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HEADACHE for FAMILY MEDICINE
Christopher S Calder MD PhD
Interim Chair Neurology
rofessor UNM Neurology
Conflicts of Interest
I have headaches, literal and figuratively!
I have be an investigator in many clinical trials in the past.
Otherwise no conflicts
Recognize and treat common headache syndromes
Understand basic headache pathophysiology
Gain a knowledge of practical headache management
Primary HA (migraine, tension, others)
Secondary HA (SAH, mass lesions, pressure syndromes, sinus thrombosis)
CONTINUUM: Lifelong Learning in Neurology. 18(4, Headache):823-834, August 2012.
TABLE 6 -1 International Classification of Headache Disorders, Second Edition Diagnostic Criteria for Tension-Type Headachea
A 41-year-old woman began having migraine attacks at the age of 14, shortly after her menarche. Triggers for these attacks included her menses, ovulation, and delaying a meal. One or two days before her attacks she would feel fatigued and yawn excessively. Before some of her more severe episodes she would experience an enlarging visual
with a shimmering edge lasting for 20 to 30 minutes, followed by a unilateral pounding headache with nausea and sometimes vomiting. If she was unsuccessful in treating the attack, it might last 2 to 3 days and she would have to lie in a dark, quiet room. She has learned that treating as soon as possible during a migraine offers her the best chance of success. Her mother had similar attacks as does one of her two daughters. When her obstetrician/gynecologist prescribed an estrogen-containing oral contraceptive she experienced an increase in the frequency and severity of her migraine attacks leading her to stop the medication.
Comment. This patient had the onset of headaches near the time of her menarche. Estrogen is known to stimulate nitric oxide synthase, which results in higher nitric oxide levels. She had other triggers besides her menses and was aware of them. She also had a
of yawning (a hypothalamic phenomenon that cannot be ascribed to a vascular etiology, but rather is dopaminergic). Sometimes she would manifest a visual aura, presumably due to cortical spreading depression traveling across her occipital cortex. Her attacks met ICHD-II criteria for migraine with and without aura. She had learned she would get a better result if she treated early (before central sensitization could occur). As is the case for many women, additional estrogen given as an oral contraceptive worsened her headache tendency; this also often occurs with hormone replacement therapy.
BRAIN TUMOR HEADACHE
As with many other medical conditions, headaches are more common in patients with brain tumors if they have a preexisting primary headache disorder. In 30% of cases involving brain tumor, headache is a major concern, but only 1% of these individuals have headache as the sole clinical manifestation of the tumor. In one study, 5% of those presenting with a brain tumor or another structural neurosurgical disorder presented with headache, and none had headache as the sole concern.1 Individuals with primary headache syndromes commonly experience a change in the preexisting headache, with an increase in frequency, severity, and duration of symptoms. Headaches associated with a brain tumor usually increase upon Valsalva maneuver and exertion (although this also occurs frequently with migraine). Headaches associated with brain tumors may awaken the individual from sleep, but this is also common with cluster headaches and migraines.
Headache (HA) affects 15 to 20% of women and 5 to 10% of men.
Migraine treatment falls into 3 categories: PREVENTIVE; ABORTIVE; and SYMPTOMATIC.
therapy should be offered to patients that have a headache once a week or more. “Low and slow” is the preferred method of starting all these medications. It often takes 1 to 2 months to see an effect. The effect being aimed for is a 50% reduction in HA frequency and/or severity. Since complete relief is not always a realistic goal, abortive and symptomatic medications should also be made available.
The medications that enjoy the best statistical support for efficacy are
, beta-blockers, and valproate. There is also some evidence for Vitamin B2 and, to a lesser extent, magnesium. The evidence for verapamil and gabapentin is relatively poor. We generally try to treat with medications that may address co-morbidities. Valproate should be avoided in women of childbearing age as there is a high risk of spinal
treatments consist of the
and DHE. The method and timing of delivery needs to be very carefully considered (early for
, parenteral if nausea/vomiting). DHE allegedly works at any point in the course of the HA. They may be more effective if taken with metoclopramide and/or a NSAID.
and DHE are CONTRAINDICATED in patients with CAD, history of CVA/TIA, PVD, or if there are substantial risk factors for the same.
ergotamines are also contraindicated in some migraine types such as hemiplegic or basilar migraine.
agents include OTC analgesics, caffeine,
combinations, Compazine, etc.
