1. Jose Paciano B.T. Reyes, MD, FPNA Headache: Determining the Appropriate Diagnostic & Treatment Approach

2. What is headache? Cephalalgia Cephalalgia Diffuse pain in the various parts of the head Diffuse pain in the various parts of the head Not confined to the area of distribution of a nerve Not confined to the area of distribution of a nerve

3. Prevalence of different types Headache Type Prevalence Tension type 69% Headache from systemic infection 63% Migraine16% Headache after head injury 4% Idiopathic stabbing headache 2% Exertional headache 1% Vascular disorders 1% Subarachnoid hemorrhage <1% Brain tumors 0.1%

4. Types of Headaches Primary headaches Primary headaches Benign Benign Recurrent Recurrent No organic disease as their cause No organic disease as their cause Secondary headaches Secondary headaches Underlying organic disease Underlying organic disease

5. Primary Headache Disorders More common More common Migraine, with or without aura Migraine, with or without aura Tension type Tension type Cluster Cluster Less common Less common Paroxysmal hemicrania Paroxysmal hemicrania Idiopathic stabbing Idiopathic stabbing Cold-stimulus Cold-stimulus Benign cough Benign cough Benign exertional Benign exertional Associated with sexual activity Associated with sexual activity

6. Secondary Headache Disorders Associated with non-vascular intracranial disorder Associated with non-vascular intracranial disorder Benign intracranial hypertension Benign intracranial hypertension Intracranial infection Intracranial infection Low CSF pressure Low CSF pressure Associated with noncepalic infection Associated with noncepalic infection Viral infection Viral infection Bacterial infection Bacterial infection Associated with vascular disorders Associated with vascular disorders Subarachnoid hemorrhage Subarachnoid hemorrhage Acute ischemic cerebrovascular disorder Acute ischemic cerebrovascular disorder Unruptured vascular malformation Unruptured vascular malformation Arteritis Arteritis Carotid or vertebral artery pain Carotid or vertebral artery pain Venous thrombosis Venous thrombosis Arterial hypertension Arterial hypertension

7. Secondary Headache Disorders Associated with head trauma Associated with head trauma Acute post-traumatic headache Acute post-traumatic headache Associated with substance use or withdrawal Associated with substance use or withdrawal Acute use or exposure Acute use or exposure Chronic use or exposure Chronic use or exposure Associated with metabolic disorders Hypoxia Hypercapnia Mixed hypoxia & hypercapnia Dialysis

8. Secondary Headache Disorders Associated with head trauma Associated with head trauma Acute post-traumatic headache Acute post-traumatic headache Headache of facial pain associated with disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures Headache of facial pain associated with disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures Cranial neuralgias, nerve trunk pain and deafferentation pain Cranial neuralgias, nerve trunk pain and deafferentation pain

9. Headache History Is this your first or worst headache? Is this your first or worst headache? How bad is your pain on a scale of 1-10? Do you have headaches on a regular basis? Is this headache like the ones you usually have? How bad is your pain on a scale of 1-10? Do you have headaches on a regular basis? Is this headache like the ones you usually have? What symptoms do you have before of during the headache? What symptoms do you have now? What symptoms do you have before of during the headache? What symptoms do you have now? When did this headache begin? How did it start (gradually, suddenly) ? When did this headache begin? How did it start (gradually, suddenly) ?

10. Headache History Where is your pain? Where is your pain? Does the pain spread to any other area? Where? Does the pain spread to any other area? Where? What kind of pain do you have (throbbing, stabbing, dull, others) ? What kind of pain do you have (throbbing, stabbing, dull, others) ? Do you have other medical problems? Do you have other medical problems? Do you take medicines? Do you take medicines? Have you recently hurt your head or had a medical or dental procedure? Have you recently hurt your head or had a medical or dental procedure?

11. Blue Flag Headaches

12. Red Flag Headaches

13. Other Red Flag Headaches Associated with rash Associated with rash May indicate Lyme disease or meningococcemia May indicate Lyme disease or meningococcemia Non-migraine headache in pregnanacy or post- partum Non-migraine headache in pregnanacy or post- partum May indicate cerebral thrombosis May indicate cerebral thrombosis Associated with changes in posture Associated with changes in posture May indicate low CSF pressure due to spontaneous CSF leak May indicate low CSF pressure due to spontaneous CSF leak Associated with pressing visual disturbances Associated with pressing visual disturbances May be due to glaucoma or optic neuritis May be due to glaucoma or optic neuritis

14. Headache Red Flags: S-N-O-O-P-S Systemic symptoms: fever, weight loss Systemic symptoms: fever, weight loss Neurological symptoms or abnormal signs: confusion, impaired alertness or consciousness Neurological symptoms or abnormal signs: confusion, impaired alertness or consciousness Onset: suddent, abrupt or split-second Onset: suddent, abrupt or split-second Older: new onset or progressive headache, specially in patients > 50 yo Older: new onset or progressive headache, specially in patients > 50 yo Previous headache history: first o new or different headache Previous headache history: first o new or different headache Secondary risk factors: systemic cancers, HIV Secondary risk factors: systemic cancers, HIV David Dodick, MD Mayo Clinic, Scottsdale

15. Diagnostic Criteria for Migraine

18. Diagnostic Criteria for Episodic Tension Type Headache

19. Diagnostic Criteria for Cluster Headache

20. Diagnostic Tests for Headache Neuroimaging Neuroimaging Indications: Indications: To rule out a structural disorder To rule out a structural disorder To assure anxious patient or his relatives To assure anxious patient or his relatives

