain2.intensity increasingto moderate or severe3.associated with fever, general malaise or other
symptoms of systemic infectionB.Evidence of systemic infectionC. Headache develops during the systemic infectionD.Headache resolves within 72 h after effective
treatment of the infection