HEADACHE Presentation By Dr. Asha Rani Natarajan 23-July-2016

HEADACHE HISTORY Headache attacks How it begins Precipitating event, illness, injury Headache attack descriptions Frequency and patterns Location Time to peak intensity Duration Quality and intensity Warning symptoms and aura Associated symptoms and level of disability Triggers and aggravating or relieving factors

SYMPTOMS THAT SUGGEST A SERIOUS UNDERLYING DISORDER Sudden-onset headache First severe headache "Worst" headache ever Vomiting that precedes headache Subacute worsening over days or weeks Paininduced by bending,lifting, cough Pain that disturbs sleep or presents immediately upon awakening Abnormal neurologic examination Pain associated with local tenderness, e.g. region of temporal artery

WHEN A SCAN IS NOT RECOMMENDED FOR HEADACHE Patient with established history of episodic headache Current headache is consistent with previous headaches or is consistent with different manifestation of a primary headache. Normal neurological exam

COMMON CAUSES OF HEADACHE Primary Headache Type % Migraine 16 Tension-Type 69 Cluster 0.1 Stabbing 2 Exertional 1 Secondary Headache Type % Systemic Infection 63 Head Injury 4 Vascular Disorder 1 SAH <1 Brain Tumor 0.1

PRIMARY HEADACHE SYNDROME Migraine Headache + Associated Features Tension Type Featureless Headache

1. MIGRAINE Benign and recurring syndrome of headache associated with other symptoms of neurological dysfunction Symptom Patients Affected % Nausea 87 Photophobia 82 Lightheadedness 72 Scalp Tenderness 65 Vomiting 56 Visual Disturbances 36 Paresthesias 33 Vertigo Photopsia 26 Alteration of consciousness 18 Diarrhea 16 Fortification Spectra 10 Syncope Seizure 4 Confusional State

MIGRAINE – A MULTISYMPTOM COMPLEX AURA SENSORY SYMPTOMS LANGUAGE SYMPTOMS VISUAL SYMPTOMS MOTOR DYSFUNCTION COGNITIVE PATHOPHYSIOLOGICAL MECHANISMS FATIGUE, MOOD CHANGE YAWNING, POLYURIA NAUSEA, VOMITING DIZZINESS, VERTIGO HEADACHE

SIMPLIFIED DIAGNOSTIC CRITERIA FOR MIGRAINE Repeated attacks of headache lasting 4-72 hours in patients with a normal physical examination, no other reasonable cause for the headache and: At Least 2 of the Following Features: Plus at-least one of the Following Features Unilateral Pain Nausea / Vomiting Throbbing Pain Photophobia and Phonophobia Aggravation by movement Moderate or severe Intensity

MIGRAINOUS AURA

CLASSIFICATION - MIGRAINE Migraine without aura Migraine with aura Migraine with typical aura Typical aura with headache Typical aura without headache Migraine with brainstem aura Hemiplegic migraine Familial hemiplegic migraine (FHM) FHM Type 1,Type 2, Type 3 Sporadic hemiplegic migraine Retinal migraine

CHILDHOOD PERIODIC SYNDROME THAT ARE COMMONLY PRECURSORS OF MIGRAINE Cyclical Vomiting Syndrome Abdominal Migraine Benign Paroxysmal Vertigo Benign Paroxysmal Torticollis

COMPLICATIONS OF MIGRAINE Chronic Migraine Status Migrainosus (> 72 Hours) Persistent Aura (30 to 60 Minutes) Without Infarction Migraine Triggered Seizures

DISABILITY ASSESSMENT EPIDEMIOLOGY Migraine accounts for 64% of severe Headache in Females and 43% of Severe Headache in Males Individuals >12 Years incidents increases with age, reaching a peak at 30 – 40 Years F:M – 3.5:1 at 40 Years FAMILY HISTORY Aprox 70% of the patients have a first degree relative with a history of migraine Migraine in inherited disorders – MELAS, CADASIL, Genetic Vasculopathies DISABILITY ASSESSMENT Simple questionnaire like MIDAS (Migraine Disability Assessment Score) cab be used to quantify the disability and for follow-up

MIGRAINE TRIGGERS Stress Excessive or insufficient Sleep Medications (OCP, Vasodilators) Strong Odors(Perfumes, Cologne) Hormonal Changes (Pregnancy and Menstruation) Weather Changes Foods containing Tyramine (Cheese, Yoghurt, Banana)

WORK UP MANAGEMENT Migraine is a clinical Diagnosis Diagnostic Investigations are performed to rule out any structural and metabolic causes of headache Visual Field Testing should be performed in patients with persistent visual phenomenon MANAGEMENT Acute Attack Preventive

ACUTE ATTACK MANAGEMENT Simple Analgesics : Acetaminophen, Aspirin, Caffeine NSAIDs: Naproxin,Ibuprofien Tryptans (Serotonin 1B/1D receptor agonist) a. Drug of Choice for patients with moderate to severe migraine b. Routes- Oral,Nasal,SC c. Drugs- Sumatriptan – 50 to 100mg tablet at onset, May repeat after 2 Hours (max 200 mg/D) * Rizatriptan and Eletriptan – Most Efficaious * Others – Naratriptan,Almotriptan,Zolmitriptan d. Not be used > 3 days weekly to avoid medication over-use headache 4. Ergot alkaloids (Non Selective 5HT1 agonists): Ergotamine 5. Dopamine Antagonists: Cholrpromozine, Metachlopramide, Prochlorparazine

