HEADACHE for FAMILY  MEDICINE
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HEADACHE for FAMILY MEDICINE

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HEADACHE for FAMILY MEDICINE




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Presentation on theme: "HEADACHE for FAMILY MEDICINE"— Presentation transcript:

Slide1

HEADACHE for FAMILY MEDICINE

Christopher S Calder MD PhD

Interim Chair Neurology

Associate

P

rofessor UNM Neurology

Slide2

Conflicts of Interest

I have headaches, literal and figuratively!

I have be an investigator in many clinical trials in the past.

Otherwise no conflicts

Slide3

OBJECTIVES

Recognize and treat common headache syndromes

Understand basic headache pathophysiology

Gain a knowledge of practical headache management

Slide4

Slide5

Headache categories

Primary HA (migraine, tension, others)

Secondary HA (SAH, mass lesions, pressure syndromes, sinus thrombosis)

Slide6

© 2012 American Academy of Neurology. Published by LWW_American Academy of Neurology.

2

TABLE 6

Tension-Type Headache.

Kaniecki, Robert

CONTINUUM: Lifelong Learning in Neurology. 18(4, Headache):823-834, August 2012.

DOI: 10.1212/01.CON.0000418645.32032.32

TABLE 6 -2 Red Flags for Secondary Headache Disorders

Red Flags for Secondary Headache Disorders.

Slide7

HEADACHES of MASS

LESIONS

Brain abscess

– fever in <50%

- focal HA

- seizures

- impaired sensorium

Subdural hematoma 80% have HA and also sensorium alteredBrain Tumor HA more common if prior 1 HA, but only 1% have HA as sole manifestation. Inc w Valsalva; awaken from sleep

Only 5% of structural lesions have HA and none of these were sole concern

Slide8

Slide9

© 2012 American Academy of Neurology. Published by LWW_American Academy of Neurology.

2

TABLE 1

Migraine Diagnosis and Pathophysiology.

Ward, Thomas; MD, FAAN

CONTINUUM: Lifelong Learning in Neurology. 18(4, Headache):753-763, August 2012.

DOI: 10.1212/01.CON.0000418640.07405.31

TABLE 1 -1 Migraine Without Auraa

Slide10

© 2012 American Academy of Neurology. Published by LWW_American Academy of Neurology.

2

TABLE 1

Migraine Diagnosis and Pathophysiology.

Ward, Thomas; MD, FAAN

CONTINUUM: Lifelong Learning in Neurology. 18(4, Headache):753-763, August 2012.

DOI: 10.1212/01.CON.0000418640.07405.31

TABLE 1 -2 Typical Aura With Migraine Headachea

Slide11

Slide12

Slide13

Slide14

© 2012 American Academy of Neurology. Published by LWW_American Academy of Neurology.

2

TABLE 6

Tension-Type Headache.

Kaniecki, Robert

CONTINUUM: Lifelong Learning in Neurology. 18(4, Headache):823-834, August 2012.

DOI: 10.1212/01.CON.0000418645.32032.32

TABLE 6 -1 International Classification of Headache Disorders, Second Edition Diagnostic Criteria for Tension-Type Headachea

Slide15

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

scotoma

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.

Slide16

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

prodrome

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.

Slide17

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.

Slide18

IDIOPATHIC INTRACRANIAL HYPERTENSION

Same as brain tumor HA

Imaging normal, may show empty

sella

/flattening of globes

etc

LP pressure elevated.

Rx with acetazolamide/weight loss etc.

LP shunt

Can lead to visual loss

Slide19

OTHER HA DISORDERS

Temporal arteritis

Chronic meningitis

Cluster

Ice pick

Hemicrania

continua

Orthostatic HA (LP< POTS)

Exertional HA –cough/coital/cardiac

Sinus thrombosis/dissection

PosttraumaticSinus (don’t upset me…)Pituitary apoplexy

Slide20

Slide21

Headache Management

Headache (HA) affects 15 to 20% of women and 5 to 10% of men.

Migraine treatment falls into 3 categories: PREVENTIVE; ABORTIVE; and SYMPTOMATIC.

