Headache

Introduction to Clinical Neurology

Daniel Lowenstein, MD Andy Josephson, MD

Wade Smith, MD, PhD

Dan Lowenstein, MD

Potential Conflicts of Interest ! None

Robert B. and Ellinor Aird Professor of Neurology

Director, UCSF Epilepsy Center

Department of Neurology, UCSF School of Medicine

Learning Objectives

Learning Objectives

o Describe the major clinical features of migraine, tension headache, cluster headache, and trigeminal neuralgia.

o Explain the principles of acute and prophylactic therapy for primary headache disorders.

o Describe the clinical features of the worrisome headache.

o Describe the presentation and acute therapeutic considerations for patients with giant cell (temporal) arteritis, tumor-associated headache with intracranial hypertension, and subarachnoid hemorrhage.

Introduction

The t reatment of headache in 1200 BC

Cartoon(drawn(by(P.(Cunningham,((from(Lance,(Mechanism*and*Management**of*Headache,(Bu:erworths,(1982(

o Global prevalence among adults of current headache disorder (symptomatic at least once within the last year) is 47%.

o Half to three quarters of the adults aged 1865 years in the world have had headache in the last year and among those individuals, more than 10% have reported migraine.

o Headache on 15 or more days every month affects 1.74% of the worlds adult population.

o Despite regional variations, headache disorders are a worldwide problem, affecting people of all ages, races, income levels and geographical areas.

From the Wor ld Heal th Organizat ion (2012)

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The most important quest ion of al l !

New Old

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Migraine Tension-type Cluster Trigeminal neuralgia

Tumor-associated Giant cell (temporal) arteritis Subarachnoid hemorrhage

Primary Headache Disorders

Secondary Headache Disorders

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Primary Headache Disorders

hemicrania hemicranium

hemigranea migranea

mygrame migraine

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o Visual disturbances or other focal symptoms o Hemicranial, throbbing, or dull/deep headache o Nausea and vomiting o Photophobia o Sensitivity to noise o Positive family history

Typical cl inical features of (classic) migraine with aura

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Migraine

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Timel ine of migra ine and c lues to pathogenesis ( f r o m A n d r e w C h a r l e s , M D , D a v i d G e f f e n S c h o o l o f M e d i c i n e a t U C L A )

Premonitory( Aura( Postdrome(Headache(

Yawning(Polyuria(

Neck(Pain(FaGgue ((Mood(change((Light(sensiGvity(Sound(sensiGvity(

Visual(symptoms(Sensory(symptoms(Language(symptoms(CogniGve(symptoms(

Nausea(

Headache(

Cutaneous(allodynia(

Hypothalamus(Brainstem(Cortex(

Cortex( Brainstem(Thalamus(Hypothalamus(

Cortex(Thalamus(Hypothalamus(

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((

Pain pathways in migraine

Dura(

Trigeminal(ganglion(

Meningeal(blood(vessel(

Peri!aqueductal(gray(

Upper(cervical(nerve(roots(

Trigeminal(cervical((complex(

Thalamus(

Pain(Matrix(

Andrew Charles, MD - UCLA(

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o Throbbing or dull/deep headache o Nausea and vomiting o Photophobia o Sensitivity to noise o Positive family history

Typical cl inical features of (common) migraine without aura

Diagnostic criteria for migraine ( I n t e r n a t i o n a l H e a d a c h e S o c i e t y - 2 0 0 5 )

A. At least 5 attacks B. Attack lasts 4-72h C. At least 2 of the following:

Unilateral Pulsating Moderate or severe intensity Aggravation by or avoidance of routine activity

D. Accompanied by at least two of the following: Nausea Vomiting Photophobia Phonophobia Osmophobia

E. Not attributed to another disorder

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o Stress o Menstruation o Oral contraceptives o Glare o Physical exertion, fatigue o Lack of sleep o Hunger o Foods and beverages containing nitrite, glutamate, salt,

tyramine, etc. o Medications

Migra ine therapy: Ident i f ica t ion of prec ip i tants

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Medical therapy of migraine "

Abortive! Prophylactic!Ergots"NSAIDs"B-blockers"Tricyclic antidepressants"Ca++ channel blockers"Anticonvulsants"and more...""

Aspirin "NSAIDs"Ergots"Triptan drugs:" Rizatriptan" Zolmitriptan" Almotriptan" Frovatriptan" Sumatriptan "

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Tension-type Headache

( I n t e r n a t i o n a l H e a d a c h e S o c i e t y - 2 0 0 5 ) A. Headache lasting from 30min to 7days

(may be episodic or chronic) B. At least 3 of the following:

Bilateral Pressing/tightening (non-pulsating) quality Mild or moderate intensity Not aggravated by routine physical activity

C. No nausea, vomiting, photophobia or phonophobia D. Not attributed to another disorder

Treatment: Stress(management,(counseling,(ASA,(NSAIDs,(biofeedback,(and((occ.)(anGdepressants(or(anxiolyGcs( !

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o Usually males, age 20-50 o Unilateral, periorbital pain o Circadian rhythmicity o Unilateral autonomic symptoms o Alcohol sensitivity o Clustering of attacks

Clinical features of cluster headache

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Cluster

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o Triptans o Prednisone o Ca++ channel blockers o Ergots o Oxygen o Lidocaine o Lithium

Medical therapy of cluster headaches

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Trigeminal neuralgia

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o Electric shock-like, staccato volleys of pain o Presence of trigger sites o Unilateral pain, V2/V3 >>> V1 o No other neurologic deficit

Clinical features of t r igeminal neuralgia ( t ic douloureux)

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Therapy of trigeminal neuralgia

o Carbamazepine o Lamotrigine o Valproate o Amitriptyline

o Decompression of vessel over the nerve

o Selective ablation

Medical

Surgical

*(

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Secondary Headache Disorders

First, worst, abrupt Onset age > 50 In setting of major medical illness Worse in AM or with Valsalva Nausea and vomiting Awakens from sleep Trauma or neurosurgery Progressive Seizure LOC Fever Stiff neck Abnormal neuro exam

Features of the WorrisomeHeadache

o Dull, non-throbbing o Intermittent but slowly increasing o Worsened by exertion or change in posture o Disturbs sleep o Associated with nausea and vomiting

Tumor-associated headache

Tumor-associated headache

Cl in ica l fea tures of g iant ce l l ( tempora l ) a r ter i t is

F > M, age 50-85 (average 70)

Headache Temporal artery tenderness Jaw claudication Thickened or nodular temporal artery Visual symptoms Polymyalgia rheumatica ESR > 50mm/hr Hematocrit < 35% Abnormal liver function

85% 70 65 45 40 40 95 50 50

Giant cell (temporal) arterit is

Treatment of giant cel l ( temporal) arter i t is

(for now)

Clinical features of subarachnoid hemorrhage

o Sudden, explosive, excruciating headache o Neck stiffness o Vomiting o Changing level of consciousness

Subarachnoid hemorrhage

"

Subhyaloid hemorrhage

Suspect SAH

I must do LP

Yet CT is negative

o Intubate and hyperventilate (pCO2 = 25) o Osmotic agents o Raise head of bed o Limit IV fluids o Call a consultant (neurologist,

neurosurgeon, or neurointerventionalist)

Management of raised ICP

Summary

Migraine Headaches" Cluster headache" Trigeminal neuralgia"

Subarachnoid "Tumor"Giant cell (temporal)" arteritis"