PREVENTIVE TREATMENT When to consider ? Pharmaco Therapy Frequency of Migraine > 2/Month Duration of individual attack longer than 24 Hrs Major disruption in lifestyle Migraine variants such as Hemiplegic migraine Pharmaco Therapy PIZOTIFEN BETABLOCKER: Propranolol Tricyclics: Amitriptyline, Nortriptyline Anticonvulsants: Topiramate, Valproate, Gabapentin Serotonergic Drugs: Methysergide, Flunarizine

2. Tension-type headache Infrequent episodic tension-type headache Frequent episodic tension-type headache Chronic tension-type headache 3.Trigeminal autonomic cephalalgias Cluster headache Episodic cluster headache Chronic cluster headache Paroxysmal hemicrania Episodic paroxysmal hemicrania Chronic paroxysmal hemicrania Short-Iasting unilateral neuralgiform headache attacks Short-Iasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) Short- Iasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) Hemicrania continua

MIGRAINE HEADACHE TENSION HEADACHE CLUSTER HEADACHE Characteristics of pain Deep throbbing and pulsating pain Dull and pressure-like pain in the head or tight band on the head and/or around the neck. Stabbing pain Gender predominance More common in women More common in females More common in men Sensitivity to light or sound Typical Rare Location of pain Pulsating pain in temporal region and around the eye usually Unilateral The pain is typically generalized, with areas of more intense pain in the scalp, forehead, temples or the back of the neck. Usually bilateral. pain located near the eye on affected side. Usually unilateral. Severity of pain Ranging from moderate to quite severe Mild to moderate in severity Very severe Time of onset Long; headache gradually peaks in around 4-24 hours Pain develops gradually, fluctuates in severity and then can remain for several days Short; headaches peak within 45 minutes Triggers Bright lights, loud noises, changes in sleep patterns, exposure to smoke, skipping meals etc. Stress Nitroglycerin, Hydrocarbons and Alcohol Prodromal Aura before headache Present Absent Nausea or vomiting Common

TREATMENT TENSION TYPE CLUSTER TYPE Simple Analegisics: Actaminophen,Aspirin or NSAIDs Oxygen Inhalation Therapy Behavioral Approaches including relaxation Sumatriptan: Injection or Nasal Spray Chronic TTH: Amitriptyline Preventive Management: Verapamil,Lithium,Methysergide ___ Deep Brain or Occipital Nerve stimulation

PAROXYSMAL HEMICRANIA SUNCT Gender F=M F~M Pain Type Severity Site CATEGORIZATION PAROXYSMAL HEMICRANIA SUNCT Gender F=M F~M Pain Type Severity Site Unilateral: Throbbing,Boring,Stabbing Excruciating Orbit, Temple Unilateral: Burning,Stabbing,Sharp Severe to excruciative Periorbital Frequency > 5 attacks/D At least 20 attacks/D Duration 2 -30 Mins 5 - 240 Seconds Autonomic Features Lacrimination & Conjuctival Injection Present Prominent  If absent Then it is SUNA Cutaneous Triggers No Yes Indomethacin Effect Abortive Treatment No Effective Treatment Lidocaine (IV) Prophylactic Treatment Indomethacin Lamotrigine, Topirimate, Gabapentin * SUNCT: Short lasting unilateral neuralgiform headache attacks with conjunctival injection & tearing * SUNA: Short lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms

CHRONIC DAILY HEADACHE Headache on 15 Days or more per month Medication Overuse Headache : - Due to Over use of Analgesic medication or using preventive medication along with analgesics - Can be avoided by reducing the medication by 10% every one to two weeks New Daily Persistent Headache (NDPH): - Present on most of the days and patient typically recall the exact day and circumstance of the onset of headache 1. Primary NDPH: Migrainous Type – Same as Preventive Therapy for migraine Featureless Type – Most Refractory to treatment

2. Secondary NDPH: Low CSF Volume Headache Raised CSF Pressure Headache M.C.C –CSF Leak Following LP M.C.C-SOL, Pseudo Tumor Cerebri Patient Feels Better on reclining Worsens on reclining Worsens during day Improves as day progress Treatment – Bed Rest , Blood Patch Initially Acetozolamide if ineffective topiramite 3. Post Traumatic Headache Developed headache following injury to the head or an infectious episode like viral meningitis or parasitic infection or after SAH Treatment – Management is emperical. TCA and anticonvulsants can be added

4. OTHER PRIMARY HEADACHE DISORDERS Primary cough headache Primary exercise headache Primary headache associated with sexual activity Primary thunderclap headache Cold-stimulus headache Headache attributed to external application of a cold stimulus Headache attributed to ingestion or inhalation of a cold stimulus External-pressure headache External-compression headache External-traction headache Primary stabbing headache Nummular headache Hypnic headache New daily persistent headache (NDPH)

SECONDARY HEADCHES MENANGITIS : Suggested if acute and severe headache with stiff neck and fever 2. INTRACRANIAL HEMORRHAGE: - A Ruptured aneurysm, AV malformation or intra parenchymal hemorrhage - Suggested if acute and severe headache with stiff neck but without fever 3. BRAIN TUMOURS: Rule out pitutory Adenoma or any cerebral metastasis 4. TEMPORAL ARTERITIS: Most Common in elderly patients with age of onset 70 years Suggested if Jaw Clawdication, fever, weight loss and malaise are present 5. GLAUCOMA: Prostating Headache with severe eye pain associated with nausea & vomiting