Slide22

Slide23

Preventive

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.

Slide24

Slide25

Slide26

The medications that enjoy the best statistical support for efficacy are

tricyclics

,

topiramate

, 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

dysraphism

.

Slide27

Abortive

treatments consist of the

triptans

and DHE. The method and timing of delivery needs to be very carefully considered (early for

triptans

, 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.

Triptans

and DHE are CONTRAINDICATED in patients with CAD, history of CVA/TIA, PVD, or if there are substantial risk factors for the same.

Triptans

and

ergotamines are also contraindicated in some migraine types such as hemiplegic or basilar migraine.

Slide28

Symptomatic

agents include OTC analgesics, caffeine,

butalbital

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

allodynia

. If a patient has daily or near daily HA, a very careful inquiry into OTC medication use and caffeine consumption must be made.

Slide29

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.

Botox

Slide30

Slide31

Upcoming/New treatments

CGRP: infusion of this precipitates a migraine attack

CGRP antagonists

CGRP monoclonal antibodies

TMS

Cefaly

Headband

Local anesthetic - sphenopalatine

Slide32

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.

Slide33

Behavioral and Physical

Treatment Goals

reduced frequency and severity of headache,

reduced

headache-related disability,

reduced

reliance on poorly tolerated or unwanted pharmacotherapies,

enhanced

personal control of migraine,

reduced

headache-related distress and psychological symptoms.

Slide34

Behavioral Treatments

Relaxation

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

imagery

standard

thermal (hand-warming) and

electromyographic

(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.

Slide35

Results of Behavioral Training

Relaxation training 32% reduction

Hypnotherapy effective vs

prochlorperazine

Thermal biofeedback 37% improvement

Thermal

biofeedback plus relaxation 33%

reduciton

EMG biofeedback

therapy 40%

Cognitive-behavioral training and thermal biofeedback 38%

Slide36

Physical Treatments

Acupuncture

: no clear data to support this

TENS:

little support

Occlusal adjustment

: not superior to sham

Cervical manipulation

: little support for chronic headache; improved frequency severity and disability but not duration

Slide37

Other Non-pharmacologic Treatments

Hyperbaric O2 – very successful for

acute

migraine

Slide38

Headache Questionnaire

How

long have you had headaches

?

2. How

often do your headaches occur?

_____

Daily____Weekly_____Days

a

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?

Slide39

5. Are there any triggers for your headaches such as foods (chocolate, nuts, peanut butter, smells, tobacco smoke, red wine, MSG, cured meats,

Nutrasweet

), activities (exercise or exertion), menstrual cycle, lack of sleep, missed meals, heat or bright light

?

6.Are your headaches:

Steady

B) Squeezing C) Throbbing D) Sharp E)

Stabbing

7. Are

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

Slide40

8

. Do

you have any warning symptoms before your headache :

Flashing Lights

B) Numbness or weakness of part of the body? C) Dizziness

D) Difficulty speaking

E) Visual loss

F) Other

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?

Slide41

11. Does

anything help your headache?

12. Does anyone else in your family have headaches? If so, Who?

Have

you ever had a CT or MRI of your head? YES or

NO

14. Have you ever taken any of these medications?

 

Now

Ever

Any

Help?

Side

Effects

Amitriptyline/Elavil

 

 

 

 

Nortriptyline/Pamelor

 

 

 

 

lnderal/Propanolol

 

 

 

 

Depakote

 

 

 

 

Verapamil/Cardizem

 

 

 

 

lmitrex/Maxalt/Zomig

 

 

 

 

Ergotamine

 

 

 

 

DHE-45/Migranal

 

 

 

 

Fioricet/Fiorinal/Butalbital

 

 

 

 

Sansert

 

 

 

 

Topamax

 

 

 

 

Amerge

 

 

 

 

Tylenol/Ibuprofen/

Alieve

 

 

 

 

Slide42

15. How often do you take Tylenol, aspirin, Excedrin or other over-the-counter preparations?

16. How

much caffeinated coffee/tea/soda do you drink?

17. Describe

your typical sleep habits

.