Headache and associated emergencies

HEADACHE& associated emergencies

Dr Ahmad Shahir bin MawardiNeurology Registrar,

Neurology DepartmentHospital Kuala Lumpur

17th October 2016

Myths about HeadacheHeadache = Migraine

Headache = CT scan

1.Introduction 2.Classification of headache3.Red flag for headache4.Diagnosis of headache

• History, Examination, Ix5.Common causes of headache

• Migraine, TTH, CH,MOH6.Management

Outlines

lifetime prevalence of over 90% of the general population in the United Kingdom (UK)

It accounts for 4.4% of consultations in primary care and 30% of neurology outpatient consultations

Headache

Migraine occurs in 15% of the UK adult population women more than men in a ratio of 3:1

>100,000 people are absent from work or school because of migraine every working day.

migraine costs the UK almost £2 billion a year

Most frequent causes of consultation in GP and neurological clinics.

Introduction

Healthcare professionals often find the diagnosis of headache difficult but treatments can cause headache themselves

Most primary headache can be managed in primary care and investigations are rarely needed

When to refer?

ICH Disorders, 3 rd Edition

HEADACHEHEADACHE

Primary Secondary Neuralgias &other headaches

not associated with an underlying

pathology

attributed to an underlying

pathological condition

> 200 headache types> 200 headache types


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1. Migraine (+ aura)2. Tension-type headache 3. Trigeminal autonomic cephalalgias (CH, Paroxysmal hemicrania, Short-lasting unilateral neuralgiform headache attacks-SUNCT/SUNA, Hemicrania continua)4. Other primary headache disorders

1. Primary cough headache2. Primary exercise headache3. Primary headache associated with sexual activity4. Primary thunderclap headache5. Cold-stimulus headache6. External-pressure headache7. Primary stabbing headache8. Nummular headache9. Hypnic headache10.New daily persistent headache (NDPH)

4. Other primary headache disorders


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1. Migraine (+ aura)2. Tension-type headache 3. Trigeminal autonomic cephalalgias (CH, Paroxysmal hemicrania, Short-lasting unilateral neuralgiform headache attacks-SUNCT/SUNA, Hemicrania continua)4. Other primary headache disorders


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6. Headache attributed to cranial or cervical vascular disorder 7. Headache attributed to non-vascular intracranial disorder 8. Headache attributed to a substance or its withdrawal 9. Headache attributed to infection10. Headache attributed to disorder of homoeostasis 11. Headache or facial pain attributed to disorder of the cranium, neck,eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure12. Headache attributed to psychiatric disorder


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13. Painful cranial neuropathies and other facial pains 14. Other headache disorders

Patients may have more than one type of primary headache each headache type should be dealt with separately

secondary headache is rare

primary headache, findings on neurological examination are usually normal Ix are not helpful for diagnosis

Diagnosis of headache

1)History2)Physical examination3)Investigations

1) History of headache The history is all-important

Headache diary- pattern of headache

Excludes sinister causes of headcahe Intracranial tumor Meningitis Sudarachoid Haemorrhages Giant Cell Arteritis Primary angle-glaucoma Idiopathic Intracranial Hypertension Carbon Monoxide posioning

Weekly Headache Diary

1) History of headache

Red Flag of Headache (I)

1.new onset or change in headache in patients aged > 50

2.thunderclap: rapid time to peak headache intensity (seconds to 5 mins)

3. focal neurological symptoms (eg limb weakness, aura <5 min or >1 hr)

4.non-focal neurological symptoms (eg cognitive disturbance)

5.change in headache frequency, characteristics or associated symptoms

6.abnormal neurological examination

7.headache that changes with posture

Red Flag of Headache (II)8. headache wakening the patient up

9.headache precipitated by physical exertion or valsalva manoeuvre (eg coughing, laughing, straining)

10.patients with risk factors for cerebral venous sinus thrombosis

11.jaw claudication or visual disturbance

12. neck stiffness

13. fever

14. new onset headache in a patient with a history of HIV infection

15. new onset headache in a patient with a history of cancer.

2) Examination of headache

Neurological examination in patients first presenting with headache:

1.fundoscopy2.cranial nerve assessment, especially pupils, visual

fields, eye movements, facial power and sensation and bulbar function (soft palate, tongue movement)

3.assessment of tone, power, reflexes and coordination in all four limbs

4.plantar responses5.assessment of gait, including heel-toe walking.

3) Headache: Investigations majority of primary headaches do not require

neuroimaging

3) Headache: InvestigationsQ:When is neuroimaging required? individual basis Neuroimaging is not indicated in patients with a

clear history of migraine, without red flag features for potential secondary eadache, and a normal neurological examination.

