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HEADACHEAlina Valdes, M.D.

Substituting for Dr. Valdes is a well know Neurologist.

Dr. Barkoff

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Causes of Headache Irritation of:

pain-sensitive intracranial structures dural sinuses intracranial portions of trigeminal, glossopharyngeal,

vagus, and upper cervical nerves large arteries venous sinuses

Referred pain from muscles, tendons, joints, skin

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Trigeminal nerve systemneurotransmitter serotonin

Insensitive to painbrain parenchymaependymal lining of ventricleschoroid plexus

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Patient History Single most important diagnostic “test” in evaluation Primary headache disorders usually do not arise from

grave underlying diseases Rarity of such grave conditions Large number of patients experiencing headaches

Routine diagnostic testing controversial• <1% of patients of patients with acute headache

and normal neurologic exam have significant abnormalities on CT scan or MRI

• 10-15% of patients with headache and abnormal neurologic symptoms or signs have significant abnormalities on neuroimaging studies

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“POUNDing” headaches Pulsatile

Are the headaches pulsating? One day

Without medication, do the headaches last between 4 and 72 hours?

UnilateralAre the headaches typically unilateral?

NauseaDo you become nauseated?

DisturbingDo the headaches disturb your daily activities?

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Migraine Headaches Clinical Features

Episodic Combination of neurologic, gastrointestinal, and

autonomic changes Physical exam and lab studies usually normal Prevalence: 15% women vs. 7% men Peak ages at onset: adolescence and early adulthood

but may begin in early childhood Onset rare later in life (>50 years old) May be familial

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Classification Migraine without aura

Common migraine Migraine with aura

Classic migraine Complicated migraine

Hemiplegic migraineConfusional migraineOphthalmoplegic migraineBasilar migraine

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Characteristics Migraine auras often precede headache

Focal neurologic symptoms• Visual phenomena: scintillating scotomata

PainOften pulsating, unilateral, and frontotemporal in

distributionInvariably accompanied by anorexia, nausea, and

vomiting Diagnosis requires presence of one of the following,

especially in absence of auraPhotophobiaPhonophobiaOsmophobia

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In children, often associated withEpisodic abdominal painMotion sicknessSleep disturbance

Complicated migraineMajor neurologic dysfunction separate from

visual aura• Hemiplegia• Coma

Neurologic dysfunction outlasts the headache by hours to 1 or 2 days

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Acute headache can reflect serious CNS disease Differential

MigraineClusterStroke

• Subarachnoid hemorrhage• Intracerebral hemorrhage• Cerebral infarction• Arterial dissection (carotid or vertebral)

Acute hydrocephalusMeningitis/encephalitisGiant cell arteritis (often chronic)Tumor (usually chronic)

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Clinical features suggesting structural lesionSymptoms

• Worst of patient’s life• Progressive• Onset > 50 years of age• Worse in early morning – awakens patient• Marked exacerbation with straining• Focal neurologic dysfunction

Signs• Nuchal rigidity• Fever• Papilledema• Pathologic reflexes or reflex asymmetry• Altered state of consciousness

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Etiology Genetic predisposition

Positive family history reported in 65% to 91% of cases

Susceptibility of CNS to certain stimuli Hormonal factors Sequence of neurovascular events

Neurologic phenomena thought to be caused by spasm of cerebral vessels

Pain thought to be caused by subsequent dilatation of extracranial arteries

Evidence that diminished cerebral blood flow accompanies aura

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Treatment Goals

1. Relief of acute attacks

2. Prevention of pain and associated symptoms of recurrent headaches

Headache diary Nonpharmacologic measures

Identify and avoid triggers Diet Sleep habits Stress management

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Pharmacologic measuresSimple analgesics – mild or moderate pain

• Acetaminophen• Aspirin• NSAID’s• Caffeine adjuvant compounds

Antiemetics – nauseaNonspecific treatment – severe pain

• Mixed analgesics• Class III narcotics

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Specific treatment – severe pain• Oral ergotamine• Oral sumatriptan• Oral or rectal neuroleptic• Dihydroergotamine nasal spray

• Subcutaneous sumatriptan• Intramuscular/subcutaneous dihydroergotamine

• Intravenous dihydroergotamine• Intramuscular/intravenous neuroleptic• Intramuscular/intravenous steroid• Parenteral narcotic• Narcotics: butorphanol NS

