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Curiculum vitae EDUCATION Curiculum vitae EDUCATION

Curiculum vitae EDUCATION - PowerPoint Presentation

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Curiculum vitae EDUCATION - PPT Presentation

Master of Medicine in Pain Management University of Santo Tomas Faculty of Medicine and Surgery Manila Philippines on going Fellowship in Pain Management Aesculap AcademyDaradia The Pain Clinic KolkataIndia Focus on blocks given for surgical procedures amp extended to acute as wel ID: 777308

attributed headache aura migraine headache attributed migraine aura criteria disorder type attacks primary pain symptoms tension cluster fulfilling minutes

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Slide1

Curiculum vitae

EDUCATION

Master of Medicine in Pain Management

, University of Santo Tomas Faculty of Medicine and Surgery, Manila, Philippines (on going).

Fellowship in Pain Management, Aesculap Academy-Daradia The Pain Clinic, Kolkata,India – Focus on blocks given for surgical procedures & extended to acute as well as chronic pain management,

Kolkata, West Bengal, India, 1

st

May 2015 to 31

st

July 2015.

Neurology Specialist Program

,Residency at Neurology Department , Medical faculty University of Indonesia, Jakarta- Indonesia, July 2000 – February 2005.

Fellowship Pediatric Neurology

,Neurology Division, Child Health department,Medical Faculty Indonesia University, Cipto Mangunkusumo Hospital, Jakarta – Indonesia ,February – August 2010.

Fellowship Electromyography

, Neurology Department, Medical Faculty Airlangga University, Dr. Soetomo Hospital, Surabaya,Indonesia,June-September 2012

British Paediatric Neurology Association distance education

,

,

2012 – 2014.

Child Neurodevelopment

Course, Suryakanti, Bandung, Indonesia Nov 2011, February 2012

VIREPA, EUREPA (Virtual Epilepsy Academy of the European Epilepsy

Academy)

- ILAE (International League Against Epilepsy) distance education course

, online

:

Clinical Pharmacology & Pharmacotherapy Epilepsy (November 5 – June 5,2011)

“EEG in the Diagnosis and Management of Epilepsy” – Basic Course September 23 – March 25,2012)

EEG in the diagnosis & management of epilepsy in neonates & children – 2

nd

edition, October 12,2012 – May 12,2013.

EEG Score – 2 nd edition, November 1,2013 – March 2,2014

Advanced EEG – October 10,2014 – April 12, 2015

EEG course : “Pediatric and Neonatal EEG”, Padjadjaran University- Hasan Sadikin Hospital, Bandung, 12-24 Juni 2009.

Faculty of Medicine, Brawijaya University, Malang – Indonesia, 1988 – 1994

Slide2

d

r.Istiana

Sari,SpS,FIPMRS Hermina Bekasi

HEADACHE

Slide3

Introduction

Commonest neurological

consultation

Need for systematic approach

3

Slide4

PAIN SENSITIVE STRUCTURES OF THE HEAD

EXTRACRANIAL :

Scalp,skin,subcutaneous

tissue,periosteum

of skull

Joint capsules :

cervical,temporomandibular

joints

Muscles,scalp,paraspinal musclesParanasal sinusesTeeth, ocular contents

INTRACRANIAL :

Blood vessels

Meninges

Cranial nerves

Slide5

Causes of headaches.

1

. Traction or dilatation of intracranial or extracranial arteries.

2. Traction of large

extracranial

veins

3. Compression, traction or inflammation of cranial and spinal nerves

4. Spasm and trauma to cranial and cervical muscles.

5. Meningeal irritation and raised intracranial pressure

6. Disturbance of intracerebral serotonergic projections

Slide6

Objectives

Become aware of the IHS classification

Be able to diagnose and treat the common types of primary headache

Be able to recognize the “red flags” of dangerous secondary headache

Slide7

Classification

IHS

ICHD-1(1988) to ICHD-2(2004)

Primary

Secondary

7

Slide8

INTERNATIONAL HEADACHE SOCIETY (HIS) CRITERIA

HIS has developed criteria to divide headaches into primary and secondary types

Primary type : headaches without specific cause (migraine,tension, cluster)

Secondary type : headaches with underlying structural or metabolic cause

Slide9

IHS CLASSIFICATION

THE PRIMARY HEADACHES

Migraine 1.1 Migraine without aura (common migraine)

1.2 Migraine with aura (classic migraine)

1.3 Basilar migraine

1.4 Familial hemiplegic migraine

Tension type headache

2.1 Infrequent episodic TTH 2.2 Frequent episodic TTH 2.3 Chronic TTHInternational Classification of Headache Disorders,2nd

ed,Cephalgia 2004;24 (supp;-1)1-160)

Slide10

IHS CLASSIFICATION

THE PRIMARY HEADACHES

Cluster headache and other trigeminal autonomic cephalgias

3.1 cluster

3.1.1 Episodic cluster

3.1.2 Chronic cluster headache

3.2 Paroxysmal hemicrania 3.3 SUNCT (short lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing)

International Classification of Headache Disorders,2nd

ed,Cephalgia

2004;24 (

supp

;-1)1-160)

Slide11

IHS CLASSIFICATION

THE PRIMARY HEADACHES

4. Other primary headaches

4.1 Primary stabbing headache

4.2 Primary

exertional

headache

4.3 Primary headache associated with sexual activity 4.4 Hypnic headache 4.5 Primary thunderclap headache

International Classification of Headache Disorders,2nd

ed,Cephalgia

2004;24 (

supp

;-1)1-160)

Slide12

IHS CLASSIFICATION

THE SECONDARY HEADACHES

5. Headache attributed to head and / or neck trauma

5.1 Chronic headache attributed to whiplash injury

5.2

Hedache

attributed to traumatic intracranial

hematoma 5.3 Post craniotomy headache6. Headache attributed to cranial or cervical vascular disorder 6.1 Headache attributed to non traumatic intracranial hemorrhage 6.1.2 Headache attributed to subarachnoid hemorrhage 6.2 Headache attributed to arteritis

6.2.1 Headache attributed to giant cell arteritis 6.3 Headache attributed to cerebral venous thrombosis

International Classification of Headache Disorders,2

nd

ed,Cephalgia

2004;24 (

supp

;-1)1-160)

Slide13

IHS CLASSIFICATION

THE SECONDARY HEADACHES

7. Headache attributed to non vascular intracranial disorder

7.1 Headache attributed to high CSF pressure

7.2 Headache attributed to low CSF pressure

7.2.1 post

dural puncture headache 7.3 Headache attributed to epileptic seizure 7.3.1 post ictal headache8. Headache attributed to substance or its withdrawl 8.1 Medication overuse headache

9. Headache attributed to infection 9.1 Headache attributed to bacterial meningitis10. Headache attributed to disorder of homeostasis

10.1 Headache attributed to hypoxia or

hypercapnia

10.2 Headache attributed to dialysis headache

10.3 Headache attributed to fasting

International Classification of Headache Disorders,2

nd

ed,Cephalgia

2004;24 (

supp

;-1)1-160)

Slide14

IHS CLASSIFICATION

THE SECONDARY HEADACHES

11. Headache or facial pain attributed to disorder of cranium,neck

,

eyes,

ears,nose,sinuses,teeth,mouth

or other facial or cranial

structures 11.1 Cervicogenic headache 11.2 Headache attributed to rhinosinusitis 11.3 Headache attributed to temporomandibular joint disorder

12. Headache attributed to psychiatric disorder

International Classification of Headache Disorders,2

nd

ed,Cephalgia

2004;24 (

supp

;-1)1-160)

Slide15

IHS CLASSIFICATION

CRANIAL NEURALGIAS ,CENTRAL AND PRIMARY

FACIAL PAIN AND OTHER HEADACHES

13. Cranial neuralgias, central and primary facial pain

and other headaches

13.1 trigeminal neuralgia

13.2 occipital neuralgia 13.3 central causes of facial pain 13.3.1 anesthesia dolorosa 13.3.2 central post stroke pain 13.3.3 attributed to multiple sclerosis