Patient reassurance

3) Headache: InvestigationsQ: CT versus MRI? The European Federation of Neurological Societies guidelines

MRI is the imaging modality of choice because of this greater sensitivity

The US headache consortium MRI may be more sensitive than CT in identifying clinically

insignificant abnormalities, but not more sensitive in identifying clinically significant pathology

relevant to the cause of the headache.

Recomendation: Brain CT should be performed in patients with abnormal

neurological signs, unless the clinical history suggests MRI is indicated.

Brain MRI should be considered in patients with cluster headache, paroxysmal hemicrania or SUNCT.

Headache assessment tools1.Headache Impact Test (HIT /HIT 6)

www.headachetest.com

2. Migraine Disability Assessment (MIDAS)www.midasmigraine.net/edu/question/Default.asp

3. ID Migraine www.migraineclinic.org.uk

Types of headache Migraine Tension-type headache (TTH) Cluster headache (CH) Medication overuse headache (MOH)

Common types of headache

Migraine

1/3 of migraine sufferers

Recurrent headache disorder

4-72 hours.

Typical characteristics : unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.

Migraine with auraAura:

Visual blurring and “spots” progressive, last 5-60 minutes prior to headache transient hemianopic disturbance/ scintillating

scotoma can occur with:

unilateral paraesthesia,of hand, arm or face dysphasia functional cortical manifestations disturbance of one cerebral hemisphere

may occur without migraine aura persisting after resolution of the headache/aura

involving motor weakness-> further Ix familial hemiplegic migraine

Scintillating scotoma

Migraine with aura: Diagnostic criteria

Recurrent attacks, lasting minutes

unilateral

fully reversible visual, sensory or other central nervous system

symptoms develop gradually and are usually followed by headache and associated migraine symptoms.

Migraine without aura: Diagnostic criteria

Migraine

Migraine headache in children and adolescents is more often bilateral, unilateral pain usually emerges in late adolescence or early adult life.

Migraine headache is usually frontotemporal.

Possible Triggers of a Migraine Attack

Food and food additives

Bright lights/glareSmells/odors

Dieting/hungerLoud noises/soundsChanges in altitude/

air travel

StressWeather changesCaffeineAlcoholic beveragesChanges in sleep

habitsHormonal

fluctuations/ menstrual cycle

Wober C et al. J Headache Pain. 2006;7(4):188-195.Friedman DI and De Ver Dye T. Headache. 2009;49(6):941-952.

Tension type Headache

Episodic, very low frequency and short-lasting (< several hours)

Generalised but can be unilateral

Nature of pain: pressure or tightness,/tight band around the head spreads into or arises from the neck can be disabling for a few hours lacks of specific features and associated symptom

May be stress-related or a/w functional or structural cervical or cranial musculoskeletal abnormality.

Chronic TTH: >15 days a month, and may be daily

Diagnostic criteria: TTH

*Frequent episodic tension-type headache often coexistswith Migraine without aura.

Trigeminal Autonomic cephalalgias

rare characterised by attacks of severe unilateral pain in a

trigeminal distribution. a/w prominent ipsilateral cranial autonomic features.

Types1.Cluster headache is the most common (1 in 1,000). 2.Paroxysmal hemicrania (1 in 50,000)3.Short-lasting unilateral neuralgiform headache

attacks with conjunctival injection and tearing (SUNCT)

4.Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) .

very rare

TAC: Cluster headache

Severe, strictly unilateral pain. The pain is located in one or a combination of orbital,

supraorbital, or temporal regions.

Restless during an attack. Starts and ceases abruptly Duration: 15 minutes to three hours Frequency: EOD day to eight per day.

Striking circadian rhythm; 'attacks often occur at the same time each day and clusters occur at the same time each year'.

a/w ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema

and/or with restlessness or agitation

TAC: Cluster headache

TAC : Cluster headache (CH)

CH affects mostly men (male to female ratio 6:1)

Age 20s or older and very often smokers.

TAC : Short-lasting unilateral neuralgiform headache attacks

Attacks of moderate or severe, strictly unilateral head pain

Duration: seconds to minutes,

Frequency: at least once a day

usually a/w prominent lacrimation and redness of the ipsilateral eye

Trigeminal Autonomic cephalalgias

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)

Short lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)

Features distinguishing TACs from migraine

Medication overuse headache (MOH)

> 15 or more days per month

developing as a consequence of regular overuse of acute or symptomatic headache medication for more than 3 months.

It usually, but not invariably, resolves after the overuse is stopped

Overused meds frequency/month duration

ergotamine >10 days >3 months

Triptan >10 days >3 months

paracetamol >15 days >3 months

acetylsalicylic acid >15 days >3 months

NSAIDs >15 days >3 months

opioid >10 days >3 months

combination analgesic medication >10 days >3 months

multiple drug classes not individually overused >10 days >3 months

unverified overuse of multiple drug classes >10 days >3 months

one or more medications other thanthose described above

>10 days >3 months


Mechanisms: not clear probably as a results in down-regulation of 5-HT1B/1D

receptors addictive properties changes in neural pain pathways

may take weeks to months for the headache to resolve after withdrawal.