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PreventionDrugs restricted to patients who have frequent

attacks and willing to take daily medications• Beta – adrenergic receptor blockers:

propranolol, nadolol• Tricyclic antidepressants: amitriptyline• Serotonin reuptake inhibitors: paroxetine,

sertraline• Calcium channel blockers: verapamil• Serotonin antagonists: methysergide• Anticonvulsants: divalproex sodium

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Cluster Headaches

Clinical FeaturesUncommon: <10% of all headachesMuch more common in men than womenMean age of onset later in life than migraineRarely begin in childhoodLess often family historyExtreme intensity

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Characteristics Associated with

Congestion of nasal mucosa and injection of conjunctiva on side of pain

May be associated withIncreased sweating of ipsilateral side of forehead

and faceOcular signs of Horner’s syndrome: miosis, ptosis,

and eyelid edema Pain usually steady, nonthrobbing, and invariably

localized retro-orbitally on one side of head but may occasionally spread to ipsilateral side of face or neck

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Attacks often awake patients, usually 2 to 3 hours after onset of sleep

Pain not relieved by resting in dark, quiet area Patients sometimes seek distracting activity Frequently recur over period of several days or weeks

with headache-free periods of varying duration in between

Precipitated by alcohol, even in small amounts

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Treatment Abortive for acute headache

Oxygen by mask (7 to 10 L/min for 15 minutes) – effective within several minutes in 70% of patients

SumatriptanDihydroergotamine

Prophylactic for preventionLithiumDivalproex sodiumVerapamilMethysergideCorticosteroids

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Tension-Type Headache Characteristics

9 out of 10 primary headachesAffect men and women equallyUsually not throbbing but steady“Pressure feeling” or “vise-like”Usually not unilateralMay be frontal, occipital, or generalizedFrequently pain in neck area, unlike migraine

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Commonly lasts for long periods of timeDoes not rapidly appear and disappear in

attacks Nausea uncommon and mild, if presentNo “aura”Photophobia and phonophobia usually absentMay occur or be exacerbated by emotional

stressMuscle-contraction headache

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TreatmentEvaluate patient’s life situations and presence

of anxiety or depressionTricyclic antidepressants in low doses proven

most useful for preventionAmitriptyline most well documentedNewer agents with fewer side effects

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Other Acute Headache Syndromes Cough headache

Coughing, sneezing, laughing, or bending Increases pressure in head Described as bursting or explosive Lasts seconds to minutes Usually occurs on both sides of head and back or

beneath skull Usually affects people >55 years old 4-to-1 male predominance >50% of people have underlying structural cause so

need MRI

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Monosodium glutamate-induced headache “Chinese restaurant syndrome” Most symptoms begin within 20 to 25 minutes after

consuming MSGChest pressureFace tightening and pressureBurning sensation in chest, neck, or shouldersFacial flushingDizzinessHeadache across front or sides of headAbdominal discomfort

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Exertional headache May be brought on by prolonged physical exercise Throbbing pain, gradually builds in intensity, and

experienced on both sides of head Pain can last from 5 minutes to 24 hours Can be benign or symptomatic of underlying cause

Hangover headache Alcohol increases blood flow to your brain Headaches may be caused by impurities in alcohol or

by-products produced as alcohol metabolized Smoke-filled rooms and lack of sleep can exacerbate

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Ice-cream headacheCold stimulus headacheMore likely to occur if overheated from

exercise or hot temperaturesPain felt in forehead, peaks 25 to 60 seconds

after exposure, and lasts from several seconds to one or two minutes

Experienced by about one-third of people>90% migraine sufferers report sensitivity to

ice cream

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Ice-pick headache “Idiopathic stabbing headache” Produces sudden, brief stabbing sensation anywhere

in scalp or even eye Stab may be isolated or occur repeatedly for a few

days Most common in migraine sufferers Not serious

Hot dog headache Nitrate/nitrite-induced headache

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Sex headache Usually not of concern Men affected more than women May be one of two types

More common• Headache occurs in neck and back of skull• Builds up during intercourse• Believed to be caused by muscle contraction in

head and scalp muscles• Pain goes away quickly with rest

Second type• More severe and sharp• Develops at height of orgasm• Pain usually goes away in minutes

