Headache (HA) JHL Module Dr. Kenisha J Evans PGY1 https://www.google.com/search?q=migraine&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiGmr6rn9TaAhUFMqwKHbaSAo0Q_AUICygC&biw=1381&bih=662#imgrc=iKMoHZYetrSBFM:

What of the following is the most appropriate next step in management? A 35 y.o M is eval. for recurrent HA. For the past 5 yrs., he has had weekly episodes of HA lasting 6-8 hrs. The patient describes the pain as a steady pressure affecting the frontal and maxillary regions that is exacerbated by physical activity. When severe, the pain radiates to the temples and occiput. He also experiences nasal congestion and sensitivity to light, noise, & odors with the HA but has had no gastrointestinal or other neurologic sx. Potential HA triggers include weather changes, strong odors, & stress. Current meds include acetaminophen and fexofenadine, which have been ineffective in relieving HA and their associated Sx. On Physical Exam, blood pressure 114/72 mmHg, and pulse is 66/min. Other physical examination findings unremarkable. What of the following is the most appropriate next step in management? CT of the HEAD CT of the Sinuses Naproxen Pseudoephedrine Sumatriptan

Objectives Recognition of Migraines Recognition of Migraine Triggers Abortive Migraine Treatment Prophylactic Migraine Treatment Other Primary Headaches Medication Overuse Headaches Secondary Headaches

Headache Classification

Headache Classification Primary Headache Migraine w/o Aura Migraine w/ Aura Migraine w/ typical aura Migraine w/ brainstem Aura Hemiplegic migraine Retinal Migrain Chronic Migraine Complicated Migraine Tension-type Headache Infrequent Episodic Frequent Episodic Chronic Trigeminal Autonomic Cephalalgias Cluster Headache Chronic Paroxysmal Hemicrania Short-Lasting Neuralgiform Headache Attacks Other Primary Headache Disorder Secondary Headache Posttraumatic Headache Headaches attributed to cranial or cervical vascular disorder Ischemic Stroke or TIA Parenchymal or subarachnoid hemorrhage Headache attributed to nonvascular intracranial disorders Intacranial Hypotension or Hypertension Brain Neoplasia Noninfectious inflammatory Disorders Headache attributed to substance use or withdrawal Headache attributed to infection Headache attributed to disorder of homeostasis Headache attributed to disorder of neck, eyes, ears, nose, sinuses, teeth, or mouth Cranial Neuralgias

What will your H & P Look Like ? Focus on ruling out secondary causes and Red Flags 3 Question Headache (PIN) ~93% PPV Photophobia Incapacitating Nausea

What will your H & P Look Like ?

What will your H & P Look Like ?

An otherwise health 19 y/o W present to clinic for a yearly physical An otherwise health 19 y/o W present to clinic for a yearly physical. She reports unilateral, pounding headache over the past year with associated nausea. You suspect she is suffering from migraine. Which of the following symptoms would not be consistent with migraines? She has headache more frequently on weekends Her vision becomes clouded like “barbed wire” just before the headache onset Her Left Lower Leg was numb for 2 weeks after a headache but has since resolve She has numbness on her right face during migraine

Objectives Recognition of Migraines Recognition of Migraine Triggers Abortive Migraine Treatment Prophylactic Migraine Treatment Other Primary Headaches Medication Overuse Headaches Secondary Headaches

Migraine without Aura Most common Primary HA causes individual to seek medical attention Characteristic acute onset of a throbbing unilateral headache that is disabling and known triggers Peak onset Adolescence Highest prevalence 4th Decade Women:Men —> 3:1 Family History ~80% of all Migraines

Migraine without Aura H & P with no other disease etiologies and Diagnostic Criteria H & P with no other disease etiologies and 5 Attacks At least 1 of Following Symptoms During Headache nausea vomiting Photophobia Phonophobia At least 2 of Following Characteristics Duration between 4-72hrs if untreated Unilateral Pulsating Quality Moderate -Severe Intensity Aggravation by Routine Physical Activity

Migraine with Aura Referred as “Classic Migraine” Classification of 1 or more fully reversible Auras Require 2 Attacks with Aura + H & P without underlying disease Associated with increase risk of ischemic stroke, MI, and Claudication Aura Develops > 4 minutes and last no longer than 60 minutes Start of the headache within 60 minutes

Migraine with Aura Sub-classification Typical migraine aura followed by headache Typical migraine aura without headache Aura followed by non-migraine headache Basiliar-type Migraine Hemiplegic Migraine

Migraine with Aura Sub-classification Complicated migraine - neurologic deficit from migraine last >24hrs Migrainous infarction- neurologic deficit that doesn’t resolve Ddx 2/2 sustained metabolic disturbance Migraine associated Symptoms - Autonomic symptoms during Headache Retinal Migraine - monocular blindness