13.3.4 burning mouth syndrome14. Other headache, cranial neuralgia, central or primary facial pain 14.1 Headache not elsewhere classified

14.2 Headache unspecified

International Classification of Headache Disorders,2

nd

ed,Cephalgia

2004;24 (

supp

;-1)1-160)

Slide16

GUIDANCE - ASSESSMENT

EVALUATE PEOPLE WHO PRESENT WITH HEADACHE AND ANY OF THE FOLLOWING FEATURES AND CONSIDER THE NEED FOR FURTHER INVESTIGATIONS :

Worsening headache, with fever

Sudden onset headache , reaching max intensity within 5

mnt

New onset neurological deficit

New onset cognitive dysfunction

Change in personality

Impaired level of consciousness

Recent head traumaHeadache triggered by cough, exerciseOrthostatic headache

Slide17

GUIDANCE - ASSESSMENT

2. CONSIDER FURTHER INVESTIGATIONS FOR PEOPLE WHO PRESENT WITH NEW ONSET HEADACHE AND ANY OF THE FOLLOWING :

Compromised immunity,HIV

Age under 20 years and history of malignancy

A history of malignancy known to

metastase

to the brain

Vomiting without other obvious cause

3. CONSIDER USING A HEADACHE DIARY TO AID THE DIAGNOSIS OF PRIMARY HEADACHE

Slide18

GUIDANCE - ASSESSMENT

4. If headache diary is used, asked the person to record the following for a minimum 8 weeks :

Frequency,duration and severity of headachesAny associated symptoms

All prescribed and over the counter medications taken to relieve headaches

Possible

precipitans

Relationship of headaches to menstruation

Slide19

Secondary headaches

19

Slide20

SECONDARY HEADACHE

Headache attributed to :

Head and or neck trauma

Cranial or cervical vascular disorder

Non vascular intracranial disorder

A substance use or its

withdrawl

Infection

Neoplasma

Disorder of homeostasisDisorder of cranium, neck, eyes,ears,nose, sinuses, teeth, mouth or other facial or cranial structuresPsychiatric disorders

Slide21

Slide22

RED FLAGS

Sudden onset (

SAH,hemorrhage,mass lesion,AVM)

Worsening pattern of headache (

freq,severity

)

Headache with

sistemic

illness

Focal neurologic signs or symptomsPapilledemaTriggered by cough exertion , by exerciseHeadache during pregnancy or post partumNew headache type in patent with cancer, HIVAge of onset over 50 years (mass lesion,TA)Metabolic disordersAcute hypertension

Slide23

SERIOUS CAUSES OF HEADACHE

Intracranial

tumours Meningitis (sign of fever,neck stiffness )Subarachnoid

haemorrhage

: “worst ever”

Giant cell temporal arteritis (new headache in any patient over 50 years of age should raise the suspicion of giant cell arteritis)

Idiopathic intracranial hypertension

Primary angle – closure glaucoma (

coloured

haloes around lights)Carbon monoxide poisoning (risk is more in households relying on solid fuel)

Slide24

Distinguish : primary or secondary headache?

Typical questions to consider

Prodrome

or aura

Onset and course

Duration and frequency

Pain quality and severity

Associated features

Precipitating factorsAmeliorating factors

Family and social history

Slide25

3. Worrisome features in history for secondary type

Thunderclap (acute) onset

Late onset headache with no previous headache history

Systemic disease (

infectious,metabolic,toxic

)

Patient with history of cancer

Patient with history of immunosuppressed state

Headache worsens with cough or strain, especially worrisome if associated with transient visual obscurations

Slide26

PHYSICAL EXAMINATION

Slide27

Aimed at distinguishing between primary and

secondary types of headacheWorrisome features in physical examination suggesting a secondary type

1. Focal neurologic deficits

2. Papilledema

Slide28

Papilledema

Slide29

Key aspects of physical examination

Slide30

Neuroimaging

Slide31

Acute onset headache

Sufficient evidence from retrospective and prospective studies to support the association of an acute sudden onset headache with a vascular event.

Sudden onset headache is a red flag

Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache: Annals of Emerg Med 2002 (1):39.

Slide32

DIFFERENTIAL DIAGNOSIS OF ACUTE THUNDERCLAP HEADACHE

Subarachnoid hemorrhage

Intracranial hemorrhageVenous sinus thrombosisArterial dissectionAcute meningitis

Hypertensive crisis

Glaucoma

Migrain

Cluster headache

Exertional

headache (

cough,coital headache)

Slide33

Primary headache

Tension type headache- 69%

Migraine- 16%Trigeminal autonomic

cephalgias

(cluster headache- 0.1%)

Other primary headache disorder (including new daily persistent headache)

Slide34

Primary headaches

Migraine

Tension type headache

Cluster headache and other trigeminal autonomic cephalalgias

Cluster

Paroxysmal hemicrania

SUNCT

Probable

34

Other types

Primary stabbing headache

Primary cough headache

Primary

exertional

headache

Primary headache associated with sexual activity

Preorgasmic

headache

Orgasmic

headache

Primary thunderclap headache

Hemicrania

continua

New daily-persistent headache (NDPH)

Slide35

Slide36

Slide37

Migraine

Migraine without aura

Migraine with aura

Typical aura with migraine headache

Typical aura with non-migraine headache

Typical aura without headache

Familial hemiplegic migraine

Sporadic hemiplegic migraine

Basilar-type migraine

37

Slide38

Tension-type headache (TTH)

Infrequent episodic tension-type headache

Infrequent episodic tension-type headache associated with

pericranial

tenderness

Infrequent episodic tension-type headache not associated with

pericranial

tenderness

38

Frequent episodic tension-type headache

Frequent episodic tension-type headache associated with

pericranial

tenderness

Frequent episodic tension-type headache not associated with

pericranial

tenderness

Slide39

Tension-type headache

Chronic tension-type headache

Chronic tension-type headache associated with

pericranial

tenderness

Chronic tension-type headache not associated with

pericranial

tenderness

39

Slide40

Cluster headache and other trigeminal autonomic cephalalgias

Cluster headache

Episodic cluster headache

Chronic cluster headache

Paroxysmal hemicrania

Episodic paroxysmal hemicrania

Chronic paroxysmal hemicrania (CPH)

Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT)

40

Slide41

Other primary headaches

Primary stabbing headache

Primary cough headache

Primary

exertional

headache

Primary headache associated with sexual activity

Preorgasmic

headache

Orgasmic headache

Hypnic

headache

Primary thunderclap headache

Hemicrania

continua

New daily-persistent headache (NDPH)

41

Slide42

Migraine

Accounts for 10% of the outpatient attendance

Unique syndrome with a psychic,

electrical,neural,chemical,vascular

,

inflammatory,genetic,environmental

&mitochondrial

Around 70%-positive family history

42

Slide43

Phases of Migraine

Prodrome-1-24

hrs

prior to onset

Aura-0-60 min prior to or with pain onset.

Visual,Sensory,Speech

Headache-4-72

hrs

Specific characteristics, Associated

symp.

Postdrome- post pain symptoms which last for hrs to days

43

Slide44

Triggers

Hormonal

Menstruation,ovulation,OCP,hormonal

replacement

Dietary triggers

Alcohol,nitrite

–laden

meat,monosodium

glutamate,aspartame,choclate, aged cheese,missing a meal,red wine

44

Slide45

Triggers

Psychologic

triggers

Stress,period

after stress(weekend or vacation),anxiety,

worry,depression

Sleep related triggers

Lack of or excessive sleep

Physical or environmental triggers

Glare, flashing lights, visual stimulation,fluorescent

light, odours, weather changes,high altitude,change in posture,physical exertion

45

Slide46

Triggers

Drugs

Nitroglycerine,histamine,reserpine

,

hydralazine,ranitidine

, estrogen

Miscellaneous

Head

trauma,physical

exertion,fatigueTrigger zones

46

Slide47

Triggers

Trigger factors increase the probability of a migraine attack in the short term (usually

<

48 hours) in a person with migraine

47

Slide48

Migraine without aura

Common migraine

,

hemicrania

simplex

Recurrent headache disorder manifesting in attacks lasting

4–72 hours.