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Swim-goggle headache “External compression headache” Results from pressure on forehead or scalp by band

around head, tight hat or goggles Pain constant but relieved by removing goggles or

headband Thunder-clap headache

Occurs so suddenly patient feels like hit on head Most cases not serious May indicate rapid onset of migraine Rarely caused by aneurysm or bleeding inside head

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Post-traumatic headache Often occurs after head injury Frequency and severity of headache usually

diminishes in 6 to 12 months Loss of consciousness (concussion) or start of

headache after head injury should be evaluated Little relationship between severity of trauma and

intensity of headache Causes

Scar formation in scalpRuptured blood vessels causing hematoma – can

be drained

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Rebound headacheOccurs with overuse of pain reliever or

migraine-specific medication for headacheWhen effect of medication wears off, pain

returns with more severity Occurs daily or nearly dailyBody unable to respond to treatments that can

prevent subsequent migrainesVary in intensity, timing, and locationMust wean patient from pain medication but

worsening of symptoms initially occurs

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Orthostatic headacheOccurs when stand up and relieved by laying

downSubsides within a minute or two of recliningMost common after spinal tap or spinal

anesthesiaUsually lasts few days and subsides

spontaneously

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Headache Secondary to Structural Brain Disease

Cerebrovascular disease Ischemic stroke Intracerebral hemorrhage Subarachnoid hemorrhage

Inflammatory disease Cranial arteritis Isolated central nervous system vasculitis Tolosa-hunt syndrome Systemic lupus erythematosus

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Infectious diseaseMeningitisAbscessEncephalitisSinusitis

Post-traumaticSubdural hematomaEmpyema

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Neoplastic diseaseMalignant brain tumorMetastasis

Other Idiopathic intracranial hypertension

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Headache and Acute Sinusitis Head pain most prominent feature Malaise and low-grade fever Dull, aching, nonpulsatile pain Exacerbated by movement, coughing, or

straining Improved with nasal decongestants Pain most pronounced on awakening or after

prolonged recumbency Pain diminished with upright posture

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Maxillary sinusitis Ipsilateral, malar, ear, and dental pain

Frontal sinusitisFrontal headache that may radiate behind eyes

and to vertex of skullTenderness to palpation with point tenderness

on undersurface of medial aspect of superior orbital rim

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Ethmoidal sinusitisPain between or behind eyes with radiation to

temporal areaEyes and orbit often tender to palpationEye movements may accentuate pain

Sphenoidal sinusitisPain in the orbit and vertex of skull and

occasionally in frontal or occipital regions Chronic sinusitis

Seldom cause of headache

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Headache and Brain Tumors Posterior fossa tumors, especially cerebellar

Usually with hydrocephalus because CSF flow partially obstructed

Supratentorial tumors less likely More frequently have altrered mental status, focal

deficiencies, or seizures Increased intracranial pressure often associated

Usually not primary mechanism as uniform increases in pressure not distort pain-sensitive structures

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Headache and Idiopathic Intracranial Hypertension

Also called benign intracranial hypertension Elevated intracranial pressure without evidence

of focal lesions, hydrocephalus, or frank brain edema

Occurs usually between ages 15 and 45 More frequent in obese women Characterized by headache – usually insidious in

onset, typically generalized, mild in severity, often worse in morning or after exertion

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Occasionally have visual disturbances – may lead to visual loss, including blindness

Fundoscopic exam shows papilledema Has been associated with drugs, corticosteroid

withdrawal, and systemic disorders CT usually normal – can show small ventricles CSF opening pressure elevated – 250 to 450 mm

Hg

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Treatment Eliminate secondary causes first Dietary counseling for weight loss Carbonic anhydrase inhibitors (acetazolamide) and

corticosteroids for headache control Furosemide to lower CSF production second-line Serial lumbar punctures – unpopular with patients CSF shunting – ventriculoperitoneal shunt Optic nerve sheath fenestration for patients with

progressive visual loss

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Post-traumatic Headache Associated with irritability, concentration

impairment, insomnia, memory disturbance, and light-headedness

Anxiety and depression present Treatment

AmitriptylineNSAID’sMuscle relaxantsAnxiolytics

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Headache and Giant Cell Arteritis Over 60% of patients have headaches Granulomatous vasculitis of medium and large

arteries More than 95% of patients >50 years old Malaise, fever, weight loss, and jaw claudication Polymyalgia rheumatica (painful stiffness in

neck, shoulders, and pelvis) found in half of patients

Visual impairment from ischemic optic neuritis

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Headache aching, worse at night and after exposure to cold

