Nur Amalina Aminuddin Baki082012100067

Headache

Introduction

1) Tension- type Headache2) Trigeminal Autonomic Cephalgias

a) Cluster headacheb) Paroxysmal hemicraniac) SUNCT/SUNA

3) Chronic Daily Headache4) Other Primary Headache

1) Tension type Headache Chronic head-pain

syndrome Diagnosis:

No nausea, vomiting, photophobia, phonophobia,

No throbbing sensation No aggravation with

movement Differential

diagnosis : MIGRAINE

Certain patient may have TTH with migraine

CharacteristicSite : Bilateral

Onset: Builds slowly

Character: Tight, bandlike discomfort

Timing: continuously for many days or episodic or chronic (>15 days/m).

Severity Flunctuates

1) Tension type Headache Pathophysiology :incompletely

understood. Due to a primary disorder of CNS pain

modulation or genetic .Treatment

Simple analgesics (acetaminophen, aspirin, or NSAIDs)

Relaxation Triptans in TTH with migraine. Chronic TTH :amitriptyline

2) Trigeminal Autonomic Cephalgias

Group of primary headaches Cluster headache Paroxysmal hemicrania Sunct /suna

Differential diagnosis: Sinus headache, trigeminal neuralgia, primary stabbing headache, and

hypnic headache Increased TACs presentation may be due to pituitary tumor.

CharactAssociation:

lacrimation, conjunctival injection,nasal congestion

Timing:

Short , occur > 1/d

Severity

Severe

a) Cluster Headache

Rare (0.1%.) M>F

Patients tend to move during attacks (pacing/ rocking/ rubbing their head for relief)

Unilateral photophobia/ phonophobia on the same side of the pain

S •Unilateral,retroorbital,

O •50% nocturnal , explosive

C •deep , stabbingA •ipsilateral conjunctival injection/

lacrimation /rhinorrhea /nasal congestion / ptosis

T •recurs at same hour for same duration•daily 1-2 short attacks X 8 - 10 w/y followed by a pain-free interval (<1y)•Chronic ( no period of sustained remission)

S •excruciating ,nonfluctuating,

Treatment :Cluster Headache

Acute attack 100% oxygen

at 10-12L/min for 15-20min

Sumatriptan 6mg SC

Nasal sprays▪ Sumatriptan

(20 mg) ▪ zolmitriptan (5

mg)

Short –term prevention

Long-term prevention

Episodic cluster headache

Episodic & prolonged chronic cluster headache

Prednisone 1 mg/kg up to

Verapamil 160–960 mg/d

60 mg qd, tapering

Lithium 400–800 mg/d

over 21 days Methysergide 3–12 mg/d Topiramate 100–400 mg/d

Methysergide 3–12 mg/d

Gabapentin 1200–3600 mg/d

Verapamil 160–960 mg/d

Melatonin 9–12 mg/d

Ergotamine 1-2mg

Deep brain stimulation of posterior hypothalamus

b) Paroxysmal Hemicrania Male:female ratio is 1:1. Treatment

Indomethacin (25–75 mg tid), Topiramate Piroxicam

Secondary PH If patient requires high doses

indomethacin (>200 mg/d) Sella turcica lesions

(arteriovenous malformation, cavernous sinus meningioma, epidermoid tumors.)

Bilateral PH Raised CSF pressure

Charact.Site : Unilateral , retroorbital

Association:

lacrimation and nasal congestion

Timing:

Frequent(>5/d) , short ( 2-45min) and rapid course(<72h)

Severity

excruciating

c) SUNCT/SUNASUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing)SUNA (short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms)

Basic patterns short-lived single stab groups of stabs a longer attack ("saw-tooth" )

Differential diagnosis trigeminal neuralgia (TN)

Secondary (Symptomatic) SUNCT Posterior fossa or pituitary lesions. Pituitary function tests ,brain MRI

Charac.Site : unilateral orbital

or temporalCharacter:

stabbing or throbbing

Association:

ipsilateral conjunctival injection and lacrimation

Timing: >20 attacks, lasting for 5–240s , no refractory period

Exacerbating factors:

Cutaneous triggers

Severity severe

TREATMENT: SUNCT/SUNA Abortive Therapy

IV lidocaine(hospitalized patients.) to arrest symptoms

Preventive Therapy Goal:minimize disability

and hospitalization Medical approaches▪ Lamotrigine, 200–400 mg/d. ▪ Topiramate and gabapentin.▪ Carbamazepine, 400–500

mg/d

Surgical approaches ▪ Microvascular

decompression or destructive trigeminal procedures

▪ Greater occipital nerve injection

▪ Occipital nerve stimulation ▪ deep-brain stimulation of

the posterior hypothalamic region

Short-term prevention (intractable cases) ▪ IV lidocaine ▪ occipital nerve stimulation.