Recognition of Migraine Triggers Presentation variable classic presentation neuromuscular headache secondary to throbbing pain and vasodilation Pathophysiology - no completely understood Pain likely begins brainstem Inflammation + Distention of meningeal vessels release of inflammatory substances via abnormal impulses to periphery Involvement of Trigeminal Vascular system

Recognition of Migraine Triggers Migraine Prodrome ~60% of Patients have an usual feeling 24 hrs before onset of Migraine Euphoria Depression Dizziness Food Craving Hypomania Fatigue Cognitive Slowing Usual yawning behavior

Migraine Triggers

Objectives Recognition of Migraines Recognition of Migraine Triggers Abortive Migraine Treatment Prophylactic Migraine Treatment Other Primary Headaches Medication Overuse Headaches Secondary Headaches

Management of Migraine

Management of Migraine Goal of Therapy is to Reduce headache frequency and intensity Abortive Headache Treatment Treatment when headache is occurring Prophylactic Headache Treatment Preventing future Headaches

Abortive Migraine Treatment First Line : ASA, Acetaminophen, NSAIDs Avoiding Triggers First Line + Caffeine Alleviate complicated Migraines Patients with Chronic Long-standing Migraines not relieved by First line agents Start with Triptans 5-hydroxtryptamine receptor agonist Quick Onset Acting Almotriptan Eletriptan Rizatrpitan Long Acting —> Eletriptan Parenteral Route —> Sumatriptan, Zolmitriptan

Abortive Migraine Treatment

Abortive Migraine Treatment When Triptans are ineffective / Contraindicated Poorly controlled Hypertensive Patient + Migraine related to vasoconstrictive properties Ergotamine MAO Inhibitors Compazine Droperidol

Prophylactic Migraine Treatment Reduce frequency of headaches per month by ~10% within 1st month & by 90% by the 6th month of Prophylactic therapy Consider when Migraines occur twice a week If abortive therapy doesn’t work If abortive therapy not tolerated Presence of features such as Hemiplegia Migrainous infarction

Prophylactic Migraine Treatment Min-Prophylaxis Predictable migraine/ Menstrual Migraine Migraines fall in Estrogen Migraines occur 2 days before menses Prophylactic therapy NSAIDS, Triptans

Prophylactic Migraine Treatment

Prophylactic Migraine Treatment

Which of the following is the most appropriate next step? A 44 y/o Male, 20 pack -year smoker, is eval for a 1-week history of severe, recurrent, left periorbital headaches. The patient has experienced a 10- to 12-week period of similar headaches every spring for the past 3 years. Headaches occur once or twice daily, last 2-3 hrs. if untreated, and are accompanied by nausea, photophobia, and ipsilateral tearing but no aura or vomiting. Resting during headache episodes brings no relief; he instead paces the floor. Simple analgesics and prednisone have been ineffective. Although subcutaneous sumatriptan generally relieves symptoms within 5 -10 minutes, his headache frequency & dosing limitations preclude his using this drug every time he has symptoms. Physical Exam blood pressure 134/82 HR 78 remaining exam including neurologic exam unremarkable Which of the following is the most appropriate next step? Amitriptyline Indomethacin Propranolol Topiramate Verapamil

Objectives Recognition of Migraines Recognition of Migraine Triggers Abortive Migraine Treatment Prophylactic Migraine Treatment Other Primary Headaches Medication Overuse Headaches Secondary Headaches

Other Primary Headaches Trigeminal Autonomic Cephalagia “Tears of Pains” 1. Cluster Headaches 2. Paroxysmal Hemicrania 3. Short-Lasting Unilateral Neuralgiform Headache Attacks Tension-Type Headache

Trigeminal Autonomic Cephalalgia Cluster Headaches “Suicide Headaches” Occurs in Batches Agitation Causes Head-Banging Lacrimation Age of Onset 20-50y/o Man to Woman 5:1 Triggers EtOH, Associated with Tobacco use

Trigeminal Autonomic Cephalalgia Cluster Headaches “Suicide Headaches” Headache Profile Rapid onset of non-throbbing, unilateral lasting <3hrs Occurs 1-2x/ day Circadian association Episodic form of cluster - daily for 4-8 weeks Headache free period for at least 2 weeks

Trigeminal Autonomic Cephalalgia Cluster Headaches “Suicide Headaches” Therapy Aim Simultaneous Abortive & Prophylactic Oxygen inhalation ~7 L/min for 10minutes + subcutaneous /nasal inhalation triptans DHE-45 lidocaine Prophylactic Verapamil Topiramate Lithium Methysergide Corticosteroid Taper

Trigeminal Autonomic Cephalalgia

Trigeminal Autonomic Cephalalgia Paroxymsal Hemicrania Autonomic Symptoms short bouts of severe unilateral pain in orbital or temple region Trigeminal Autonomic Cephalalgia

Which of the follow do you suspect A 62 y/o M who is a government worker describes longstanding intermittent quick stabbing pain on the Left temple that causes tearing of the left eye. He already been to the ophthalmologist and was told his eyes are healthy . Which of the follow do you suspect SUNCT syndrome SUNA Tension -type Headache Retinal Migraine