Superficial temporal artery frequently swollen, red, and very tender and may be pulseless

ESR usually elevated – mean 100 mm/hr Anemia frequent Temporal artery biopsy – disease segmental so

may miss Prednisone therapy – dramatically effective but

must be given promptly to preserve vision on affected side

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Headache in Systemic Disease Endocrine/metabolic

Malignant hypertension (e.g., pheochromocytoma) Acromegaly Cushing’s disease Carcinoid Hyperparathyroidism Paget’s disease

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PulmonaryHypercapneaSleep apnea

PharmacologicAlcoholNitratesCaffeine withdrawalAnalgesic withdrawal (“rebound”) headacheOthers: dipyridamole, cyclosporine,

tacrolimus, calcium channel antagonists

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Cranial Neuralgias Trigeminal neuralgia

Stabbing, spasmodic pain unilaterally in one of divisions of trigeminal nerve

Lasts seconds but may occur many times in day for weeks at a time

Induced by lightest touch to particular areas of face May be life threatening if interferes with eating If medical treatments unsuccessful (anticonvulsants),

may need surgical procedure to ablate sensory portion of nerve

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Glossopharyngeal neuralgiaRareBrief paroxysms of severe stabbing unilateral

pain radiate from throat to ear or vice versaFrequently initiated by stimulation of “trigger

zones” (e.g., tonsillar fossa or pharyngeal wall)

Swallowing occasionally provokes, as can yawning, talking, and coughing

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Postherpetic neuralgia Herpes zoster produces pain by involving cranial

nerves in one third of cases Persistent intense burning pain may follow acute

illness Discomfort may subside after several weeks or

persist for months or years Pain localized over distribution of affected nerve and

associated with exquisite tenderness to light touch First division of trigeminal nerve most frequently

involved – occasionally associated with keratoconjunctivitis

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Occipital neuralgia Occipital pain starting at base of skull Often provoked by neck extension Tenderness in region of occipital nerves Altered sensation in C2 dermatome Treatment

Use of soft collarMuscle relaxantsPhysical therapyLocal injection of analgesics and anti-inflammatory

agents

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Reflex Sympathetic Dystrophy

Pain and hyperesthesia and autonomic changes Any type of injury can cause Often associated with marked behavioral changes Diagnosis primarily clinical – patient’s history

and physical exam No specific diagnostic tests

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Symptoms usually develop gradually over days or weeks and divided into three stages Acute stage

Spontaneous aching or burning pain restricted to particular vascular, peripheral nerve, or root territory

Hyperpathia (pain characterized by overreaction and “aftersensation” to stimulus) and dysesthesia

Dystrophic stage Usually begins 3 to 6 months after injury Spontaneous burning pain and more marked hyperpathia Nails cracked, grooved, or ridged ,and hair growth

decreased Decreased range of joint motion, muscle wasting,

osteoporosis, and edema

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AtrophyUsually occurs more than 6 months after injuryPain less prominentSkin cold, pale, and cyanotic with increased or

decreased sweatingIrreversible trophic changes in skin and

subcutaneous tissues – smooth, glossy skin, with subcutaneous atrophy, tapering of digits, and fixed joints with contractures

Mainstay of treatment – sympathetic blockade Anti-inflammatory agents and amitriptyline may be

useful in chronic burning pain Anticonvulsants may relieve episodic allodynia

(ordinarily nonpainful stimuli evoke pain)

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Headache: Guide to Treatment

Rest, heat or ice packs, or a long, hot shower Over-the-counter pain reliever, such as aspirin,

acetaminophen or ibuprofen - minimal dose needed to relieve pain, only when necessary - overuse may cause chronic daily headaches.

Finding the right medication may take a period of trial and error

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Headache medications fall into two broad categories:abortive drugs to stop or reduce pain after

a headache startsprophylactic drugs to prevent headaches.