Typical characteristics

are unilateral location(60%), pulsating

quality,moderate

or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and

phonophobia

.

Commonest

subtype,has

a higher average attack frequency and is usually more disabling than

Migraine with aura

48

Slide49

Migraine without aura

Diagnostic criteria:

A. At least 5 attacks fulfilling criteria B–D

B. Headache attacks lasting 4–72 hours (untreated

or unsuccessfully treated)

C. Headache has at least two of the following:

unilateral location

pulsating quality

moderate or severe pain intensity

aggravation by or causing avoidance of routine physical activity (

eg

, walking or climbing stairs)

49

Slide50

Migraine without aura

D. During headache at least one of the following

:

1. nausea and/or vomiting

2. photophobia and

phonophobia

E. Not attributed to another

disorder

50

Slide51

Migraine without aura

Migraine headache is usually

frontotemporal.Occipital

headache in

children

, whether unilateral or bilateral, is rare and calls for diagnostic caution; may be structural

Pulsating

means throbbing or varying with the heartbeat.

In

young children

, photophobia and

phonophobia

may be inferred from their

behaviour

.

Migraine without aura often has a strict

menstrual relationship.

51

Slide52

Migraine with aura

Classic or classical migraine

, ophthalmic,

hemiparaesthetic,hemiplegic

migrain

Recurrent disorder manifesting in attacks of reversible focal neurological symptoms that usually develop gradually over 5–20 minutes and last for less than 60 minutes.

52

Slide53

Migraine with aura

The aura

is the complex of neurological symptoms that occurs just before or at the onset of migraine

headache

Premonitory

symptoms occur hours to a day or two before a migraine attack (with or without aura).They include various combinations of fatigue, difficulty in concentrating, neck stiffness, sensitivity to light or sound, nausea, blurred vision, yawning and

pal

lor.

53

Slide54

Migraine with aura

Typical aura with migraine headache

Typical aura with non-migraine headache

Typical aura without headache

Familial hemiplegic migraine (FHM)

Sporadic hemiplegic migraine

Basilar-type migraine

54

Slide55

Migraine with aura

Diagnostic criteria:

A. At least 2 attacks fulfilling criterion B

B. Migraine aura fulfilling criteria B and C for one

of the

subforms

C. Not attributed to another disorder

55

Slide56

Typical aura with migraine headache

Diagnostic criteria:

A. At least 2 attacks fulfilling criteria B–D

B. Aura consisting of at least one of the following, but no motor weakness:

1. fully reversible visual symptoms including positive features (

eg

, flickering lights, spots or lines) and/or negative features (loss of vision)

2. fully reversible sensory symptoms including positive features (pins and needles) and/or negative features (numbness)

3. fully reversible dysphasic speech disturbance

56

Slide57

Typical aura with migraine headache

C. At least two of the following:

homonymous visual symptoms and/or unilateral sensory symptoms

at least one aura symptom develops gradually over

5 minutes and/or different aura symptoms occur in succession over

5min

each symptom lasts

5 and < 60 minutes

D. Headache fulfilling criteria B–D for

Migraine without aura

begins during the aura or follows aura within 60 minutes

E. Not attributed to another disorder

57

Slide58

Typical aura with migraine headache

Additional loss or blurring of central vision may occur.

Rare secondary mimics including carotid dissection,

arteriovenous

malformation and seizure.

Visual aura is the most common type of aura, often presenting as a fortification spectrum,

scotoma

If the aura includes motor weakness-

Familial hemiplegic migraine

or

Sporadic hemiplegic migraine

.

Symptoms usually follow one another in succession beginning with visual, then sensory symptoms and dysphasia.

58

Slide59

Typical aura with non-migraine headache

Description

Typical aura consisting of visual and/or sensory

and/or speech symptoms. Gradual development,

duration no longer than one hour, a mix of positive and negative features and complete reversibility characterize the aura which is associated with a headache that does not

fulfil

criteria for

Migraine without aura

.

59

Slide60

Typical aura with non-migraine headache

Diagnostic criteria:

A. At least 2 attacks fulfilling criteria B–D

B. Aura consisting of at least one of the

following,but

no motor weakness:

1 fully reversible visual symptoms including positive features (

eg

, flickering lights, spots or lines) and/or negative features (

ie

, loss of vision)

2. fully reversible sensory symptoms including positive features (

ie

, pins and needles) and/or negative features (

ie

, numbness)

3. fully reversible dysphasic speech disturbance

60

Slide61

Typical aura with non-migraine headache

C. At least two of the following:

1. homonymous visual symptoms and/or unilateral sensory symptoms

2. at least one aura symptom develops gradually over

5 minutes and/or different aura symptoms occur in succession over

5 minutes

3. each symptom lasts

5 and <60 minutes

D. Headache that does not fulfill criteria B–D for m

igraine without aura

begins during the aura or follows aura within 60 minutes

E. Not attributed to another disorder

61

Slide62

Typical aura without headache

Typical aura

consisting of visual and/or sensory symptoms with or without speech

symptoms.Gradual

development, duration no longer than one hour, a mix of positive and negative features and complete reversibility characterize the aura which is not associated with headache.

Diagnostic criteria:

A. At least 2 attacks fulfilling criteria B–D

B. Aura consisting of at least one of the

following,with

or without speech disturbance but no motor weakness:

1. fully reversible visual symptoms

2. fully reversible sensory symptoms

62

Slide63

Typical aura without headache

C. At least two of the following:

homonymous visual symptoms and/or unilateral sensory symptoms

at least one aura symptom develops gradually over

5 minutes and/or different aura symptoms occur in succession over

5 minutes

each symptom lasts

5 and <60 minutes

D. Headache does not occur during aura nor follow aura within 60 minutes

E. Not attributed to another disorder

63

Slide64

Basilar-type migraine

Migraine with aura symptoms

clearly originating from the

brainstem

and/or from both hemispheres simultaneously affected, but

no motor weakness.

Diagnostic criteria:

A. At least 2 attacks fulfilling criteria B–D

B. Aura consisting of at least two of the following fully reversible symptoms, but no motor weakness:

1. dysarthria

2. Vertigo

3. tinnitus

4.

hypacusia

64

Slide65

Basilar-type migraine

5. diplopia

6. visual symptoms simultaneously in both temporal and nasal fields of both eyes

7. ataxia

8. decreased level of consciousness

9. simultaneously bilateral

paraesthesias

C. At least one of the following:

1. at least one aura symptom develops gradually over

5 minutes and/or different aura symptoms occur in succession over

5 min

2. each aura symptom lasts

5 and < 60 minutes

D. Headache fulfilling criteria B–D for

Migraine without aura

begins during the aura or follows aura within 60 minutes

E. Not attributed to another disorder

65

Slide66

Basilar-type migraine

Basilar-type attacks are mostly seen in young

adults.Many

patients who have basilar-type attacks also report attacks with typical aura

Familial hemiplegic migraine

have basilar-type symptoms in 60% of cases.

Basilar-type migraine

should be diagnosed only when no motor weakness occurs

.

66

Slide67

Complications of migraine

Chronic migraine

Status

migrainosus

Persistent aura without infarction

Migrainous

infarction

Migraine-triggered seizure

67

Slide68

Migrainous infarction

Description:

One or more

migrainous

aura symptoms associated with an ischemic brain lesion in appropriate territory demonstrated by neuroimaging.

