Classification of headaches

Primary headaches Secondary headaches OR Idiopathic headaches OR Symptomatic headaches

THE HEADACHE IS ITSELF THE DISEASE NO ORGANIC LESION IN THE BEACKGROUND TREAT THE HEADACHE! THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER UNDERLYING DISEASE TREAT THE UNDERLYING DISEASE!

HISTORY AND EXAMINATIONS SHOULD CLARIFY IF

THE PATIENT HAS PRIMARY OR SECONDARY HEADACHE IS THERE ANY URGENCY IN CASE OF PRIMARY HEADACHE ONLY THE HEADACHE ATTACKS SHOULD BE TREATED (ATTACK THERAPY), OR PROPHYLACTIC THERAPY IS ALSO NECESSARY (PREVENTIVE THERAPY, INTERVAL THERAPY)

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

 Secondary headache disorders

Headache attributed to ... 5. head and/or neck trauma 6. cranial or cervical vascular disorder 7. non-vascular intracranial disorder 8. a substance or its withdrawal 9. infection 10. disorder of homoeostasis 11. disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures 12. psychiatric disorder 13. cranial neuralgias and central causes of facial pain

Primary, idiopathic headaches

Tension type of headache Migraine Cluster headache Other, rare types of primary headaches

Treatment of tension type of headache

Acute, episodic form: NSAID drugs, 500-1000 mg ASA, paracetamol, or noraminophenazon Indication of prophylactic treatment: tension type of headache in at least 14 days per moth

Prophylactic treatment of the chronic tension type of headache

Tricyclic antidepressants Guidelines:
Start with low dose (10-25 mg) and increase the dose if no beneficial effect after 1-2 weeks Maximal dose should not be more than 75 mg/day Change to other tricyclic antidepressant only after 6-8 weeks Ask the patient to use headache diary Use the tricyclic antidepressant for 6-9 months Decrease the dose gradually

Prophylactic treatment of the chronic tension type of headache

First choice of drug: amitryptiline (Teperin tabl, 25 mg)
1st week: 25 mg in the evening 2nd week: 50 mg in the evening 3rd week: 75 mg in the evening continuously Change to other drug (e.g. clomipramine) if no beneficial effect within 6 weeks

Common side effects of tricyclic antidepressants

Anticholinergic side effects:
Dry mouth Increased pulse rate Urinary retention (in prostate hyperplasia!!!) Increased intraocular pressure (glaucoma!!!)

Sleepiness or hyperactivity Serotonine syndrome (do not use if the patient takes SSRI drug)

If the patient does not tolerate the TCA drugs, or cannot be administared because of danger of interaction
Anxiolytics (e.g.: alprasolam, clonazepam) and selective antidepressants (e.g. SSRI) Change of lifestyle Psychotherapy, psychological treatments, biofeedback, behavioral therapy, relaxation methods

Migraine: epidemiology
Life-time prevalence 10%-12% 1% chronic migraine (>15 days/months) Sex ratio 2.5 (f) to 1 (m); in childhood 1 to 1 Mean frequency 1.2/month Mean duration 24 h (untreated) 10% always with aura, >30% sometimes with aura 30% treated by physicians

Migraine: pathophysiology
Genetic disposition, hormonal influence Activation of brainstem nuclei by trigger factors Neurovascular inflammation of intracranial vessels Impaired antinociception Spreading Depression as mechanism of aura

Migraine classification
1.1 migraine without aura 1.2 migraine with aura 1.3 periodic syndromes in childhood 1.4 retinal migraine 1.5 migraine complications 1.6 probable migraine

Migraine
WITHOUT AURA Typical headache 2/4
Unilateralsi Severe Pulsating Physical activity aggravates

WITH AURA

VISUAL SENSORY MOTOR SPEECH DISTURBANCE before migraineous headache

AURA SYMPTOMS
USUALLY<1/2 HOUR LESS THAN 1 HOUR

Accompanying signs 1/2

Photophobia and phonophobia Nausea, or vomitus

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 AURA SPREADING DEPRESSION 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%).

