Headaches

Anne Mounsey M.D.Dept. of Family Medicine

Univ. of Virginia School of Medicine

Objectives

• Learn 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.

Acute onset headache

• Sufficient 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 hemorrhage– Subdural hemorrhage

– Subarachnoid hemorrhage.

• Meningitis• Hypertensive

encephalopathy.

Subarachnoid hemorrhage:causes

• 80% 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.

• HTN• Smoking and alcohol• Sympathomimetic drugs• Polycystic kidney disease• Coarctation of the aorta• Marfans syndrome

Subarachnoid hemorrhage:useful signs and symptoms

• Sudden 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.

Risk factors for SDH

• Age, alcohol, anticoagulation or anti-platelet treatment.

• May be minimal trauma such as coughing

• The signs and symptoms of brain compression may not appear until up to 2 weeks after the trauma..

Subdural hemorrhage

• Dull, 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

hematoma• On exam patient may have unilateral

weakness and increased reflexes.

Hypertensive Encephalopathy

• Associated with high blood pressure, nausea, vomiting and blurred vision

• Usually 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

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.

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.

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.

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

Clinical Policy of ACEP cont.

Level C recommendation:

• Patients over 50 with a new headache should be considered for urgent neuroimaging.– Emergent means done immediately– Urgent means scan appointment is arranged

prior to discharge and included in disposition.Annals of Emergency Medicine: Vol 39:1:Jan 2002.

Migraine: IHS criteria

5 attacks of• Headache lasting 4-72 hours.• Must be associated with nausea or vomiting or

photophobia and phonophobia• Must have 2 of the following

1. Unilateral2. Pulsating3. Moderately severe.4. Aggravated by physical activity

Sinus H/A vs. Migraine

Summit 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

Phases of migraine

• Premonition: eg hunger, energy surges, irritability.

• Prodrome: aura.

• Headache phase

• Postdrome.

Migraine TreatmentDrug Level of

Evidence

Tylenol B

NSAIDS A

Triptans A

Fiorinal A

Midrin B

Opiates A

DHE B

Steroids C

Triptans

• Meta-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.

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/week• Acute medications ineffective or

contraindicated.• Presence of uncommon migraine conditions

– Hemiplegic migraine– Basilar migraine– Migraine with prolonged aura.

Drug Evidence

Valproate A

Amitriptyline A

Propranolol A

Prozac B

Riboflavin B

Gabapentin B

ACE B

Aspirin B

Clonidine B

Verapamil B

Migraine Prevention

Episodic Tension Type Headache.

IHS Criteria• Tension type headaches < 15 per month.• Lasts 30 mins to 7 days• No nausea or vomiting• No photophobia and phonophobia (1 ok)• Headache has at least 2 of the following criteria:

a. pressing/tighteningb. Bilateralc. Mild-moderated. Not aggravated by physical activity.

Causes of TTH

• Some evidence that like migraine caused by serotonin imbalance but to a lesser extent than migraine.

• This would indicate that similar treatments would work.

Treatment of TTH

• Simple 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.

Chronic Daily Headache

• Affects 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 headache

• Includes chronic tension type headache(CTTH) and chronic daily migraine

Chronic Tension Type Headache.

• Develops from episodic tension type headaches

• The 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 Headache

• Affect women more than men

• Most common in middle age

• Stress is often a trigger

• Average duration is 4-13 hours.

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.

Prevention of CTTH

• Tricyclic antidepressants.

• Stress management

• Tizanidine

• SSRIs:prozac

• Anticonvulsants: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.

a. Bilateralb. Pressing/tight non pulsating qualityc. Mild/moderate intensity

• Simple analgesic use >15 days a month for 3 months

• Headache has increased during analgesic use• Headache resolves or reverts to previous pattern

within 2 months after discontinuation of analgesia.

Rebound headaches

• Most significant factor in their development is the lack of awareness by physicians and patients. “Prevention better than cure”

• Triptans, all analgesics and ergotamines have been associated with medication rebound headaches.

Rebound headaches

• If patient is unable to tolerate abrupt cessation of medication may need to titrate down over 2 weeks.

• May need inpatient treatment to successfully withdraw

• Various regimes including tizanidine, daily triptans, steroids and parenteral DHE have been used.