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Abortive medications serotonin agonists: work by influencing the behavior

of serotonin, a nerve chemical that plays a key role in causing headaches

triptans – among most effective; able to target specific serotonin receptors in the brain; generally used for migraine and cluster headaches; not been proven effective for tension headaches; manufactured in a variety of forms, so options for people who experience nausea with headaches or not able to swallow pills• Sumatriptan (Imitrex) — effect lasts only

about 5 hours; best for stopping severe migraines; available by tablet, nasal spray, and injection

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• Zolmitriptan (Zomig) — very similar to sumatriptan; tends to work faster; also effective in significant percentage of people for whom sumatriptan does not provide adequate relief

• Naratriptan (Amerge) — geared toward people with prolonged headaches and frequent recurrences; longer lasting effect than sumatriptan

• Rizatriptan (Maxalt) — relieves headaches more quickly than sumatriptan

Vasoconstrictors — work by preventing blood vessels from swelling

Ergotamine tartrate (Cafergot, Wigraine, Ergostat) Dihydroergotamine – available as subcutaneous injection

(DHE-45) and nasal spray (Migranol)

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Lidocaine nasal drops — may provide short-term relief as anesthetic on nerves in nasal passages. It can ease pain within 5 minutes, but relief usually does not last more than 1 hour.

Excedrin Migraine — same formula as Excedrin Extra Strength but received FDA approval as a migraine drug after showed effectiveness against migraines in clinical trials.

Aspirin and other NSAIDS — Nonsteroidal anti-inflammatories, available as over-the-counter medications (ibuprofen — Aleve, Motrin, Advil) or by prescription can be very useful for the treatment of mild to moderate tension-type and migraine headaches.

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Prophylactic medications: prevent headaches from starting or reduce frequency and severity Antidepressants

Tricyclic antidepressants – the most common of these drugs; also may ease headache by affecting serotonin levels; depression also linked to serotonin activity

Serotonin antagonistsCyproheptadine – more commonly used for

childhood migraineMethysergide – used for prevention of both

migraine and cluster headache; rare but potentially serious side effects when used continually for longer than 6 months

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Cardiovascular drugsBeta-blockers and calcium channel blockers

Anti-seizure drugsValproic acid (Depakote) can prevent migraines

Riboflavin (vitamin B2) High dose (400 milligrams of riboflavin per day)

may prevent migrainesMay correct small deficiencies of B2 in the brain

cells of some people with migraines Magnesium

Infusions of magnesium relieve headache pain in some people who suffer from migraine

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Neck and Back Pain Most patients with acute pain have self-limiting

musculoskeletal disorder – not need specific therapy

Pain may come fromVertebrae and intervertebral discsFacet jointsMuscles and ligaments of vertebral column

Thoracic spine made for rigidity rather than mobility so disc rupture rare

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Cervical Spondylosis Degenerative disorder of cervical intervertebral

discs Hypertrophy of adjacent facet joints and

ligaments Most common pathology seen in neuro office Seen on X-ray in > 90% of population over 60

y.o. Degree of anatomic abnormality not directly

correlated with clinical signs and symptoms

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Clinical disease Normal age-related, degenerative changes with

congenital/developmental stenosis of cervical canal May be aggravated by trauma May present as painful, stiff neck with/without

cervical root irritation or spinal cord compressionWith root irritation have pain and paresthesias

down arm in dermatomal distribution – symptoms more common than discrete sensory loss

With spinal cord compression present with gait and bladder problems and evidence of spasticity in lower extremities – require investigation with imaging study like MRI or CT myelography

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Differential diagnosis Multiple sclerosis Amyotrophic lateral sclerosis Subacute combined system disease (B12 deficiency)

Treatment Anti-inflammatory meds Cervical immobilization Physical therapy for strengthening neck muscles Surgery if progression of neuro deficit

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Acute Low Back Pain Lumbar canal stenosis from intervertebral disc disease

and degenerative spondylosis will affect roots of cauda equina Most common levels affected are L4-5 and L5-S1

Complain of sciatica Pain improves by sitting or lying down

Vs. spinal or vertebral tumors, where pain worsened

Loss of normal lumbar lordosis, paraspinal muscle spasm, worsening of pain with straight-leg raising

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“Neurogenic claudication” Unilateral or bilateral buttock pain worse on standing

or walking and relieved by rest or flexion at waist Pain may worsen walking downhill

Treatment Short period of rest Muscle relaxants Analgesics Proper posture and back exercises Physical therapy Surgery only if neuro signs or pathology seen on

imaging studies