Is there a relationship between aura and patent foramen ovale

? Paradoxic emboli theory is not likely Shunting of venous blood to the arterial side could be the reason no breakdown of certain neurotransmitters (5HT) in the lung! Comorbidity could be also an explanation.

However, closure of patent foramen ovale decreases the frequency of migraine attacks. BUT! Migraine is a benign disease. Please do not indicate closure of patent foramen ovale just because of migraine with aura!

Treatment of migraine attack

Try to sleep Antiemetics Analgetics Ergot derivatives Triptans

Treatment of migraine attack

I. Antiemetics
1. Metoclopramid (Cerucal tabl 10 mg)
10-20 mg per os

20 mg rectal
10 mg parenteral

2. Domperidon (Motilium tabl 10 mg)

10-20 mg per os

Treatment of migraine attack

II. Analgetics
1. ASA (Aspirin, Colfarit, etc)
500-1000 mg per os 500 mg parenteral (Aspisol i.v.)

2. Paracetamol (Rubophen, Panadol, etc)

500-1000 mg per os

3. NSAIDs
Ibuprofen (Ibuprofen, Humaprofen, etc) 400-800 mg per os Diclofenac (Voltaren, Cataflam etc) 50 mg per os Naproxen (Naprosyn, Apranax) 250-550 mg per os

Treatment of migraine attack III. Ergot derivatives

1. Ergotamin tartarate
2-4 mg per os, sublinguali or rectal 1 mg nasal spray

2. Dihydrergotamin (Neomigran) nasal spray

no more available

Treatment of migraine attack IV. Combinations in Hungary

Migpriv:
lizin-acetylsalicilate + metoclopramid

Quarelin:
aminophenazon+coffein+drotaverin

Kefalgin
ergotamin tartarate+ atropin+coffein+aminophenazon

Treatment of migraine attack

V. Triptans
1. Sumatriptan (Imigran 6 mg inj, 50 and 100 mg tabl, Imitrex nasal spray, supp, Glaxo) 2. Zolmitriptan (Zomig, Zeneca) 3. Naratriptan (Naramig, Glaxo) 4. Rizatriptan (Maxalt, MSD) 5. Eletriptan (Relpax, Pfizer) 6. Frovatriptan (Smith-Kleine Beecham) 7. Avitriptan (Bristol-Myers Squibb) 8. Alniditan (Janssen)
6 mg sc with autoinjector 50-100 mg per os, nasal spray 20 mg 2,5 5 mg 2,5 mg 5 10 mg per os 20 80 mg per os 2,5 mg per os 75 150 mg 2 4 mg, nasal spray

The ideal triptan

Effective Rapid onset No recurrence Good consistency Different applications Good tolerability No interactions Cheap

Attack treatment in emergency

Very severe migraine attack / status migrainosus:

Triptan (sumatriptan 6 mg s.c.)

Lysin-ASA 1,000 mg i.v. Metamizol 500-1,000 mg i.v.

Antiemetics i.v.
Steroids i.v.

Strategy of treatment of migraine attacks

Step care accross or within attacks
1: NSAID 2: ergot 3: triptan

Stratified care
do not go through all the steps, but drug can be chosen depending on the severity of the attack

Prophylactic treatment of migraine attacks

Indication:
2 or more attacks/month At least one long (>4 days) attack/month

Start of prophyalactic treatment: gradually Duration of prophylactic treatment: 2-9 months Stop of prophylactic treatment: gradually, within 4 weeks Use headache diary INFORM THE PATIENT ABOUT THE PROPHYLACTIC TREATMENT!!!

