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Hoofdpijn – casuistiek
9 - 10 - 07
Prof. Dr. Koen PaemeleireDr. Phyllis Van Walleghem
Casus 1
34-jarige dame CDH sinds een 2-tal jaarhoofdpijn meest uitgesproken ’s ochtendssporadisch wazig zicht+ 10-tal kgKNO obesitas; bilateraal papiloedeemNMR hersenen inclusief venografie normaal
headache (94%) transient visual obscurations or blurring (68%) pulse synchronous tinnitus (58%) pain behind the eye (44%) double vision (38%) visual loss (30%) pain with eye movement (22%)
AM PM
What are the typical symptoms of IIH?
‘Benigne’ intracraniële hypertensie
Papiloedeem
What causes IIH ?
> women in the childbearing yearsstart or worsen during a period of weight gain
mimics
7.1 Headache attributed tohigh cerebrospinal fluid
pressure
©International Headache Society 2003/4ICHD-II. Cephalalgia 2004; 24 (Suppl 1)
7.1 Headache attributed tohigh cerebrospinal fluid pressure
7.1.1 Headache attributed to idiopathicintracranial hypertension (IIH)
7.1.2 Headache attributed to intracranialhypertension secondary to metabolic, toxic or hormonal causes
7.1.3 Headache attributed to intracranialhypertension secondary to hydrocephalus
7.1.1 Headache attributed to IIH
©International Headache Society 2003/4ICHD-II. Cephalalgia 2004; 24 (Suppl 1)
7.1.1 Headache attributed to IIH
A. Progressive headache with ≥1 of the following characteristics and fulfilling criteria C and D:
1. daily occurrence2.diffuse and/or constant (non-pulsating) pain3.aggravated by coughing or straining
B. Intracranial hypertension
C. Headache develops in close temporal relation to increased intracranial pressure
D.Headache improves after withdrawal of CSF to reduce pressure to 120-170 mm H2O and resolves within 72 h of persistent normalisation of intracranial pressure
7.1.1 Headache attributed to IIH
©International Headache Society 2003/4ICHD-II. Cephalalgia 2004; 24 (Suppl 1)
7.1.1 Headache attributed to IIH
B. Intracranial hypertension fulfilling the following criteria:1. alert patient with neurological examination that either is normal or
demonstrates any of the following abnormalities:a) papilloedemab) enlarged blind spotc) visual field defect (progressive if untreated)d) sixth nerve palsy
2. increased CSF pressure (>200 mm H2O [non-obese], >250 mm H2O [obese]) measured by lumbar puncture in the recumbent position or by epidural or intraventricular pressure monitoring
3. normal CSF chemistry (low CSF protein acceptable) and cellularity4. intracranial diseases (including venous sinus thrombosis) ruled out
by appropriate investigations5. no metabolic, toxic or hormonal cause of intracranial hypertension
Casus 2
42-jarige man acuut opgetreden hoofdpijnklachtenheffen van een boomstronkblanco voorgeschiedenis, FA migraine +5-tal minuten crescendo tot 10/10 discrete nauseaKO: discrete terminale nekstijfheid
Thunderclap headache
Definitie
Ernstige hoofdpijn met plots begin en maximum intensiteit < 1 minuut na beginBij 2/3 ernstige onderliggende pathologie, meest frequent vasculair
SecundairVasculair Subarachnoidale hemorrhagie
Ongeruptureerd aneurysmaIntracerebrale bloedingIschemisch CVACerebrale veneuze sinusthromboseArteriële dissectie (carotis/vertebralis; intra- en extracranieel)CNS angiitisReversibele benigne CNS angiopathieHypofysaire bloeding
Niet-vasculair Colloid cyste derde ventrikel(spontane) LiquorhypotensieAcute sinusitis (in het bijzonder met barotrauma)(Pre-) eclampsiePhaeochromocytomaAcute arteriële hypertensie (oa medicamenteus-geïnduceerd: MAOI)Meningo-encefalitisIntermittente hydrocefalieAcuut glaucomaCervicaal (oa Nervus occipitalis major neuralgie)Idiopathische intracraniële hypertensie
