Headache
ByWael Hamdy Mansy, MD
Assistant Professor of Clinical PharmacyKing Saud University
Classification of headaches
• Primary headaches• OR Idiopathic
headaches
– THE HEADACHE IS ITSELF THE DISEASE
– NO ORGANIC LESION IN THE BEACKGROUND
– TREAT THE HEADACHE!
• Secondary headaches• OR Symptomatic
headaches
– THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER UNDERLYING DISEASE
– TREAT THE UNDERLYING DISEASE!
SECONDARY, SYMPTOMATIC HEADACHES
• THE HEADACHE IS A SYMPTOM OF AN UNDERLYING DISEASE, LIKE– Hypertension– Sinusitis– Glaucoma– Eye strain– Fever– Cervical spondylosis – Anaemia– Temporal arteriitis – Meningitis, encephalitis– Brain tumor, meningeal carcinomatosis– Haemorrhagic stroke…
Primary, idiopathic headaches
• Tension type of headache• Migraine• Cluster headache• Other, rare types of primary headaches
Tension headache
• Renamed tension-type headaches by the International Headache Society in 1988, are the most common type of primary headaches.
• The pain can radiate from the neck, back, eyes, or other muscle groups in the body.
• Tension-type headaches account for nearly 90% of all headaches. Approximately 3% of the population has chronic tension-type headaches
• Tension –type headaches can be episodic or chronic.
• Episodic tension-type headaches occur 15 days a month.
• Chronic tension-type headaches 15 days or more a month for at least 6 months.
• Can last from minutes to days, months or even years, though a typical tension headache lasts 4-6 hs
Cluster headache• Nicknamed "suicide headache", is a neurological
disease that involves an immense degree of pain. • "Cluster" refers to the tendency of
these headaches to occur periodically, with active periods interrupted by spontaneous remissions.
• The cause of the disease is currently unknown. It affects approximately 0.1% of the population, and men are more commonly affected than women
Migraine Headache
Prevalence
• Familial• Young, healthy women; F>M: 3:1– 17 – 18.2% of adult females– 6 – 6.5% adult males
• 2-3rd decade onset… can occur sooner• Peaks ages 22-55.• ½ migraine sufferers not diagnosed.• 94% of patients seen in primary care settings
for headache have migraines
• Common misdiagnoses for migraine:– Sinus Headache (HA)– Stress HA
• Referral to ENT for sinus disease and facial pain.
• The International Headache Society (IHS) classifies migraine headache
• The IHS defines the intensity of pain with a verbal, four-point scale:
Number Pain Annotations
0 NO
1 Mild does not interfere with usual activities
2 Moderate inhibits, but does not wholly prevent usual activities
3 Severe prevents all activities
Migraine Definition• IHS Diagnostic criteria: migraine w/o aura
– HA lasting for 4-72 hrs– HA w/2+ of following:
• Unilateral• Pulsating• Mod/severe intensity.• Aggravated by routine physical
activity.– During HA at least 1 of following
• N/V• Photophobia• Phonophobia
• IHS criteria: Migraine/aura (3 out of 4)– One or more fully reversible aura
symptoms indicates focal cerebral cortical or brainstem dysfunction.
– At least one aura symptom develops gradually over more than 4 minutes.
– No aura symptom lasts more than one hour.
– HA follows aura w/free interval of less than one hour and may begin before or w/aura.
History, PE, Neuro exam show no other organic disease.
At least five attacks occur
Aura Mechanism• Cortical spreading depression
– Self propagating wave of neuronal and glial depolarization across the cortex• Activates trigeminal afferents
– Causes inflammation of pain sensitive meninges that generates HA through central/peripheral reflexes.
• Alters blood-brain barrier.– Associated with a low flow state in the dural sinuses.
• Auras– Vision – most common
neurologic symptom– Paresthesia of lips, lower face
and fingers… 2nd most common
– Typical aura• Flickering uncolored zigzag
line in center and then periphery
• Motor – hand and arm on one side
• Auras (visual, sensory, aphasia) – 1 hr
• Prodrome– Lasts hours to days…
MIGRAINE WITH AURA• DURING AURA: – VASOCONSTRICTION – HYPOPERFUSION
• DURING HEADACHE– VASODILATION– HYPERPERFUSION
BUT: AURA SYMPTOM IS NOT CONSEQUENCE OF VASOCONSTRICTION INDUCED HYPOPERFUSION
CUASE OF THE AURA: SPREADING DEPRESSION. THE VASOCONSTRICTION AND HYPOPERFUSION ARE CONSEQUENCES OF THE SPREADIND DEPRESSION
SPREADING DEPRESSIONAURA
VASOCONSTRICTION, HYPOPERFUSION
IMPORTANT TO KNOW! MIGRAINE WITH AURA
• IS A RISK FACTOR FOR ISCHAEMIC STROKE– THEREFORE PATIENTS SUFFERING FROM MIGRAINE
WITH AURA• SHOULD NOT SMOKE!!!• SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!!
• THE PROPROTION OF PATENT FORAMEN OVALE IN PATIENTS WITH MIGRAINE WITH AURA IS ABOUT 50-55%! (IN THE POPULATION IS ABOUT 25%).
Clinical manifestations
• Clinical manifestations– Lateralized in severe attacks – 60-
70%– Bifrontal/global HA – 30%– Gradual onset with crescendo
pattern.– Limits activity due to its intensity.– Worsened by rapid head motion,
sneezing, straining, constant motion or exertion.
– Focal facial pain, cutaneous allodynia, GI dysfunction, facial flushing, lacrimation, rhinorrhea, nasal congestion and vertigo…
Precipitating factorsstresshead and neck infectionhead trauma/surgeryaged cheesedairyred winenutsshellfishcaffeine withdrawalvasodilatorsperfumes/strong odorsirregular diet/sleeplight
Treatment
• Abortive– Stepped– Stratified– Staged
• Preventive
Abortive Therapy• Reduces headache recurrence.• Alleviation of symptoms.• Analgesics
– Tylenol, opioids…• Antiphlogistics
– NSAIDs• Vasoconstrictors
– Caffeine– Sympathomimetics– Serotoninergics
• Selective - triptans• Nonselective – ergots
• Metoclopramide
Abortive care strategies• Stepped
– Start with lower level drugs, then switch to more specific drugs if symptoms persist or worsen.• Analgesics – Tylenol, NSAIDs…• Vasoconstrictors – sympathomimetics…• Opioids (try to avoid) - Butorphanol• Triptans – sumatriptan (oral, SQ, nasal), naratriptan, rizatripatan,
zomatriptan.– Limited by patient compliance.
• Stratified– Adjusts treatment according to symptom intensity.
• Mild – analgesics, NSAIDs• Moderate – analgesic plus caffeine/sympathomimetic• Severe – opioids, triptans, ergots…
– Severe sx treatment limited due to concomitant GI sx’s.• Staged
– Bases treatment on intensity and time of attacks.– HA diary reviewed with patient.– Medication plan and backup plans.
Preventive therapy• Consider if pt has more than 3-4 episodes/month.• Reduces frequency by 40 – 60%.• Breakthrough headaches easier to abort.• Beta blockers• Amitriptyline• Calcium channel blockers• Lifestyle modification.• Biofeedback.
Botox51% migraineurs treated had
complete prophylaxis for 4.1 months.
38% had prophylaxis for 2.7 months.
Randomized trial showed significant improvement in headache frequency with multiple treatments.
Conclusions
• Migraine is common but unrecognized.• Keep migraine and its variants in the
differential diagnosis.
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