Headaches .

Mini Medical School .

November 10, 2016

A. Laine Green MSc, MD FRCP(C) Assistant Professor Department of Medicine (Neurology)

Artist Agnes Cecile

Disclosures

• I have received an honorarium from and/or acted as a consultant for:

– Tribute Pharmaceuticals

• Cambia® (diclofenac potassium for oral solution)

– Allergan Canada

• BOTOX® (onabotulinumtoxinA)

Cartoon by Dan Wasserman

US News & World Report

How do Neurologists Think??

4 questions

• Is the problem neurological?

• Where is the problem?

– Brain, brainstem, cerebellum, spinal cord, nerve root, peripheral nerve, muscle

• What is causing the problem?

• What are we going to do about it?

Additional 2 questions in Headache cases

2014-2015 8

How common are headaches

• Headaches are very common

– Tension Headache

• most common

• > 50% of the population

– Migraine - lifetime prevalence

• Female = 25%

• Male = 10%

9

• Gender preference

– Pre-puberty F > M

– Post-puberty F >>> M (3:1)

• Estrogen

– Exception – Cluster Headache

• M > F

• 10% of the Population has Migraine!!!!

Burden of Headache

• 10% of population have migraine

• Up to 4% have headache more than half the days of the month

• Direct medical costs $1,000,000,000/yr

• 12-15 million lost school or work days/year

• Indirect costs may be double the direct costs

2014-2015 10

Chronic Migraine

• 0.9% and 1.4% of the population

• 11,678 in Nova Scotia

• Less than 1/3 work full time

• 1 in 5 can’t work

• Use a lot of resources

– Family MD, specialist visits, pain clinic visits, ERs

– $1,884 per patient per year

• $22 million a year to the Nova Scotia health care system

Invisible disease

2014-2015 13

Classification

• International Classification of Headache Disorders

– Over 300 types of headaches

– Two main types

• Primary

• Secondary – trauma, vascular, substance, infection, psychiatric…

– Subtypes

• Episodic

• Chronic 14

The Headaches

• Tension

• Migraine

– And related

• Cluster

– And other similar

• Secondary

Secondary Headaches

• Serious or ominous

• And not so

Diagnosis

• History

• Physical

2014-2015 17

History

• How long?

• Attacks or continuous

– frequency

• Details about the headache

• Details

• Details

Details • Location

• Severity

• Quality

• Duration

• Recurrence

• Associated symptoms

– Nausea/Vomiting

– Face changes

• Warning

• Triggers

• Aggravating factors

– Activity

– Light

– Sound

– Smell

• Effect of sleep

• Menstrual cycle

– Pill effects

– Hormone replacement therapy

Details

• Sleep disorder

• Caffeine

• Head/neck injuries

• TMJD/Bruxism

• Brain infections

• Anxiety

• Depression

• Fibromyalgia

• Other pain

• Abuse history

• Other specialists

• Tests done to date

• Other medical problems

• Family history

• Smoking/alcohol

• Job

• FUNCTION

Details on Treatments

Concerning features

• Signs of infection

• Weight change

• Cancer

• HIV

• Other body systems

• Focal neurological deficits

• Thunderclap Headache

• Change in Headache

• Headaches that change with position

• Headaches that start with bending, lifting, coughing, sneezing

• Progressive vision loss

Tension Type Headache

Tension Type Headache (TTH)

• Most common primary headache

• May be not the most common you will see

• Also called • Muscle contraction headaches

• Stress headaches

• Ordinary

• Essential…

24

Tension Type Headache • Last 30 minutes to 7 days

• Both sides of head

• Pressing or tightening quality – Not throbbing

• Mild or Moderate intensity

• Not worse with routine activity

• No nausea

• No vomiting

• May be light sensitive

• May be sound sensitive 25

Migraine

Migraine

• Last 4-72 hours

• One side of head

• Throbbing

• Moderate or severe intensity

• Worse with routine activity

• Nausea and/or vomiting

• Light and sound sensitive

• May be smell sensitive

Migraine with Aura

• Headache as described before

• Aura before headache • Sometimes with

• Sometimes without headache

• Usually a visual phenomenon

• Lasts 5- 60 minutes

• Reversible • Person goes back to normal

• Can be sensory

• Can be speech

• Very rarely weakness

Cortical Spreading Depression

Cluster

Cluster Headache

• Also known as – Suicide Headache

• Uncommon – 0.1% lifetime prevalence

• Onset 20-40 yrs

• Male >>> Female

• Risk – heavy smoking

• Precipitants – alcohol, histamine, nitroglycerin

• Coarse facial features

• Seasonal and clockwise periodicity – Same time of year

– Same time of night (often within 90 mins of sleep onset)

Leonine Facial Features

Cluster Headache

• Last 15 minutes to 3 hours – 45 – 60 minutes

• Up to 8 per day – 1-2 most common

• Severe or Very severe pain in or around the eye

• One sided – Red eye, tearing eye

– Runny congested nose

– Swollen eye

– Red face

– Muffled hearing

– Droopy eye lid

– Small pupil

• Don’t like to be still!

Thunderclap Headache

Treatment

Contributing Factors

• Sleep disorders

– Sleep apnea

• TMJ and bruxism

• Anxiety or mood disorders

• Other pain disorders

• Other medical disorders

• Stressors

• Caffeine

Patient education • Diagnosis

• Medications

• Trouble shooting

• Goal setting

– Patient Satisfaction = Reality

Expectations

• Headache diary

– Absolutely essential

• Medication side effects

• Implications of disorder

– Migraine with aura in women doubles their stroke risk!

• Medication Overuse

Treatment

• Lifestyle

• Non pharmacologic

• Acute Treatments

• Preventative Treatments

– >4 headaches per month

• Removing/modifying things that are counter productive

• Follow up

Treatment • Lifestyle

– Diet • Well balanced, good choices, all food groups

• No skipping meals

– Exercise

– Stress reduction

– Trigger identification and avoidance

– Hydration with water • Avoid caffeine

– Sleep hygiene

Non Drug Treatments

• Heat

• Cold

• Rest

• decrease environmental stimulus

• Acupuncture

• Massage

• Biofeedback

• Cognitive Behavior Therapy

• Other – As long it is helpful

– As long as it is not harmful

– As long as poverty is not a side effect

Medications

• When you have a headache

• Help prevent headaches

– >4 headaches per month

– Less frequent

– Less severe

– Do nothing for an individual headache attack

• Transitional treatments

Medication Overuse

• To be avoided

Other Treatments

Nerve Blocks

• Injections of anesthetic +/- steroids

Botox Chronic Migraine

Non Invasive Nerve Stimulators

Invasive Nerve Stimulators

Challenges in Headache Treatment

• Triptans only specific medicine

• Medicines with other intended purposes

– Anti-Seizure

– Anti-depressants

– Blood pressure

– Alzheimer’s

– Efficacy

– Side effects

Removal of Non-Helpful Things

• Caffeine

• Caffeine

• Caffeine

• Any acute medication being overused

– Appropriate limits

• Vent Starbucks

• =12 cans coca cola

• =2 medium Tim Hortons

Headache is kind of a big deal!

Live as if you were

to die tomorrow.

Learn as if you were

to live forever.

-M.K. Gandhi