Diagnostic criteria:

A. The present attack in a patient with

Migraine with aura

is typical of previous attacks except that one or more aura

symptoms persists for

>

60 minutes

B. Neuroimaging demonstrates ischemic infarction in a relevant area

C. Not attributed to another disorder

68

Slide69

Migrainous infarction

Ischemic stroke in a migraine sufferer may be categorized as cerebral infarction of other cause coexisting with migraine, cerebral infarction of other cause presenting with symptoms resembling migraine with aura, or cerebral infarction occurring during the course of a typical migraine with aura attack. Only the last

fulfils

criteria for

Migrainous

infarction

.

Increased risk for stroke in migraine patients has been demonstrated in women under age 45 in several studies.

69

Slide70

Migraine-triggered seizure

Description:

A seizure triggered by a migraine aura.

Diagnostic criteria:

A. Migraine fulfilling criteria for

Migraine with aura

B. A seizure fulfilling diagnostic criteria for one type of epileptic attack occurs during or within 1 hour after a migraine aura

Migraine and epilepsy are prototypical examples of paroxysmal brain disorders. While migraine-like headaches are quite frequently seen in the postictal period, sometimes a seizure occurs during or following a migraine attack. This phenomenon, sometimes referred to as

migralepsy

, has been described in patients with migraine with aura.

70

Slide71

MIGRAIN WITH OR WITHOUT AURA TREATMENT

ACUTE TREATMENT

Offer combination oral

Triptan

& NSAID, oral

Triptan

&

paracetamol

For people who prefer to take only one drug, consider

monotherapy with an oral Triptan,NSAID,aspirin (900 mg) or paracetamol Do not offer ergots or opioids for the acute treatment of migraineFor people in whom oral preparation are not tolerated : offer a non oral preparation of metoclopramide or prochlorperazine,consider adding a non oral NSAID or

triptan

Slide72

MIGRAIN WITH OR WITHOUT AURA TREATMENT

PROPHYLACTIC TREATMENT

Topiramate

(associated with risk of fetal malformation &

can impair the effectiveness of hormonal

contraception)

Valproic acid10 session of acupuncture over 5-8 weeksRiboflavin (400 mg once a day) may be effective in reducing migraine frequency & intensity Review the need for continuing migraine prophylaxis 6

monts after start

Slide73

evidence

ANTIDEPPRESSANTS : Amitriptyline,venlafaxine

for

migrain

prevention (Level B)

Divalproex

sodium,sodium

valproate,and topiramate are established as effective and should be offered for migrain prevention

Slide74

Tension-type headache (TTH)

most common type of primary headache

:

its lifetime prevalence in the general population ranges from 30 to 78%

Previously considered to be primarily psychogenic but now

neurobiologic

basis. Peripheral pain mechanisms are most likely to play a role in

Infrequent &

Frequent episodic tension type headache

whereas central pain mechanisms play a more important role in

Chronic tension-type headache

.

74

Slide75

Tension-type headache (TTH)

Infrequent episodic tension-type headache

Infrequent episodic tension-type headache associated with

pericranial

tenderness

Infrequent episodic tension-type headache not associated with

pericranial

tenderness

75

Frequent episodic

tension-type headache

Frequent episodic tension-type headache associated with

pericranial

tenderness

Frequent episodic tension-type headache not associated with

pericranial

tenderness

Slide76

Tension-type headache

Chronic tension-type headache

Chronic tension-type headache associated with

pericranial

tenderness

Chronic tension-type headache not associated with

pericranial

tenderness

76

Slide77

Slide78

Infrequent

episodic tension-type headache

Description

Infrequent episodes of headache

lasting minutes to days

. The pain is

typically bilateral

, pressing or tightening in quality and of mild to moderate

intensity,and

it does not worsen with routine physical activity. There is

no nausea

but photophobia or

phonophobia

may be present.

Diagnostic criteria

:

A. At least 10 episodes occurring on

<

1 day per month

on average

(

<

12 days per year

) and fulfilling criteria B–D

B. Headache lasting from

30 minutes to 7 days

78

Slide79

Infrequent episodic tension-type headache

C. Headache has at least two of the following characteristics:

1. bilateral location

2. pressing/tightening (non-pulsating) quality

3. mild or moderate intensity

4. not aggravated by routine physical activity such as walking or climbing stairs

D. Both of the following:

1. no nausea or vomiting (anorexia may occur)

2. no more than one of photophobia or

phonophobia

E. Not attributed to another disorder

79

Slide80

Infrequent episodic tension-type headache

associated with

pericranial tenderness

Diagnostic criteria:

A. Episodes fulfilling criteria A–E for

Infrequent episodic tension-type headache

B. Increased

pericranial

tenderness on manual palpation

80

Slide81

Infrequent episodic tension-type headache

not associated with

pericranial tenderness

Diagnostic criteria:

A. Episodes fulfilling criteria A–E for

Infrequent episodic tension-type headache

B. No increased

pericranial

tenderness

Points

Pericranial

tenderness is easily recorded by manual palpation by small rotating movements and a firm pressure (preferably aided by use of a

palpometer

) with the second and third finger on the frontal, temporal, masseter,

pterygoid

, sternocleidomastoid, splenius and trapezius muscles. A local tenderness score from 0–3 on each muscle can be summated to yield a total tenderness score for each individual.

81

Slide82

Frequent

episodic tension-type headache

Description:

Frequent episodes of headache lasting minutes to

days.The

pain is typically bilateral, pressing or tightening in quality and of mild to moderate

intensity,and

it does not worsen with routine physical activity. There is no nausea but photophobia or

phonophobia

may be present.

Diagnostic criteria

A. At least 10 episodes occurring on

1 but

<

15 days per month for at least 3 months (

12 and

<

180 days per year)

and fulfilling criteria B–D

B. Headache lasting from

30 minutes to 7 days

82

Slide83

Frequent episodic tension-type headache

C. Headache has at least two of the following characteristics:

1. bilateral location

2. pressing/tightening (non-pulsating) quality

3. mild or moderate intensity

4. not aggravated by routine physical activity such as walking or climbing stairs

D. Both of the following:

1. no nausea or vomiting (anorexia may occur)

2. no more than one of photophobia or

phonophobia

E. Not attributed to another disorder

83

Slide84

Chronic tension-type headache

Description:

A disorder evolving from episodic tension-type headache, with daily or very frequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There may be mild nausea, photophobia or

phonophobia

.

84

Slide85

Chronic tension-type headache

A. Headache occurring on

15 days per month

on average for

>

3 months (

180 days per year)

and fulfilling criteria B–D

B. Headache

lasts hours or may be continuous

C. Headache has at least two of the following characteristics:

1. bilateral location

2. pressing/tightening (non-pulsating) quality

3. mild or moderate intensity

4. not aggravated by routine physical activity such as walking or climbing stairs

D. Both of the following:

1. no more than one of photophobia,

phonophobia

or mild nausea

2. neither moderate or severe nausea nor vomiting

E. Not attributed to another disorder

85

Slide86

TENSION TYPE HEADACHE TREATMENT

ACUTE TREATMENT

Aspirin,

Paracetamol

, NSAID

Taking into account the person’s preference,

comorbidities and risk of adverse events

Do not offer opioids for the acute treatment

of Tension Type HeadachePROPHYLACTIC TREATMENTConsider a course of up to 10 sessions of accupuncture over 5-8 weeks for the prophylactic treatment of chronic tension type headache

Slide87

Treatment

of TTH

Slide88

Cluster headache and other trigeminal autonomic cephalalgias

Cluster headache

Episodic cluster headache

Chronic cluster headache

Paroxysmal

hemicrania

Episodic paroxysmal

hemicrania

Chronic paroxysmal

hemicrania

(CPH)

Short-lasting Unilateral

Neuralgiform

headache attacks with

Conjunctival

injection and Tearing (SUNCT)

88

Slide89

Cluster headache

Attacks of

severe, strictly unilateral pain

which is orbital, supraorbital, temporal or in any combination of these sites, lasting

15–180 minutes

and occurring

from once every other day to 8 times a day

. The attacks are associated with one or more of the

following,all

of which are

ipsilateral: conjunctival

injection, lacrimation, nasal congestion,

rhinorrhoea

, forehead and facial sweating,

miosis

, ptosis, eyelid

oedema

. Most patients are restless or agitated during an attack.