21. Diagnostic testing for the evaluation of headaches Yield of neuroimaging in the evaluation of patients with headache and a normal neurologic examination is quite low (N = 3026 scans) Brain tumors 0.8% AVMs0.2% Hydrocephalus0.2% Aneurysm0.1% Subdural hematoma 0.2% Strokes1.2% Neurol Clin 1996 Feb; 14(1):1-26

22. Neuroimaging recommendations for non-acute headache Consider neuroimaging in: Patients with an unexplained abnormal finding on the neurologic examination (Grade B) Patients with atypical headache features or headaches that do not fulfill the strict definition of migraine or other primary headache disorder (or have some additional risk factor, such as immune deficiency), when a lower threshold for neuroimaging may be applied (Grade C) Neuroimaging is not usually warranted in patients with migraine and a normal neurologic examination (Grade B) AAN Sept 2000

23. Neuroimaging algorithm for headache of >4 weeks & normal neurologic exam Tension-type headache? Migraine-type headache? Any atypical features? Neuroimaging unlikely to show abnormality See other pathway NO YES CONSIDER BRAIN IMAGING

24. Neuroimaging algorithm for headache of >4 weeks Worse with Valsalva? Wakes patient from sleep? New headache in older patient? Consider Brain Imaging (CT or MRI) Brain Imaging Not Necessary NO YES Headache progressively worsening? YES NO Other RED FLAGS? YES NO Exertion induced Maximum severity at onset Seizures Systemic illness Worst headache ever Strong patient or family concerns Family history of tumors or aneurysms Abnormal neuro findings? NO YES

25. Computed Tomographic Scanning Advantages Procedure of choice for acute hemorrhage and skull fractures Procedure of choice for acute hemorrhage and skull fractures Cheaper than MRI Cheaper than MRI Faster testing time Faster testing time CT angiography CT angiography Disadvantages False negative results for small lesions Radiation exposure Allergic reaction to contrast dye Contraindicated in pregnancy Monitor creatinine levels in elderly and renal disease

26. Magnetic Resonance Imaging Advantages Better images, brainstem lesions Better images, brainstem lesions Detect vascular anatomy for suspected aneurysms and vasculitis Detect vascular anatomy for suspected aneurysms and vasculitis Detect small aneurysms Detect small aneurysms No radiation No radiation Disadvantages Metal implants contraindicated Pregnancy up to 2 nd trimester contraindicated Costly Availability Long testing time

27. Electroencephalography Indications Loss of consciousness Loss of consciousness Depressed sensorium or alertness Depressed sensorium or alertness Seizures Seizures Suspected metabolic encephalopathy Suspected metabolic encephalopathy

28. Electroencephalography in headache …not useful in the routine evaluation of patients with headache. This does not exclude the use of EEG to evaluate headache patients with associated symptoms suggesting a seizure disorder, such as atypical migrainous aura or episodic loss of consciousness. Assuming head- imaging capabilities are readily available, EEG is not recommended to exclude a structural cause for headache. Practice Guideline, AAN, 1995

29. Other Diagnostic Tests Lumbar puncture Lumbar puncture CNS infection CNS infection MS MS Increased or decreased CSF pressure Increased or decreased CSF pressure Blood examination Blood examination

30. Symptomatic Therapy As abortive therapy As abortive therapy Goal: to abort, reduce or stop a headache, head pain or symptoms accompanying a headache Goal: to abort, reduce or stop a headache, head pain or symptoms accompanying a headache Purpose: Purpose: for acute attacks that are infrequent for acute attacks that are infrequent for breakthrough attacks while on preventive therapy for breakthrough attacks while on preventive therapy

31. Symptomatic Therapy Notes: Notes: Better used at onset of headache Better used at onset of headache Frequently combined with preventive therapy Frequently combined with preventive therapy Can cause rebound headaches Can cause rebound headaches Should not exceed 3 days/week Should not exceed 3 days/week

32. Preventive Therapy As prophylaxis or prevention of recurrence As prophylaxis or prevention of recurrence Goal: reduce frequency, severity and duration of attacks Goal: reduce frequency, severity and duration of attacks Purpose: Purpose: For frequent attacks of headache For frequent attacks of headache For moderate to severe headaches For moderate to severe headaches For those on excessive use of symptomatic medication without relief For those on excessive use of symptomatic medication without relief

33. Preventive Therapy Notes: Notes: Given daily for at least 3-6 months Given daily for at least 3-6 months Begin at lower dose with upward titration Begin at lower dose with upward titration Reassess every 6 months Reassess every 6 months Some medications need tapering before discontinuation Some medications need tapering before discontinuation Encourage effective birth control in fertile women while on preventive therapy Encourage effective birth control in fertile women while on preventive therapy

34. Drugs for Acute Treatment of Migraine

36. Indications for Preventive Treatment in Migraine Migraine that significantly interferes with the patient’s daily routine despite acute treatment Migraine that significantly interferes with the patient’s daily routine despite acute treatment Failure of, contraindication to, or troublesome AEs from acute medications Failure of, contraindication to, or troublesome AEs from acute medications Acute medication overuse Acute medication overuse Very frequent headaches (>2/week) (risk of medication overuse) Very frequent headaches (>2/week) (risk of medication overuse) Patient preference Patient preference Special circumstances, such as hemiplegic migraine or attacks with a risk of permanent neurologic injury Special circumstances, such as hemiplegic migraine or attacks with a risk of permanent neurologic injury

37. Choices of Preventive Treatment in Migraine: Influence of Co-morbid Conditions

39. Candidates for botulinum toxin type A injections in migraine Headache refractory to routine preventive treatment Headache refractory to conventional treatment Patient overusing acute headache medications Patient in special population or situation (elderly, those at risk of unacceptable side effects) Patient preference Co-existent cervical dystonia Noncompliance with oral medications Contraindications, noncompliance, or adverse events from standard prevention drugs

40. Thank You!