Headache and increased Headache and increased intracranial pressureintracranial pressure

Causes of HeadachesCauses of HeadachesCauses of HeadachesCauses of Headaches

1.1.Traction, tension, or displacement of pain-Traction, tension, or displacement of pain-sensitive structuressensitive structures

2.2. Distention or dilation of intracranial arteries Distention or dilation of intracranial arteries

3.3. Inflammation of pain-sensitive structures Inflammation of pain-sensitive structures

4.4. Obstruction of CSF pathways with consequent Obstruction of CSF pathways with consequent increased intraventricular pressureincreased intraventricular pressure

5.5. Primary central pain: involvement of pain- Primary central pain: involvement of pain-modulating systemsmodulating systems

1.1.Traction, tension, or displacement of pain-Traction, tension, or displacement of pain-sensitive structuressensitive structures

2.2. Distention or dilation of intracranial arteries Distention or dilation of intracranial arteries

3.3. Inflammation of pain-sensitive structures Inflammation of pain-sensitive structures

4.4. Obstruction of CSF pathways with consequent Obstruction of CSF pathways with consequent increased intraventricular pressureincreased intraventricular pressure

5.5. Primary central pain: involvement of pain- Primary central pain: involvement of pain-modulating systemsmodulating systems

Tentorium cerebri

Meninges

Vascular-arteriesVascular-arteries

Cranial nervesCranial nerves

The Fifth cranial nerve The Fifth cranial nerve

Trigeminal nerveTrigeminal nerve

V1 (Ophthalmic) V1 (Ophthalmic) sensation sensation V2 (Maxillary) V2 (Maxillary) sensation sensation V3 (Mandibular) V3 (Mandibular) sensation sensation

Trigeminal neuralgiaTrigeminal neuralgia

Intense momentary spasms Intense momentary spasms of pain make the patient of pain make the patient wincewince

Pain occur in the face, usually Pain occur in the face, usually radiating from the corner of radiating from the corner of the mouth or from the gums the mouth or from the gums towards the cheek and eartowards the cheek and ear

Sudden electric-shock-like Sudden electric-shock-like qualityquality

Pain triggered by touching, Pain triggered by touching, shaving, cold winds, eatingshaving, cold winds, eating

Usually occur in elderly. If Usually occur in elderly. If occurs in young adults, occurs in young adults, multiple sclerosis should be multiple sclerosis should be suspected.suspected.

Headache classificationHeadache classification

Headache

Primary Secondary

Migraine

Tension

Cluster

Miscellaneous

Extracranial Intracranial

Pain sensitive

• meninges

• vascular

• nerves

Secondary headacheSecondary headache

IntracranialIntracranial

ExtracranialExtracranial

What should be asked when What should be asked when you see a patient with you see a patient with

headache ??headache ??

HistoryHistory Temporal profileTemporal profile

– Age of onsetAge of onset– Time to maximum intensityTime to maximum intensity– FrequencyFrequency– Time of the dayTime of the day– DurationDuration

Headache featureHeadache feature– LocationLocation– Quality of painQuality of pain– Severity of painSeverity of pain

Associated symptoms and signsAssociated symptoms and signs– Before, during, and after headacheBefore, during, and after headache

Aggravating or precipitating factorsAggravating or precipitating factors– TraumaTrauma– Medical conditions; pregnancy, obese women, Medical conditions; pregnancy, obese women,

pheochromocytoma, HIV-cryptococcal meningitis, pheochromocytoma, HIV-cryptococcal meningitis, metastatic diseasemetastatic disease

– Triggers : menstruation, loud noise, heat, alcohol, Triggers : menstruation, loud noise, heat, alcohol, stressstress

– Activity and posturesActivity and postures– Pharmacologic : drug-abused headache, oral Pharmacologic : drug-abused headache, oral

contraceptive pillscontraceptive pills

Relieving factorsRelieving factors– NonpharmacologicNonpharmacologic– PharmacologicPharmacologic

Evaluation and treatment historyEvaluation and treatment history Psychosocial historyPsychosocial history

– Substance useSubstance use– Occupational and personal lifeOccupational and personal life– Psychologic historyPsychologic history– Sleep historySleep history– Impact of headacheImpact of headache

Family historyFamily history

HeadacheHeadache

Primary headachePrimary headache

Secondary headacheSecondary headache

DIAGNOSIS AND TESTINGDIAGNOSIS AND TESTING

Red flagPrimary headache?