Diagnostic criteria:

A. At least 5 attacks fulfilling criteria B–D

B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes if untreated

89

Slide90

Cluster headache

C. Headache is accompanied by at least one of the following:

1.

ipsilateral

conjunctival

injection and/or lacrimation

2.

ipsilateral

nasal congestion and/or

rhinorrhoea

3.

ipsilateral

eyelid

oedema

4.

ipsilateral

forehead and facial sweating

5.

ipsilateral

miosis

and/or ptosis

6. a sense of restlessness or agitation

D. Attacks have a frequency from one every other day to 8 per day

E. Not attributed to another disorder

90

Slide91

Cluster headache

Attacks usually occur in series (

cluster periods

) lasting for weeks or months separated by remission periods usually lasting months or years.

However,about

10–15% of patients have chronic symptoms without remissions

During a cluster period, and in the chronic subtype, attacks occur regularly and may be provoked by alcohol, histamine or nitroglycerine. Pain almost invariably recurs on the same side during an individual cluster period.

91

Slide92

Cluster headache

During the worst attacks, the intensity of pain is excruciating. Patients are usually unable to lie down and characteristically pace the floor.

Age at onset is usually 20–40 years. Prevalence is 3–4 times higher in men than in women.

Cluster headache with coexistent trigeminal neuralgia (cluster-tic syndrome).Some patients have been described who have both

Cluster headache

and

Trigeminal

neuralgia

.They

should receive both diagnoses

92

Slide93

Episodic cluster headache

Cluster headache attacks occurring in periods lasting 7 days to 1 year separated by pain-free periods lasting 1 month or longer.

Diagnostic criteria

:

Attacks fulfilling criteria A–E for

Cluster headache

At least two cluster periods lasting 7–365 days and separated by pain-free remission periods of

1 month

Note:

Cluster periods usually last between 2

wks

- 3 months.

93

Slide94

Chronic cluster headache

Cluster headache attacks occurring for more than 1year without remission or with remissions lasting less than 1 month.

Diagnostic criteria:

Attacks fulfilling criteria A–E for

Cluster headache

Attacks recur over

>

1 year without remission periods or with remission periods lasting

<

1month

Primary and secondary

94

Slide95

CLUSTER HEADACHE TREATMENT

ACUTE TREATMENT

First bout of cluster headache --- neuroimaging

Offer oxygen , nasal

triptan

for the acute treatment of cluster headache

When using oxygen for the acute treatment of cluster headache :

- use 100% oxygen at a flow rate of at least 12

litres per minute with a non rebreathing mask and and a reservoir bag and - arrange provision of home and ambulatory oxygenDo not offer

paracetamol,NSAIDs,opioids,ergots or oral triptans for the acute treatment of cluster

headache

Slide96

Cluster headache

Abortive

Prophylactic

Slide97

Surgical management

Slide98

Secondary headaches

98

Slide99

Headache attributed to head and/or neck trauma

Acute post-traumatic headache

Acute

post-traumatic headache attributed to moderate or severe head injury

Acute

post-traumatic headache attributed to mild head injury

Chronic post-traumatic headache

Chronic

post-traumatic headache attributed to moderate or severe head injury

Chronic

post-traumatic headache attributed to mild head injury

99

Slide100

Headache attributed to head and/or neck trauma

Acute headache attributed to whiplash injury

Chronic headache attributed to whiplash injury

Headache attributed to traumatic intracranial

haematoma

-

Headache attributed to epidural

haematoma

-

Headache

attributed to subdural

haematoma

100

Slide101

Headache attributed to head and/or neck trauma

Headache attributed to other head and/or neck trauma

Acute

headache attributed to other head and/or neck

tr

Chronic

headache attributed to other head and/or

neck

tr

Post-craniotomy

headache

Acute

post-craniotomy headache

Chronic post-craniotomy headache

101

Slide102

Headache attributed to cranial or cervical vascular disorder

Headache

attributed to

ischaemic

stroke or

transientischaemic

attack

Headache

attributed to

ischaemic

stroke

Headache

attributed to transient

ischaemic

attack

Headache

attributed to non-traumatic

intracranial

haemorrhage

Headache attributed to

intracerebral

haemorrhage

Headache attributed to subarachnoid

haemorrhage

102

Slide103

Headache attributed to cranial or cervical vascular disorder

Headache attributed to

unruptured

vascular malformation

Headache

attributed to

saccular

aneurysm

Headache

attributed to

arteriovenous

malformation

Headache

attributed to

dural

arteriovenous

fistula

Headache

attributed to cavernous

angioma

Headache

attributed to

encephalotrigeminal

or

leptomeningeal

angiomatosis

(

Sturge

Weber Syndrome)

103

Slide104

Headache attributed to cranial or cervical vascular disorder

Headache attributed to arteritis

Headache

attributed to giant cell arteritis

Headache

attributed to primary (CNS)

angiitis

Headache

attributed to secondary (CNS)

angiitis

Carotid or vertebral artery pain

Headache

or facial or neck pain attributed to arterial dissection

Post-

endarterectomy

headache

Carotid

angioplasty headache

Headache

attributed to intracranial endovascular procedures

Angiography headache

104

Slide105

Headache attributed to cranial or cervical vascular disorder

Headache attributed to cerebral venous thrombosis

Headache attributed to other intracranial vascular

disorder

Headache

attributed to benign

angiopathy

of the

CNS

Headache

attributed to pituitary apoplexy

105

Slide106

Headache attributed to non-vascular intracranial disorder

Headache

attributed to high cerebrospinal fluid

pressure

Headache

attributed to idiopathic intracranial hypertension

Headache

attributed to intracranial hypertension secondary to

metabolic,toxic

or hormonal causes

Headache

attributed to intracranial hypertension secondary to

hydrocephalus

106

Slide107

Headache attributed to non-vascular intracranial disorder

Headache attributed to low cerebrospinal fluid pressure

-

Post-

dural

puncture headache

-

CSF

fistula headache

-

Headache

attributed to

spontaneous

/idiopathic

low CSF pressure

107

Slide108

Headache attributed to non-vascular intracranial disorder

Headache attributed to non-infectious inflammatory disease

Headache

attributed to

neurosarcoidosis

Headache

attributed to aseptic (non-infectious) meningitis

Headache

attributed to other non-infectious inflammatory disease

Headache

attributed to lymphocytic

hypophysitis

108

Slide109

Headache attributed to non-vascular intracranial disorder

Headache attributed to intracranial neoplasm

Headache

attributed to increased intracranial pressure or hydrocephalus

caused by neoplasm

Headache

attributed directly to neoplasm

Headache

attributed to carcinomatous meningitis

Headache

attributed to hypothalamic or pituitary

hyper

or

hyposecretion

Headache attributed to

intrathecal

injection

109

Slide110

Headache attributed to non-vascular intracranial disorder

Headache attributed to epileptic seizure- to

specify seizure

type

Hemicrania

epileptica

Post-seizure

headache

Headache attributed to

Chiari

malformation type I

Headache

attributed to other non-vascular intracranial disorder

110

Slide111

Headache attributed to a substance use

or its withdrawal

Headache induced by acute substance use

or

exposure

Nitric

oxide (NO) donor-induced headache

Immediate NO donor-induced headache

Delayed NO donor-headache

Phosphodiesterase

(PDE) inhibitor-induced headache

Carbon

monoxide-induced headache

Alcohol-induced

headache

Immediate alcohol-induced headache

Delayed alcohol-induced headache

111

Slide112

Headache attributed to a substance use

or its withdrawal

Headache induced by food components and additives

Monosodium

glutamate-induced

headach

e

Cocaine-induced

headache

Cannabis-induced

headache

Histamine-induced

headache

Immediate

histamine-induced headache

Delayed

histamine-induced headache

112

Slide113

Headache attributed to a substance use

or its withdrawal

Headache as an acute adverse event attributed to medication used for other indications