Cluster Headache

Paroxysmal Hemicrania

SUNCT

Gender M > F F = M F ≈MType Stabbing, boring Throbbing, boring,

stabbingBurning, stabbing, sharp

Severity Excruciating Excruciating Severe to excruciating

Site Orbit, temple Orbit, temple PeriorbitalAttack frequency

1/alternate day–8/d

1–40/d (>5/d for more than half the time)

3–200/d

Duration 15–180 min 2–30 min 5–240 sAlcohol trigger

Yes No No

Cutaneous triggers

No No Yes

Abortivetreatment

Sumatriptan injection or nasal sprayOxygen

No effective treatment

Lidocaine (IV)

Prophylactictreatment

Verapamil MethysergideLithium

Indomethacin Lamotrigine TopiramateGabapentin

3) Chronic Daily Headache >15days/month

Primary Secondary<4 h Daily >4 h Daily Posttraumatic

• Head injury• Iatrogenic• Postinfectious

Chronic cluster headache

Chronic migraine

Chronic paroxysmal hemicrania

Chronic tension-type headache

Inflammatory• Giant cell arteritis• Sarcoidosis• Behçet's syndrome

SUNCT/SUNA Hemicrania continua Chronic CNS infectionHypnic headache New daily persistent

headacheMedication-overuse headache

If it is a medically intractable disabling CDH Occipital nerve

stimulation

a) Primary CDH <4h daily : Hypnic Headache

Most are female Onset >60 years. Differential diagnosis:

Poorly controlled hypertension. Treatment:

Lithium carbonate (200–600 mg) at bedtime

Verapamil (160 mg) Methysergide (1–4 mg at

bedtime) One to two cups of coffee

/caffeine, 60 mg orally, at bedtime

Flunarizine, 5 mg nightly.

Charac.

Site :

Uni/bilateral

Onset:

a few hours after sleep

Character:

generalized /throbbing

Timing:

15 – 30 min , <3 repetitions/ night

Severity

moderately severe

b) Primary CDH >4h daily : Hemicrania Continua

Essential features : Moderate , continuous unilateral pain with fluctuations of severe

pain Complete resolution of pain with indomethacin Associated with conjunctival injection, lacrimation, and

photophobia on same side Age of onset :11 to 58 years. Woman: man = 2:1

Treatment IM injection of 100 mg indomethacin Oral indomethacin (initial,25 mg tid, then 50 mg tid,75 mg Topiramate Patients unable to tolerate indomethacin ▪ Occipital nerve stimulation

c) Primary CDH >4h daily : New Daily Persistent Headache

Abrupt onset / gradual

Primary NDPH Migrainous type

unilateral headache,throbbing pain, nausea, photophobia, phonophobia

Treatment :preventive therapies of migraine

Featureless type refractory to treatment

86% headache-free after 2 years

Primary NDPH

Secondary NDPH

Migrainous-type

Subarachnoid hemorrhage

Featureless (tension-type)

Low CSF volume headache

Raised CSF pressure headachePosttraumatic headacheChronic meningitis

Secondary NDPHi. Low CSF Volume

Headache Dull, throbbing

occipitofrontal headache that not present on waking up , worsen as day progress and relieved by recumbency position

Cause : CSF leak after lumbar puncture

(within 48 h -12 d) index events (epidural injection

or vigorous Valsalva maneuver)

Differential diagnosis: Postural orthostatic tachycardia

syndrome [POTS ]

Investigations: Brain MRI -diffuse

meningeal enhancement, chiari malformation

Spinal MRI, CT Treatment

Bed rest IV caffeine (500 mg in 500

ml saline administered over 2 h)

Abdominal binder Autologous blood patch Oral

theophylline(intractable pain)

Secondary NDPHii. Raised CSF Volume Headache Generalized headache present on waking and improves as the

day goes on, worse with recumbency.

Investigations Funduscopy-papilledema MRI, including an MR venogram Lumbar puncture

Differential diagnosis: Obstructive sleep apnea Poorly controlled hypertension Idiopathic intracranial hypertension without visual problems

Treatment Acetazolamide (250–500 mg bid) Topiramate Severe disabled patient that do not respond to medication -intracranial pressure

monitoring ,shunting

Secondary NDPHiii. Post-traumatic HeadacheHeadache that remit after several weeks or persist after the

trauma associated with dizziness, vertigo and impaired memory Injury to the head Carotid dissection and subarachnoid hemorrhage,and following intracranial surgery Infection (viral meningitis / parasitic infection)

Differential diagnosis: Chronic subdural hematoma Iatrogenic low CSF volume headache