Secondary headache

Diagnostic testing

Detailed history and physical examination

Atypical features

No

Yes

Red flags in the diagnosis of Red flags in the diagnosis of headache(1)headache(1)

Sudden onset headache Sudden onset headache – Subarachnoid hemorrhageSubarachnoid hemorrhage

Worsening pattern headacheWorsening pattern headache– Mass lesion, subdural hematomaMass lesion, subdural hematoma– Medication overuseMedication overuse

Headache with systemic illnessHeadache with systemic illness– Meningitis, encephalitisMeningitis, encephalitis– Systemic infectionSystemic infection– Collagen vascular disease, arteritisCollagen vascular disease, arteritis

Red flags in the diagnosis of Red flags in the diagnosis of headache(2)headache(2)

Focal neurological signs or symptomsFocal neurological signs or symptoms– Mass lesionMass lesion– AVMAVM

Triggered by cough, exertion, or ValsalvaTriggered by cough, exertion, or Valsalva– SAHSAH– Mass lesionMass lesion

New headache type in a patient New headache type in a patient – with cancer : metastasiswith cancer : metastasis– With HIV : opportunistic infection, tumorWith HIV : opportunistic infection, tumor

Causes of Secondary headacheCauses of Secondary headache

IntracranialIntracranial ParacranialParacranial ExtracranialExtracranial

Head traumaHead traumaVascular Vascular disordersdisordersNonvascular Nonvascular disorderdisorder

Disorder of Disorder of cranium, neck, cranium, neck, eyes, ears, nose, eyes, ears, nose, sinuses, teeth, sinuses, teeth, mouth, other facial mouth, other facial or cranial or cranial structuresstructures

Substances Substances or their or their withdrawalwithdrawalNoncephalic Noncephalic infectioninfectionMetabolic Metabolic disorderdisorder

SinusitisSinusitis

Pain is Pain is localized to the cheek localized to the cheek

: maxillary sinusitis: maxillary sinusitis To the forehead : To the forehead :

frontal sinusitisfrontal sinusitis Midline behind the Midline behind the

nose : ethmoid and nose : ethmoid and sphenoid sinusitissphenoid sinusitis

** the pain is throbbing and the pain is throbbing and tenderness of overlying tenderness of overlying skinskin

Posttraumatic headachesPosttraumatic headaches

Mild head injury and postconcussion Mild head injury and postconcussion syndromesyndrome– Mild head injury >= 75% of all brain injuriesMild head injury >= 75% of all brain injuries– Mild closed head injuryMild closed head injury– 50% of patient with mild Head injury will 50% of patient with mild Head injury will

develop postconcussion syndromedevelop postconcussion syndrome

Postconcussion syndromePostconcussion syndrome

Headache : within 14 days or 3 monthsHeadache : within 14 days or 3 months Cranial nerve signs and symptoms Cranial nerve signs and symptoms Psychologic and somatic complaint Psychologic and somatic complaint Cognitive impairmentCognitive impairment Rare sequelae Rare sequelae

– Subdural and epidural hematoma, Subdural and epidural hematoma, cerebral venous thrombosis, seizurecerebral venous thrombosis, seizure

Subarachnoid hemorrhage (SAH)Subarachnoid hemorrhage (SAH)

Abrupt onset : Abrupt onset : subarachnoid subarachnoid hemorrhage(SAH)hemorrhage(SAH)

Headache on awakening Headache on awakening after lying down or occur after lying down or occur everyday : suspect raised everyday : suspect raised intracranial pressureintracranial pressure

Focal neurological deficit : Focal neurological deficit : brain tumor, stroke, brain tumor, stroke, abscess, encephalitisabscess, encephalitis

Subarachnoid hemorrhage (SAH)Subarachnoid hemorrhage (SAH)

Headache occurs in about 90% of SAH Headache occurs in about 90% of SAH patientpatient

Classic : acute, severe, continuous, and Classic : acute, severe, continuous, and generalized and is often associated with generalized and is often associated with nausea, vomiting, meningismus, focal nausea, vomiting, meningismus, focal neurologic symptoms, and loss of neurologic symptoms, and loss of consciousnessconsciousness

““worst headache of my life”worst headache of my life”

Investigation in suspected SAHInvestigation in suspected SAH

CT brainCT brain– First 24 hrs ---- First 24 hrs ----

detect SAH detect SAH ~95%~95%

Investigation in suspected SAHInvestigation in suspected SAH

• Lumbar puncture Lumbar puncture in suspected SAH in suspected SAH with normal CT or with normal CT or MRI brainMRI brain

Differentiate Differentiate traumatic tap traumatic tap from SAH by from SAH by xanthochromiaxanthochromia (colored (colored supernatant)supernatant)

Further investigation for SAHFurther investigation for SAH

4 vessel cerebral arteriogram 4 vessel cerebral arteriogram MRA (magnetic resonance angiography)MRA (magnetic resonance angiography) Spiral (helical) CT angiographySpiral (helical) CT angiography

StrokeStroke

Headaches may be due to Headaches may be due to electrochemical electrochemical or mechanical stimulation of or mechanical stimulation of trigeminovascular afferent systemtrigeminovascular afferent system

Headache occurred in infarcts, parenchymal Headache occurred in infarcts, parenchymal hemorrhage, TIA, lacunar infarctshemorrhage, TIA, lacunar infarcts

Quality, onset, duration of headache varied Quality, onset, duration of headache varied widelywidely

Clinical manifestations of headache Clinical manifestations of headache in strokein stroke