Headache induced by other acute substance use or exposure

Medication-overuse

headache (MOH)

Ergotamine-overuse

headache

Triptan

-overuse

headache

Analgesic-overuse

headache

Opioid-overuse

headache

Combination

medication-overuse headache

Headache

attributed to other medication overuse

Probable

medication-overuse headache

113

Slide114

Headache attributed to a substance use

or its withdrawal

Headache as an adverse event attributed to

chronic

medication

Exogenous

hormone-induced headache

Headache attributed to substance withdrawal

Caffeine-withdrawal

headache

Opioid-withdrawal

headache

Oestrogen

-withdrawal

headache

Headache

attributed to withdrawal from chronic use of other

substances

114

Slide115

Headache attributed to infection

Headache attributed to intracranial infection

Headache attributed to bacterial meningitis

Headache attributed to lymphocytic meningitis

Headache attributed to encephalitis

Headache attributed to brain abscess

Headache attributed to subdural empyema

Headache attributed to systemic infection

Headache attributed to systemic bacterial infection

Headache attributed to systemic viral infection

Headache attributed to other systemic infection

115

Slide116

Headache attributed to infection

Headache attributed to HIV/AIDS

Chronic post-infection headache

Chronic post-bacterial meningitis headache

116

Slide117

Headache attributed to disorder of homoeostasis

Headache attributed to hypoxia and/or

hypercapnia

High-altitude

headache

Diving

headache

Sleep

apnoea

headache

Dialysis headache

Headache attributed to hypothyroidism

Headache attributed to fasting

Cardiac

cephalalgia

Headache attributed to other disorder of homoeostasis

117

Slide118

Headache attributed to disorder of homoeostasis

Headache attributed to arterial hypertension

Headache

attributed to

phaeochromocytoma

Headache

attributed to hypertensive crisis without

hypertensiv

e encephalopathy

Headache attributed to hypertensive encephalopathy

Headache attributed to pre-

eclampsia

Headache attributed to

eclampsia

Headache attributed to acute

pressor

response to an exogenous agent

118

Slide119

Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures

Headache

attributed to disorder of cranial bone

Headache attributed to disorder of neck

Cervicogenic

headache

Headache attributed to retropharyngeal tendonitis

Headache attributed to

craniocervical

dystonia

Headache attributed to disorder of eyes

Headache attributed to acute glaucoma

Headache attributed to refractive errors

Headache attributed to

heterophoria

or

heterotropia

Headache attributed to ocular inflammatory disorder

119

Slide120

Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures

Headache

attributed

to disorder of ears

Headache attributed to

rhinosinusitis

Headache attributed to disorder of teeth, jaws or related structures

Headache or facial pain attributed to

temporomandibular

joint disorder

Headache attributed to other disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structures

120

Slide121

Headache attributed to psychiatric disorder

Headache

attributed to

somatisation

disorder

Headache attributed to psychotic disorder

121

Slide122

Cranial neuralgias and central causes of facial pain

Trigeminal neuralgia

Classical trigeminal neuralgia

Symptomatic trigeminal neuralgia

Glossopharyngeal neuralgia

Classical glossopharyngeal neuralgia

Symptomatic glossopharyngeal neuralgia

Nervus

intermedius

neuralgia

Superior laryngeal neuralgia

Nasociliary

neuralgia

Supraorbital neuralgia

122

Slide123

Int

erventional Management for headache

SPHENOPALATINE GANGLION BLOCK

Cluster headache

Sphenopalatine

neuralgia

Migraine

Atypical facial pain

Cancer pain

Herpes zoster

opthalmicus

123

Slide124

Int

erventional Management for headache

2. STELLATE GANGLION BLOCK

Atypical facial pain

Cancer pain of head

124

Slide125

Int

erventional Management for headache

3. OCCIPITAL NERVE BLOCK

Occpital

neuralgia

Tension type headache

Migraine

125

Slide126

Int

erventional Management for headache

4. GASSERIAN GANGLION BLOCK

Trigeminal neuralgia

126

Slide127

Int

erventional Management for headache

5

. SUPRA ORBITAL NERVE BLOCK

Hemicrania

continua

Supraorbital neuralgia

127

Slide128

Int

erventional Management for headache

6

. THIRD OCCIPITAL NERVE BLOCK

Cervicogenic

headache

128

Slide129

Int

erventional Management for headache

7

. OCCIPITAL NERVE STIMULATION

Greater occipital neuralgia

Tension type headache

Whiplash injury

129

Slide130

THANK YOU

Slide131

Familial hemiplegic migraine (FHM)

Migraine with aura

including

motor weakness

and at least one

first- or second-degree relative

has migraine aura including motor weakness

.

Diagnostic criteria:

A. At least 2 attacks fulfilling criteria B and C

B. Aura consisting of fully reversible motor weakness and at least one of the following:

fully reversible visual symptoms

fully reversible sensory symptoms

fully reversible dysphasic speech disturbance

131

Slide132

Familial hemiplegic migraine (FHM)

C. At least two of the following:

at least one aura symptom develops gradually over

5 minutes and/or different aura symptoms occur in succession over

5 minutes

each aura symptom lasts

5 minutes and

<

24hours

headache fulfilling criteria B–D for

Migraine without aura

begins during the aura or follows onset of aura within 60 minutes

D. At least one first- or second-degree relative has had attacks fulfilling these criteria A–E

E. Not attributed to another disorder

132

Slide133

Sporadic hemiplegic migraine

Migraine with aura

including

motor weakness

but

no first- or second-degree relative

has aura including motor weakness

.

Diagnostic criteria:

A. At least 2 attacks fulfilling criteria B and C

B. Aura consisting of fully reversible motor weakness and at least one of the following:

1. fully reversible visual symptoms

2. fully reversible sensory symptoms

3. fully reversible dysphasic speech disturbance

133

Slide134

Sporadic hemiplegic migraine

C. At least two of the following:

1. at least one aura symptom develops gradually over

5 minutes and/or different aura symptoms occur in succession over

5 minutes

2. each aura symptom lasts

5 minutes and

<24 hours

3. headache fulfilling criteria B–D for

Migraine without aura

begins during the aura or follows onset of aura within 60 minutes

D. No first- or second-degree relative has attacks fulfilling these criteria A–E

E. Not attributed to another disorder

134

Slide135

Sporadic hemiplegic migraine

Sporadic cases occur with approximately the same prevalence as familial cases.

More prevalent in males and often associated with transient hemiparesis and aphasia.

Sporadic cases always require neuroimaging and other tests to rule out other cause. A lumbar puncture is also necessary to rule out

pseudomigraine

with temporary neurological symptoms and lymphocytic

pleocytosis

.

135

Slide136

Childhood periodic syndromes that are commonly

precursors of migraine

Cyclical vomiting

Abdominal migraine

Benign paroxysmal vertigo of childhood

136

Slide137

Cyclical vomiting

Description:

Recurrent episodic attacks, usually

stereotypical

in the individual patient, of

vomiting and intense nausea

. Attacks are associated with pallor and lethargy. There is complete resolution of symptoms between attacks.

Diagnostic criteria

:

A. At least 5 attacks fulfilling criteria B and C

B. Episodic attacks, stereotypical in the individual patient, of intense nausea and vomiting lasting from 1 hour to 5 days

C. Vomiting during attacks occurs at least 4 times/hour for at least 1 hour

137

Slide138

Cyclical vomiting

D. Symptom-free between attacks

E. Not attributed to another disorder

Note:

In particular, history and physical examination do not show signs of gastrointestinal disease.