Aims of prophylactic treatment of migraine

To decrease the frequency of attacks To decrease the intensity of the pain To increase the efficacy of attack therapy

Prophylactic treatment of migraine

Beta-receptor-blockers (propranolol) Calcium channel blockers (flunarizine) Antiepileptics (valproic acid) Tricyclic antidepressants (amitriptyline) Topiramate (Topamax) Serotonin antagonists NSAID

Beta-receptor-blockers (propranolol 2x20-40 mg)

Use: hypertension, tachycardia Do not use: hypotension, bradicardia, heart conduction disturbances
Do not use: obesity, maior depression in the history

Calcium channel blockers (flunarizine, 10 mg every evening) Side effects: provokes depression, increases appetite, cause sleepiness

Tricyclic antidepressants (amitryptiline, 10-75 mg every evening)

Use: if tension type of headache is present besides migraine Do not use: see above
Few side effects, but Pregnancy should be avoided

Antiepileptics (valproic acid, 2x300-500 mg)

Other prophylactic treatment of migraine

Change of life-style Regular, not exhausting physical activities Cognitive behavioral therapy Regular sleeping Avoid the precipitating factors Acuouncture?

Migraine and pregnancy

Migraine without aura in >70% of women less frequent or absent (prognostic factor: menstrual migraine) Significantly more manifestation of migraine with aura Acute treatment: paracetamol; NSAIDs in second trimenon Triptans not allowed Prophylaxis: magnesium, metoprolol, (fluoxetine)

Migraine in childhood I
Prevalence 5% Sex ratio 1:1 (boys with good prognosis) Abdominal symptoms often predominant Semiology of attacks as in adulthood except shorter duration of attacks Short sleep very effective

Migraine in childhood II
Acute treatment:
First choice: ibuprofen 10 mg/kg Second choice: paracetamol 15 mg/kg Third choice: sumatriptan nasal spray 10-20 mg

Prophylaxis:
Flunarizine 5-10 mg Propranolol 80 mg

Treatment of cluster attack

Oxygen:7 liters/min 100% oxign for 15 minutes
Effective in 75% of patients within 10 minutes

Sumatiptan 6 mg s.c., 50-100 mg per os Ergot derivatives (lot of side effects) Anaesthesia of the ipsilateral fossa sphenopalatina)
1 ml 4% Xylocain nasal drop The head is turned back and to the ipsilateral side in 45 degree

Prophylactic treatment of the episodic form of cluster headache

Epizodic form: prednisolon Treatment:
1-5. days 40 mg 6-10. days daily 30 mg 10-15. days daily 20 mg 16-20. days daily 15 mg 21-25. days daily 10 mg 26-30. days daily 5 mg nothing

Prophylactic treatment of the chronic form of cluster headache

Lithium carbonate Daily 600-700 mg Can be decreased after 2 weeks remission Control of serum level is necessary (0,4 - 0,8 mmol/l)

3. Cluster headache and trigemino-autonomic cephalgias

Trigemino-autonomic cephalgias (TAC) Cluster headache Paroxysmal hemicrania SUNCT-syndrome (Hemicrania continua)

Headache of cervical origin

Lidocain infiltration NSAID: 50-150 mg indomethacin, 20-40 mg piroxicam (Hotemin, Feldene), etc Surgical methods (CV-CVII fusion of vertebrae) Other methods (physiotherapy, TENS)

Arteriitis temporalis
Arteriitis temporalis (age>50y, We>50 mm/h) Autoimmune disease, granulomatose inflammation of branches of ECA
Unilateral headache Pulsating pain, more severe at night Larger STA 1/3 jaw claudication inflammation of internal maxillary artery Weakness, loss of appetite, low fever, Danger of thrombosis of ophthalmic or ciliary artery!!! Amaurosis fugax may precede the blindness Treatment: steroid 45-60 mg methylprednisolone decrease the dose after 1-2 weeks to 10 mg!!! Diagnosis: STA biopsy. BUT Start the steroid before results of biopsy!!! We, pain decrease

Facial pains
Tolosa-Hunt syndrome (ophthalmoplegia dolorosa) granulomatose inflammation in cavernous sinus, superior orbital fissure Treatment: steroid Gradenigos syndrome: otitis media inflammation of apex of petrous bone lesion of ipsilateral abducent nerve and facial pain around the ear and forehead

Carotid dissection
After neck trauma, extensive neck turning Neck pain Horners syndrome Diagnosis: carotid duplex, MRI-T2