Treatment Tricyclic antidepressants (amitriptyline) Anticonvulsants (topiramate, valproate, and gabapentin) MAOI (phenelzine) Resolves within 3–5 years

d) Secondary CDH: Medication – Overuse Headache

Increased headache frequency and induce - refractory daily headache due to overuse of analgesic for headache

Management : Outpatients Reduce and stop analgesic

(reduce dose by 10% every 1–2 w)

A small dose NSAID Naproxen, 500 mg bid

( overuse problems with more frequent dosing )

Preventive medication (when analgesic is stopped)

Management : InpatientsFailed at outpatient withdrawal/ significant medical condition

Withdrawn analgesics Antiemetics and fluids Clonidine (opiate withdrawal

) Aspirin 1 g IV (acute

intolerable pain during day) IM chlorpromazine (night) After effect of withdrawn

substance settles (3-5d) IV dihydroergotamine (DHE)

every 8 h for 5 days + 5-HT3 antagonists (ondansetron/ granisetron) or domperidone oral/ suppository

4) Other Primary Headachea) PRIMARY STABBING HEADACHE Features:

Stabbing pain Lasting from 1 to many seconds or minutes Occurring as a single or series of stab No associated cranial autonomic features No cutaneous triggering of attacks Recurrence at irregular intervals (hours to days). "Ice-pick pains" or "jabs and jolts." More common in patients with other primary headaches

(migraine, TACs, and hemicrania continua)

Treatment: Indomethacin (25–50 mg two to three times daily

4) Other Primary Headacheb) PRIMARY COUGH HEADACHE

Generalized headache that begins suddenly Lasts for several minutes Precipitated by coughing, preventable by avoiding coughing

Exclude serious etiology : Chiari malformation /any lesion causing obstruction of CSF

pathways /displacing cerebral structures. Cerebral aneurysm, carotid stenosis, and vertebrobasilar disease.

Can resemble benign exertional headache (patients is typically younger)

Treatment: Indomethacin 25–50 mg two to three times daily Lumbar puncture

4) Other Primary Headachec) PRIMARY EXERTIONAL

HEADACHE Features resembling both

cough headache and migraine Precipitated by any form of exercise Pulsatile 5 min - 24 h, Bilateral and throbbing at onset Migrainous features Prevented by avoiding excessive

exertion, Mechanism :unclear. ??? Possible etiologies:

Cardiac cephalgia Pheochromocytoma Intracranial lesions and stenosis of

the carotid arteries

Treatment: Modest and progressive

exercise regimens Indomethacin 25 to 150

mg daily Prophylactic

measures. Indomethacin (50 mg) Ergotamine (1 mg orally) Dihydroergotamine (2 mg

by nasal spray) Methysergide (1–2 mg

orally given 30–45 min before exercise)

4) Other Primary Headached) PRIMARY SEX HEADACHE

Dull bilateral headache that intensify at orgasm.

Prevented by ceasing sexual activity before orgasm.

Types : Dull ache in head and neck Sudden, severe, explosive

headache Postural headache after coitus

5–12% are caused by subarachnoid hemorrhage

Occur more in men than women Subside within 5min -2 h. ( In

patient who stop sexual activity when notice headache)

Subside within 6 months.

More common in patients with exertional headache and migraine

Treatment: Recur irregularly and

infrequently Reassurance and advice about

ceasing sexual activity Recurs regularly or

frequently Propranolol 40 to 200 mg/d Diltiazem, 60 mg tid. Ergotamine (1 mg) or Indomethacin (25–50 mg) 30–45

min prior to sexual activity

4) Other Primary Headachee) PRIMARY THUNDERCLAP

HEADACHE Differential diagnosis

Subarachnoid hemorrhage Cervicocephalic arterial

dissection Cerebral venous

thrombosis. Ingestion of tyramine-

containing foods in a patient taking MAOIs

Pheochromocytoma. If posterior

leukoencephalopathy present, ▪ Cerebral angiitis, ▪ Drug toxicity

(cyclosporine,methotrexate or cocaine)

▪ Postpartum angiopathy.

Excluding subarachnoid hemorrhage Patients do very well over

the long term. Some developed migraine

or tension-type headache. Investigations :

Neuroimaging (CT or, when possible, MRI with MR angiography)

CSF examination Cerebral angiography

Treatment with nimodipine

Conclusion

1) Tension- type Headache

2) Trigeminal Autonomic Cephalgias

a) Cluster headacheb) Paroxysmal hemicraniac) SUNCT/SUNA

3) Chronic Daily Headache

a) Primary (<4h/day and >4h/day)

b) Secondary

4) Other Primary Headache

a) Stabbing Headache

b) Exertional Headache

c) Cough Headached) Sex Headachee) Thunderclap

Headache

References Harrison’s Principle of Internal

Medicine, 18th Edition, Volume 1

Davidson’s Principles and Practice of Medicine, 22nd Edition