PrimairMet trigger
Primary cough headachePrimary exertional headachePrimary headache associated with sexual activity
Zonder triggerPrimary thunderclap headache (per exclusionem; controversieel)‘Crash’ migraine (per exclusionem)Cluster headache
DD Thunderclap headache
Anamnese en klinisch onderzoek
Labo – infuus
Bij elke patiënt direct 1. CT hersenen A< 12 uur bij niet-traumatische SAH sensitiviteit 98 %2. CT angiografie circulus van Willisbij vermoeden dissectie: CT angiografie halsvaten!3. CT hersenen B 30 % empty delta sign bij CVST
LP - direct bij vermoeden meningo-encefalitis- na ≥ 12 uur tot max 24 uur bij vermoeden SAH als CT negatief
Thunderclap headacheUitwerking op spoedopname
Subarachnoidale bloeding
CT MRA DSA
Casus 3
55-jarige man recidiverende bruuske hoofdpijnklachten Re hemicranieel45-tal minuten tot 2 uur duren frequent ’s ochtends of na het dutten 10/10 zeer ongeduriglacrimatie en ptosis Re oog
Cluster hoofdpijn
Migraine
CTTH
Episodische cluster hoofdpijn
Hersentumor
Tijd (maanden)
0 3 6 9 12
0
2
4
6
8
10
00:00 6:00 12:00 18:00 24:00time
VAS score
pain
inte
nsity
Cluster hoofdpijn
Hypothalamic activation in cluster headache attacks
May et al., Lancet 1998;351:275-278
A. ≥ 5 attacksB. Severe unilateral (supra-)orbital and/or
temporal pain lasting 15-180 minsC. Attacks accompanied by at least one of-
1. Conjunctival injection and/or lacrimation2. Nasal congestion and/or rhinorrhoea3. Eyelid oedema4. Forehead/facial sweating5. Miosis and/or ptosis6. A sense of restlessness or agitation
D. Frequency: 1/2 d - 8/dE. Not attributed to another disorder
Cephalalgia 2004; 24[Suppl 1]: 1-160)
Cluster hoofdpijn
Casus 4
42-jarige damemigraine zonder aura sinds jarenonder controle met topiramaatEcho cor: patent foramen ovale? associatie van PFO en migraine.
Patent foramen ovale en migraine
Prevalence of PFO
17-23% of the population (autopsy)25.6% transoesophageal echo (TEE)
Seib, 1934; Meissner et al, 1999;
PFO and migrainehigh prevalencehigh chance of overlap
PFO and Migraine with Aura
PFO 48% Migraine + auraPFO 23% Migraine – auraPFO 20% Controls
Anzola et al, Neurology, 1999
Migraine with aura higher prevalence of PFOMost likely inherited in a dominant way
PFO closure
Improvement of migraine with aura afterPFO closure can be due to
Spontaneuos course of the disease (age)Placebo effectIntake of aspirinRegression to the mean
PFO closure and Migraine
MIST Analysis
primary endpoint for the complete elimination of headache was not achieved
however using more conventional migraine trial endpoints significant differences were found
MIST 50% Reduction in Headache Days
42
23
0
5
10
15
20
25
30
35
40
45
50
% of patients with 50% reduction
ImplantSham
p=.038
MIST Serious Adverse Events
chest pain
brainstem strokeatrial fibrillation
nose bleedretroperitoneal bleed
anemiapericardial effusion
incision site bleedtamponade
sham groupimplant group
Closure of PFO and Migraine
With two exceptions retrospective dataOne negative randomised trial (missed primary endpoint)
PFO closure: potentially dangerous procedure
Up to now there is no scientific evidence from properly conducted trials that closure of PFO leads to a reduction of migraine frequency that would justify
the risk of the procedure
Casus 5
Wat past niet bij de diagnose van migraine ?
geassocieerde klachten van foto- en fonofobievisuele klachten voor starten van de aanvalrusteloosheidpositieve familiale anamnese voor migraine
A) n ≥≥≥≥ 5
B) 4 - 72 h
C) 1.
2.
3. ++ / +++
4. ����
1. + ֠֠֠֠
2.