Cyclical vomiting is a self-limiting episodic condition of childhood, with periods of complete normality between episodes.

No pain

138

Slide139

Abdominal migraine

Description:

An idiopathic recurrent disorder seen mainly in children and characterized by

episodic midline abdominal pain

manifesting in attacks lasting

1–72 hours

with normality between episodes. The pain is of moderate to severe intensity and associated with

vasomotor symptoms

, nausea and vomiting.

Diagnostic criteria:

A. At least 5 attacks fulfilling criteria B–D

B. Attacks of abdominal pain lasting 1–72 hours (untreated or unsuccessfully treated)

139

Slide140

Abdominal migraine

C. Abdominal pain has all of the following characteristics:

midline location,

periumbilical

or poorly

localised

dull or ‘just sore’ quality

moderate or severe intensity

D. During abdominal pain at least 2 of the following:

anorexia

nausea

vomiting

pallor

E. Not attributed to another disorder

140

Slide141

Abdominal migraine

In particular, history and physical examination do not show signs of gastrointestinal or renal disease or such disease has been ruled out by appropriate investigations.

Pain is severe enough to interfere with normal daily activities.

Children may find it difficult to distinguish anorexia from nausea. The pallor is often accompanied by dark shadows under the eyes. In a few patients flushing is the predominant vasomotor phenomenon.

Most children with abdominal migraine will develop migraine headache later in life.

141

Slide142

Benign paroxysmal vertigo of childhood

Description

:

This probably heterogeneous disorder is characterized by

recurrent brief episodic attacks of

vertigo occurring without warning and resolving spontaneously

in otherwise healthy children.

Diagnostic criteria:

A. At least 5 attacks fulfilling criterion B

B. Multiple episodes of severe vertigo, occurring without warning and resolving spontaneously after minutes to hours

C. Normal neurological examination and audiometric and vestibular functions between attacks

D. Normal electroencephalogram

142

Slide143

Benign paroxysmal vertigo of childhood

Note:

Often associated with nystagmus or vomiting;

Unilateral throbbing headache may occur in some attacks.

143

Slide144

Retinal migraine

Description:

Repeated attacks of monocular visual disturbance, including scintillations,

scotomata

or blindness, associated with migraine headache.

Diagnostic criteria

:

A. At least 2 attacks fulfilling criteria B and C

B. Fully reversible monocular positive and/or negative visual phenomena (

eg

, scintillations,

scotomata

or blindness) confirmed by examination during an attack or (after proper instruction) by the patient’s drawing of a monocular field defect during an attack

C. Headache fulfilling criteria B–D for

Migraine without aura

begins during the visual symptoms or follows them within 60 minutes

D. Normal ophthalmological examination between attacks

E. Not attributed to another disorder

144

Slide145

Retinal migraine

Appropriate investigations exclude other causes of transient monocular blindness.

Some patients who complain of monocular visual disturbance in fact have hemianopia. Some cases without headache have been reported, but their

migrainous

nature cannot be ascertained.

Other causes of transient monocular blindness (

amaurosis

fugax

), such as optic neuropathy or carotid dissection, must be excluded.

145

Slide146

Paroxysmal hemicrania

Attacks with similar characteristics of pain and associated symptoms and signs to those of cluster headache, but they are shorter-lasting, more

frequent,occur

more commonly in females and respond absolutely to indomethacin.

Diagnostic criteria:

A. At least 20 attacks fulfilling criteria B–D

B. Attacks of severe unilateral orbital, supraorbital or temporal pain lasting 2–30 minutes

146

Slide147

Paroxysmal hemicrania

C. Headache is accompanied by at least one of the following:

1.

ipsilateral

conjunctival

injection and/or lacrimation

2.

ipsilateral

nasal congestion and/or

rhinorrhoea

3.

ipsilateral

eyelid

oedema

4.

ipsilateral

forehead and facial sweating

5.

ipsilateral

miosis

and/or ptosis

D. Attacks have a frequency above 5 per day for more than half of the time, although periods with lower frequency may occur

147

Slide148

Paroxysmal hemicrania

E. Attacks are prevented completely by therapeutic doses of indomethacin

F. Not attributed to another disorder

In order to rule out incomplete response, indomethacin should be used in a dose of

150mg daily orally or rectally, or

100 mg by injection, but for maintenance smaller doses are often sufficient

.

There is no male predominance. Onset is usually in adulthood, although childhood cases are reported. Paroxysmal

hemicrania

with trigeminal neuralgia (CPH-tic syndrome)

148

Slide149

Episodic paroxysmal hemicrania

Attacks of paroxysmal

hemicrania

occurring in periods lasting 7 days to 1 year separated by

painfree

periods lasting 1 month or longer.

Diagnostic criteria:

A. Attacks fulfilling criteria A–F for 3.2

Paroxysmal

hemicrania

B. At least two attack periods lasting 7–365 days , separated by pain-free remission periods of

1 month

149

Slide150

Chronic paroxysmal hemicrania

Attacks of paroxysmal

hemicrania

occurring for more than 1 year without remission or with remissions lasting less than 1 month.

Diagnostic criteria:

A. Attacks fulfilling criteria A–F for

Paroxysmal

hemicrania

B. Attacks recur over

>

1 year without remission periods or with remission periods lasting

<

1 month

150

Slide151

Short-lasting Unilateral Neuralgiform headache

attacks with Conjunctival injection and Tearing

(SUNCT)

This syndrome is

characterised

by

short-lasting attacks of unilateral pain that are much briefer

than those seen in any other TAC and very often accompanied by prominent lacrimation and redness of the

ipsilateral

eye.

Diagnostic criteria:

A. At least 20 attacks fulfilling criteria B–D

B. Attacks of unilateral orbital, supraorbital or temporal stabbing or pulsating pain

lasting 5–240 seconds

C. Pain is accompanied by

ipsilateral

conjunctival

injection and lacrimation

D. Attacks occur with a frequency from

3 to 200 per day

E. Not attributed to another disorder

151

Slide152

(SUNCT)

Patients may be seen with only one of

conjunctival

injection or tearing, or other cranial autonomic symptoms such as nasal congestion,

rhinorrhoea

or eyelid

oedema

may be seen.

The literature suggests that the most common

mimics of SUNCT

are lesions in the posterior

fossa or involving the pituitary gland.

SUNCT with coexistent trigeminal neuralgia

SUNCT with autonomic symptoms-SUNA

152

Slide153

Probable trigeminal autonomic

cephalalgia

Headache attacks that are believed to be a subtype of trigeminal autonomic

cephalalgia

but which do not quite meet the diagnostic criteria for any of the subtypes described above.

Probable cluster headache

Probable paroxysmal hemi crania

Probable SUNCT

153

Slide154

Other primary headaches

Primary stabbing headache

Primary cough headache

Primary

exertional

headache

Primary headache associated with sexual activity

Preorgasmic

headache

Orgasmic headache

Hypnic

headache

Primary thunderclap headache

Hemicrania

continua

New daily-persistent headache (NDPH)

154

Slide155

Contd--

Includes headaches that are clinically heterogeneous. The pathogenesis of these types of headache is still poorly understood, and their treatment is suggested on the basis of anecdotal reports or uncontrolled trials

Several headache disorders included in this chapter can be symptomatic and need careful evaluation by imaging and/or other appropriate tests.

155

Slide156

Primary stabbing headache

Previously used terms:

Ice-pick pains, jabs and jolts,

ophthalmodynia

periodica

Description:

Transient and

localised

stabs of pain in the head that occur spontaneously in the absence of organic disease of underlying structures or of the cranial nerves.

