1. Approach to Headaches AIMGP Seminar April 2004 Gloria Rambaldini

2. Case 1 A 28 y.o. woman is referred to you for management of her headaches Headaches are described as right-sided pounding, with associated nausea and photophobia Aggravated by activity ASA and Tylenol have not provided relief What next?

3. Case 2 A 72 y.o. woman presents with a four month history of a bitemporal headache with aching and morning stiffness of her shoulders She has noted a low grade fever and some weight loss What next?

4. Case 3 A 62 y.o. man is referred for new onset headaches For the last 4 weeks he has awoken with a diffuse headache and nausea What next?

5. Objectives To learn about the major types of headaches To understand the difference between primary and secondary headaches Be familiar with the ‘RED FLAGS’ Treatment and prophylaxis of primary headaches

6. Origins of Pain in the Head Extra-cranial pain sensitive structures: Sinuses Eyes/orbits Ears Teeth TMJ Blood vessels Intra-cranial pain sensitive structures: Arteries Veins Meninges Dura

7. Classification of Headaches PRIMARY - NO structural or metabolic abnormality: Tension Migraine Cluster SECONDARY – structural or metabolic abnormality: Extracranial: sinusitis, otitis media, glaucoma, TMJ ds Inracranial: SAH, vasculitis, dissection, central vein thrombosis, tumor, abscess, meningitis Metabolic disorders: CO2 retention, CO poisoing

8. HISTORY Headache Characteristics: Temporal profile: acute vs chronic, frequency Location and radiation Quality Alleviating and exacerbating factors Associated symptoms Constitutional symptoms PMH: HTN, DM, hyperlipidemia, smoking

9. RED Flags

10. New onset headache in a patient >50 y.o. Sudden, worst headache of one’s life Morning headache associated with N/V Fever, weight loss Worsens with valsalva maneuvers Focal neurologic deficits, jaw claudication Altered LOC Hx of trauma, cancer or HIV

11. Physical Exam Blood pressure Fundoscopy Auscultation for bruits in H/N Temporal artery inspection and palpation Meningismus Neurologic exam: motor, sensory, coordination and gait

12. MIGRAINE Headaches Affects 15% of the general population Female > Males Family History present in 70% Pathophysiology: vascular vs neurologic Precipitants: caffeine, chocolate, alcohol, cheese, BCP/HRT, menses, stress

13. MIGRAINE Headaches Diagnostic criteria: 1. 5 attacks in 6 months 2. Headaches lasting 4-72 h with >/= 2: - unilateral - pulsatile - moderate to severe in intensity - aggravated by activity 3. Associated with >/= 1: - nausea/vomiting - photophobia/phonophobia

14. MIGRAINE Headaches Subtypes: Auras – visual or sensory Scintillating scotoma Fortification spectra Ophthalmoplegic CN III palsy Vertbrobasilar hemiplegic

15. Visual Auras: Patient drawings Scintillating Scotomas Progression of a typical aura over 30 minutes BMJ 2002; 325:881-6

16. MIGRAINE: Acute Treatment Mild attacks: NSAIDS +/- dopamine antagonists eg. ASA 650-1300 mg q4h + metoclopromide 10 mg PO/IV Moderate attacks: NSAIDS (ibuprofen 400-800 mg PO q2-6h) 5-HT1 receptor agonists Selective – sumatriptan 50-100 mg PO Nonselective – ergot 1-2 mg PO q1h x 3 CMAJ 1997; 156: 1273-87

17. MIGRAINE: Acute Treatment Severe & Ultra-severe attacks: First line: DHE 0.5-1 mg q1h IM/SC/IV sumatriptan 50-100 mg PO or 6 mg SC Second line: chlorpromazine 50 mg IM Prochlorperazine 5-10 mg IV/IM dexamethasone 12-20 mg IV CMAJ 1997; 156: 1273-87

18. MIGRAINE: Prophylaxis Consider if >/3 attacks/month, impaired quality of life: B-blockers Calcium channel blockers TCA (amitriptyline) NSAIDS Valproic acid 5HT2 Antagonists (methysergide, pizotyline) CMAJ 1997; 156: 1273-87

19. TENSION Headaches Most common type, typically brought on by stress, lasting 30 min to 7 d Diagnostic Criteria >/= 2: Pressing/tightening, non-pulsating Mild-moderate Bilateral Not worsened by ADLs Photo or phonophobia (not coincident) Not associated with N/V Treatment: reassurance, NSAIDS

20. CLUSTER Headaches Age of onset 25-50 y.o., M>F Features: Attacks clustered in time (>5) Severe unilateral, orbital or temporal pain Lasting 15 min – 3 h Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead/facial swelling, miosis, ptosis Treatment: Acute: O2, 5HT1 antagonists, DHE Prophylaxis: Calcium Channel Blockers, ergots, Li

21. Medication Induced Headaches Rebound headaches due to overuse of analgesics or prophylactic meds 25% of patients referred to neurologists for ‘intractable’ headaches have medication- overuse or medication-induced headaches

22. Giant Cell Arteritis Chronic granulomatous vasculitis affecting the arteries originating from the aortic arch 18/100 000 persons >50 y.o. Features: Headache 2/3 of patients (LR 1.2) Fever, weight loss, malaise Scalp tenderness Jaw claudication (LR 4.2) Diplopia (LR 3.4) PMR related Sx (50% of GCA patients have PMR)

23. Giant Cell Arteritis Physical Exam: BP and pulse deficits in arms Fundoscopy Temporal Artery: beaded (LR 4.6), prominent (LR 4.3), tender (LR 2.6) H/N and subclavian bruits MSK exam Investigations: Normocytic normochromic anemia ESR (typically > 50) TA biopsy JAMA 2002; 287(1): 92-101

24. Giant Cell Arteritis Diagnostic Criteria – 3/5 (Sn 94%, Sp 91%) Age > 50 y.o. New onset headache TA tender +/- decreased pulse ESR > 50 Bx: necrotizing granulomatous arteritis

25. Giant Cell Arteritis Treatment: Prednisone 40-80 mg PO od until symptoms resolve and ESR normalizes Once in remission decrease dose by 10% q1- 2w Osteoporosis prevention: vitamin D and calcium +/- bisphosphonate AIM 2003; 139:505-515

26. Case 1 A 28 y.o. woman is referred to you for management of her headaches Headaches are described as right-sided pounding, with associated nausea and photophobia Aggravated by activity ASA and Tylenol have not provided relief What next?

27. Case 2 A 72 y.o. woman presents with a four month history of a bitemporal headache with aching and morning stiffness of her shoulders She has noted a low grade fever and some weight loss What next?

28. Case 3 A 62 y.o. man is referred for new onset headaches For the last 4 weeks he has awoken with a diffuse headache and nausea What next?