Classification of headachesProfessor Yasser Metwally

• 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!

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. infection10. disorder of homoeostasis11. disorder of cranium, neck, eyes, ears, nose,

sinuses, teeth, mouth or other facial or cranial structures

12. psychiatric disorder13. 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

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

Prophylactic treatment of the chronic tension type of headache

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

• WITH AURA +– VISUAL– SENSORY– MOTOR– SPEECH DISTURBANCE

before migraineous headache

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

• WITHOUT AURA• Typical headache 2/4

– Unilateralsi– Severe– Pulsating– Physical activity

aggravates

• 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

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%).

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

• 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 III. Ergot derivatives

• Migpriv:– lizin-acetylsalicilate + metoclopramid

• Quarelin: – aminophenazon+coffein+drotaverin

• Kefalgin

– ergotamin tartarate+ atropin+coffein+aminophenazon

Treatment of migraine attack IV. Combinations in Hungary

Treatment of migraine attack V. Triptans

1. Sumatriptan (Imigran® 6 mg inj, 50 and 100 mg tabl, Imitrex nasal spray, supp, Glaxo)

6 mg sc with autoinjector

50-100 mg per os,

nasal spray 20 mg

2. Zolmitriptan (Zomig®, Zeneca) 2,5 – 5 mg

3. Naratriptan (Naramig®, Glaxo) 2,5 mg

4. Rizatriptan (Maxalt®, MSD) 5 – 10 mg per os

5. Eletriptan (Relpax, Pfizer) 20 – 80 mg per os

6. Frovatriptan (Smith-Kleine Beecham) 2,5 mg per os

7. Avitriptan (Bristol-Myers Squibb) 75 – 150 mg

8. Alniditan (Janssen) 2 – 4 mg, nasal spray

The ideal triptan• Effective• Rapid onset• No recurrence• Good consistency• Different applications• Good tolerability• No interactions• Cheap

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.

Attack treatment in emergency

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)

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

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

Antiepileptics(valproic acid, 2x300-500 mg)

Use: hypertension, tachycardiaDo not use: hypotension,

bradicardia,heart conduction disturbances

Do not use: obesity, maior depressionin the history

Use: if tension type of headache ispresent besides migraine

Do not use: see above

Few side effects, butPregnancy should be avoided

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

• Non-drug therapy very effective

Treatment of cluster attack

• Oxygen:7 liters/min 100% oxigén 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

• 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)

Prophylactic treatment of the chronic form of cluster headache

3. Cluster headache and trigemino-autonomic cephalgias

• Trigemino-autonomic cephalgias (TAC)

–Cluster headache–Paroxysmal hemicrania–SUNCT-syndrome–(Hemicrania continua)

• Episodic and chronic forms

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

• Gradenigo’s 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

• Horner’s syndrome

• Diagnosis: carotid duplex, MRI-T2