156

Slide157

Primary stabbing headache

Diagnostic criteria:

A. Head pain occurring as a single stab or a series of stabs and fulfilling criteria B–D

B. Exclusively or predominantly felt in the distribution of the first division of the trigeminal nerve (orbit, temple and parietal area)

C. Stabs last for up to a few seconds and recur with irregular frequency ranging from one to many per day

D. No accompanying symptoms

E. Not attributed to another disorder

157

Slide158

Primary stabbing headache

Stabbing pains are more commonly experienced by people subject to migraine (about 40%) or cluster headache (about 30%), in which cases they are felt in the site habitually affected by these headaches.

A positive response to indomethacin has been reported in some uncontrolled studies, whilst others have observed partial or no responses.

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Primary cough headache

Benign cough headache,

Valsalva

-maneuver headache

Description:

Headache precipitated by coughing or straining in the absence of any intracranial disorder.

Diagnostic criteria:

A. Headache fulfilling criteria B and C

B. Sudden onset, lasting from one second to 30 minutes

C. Brought on by and occurring only in association with coughing, straining and/or

Valsalva

maneuver

D. Not attributed to another disorder

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Primary cough headache

Primary cough headache is usually bilateral and predominantly affects patients older than 40 years of age.

Whilst indomethacin is usually effective in the treatment of primary cough headache, a positive response to this medication has also been reported in some symptomatic cases.

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Primary cough headache

Cough headache is symptomatic in about 40% of cases and the large majority of these present with Arnold-

Chiari

malformation type I. Other reported causes of symptomatic cough headache include carotid or

vertebrobasilar

diseases and cerebral aneurysms. Diagnostic neuroimaging plays an important role in differentiating secondary cough headache from

Primary cough headache

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Primary exertional headache

Benign

exertional

headache

Headache precipitated by any form of exercise.

Subforms

such as ‘weight-lifters’ headache’ are

recognised

.

Diagnostic criteria:

A. Pulsating headache fulfilling criteria B and C

B. Lasting from 5 minutes to 48 hours

C. Brought on by and occurring only during or after physical exertion

D. Not attributed to another disorder

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On first occurrence of this headache type it is mandatory to exclude subarachnoid

haemorrhage

and arterial dissection. Primary

exertional

headache occurs particularly in hot weather or at high altitude. There are reports of prevention in some patients by the ingestion of ergotamine tartrate. Indomethacin has been found effective in the majority of the cases.

Headache described in weight-lifters has been considered a

subform

of

Primary

exertional headache

; because of its sudden onset and presumed mechanism it may have more similarities to Primary cough headache.

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Primary headache associated with sexual activity

Benign sex headache, coital

cephalalgia

, benign vascular sexual headache, sexual headache

Headache precipitated by sexual activity, usually starting as a dull bilateral ache as sexual excitement increases and suddenly becoming intense at

orgasm,in

the absence of any intracranial disorder.

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Preorgasmic headache

Diagnostic criteria:

A. Dull ache in the head and neck associated with awareness of neck and/or jaw muscle contraction and fulfilling criterion B

B. Occurs during sexual activity and increases with sexual excitement

C. Not attributed to another disorder

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Orgasmic headache

Postural headache resembling that of low CSF pressure has been reported to develop after coitus. Such headache should be coded as

Headache attributed to spontaneous (or idiopathic) low CSF pressure

because it is due to CSF leakage.

Diagnostic criteria:

A. Sudden severe (‘explosive’) headache fulfilling criterion B

B. Occurs at orgasm

C. Not attributed to another disorder

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Orgasmic headache

On first onset of orgasmic headache it is mandatory to exclude conditions such as subarachnoid

haemorrhage

and arterial dissection.

Two subtypes (

dull type

and

explosive type headache

) were included in the first edition of

The International Classification of Headache Disorders

. Now excluded

No firm data are available on the duration of primary headache associated with sexual activity, but it is usually considered to last from 1 min-3

hr

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Hypnic headache

Hypnic

headache syndrome, ‘alarm clock’ headache

Attacks of dull headache that always awaken the patient from asleep.

Diagnostic criteria:

A. Dull headache fulfilling criteria B–D

B. Develops only during sleep, and awakens patient

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C. At least two of the following characteristics:

1. occurs

>

15 times per month

2. lasts

15 minutes after waking

3. first occurs after age of 50 years

D. No autonomic symptoms and no more than one of nausea, photophobia or

phonophobia

E. Not attributed to another disorder

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Intracranial disorders must be excluded. Distinction from one of the trigeminal autonomic

cephalalgias

is necessary for effective management.

The pain of

hypnic

headache is usually mild to

moderate,but

severe pain is reported by approximately 20% of patients. Pain is bilateral in about two-thirds of cases. The attack usually lasts from 15 to 180 minutes, but longer durations have been described.

Caffeine and lithium have been effective treatments in several reported cases.

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Primary thunderclap headache

Primary cough headache

,

Primary

exertional

headache

and

Primary headache associated with sexual activity

can all present as thunderclap headache but should be diagnosed as those headache types not as

Primary thunderclap headache

.Description:

High-intensity headache of abrupt onset mimicking that of ruptured cerebral aneurysm.

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Diagnostic criteria:

A. Severe head pain fulfilling criteria B and C

B. Both of the following characteristics:

1. sudden onset, reaching maximum intensity in

<

1 min

2. lasting from 1 hour to 10 days

C. Does not recur regularly over subsequent weeks or months

D. Not attributed to another disorder

1. Headache may recur within the first week after onset.

2. Normal CSF and normal brain imaging are required.

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Evidence that thunderclap headache exists as a primary condition is poor: the search for an underlying cause should be exhaustive.

Thunderclap headache is frequently associated with serious vascular intracranial disorders, particularly subarachnoid

haemorrhage

.

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Other conditions including

intracerebral

haemorrhage

, cerebral venous thrombosis,

unruptured

vascular malformation (mostly aneurysm), arterial dissection (intra and

extracranial

), CNS

angiitis, reversible benign CNS angiopathy and pituitary apoplexy. Other organic causes of thunderclap headache are colloid cyst of the third ventricle, CSF hypotension and acute sinusitis (particularly with barotrauma).

Primary thunderclap headache should be the diagnosis only when all organic causes have been excluded.

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Hemicrania continua

Persistent strictly unilateral headache responsive to indomethacin.

Diagnostic criteria:

A. Headache for

>

3 months fulfilling criteria B–D

B. All of the following characteristics:

1. unilateral pain without side-shift

2. daily and continuous, without pain-free periods

3. moderate intensity, but with exacerbations of severe pain

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C. At least one of the following autonomic features occurs during exacerbations and

ipsilateral

to the side of pain:

1.

conjunctival

injection and/or lacrimation

2. nasal congestion and/or

rhinorrhoea

3. ptosis and/or

miosis

D. Complete response to therapeutic doses of indomethacin

E. Not attributed to another disorder

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Hemicrania

continua is usually unremitting, but rare cases of remission are reported. Whether this headache type can be subdivided according to length of history and persistence is yet to be determined

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New daily-persistent headache

De novo

chronic headache; chronic headache with acute onset

Description:

Headache that is daily and unremitting from very soon after onset (within 3 days at most). The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity. There may be photophobia,

phonophobia

or mild nausea.

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Diagnostic criteria:

A. Headache for

>

3 months fulfilling criteria B–D

B. Headache is daily and unremitting from onset or from

<

3 days from onset

C. At least two of the following pain characteristics:

1. bilateral location

2. pressing/tightening (non-pulsating) quality

3. mild or moderate intensity

4. not aggravated by routine physical activity such as walking or climbing stairs

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D. Both of the following:

1. no more than one of photophobia,

phonophobia

or mild nausea

2. neither moderate or severe nausea nor vomiting

E. Not attributed to another disorder

Headache may be unremitting from the moment of onset or very rapidly build up to continuous and unremitting pain. Such onset or rapid development must be clearly recalled and unambiguously described by the patient. Otherwise called as

Chronic tension-type headache

.

180