It must be remembered that frequent use of any of the abortive and symptomatic agents can be responsible for causing drug rebound headache syndromes (DRHA). Even 6 Tylenol a week has been reported to cause DRHA. Opiates cause headaches to become more frequent and to more rapidly develop
. If a patient has daily or near daily HA, a very careful inquiry into OTC medication use and caffeine consumption must be made.
One of the most common referrals we receive is for CDHA. The treatment of this condition is detoxification (usually a slow taper of medication).
Early and aggressive prophylactic treatment of HA is very important in terms of decreasing the morbidity of this disorder.
CGRP: infusion of this precipitates a migraine attack
CGRP monoclonal antibodies
Local anesthetic - sphenopalatine
Indications for Behavioral and Physical Treatments
(a) patient preference for nonpharmacological interventions;
b) poor tolerance for specific pharmacological treatments;
c) medical contraindications for specific pharmacological treatments;
d) insufficient or no response to pharmacological treatment;
e) pregnancy, planned pregnancy, or nursing;
(f) history of long-term, frequent, or excessive use of analgesic or acute medications that can aggravate headache problems (or lead to decreased responsiveness to other pharmacotherapies); g) significant stress or deficient stress-coping skills.
Behavioral and Physical
reduced frequency and severity of headache,
reliance on poorly tolerated or unwanted pharmacotherapies,
personal control of migraine,
headache-related distress and psychological symptoms.
training, biofeedback training, cognitive-behavioral (or stress-management) therapy, hypnosis, and various combinations of these interventions
control muscle tension and those that teach patients to use mental relaxation and/or visual
thermal (hand-warming) and
(EMG) biofeedback training
.psychotherapeutic intervention that had as its primary goal to teach skills for identifying and controlling stress and minimizing the effects of stress.
Results of Behavioral Training
Relaxation training 32% reduction
Hypnotherapy effective vs
Thermal biofeedback 37% improvement
biofeedback plus relaxation 33%
Cognitive-behavioral training and thermal biofeedback 38%
: no clear data to support this
: not superior to sham
: little support for chronic headache; improved frequency severity and disability but not duration
Other Non-pharmacologic Treatments
Hyperbaric O2 – very successful for
long have you had headaches
often do your headaches occur?
week______Days a month3. How long do your headaches usually last?
4. How long does it take from the onset of the headache (the first clear warning that it is going to occur) to its maximum intensity?
5. Are there any triggers for your headaches such as foods (chocolate, nuts, peanut butter, smells, tobacco smoke, red wine, MSG, cured meats,
), activities (exercise or exertion), menstrual cycle, lack of sleep, missed meals, heat or bright light
6.Are your headaches:
B) Squeezing C) Throbbing D) Sharp E)
your headaches in any specific area of your head?
A) One-sided B) Back of head C) Band Like D
) Behind the eyes E) Forehead F) Other
you have any warning symptoms before your headache :
B) Numbness or weakness of part of the body? C) Dizziness
D) Difficulty speaking
E) Visual loss
9. Are there other symptoms that accompany your headaches? Nausea or vomiting B) Sensitivity to light C) Sensitivity to sound D) Passing out E) Loss of or blurring of vision
10.Do your headaches keep you awake? _____Do your headaches wake you up?
_____Get worse with activity?
anything help your headache?
12. Does anyone else in your family have headaches? If so, Who?
you ever had a CT or MRI of your head? YES or
14. Have you ever taken any of these medications?
15. How often do you take Tylenol, aspirin, Excedrin or other over-the-counter preparations?