Small amounts are sufficient to induce MOH >15 days a month or of codeine-containing analgesics, >10 or more days a month of ergot or triptans

Frequency is important: low doses daily carry greater risk than larger doses

weekly.

Nature of pain worst on awakening in the morning increases after physical exertion In the end-stage, headache persists all day, fluctuating with

medication use repeated every few hours.


Prophylactic medication aggravate the condition

Headache diary

The (presumptive) diagnosis made based on symptoms and drug used.

Confirmed when symptoms improve after medication is withdrawn.

Treatment for migraine: history

Aretaeus A.D. 81?

For the treatment of headache,

Aretaeus recommended

inducing sneezing by placing testicle of beaver powder

intranasally to “bring off phlegm”

Management- GeneralDuring consultation:1. Explanation of the diagnosis and reassurance

that other pathology has been excluded

2. the options for management

3. recognition that headache is a valid medical disorder with significant psychosocial impact

*headache diary (minimum of 8/52)

MIGRAINE WITH OR WITHOUT AURAAcute treatment

Monotherapy: oral triptan, NSAID, aspirin(900 mg) or paracetamol

Combination: Oral triptan + an NSAID/

Oral triptan + paracetamol.

Consider an anti-emetic even in the absence of nausea and vomiting.Do not offer ergots or opioids

If ineffective or not tolerated:IV NSAID or IV triptan + IV metoclopramide or prochlorperazine

Migraine

Triptans

Triptans provide significant pain relief to patients with acute migraine within two hours & improve patients’ QoL

Anti-emetics prochlorperazine 3-6 mg buccal tablets or domperidone 10 mg oral or 30 mg rectal metoclopramide 10 mg or * domperidone 20 mg *

are also useful as a prokinetic to promote gastric emptying

Caffeine?? Evidence was limited to the inclusion of

caffeine with combinations of other therapies

MIGRAINE WITH OR WITHOUT AURAProphylactic treatment

First line: Topiramate or propranolol

Review the meds after 6 months.

Diet: riboflavin (400 mg OD) may be effective in reducing migraine frequency and intensity for some people

MIGRAINE WITH OR WITHOUT AURAOther meds

Amitriptyline is widely used, off-label, to treat chronic painful disorders, including migraine. Inadequate evidence. If effective--> continue the current treatment

Pizotifen is a popular treatment for migraine prevention, been in use since the 1970s and appears to be well tolerated. Inadequate evidence.

Treatment of migraine during pregnancy: PCM

TENSION-TYPE HEADACHE Acute treatment

Aspirin, paracetamol or an NSAID Do not offer opioids

Prophylactic treatment Acupuncture (10 sessions over 5–8 weeks)

CLUSTER HEADACHEAcute treatment

Offer oxygen and/or a subcutaneous 6 mg or nasal triptan (if cannot tolerate subcute).

use 100% oxygen at a flow rate of at least 12 litres per minute with a non- rebreathing mask and a reservoir bag

Do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans

Prophylactic treatment

Verapamil 240-960 mg/day

Medication overuse headache Treated by withdrawing overused medication--> Explain,

explain, explain!!!

Advise: to stop all overused meds abruptly rather than gradually for < 1

month headache symptoms are likely to get worse in the short term before

they improve + withdrawal symptoms

Consider prophylactic treatment for the underlying primary headache disorder

Consider specialist referral for people who are using strong opioids withdrawal (Addiction team)

Review the diagnosis & mx 4–8 weeks after the start of withdrawal of overused medic

Headaches That Require Emergency Attention

Stroke (focal neurological deficit, nausea, vomiting)

Aneurysm (The worst headache ever!) subarachnoid hemorrhage (SAH)

Meningitis (fever & neck pain)

Subarachnoid hemorrhage

severe and sudden, peaking in seconds (thunderclap headache) or minutes.

mortality rate is 40–50% 10–20% of patients die

before arriving at hospital;

50% of survivors are left disabled



Plain CT scan, sensitivity of 98% in the first 12 hours after onset 93% at 24 hours 50% at 7 days)

Lumbar puncture (if CT results are non-diagnostic) Xanthochromia 100% of cases if collected between 12 hours

and 2 weeks

MRI is not indicated FLAIR and gradient-echo T2-weighted images may be

useful when the CT is normal and the CSF abnormal.


SAH is a neurointerventional emergency. the next urgent step

is to identify a ruptured aneurysm (80% of cases - ruptured saccular aneurysms).

References


Thank you