Trigeminal Autonomic Cephalalgia Unilateral Neuralgiform Headaches SUNA- Short-lasting Unilateral Neuralgiform Headaches with cranial Autonomic Symptoms SUNCT Syndrome - Short-lasting Unilateral Neuralgiform headache with Conjuntival injection & Tearing Both syndromes are characterized by many short- lasting (1-600 secs) unilateral headache attacks ~200/day

Trigeminal Autonomic Cephalalgia Unilateral Neuralgiform Headaches Pain occurs as single stab, series of stabs, or a saw-tooth pattern Drug of choice Indomethacin Antiepileptic therapy Trigeminal Autonomic Cephalalgia

What is the most likely diagnosis ? A 32 y/o M present with a moderate intensity dull occipital headache that occurs intermittently and last for one hour at a time. He denies any photophobia or phonophobia. He has not missed work, and the pain has been adequately controlled Tylenol. Physical exam is otherwise normal. What is the most likely diagnosis ? Tension-Type Headache Migraine without Aura Cluster Headache Low Pressure Headache SUNA

Tension -Type Headache “Annoying” Headaches Absence of associated features mild to moderate intensity non debilitating Headache Profile Dull (non-throbbing ) bilateral (band-like) Persistent last up to one week Not Aggravated by Physical Activity

Tension- Type Headaches Therapy first line Analgesics limited to 2-3 days per week Avoid medication -overuse headaches Therapy Consists of Acetaminophen Aspirin NSAIDS Anti-Anxiety Antidepressant TCAs Biofeedback technique

Which of the follow should you recommend? A 30 y/o M with a history of Migraines since adolescence has been having daily headaches over the past few months despite taking Exedrin on a daily basis. He drinks two can of Jolt energy drink every day Which of the follow should you recommend? continue Excedrin, discontinue Jolt Taper Excedrin to less than 3 times/ week, Jolt is okay Switch to Naproxen only Taper Excedrin to less than 3 times/week, discontinue Jolts Discontinue Excedrin, Discontinue Jolt

Medication- Overuse Headaches Category of Chronic Daily headache Presence of a headache > 15 days per month for > 3 months frequency of use vs quantity of use any analgesic use more than 15 days/month Ergotamine Triptan Opioid Combination of analgesic use > 10 days/month

Medication- Overuse Headaches Category of Chronic Daily headache Ddx Transformed Migraine- Patient headache persistent after removal of medication Analgesic or Ergotamine overuse Therapy is STOP medication Taper for Barbituates or Opioids Behavioral therapy (biofeedback, relaxation therapy_ Life modifications Consider short course of Prednisone for sever headaches

Which of the following is the most appropriate next step? A 65 y/o W is eval in the emergency department for a 2-day history of nausea and vomiting and a 3-week history of increasingly persistent and severe morning headaches. Breast Cancer was diagnosed 8 months ago and treated with lumpectomy, radiation therapy, and chemotherapy, which she recently completed. On physical examination, T 36.7 C bp 110/70, HR 95 RR 18. The patient is alert & oriented x3. Difficulty with tasks requiring attention, such as stating months of year backward. Mild bilateral papilledema is present. Increase tone of the left upper and lower extremities is noted. Left toe exhibits a plantar extensor response. Which of the following is the most appropriate next step? PET scan of body MRI Brain Lumbar Puncture Whole-Brain Radiation PET Brain

Which of the following is the most appropriate next step? Women receive MRI of brain shows a 3 x 2 x2 cm ring-enhancing lesion at the gray-white junction of the Right frontal lobe surrounding edema A Recent PET scan of the body showed no evidence of metastatic disease Which of the following is the most appropriate next step? Brain PET Surgical Resection of the brain lesion Lumbar Puncture Whole-Brain Radiation

Objectives Recognition of Migraines Recognition of Migraine Triggers Abortive Migraine Treatment Prophylactic Migraine Treatment Other Primary Headaches Medication Overuse Headaches Secondary Headaches

Secondary Headaches

Secondary Headaches

Secondary Headaches Subarachnoid Hemorrhage -“the worst Headache” of the patient life Acute Ischemic Cerebrovascular Events Brain Tumors - Tension-type headache increasing frequency Low Pressure Headache -“Orthstatic Headache” Idiopathic Intracranial Hypertension Symptoms of increase intracranial pressure Signs of increase pressure papilledema, possible facial palsy LP opening pressure>250mmH2O + normal CSF

Secondary Headaches Subdural Headaches gradual onset & associated with hx of trauma or fall episodic headaches Cerebral Venous Thrombosis increase intracranial pressure Gold standard MRI & MR Venogram Giant Cell Arteritis or Temporal Arteritis Vasculitis of large & medium blood vessel Typical patient >50y/o with + Polymyalgia Rheumatica

Summary Headaches

References MKSAP Neurology Internal Medicine JHL https://ilc.peaconline.org/m/1324/p/4128/i/21826