2/4
1/2
unilateral
pulsating
photo- & phonophobia
nausea ± vomiting
D)
Cephalalgia (2004), Suppl 1, 24, 1-152
±±±± aura
Diagnostische criteria migraine
Casus 6
Een migraine aura duurt volgens de criteria
<10 min per aura symptoom<1 uur per aura symptoom<1 uur voor alle aura symptomen <24 uur per aura symptoom
Diagnostische criteria aura
1.2.1 Typical aurawith migraine headache
©International Headache Society 2003/4ICHD-II. Cephalalgia 2004; 24 (Suppl 1)
1.2.1 Typical aurawith migraine headache
A. At least 2 attacks fulfilling criteria B–D
B. Aura consisting of ≥1 of the following, but no motorweakness:
1. fully reversible visual symptoms including positive and/or negative features
2. fully reversible sensory symptoms including positive and/or negative features
3. fully reversible dysphasic speech disturbance
1.2.1 Typical aurawith migraine headache
©International Headache Society 2003/4ICHD-II. Cephalalgia 2004; 24 (Suppl 1)
1.2.1 Typical aurawith 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 min and/or different aura symptoms occur in succession over ≥5 min
3. each symptom lasts ≥5 and ≤60 min
D.Headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follows aura within 60 min
E. Not attributed to another disorder
Casus 7
17-jarige jongedame
hoofdpijnaanvallen sinds PO contraceptivumaanvallen 2-tal dagen
kloppende hoofdpijnklachten nausea en braken
sporadisch vooraf visuele klachtenmoeder en tante migraine
blanco voorgeschiedenis
rookt ± 15-tal sigaretten/dag
> MA> Posterior circulatie>Jonge ♀ (< 35-45 jaar)
Overall M RR 3MA RR 4-9M+smoking RR 10M+OC RR 16M+OC+smoking RR 34
Migraine as a risk factor for ischemic stroke
Migraine-roken-pil
Migraine met aura en de pil
Alternatives to COC are recommended forwomen with migraine with aura and additionalrisk factors for stroke (including smoking)
Migraine since COCconsider change to progestogen-only ornonhormonal contraception
Migraine without aura, aura appears: stop COC
Casus 8
50-jarige man hevige hoofdpijnunilateraal kloppend sporadisch nausea en brakenfoto- en fonofobieverhoogde mechanosensitiviteitmedicatie: ASA en ACE-inhibitorvoorgeschiedenis: CABG behandeling
Triptanen en coronair lijden
Contra-indicaties triptanen
angor, AMIcoronaire vaatspasmen (Prinzmetal)ischemische cardiomyopathie
TIA, CVA
Perifere vaataandoeningen
Ongecontroleerde hypertensie
Acute behandeling migraine
Step1: NSAID’s (naproxen, ibuprofen, diclofenac)
Step 2: triptanen
Paracetamolbij contra-indicatie NSAID als step 1zwakke evidentie
Gastroprokineticum
Casus 9
39-jarige manblanco voorgeschiedenis hoofdpijnklachten sinds 2-tal maanddagelijks, voornamelijk naar de avondholocranieelsporadisch discrete nauseana platte bedrust verbetert de hoofdpijnna arthroscopie van de linker kniesporadisch paracetamol of Apranax
Inte
nsite
it
Tijd
0
2
4
6
8
10
00:00 06:00 12:00 18:00 23:55
cm H20
am pm
Liquor hypotensie syndroom
Pachymeningeale aankleuring
MR/CT myelografie - RISA
Casus 10
21-jarige jongedame hevige unilaterale aangezichtspijnkortdurend (seconden), schietend, hevig Re kaak met uitstraling naar de tandenTandheelkundig normaalKNO normaal
Trigeminus neuralgia
Trigeminus neuralgie
Etiologie
Classical: ± vasculaire loopSymptomatic:
multiple sclerosis (2%)RIPvasculair: aneurysma eadental pathology/procedures
Paroxysmale pijn fractie seconde tot 2 minuten
Trigeminaal gebied (> Va,b) Unilateraal Triggers: wassen, scheren, spreken,
poetsen,kauwen, wind, rokenTic douloureuxTendens spontane remissie
Trigeminus neuralgie
NMR hersenen + verloop N trigeminus (CISS) + Gd
Vasculaire loop
Medicamenteuze behandeling:
Carbamazepine ea.
Chirurgische behandeling
Glycerol rhizotomy
Microvasculaire decompressie
Trigeminus neuralgie
Microvasculaire decompressie
Glycerol rhizotomy
Casus 11
Welke bewering is juist over cluster headache ?
verapamil eerste keuze aanvalsbehandelingfrequente positieve familiale anamnese CHeen passagère syndroom van Horner kan aanvallen duren gemiddeld 2- tot 3-tal dagen
Partieel Horner syndroom
Acute behandeling cluster hoofdpijn
Established– Sumatriptan 6 mg SC– Oxygen: 100% @ 7-12 L/min 15-20 min
Short term(methyl)prednisolonemethysergideergotamineGON injectionDHE 1mg 8hrly iv
Long termverapamillithiummethysergideneuromodulators
GabapentinTopiramate
melatoninsurgery
Preventieve behandeling CH
GON infiltratie