Unilateral and focal headache Unilateral and focal headache Mild to moderate severityMild to moderate severity Abrupt or gradual in onsetAbrupt or gradual in onset throbbing or nonthrobbing throbbing or nonthrobbing More often ipsilateral than contralateral to side of More often ipsilateral than contralateral to side of

cerebral ischemiacerebral ischemia Associated symptoms : nausea, vomiting, light and Associated symptoms : nausea, vomiting, light and

noise sensitivitynoise sensitivity

Unruptured AVM and migraineUnruptured AVM and migraine

Migraine-likeMigraine-like headaches with and without visual headaches with and without visual symptomssymptoms

Typical migraine-like due to an AVMTypical migraine-like due to an AVM– Unusual associated signs (papilledema, field cut, bruit)Unusual associated signs (papilledema, field cut, bruit)– Short duration of headache attacksShort duration of headache attacks– Brief scintillating scotomaBrief scintillating scotoma– Absent family historyAbsent family history– Atypical sequence of aura, headache and vomitingAtypical sequence of aura, headache and vomiting– seizureseizure

MRI T1 and Angiogram of AVMMRI T1 and Angiogram of AVM

Carotid and vertebral artery Carotid and vertebral artery dissectionsdissections

Dissections occur due Dissections occur due to penetration of to penetration of circulating blood circulating blood through an intimal tear through an intimal tear into subintimal, medial, into subintimal, medial, and, less commonly and, less commonly adventitial layers of adventitial layers of vascular wallvascular wall

Clinical manifestation of carotid or Clinical manifestation of carotid or vertebral artery dissectionvertebral artery dissection

Head, face, orbital, or neck painHead, face, orbital, or neck pain Cerebral ischemic symptoms Cerebral ischemic symptoms SAH [intracranial artery dissection]SAH [intracranial artery dissection] Incomplete ipsilateral Horner’s syndrome Incomplete ipsilateral Horner’s syndrome

[extracranial ICA dissection][extracranial ICA dissection] Subjective or objective bruitsSubjective or objective bruits

Character of headache in artery Character of headache in artery dissectiondissection

Onset : gradual 75%, thunderclap headache Onset : gradual 75%, thunderclap headache 10-20%, 10-20%,

Constant, steady aching or steady sharp Constant, steady aching or steady sharp pain or less commonly as throbbingpain or less commonly as throbbing

Headache in CVTHeadache in CVT

Usually due to raised intracranial pressureUsually due to raised intracranial pressure– Diffuse, progressive and constantDiffuse, progressive and constant

Almost always associated withAlmost always associated with– PapilledemaPapilledema– Focal deficitsFocal deficits– Partial/ generalized seizuresPartial/ generalized seizures

Diagnostic evaluation in CVTDiagnostic evaluation in CVT

CT brainCT brain– Exclude cerebral infarction and hemorrhageExclude cerebral infarction and hemorrhage– ‘‘Empty delta sign’ ; nonenhancing clot within the sinus Empty delta sign’ ; nonenhancing clot within the sinus

is present in only 35%is present in only 35% MRI and MRVMRI and MRV

– Best way to detect CVTBest way to detect CVT Lumbar puncture ---should be avoided if there is Lumbar puncture ---should be avoided if there is

a large cerebral infarction or hemorrhagea large cerebral infarction or hemorrhage– Document elevated intracranial pressure and help Document elevated intracranial pressure and help

exclude infectious or leptomeningeal malignancyexclude infectious or leptomeningeal malignancy

MRV of Superior sagittal, transverse MRV of Superior sagittal, transverse sinus thrombosissinus thrombosis

Temporal arteritis Temporal arteritis (Giant cell arteritis)(Giant cell arteritis)

Systemic panarteritis that selectively Systemic panarteritis that selectively involves arterial walls with significant involves arterial walls with significant amount of elastinamount of elastin

50% of patient with temporal arteritis have 50% of patient with temporal arteritis have polymyalgia rheumaticapolymyalgia rheumatica

15% of patient with polymyalgia rheumatica 15% of patient with polymyalgia rheumatica have temporal arteritishave temporal arteritis

Mean age of onset ~70 yearsMean age of onset ~70 years

Temporal arteritis Temporal arteritis (giant cell (giant cell arteritis)arteritis)

Temporal arteritis (Giant cell arteritis)Temporal arteritis (Giant cell arteritis)

Headache 60-90%Headache 60-90%– Often throbbingOften throbbing– Intermittent or continuousIntermittent or continuous– SevereSevere– Location : temporofrontal, Location : temporofrontal,

temple, not involve temple, temple, not involve temple, generalizedgeneralized

– 50% tenderness or decreased 50% tenderness or decreased pulsation of superficial temporal pulsation of superficial temporal arteryartery

Temporal arteritisTemporal arteritis (cont)(cont)

Intermittent jaw claudication 38%Intermittent jaw claudication 38% Neurologic manifestation are commonNeurologic manifestation are common

– Ophthalmologic findings ; visual loss, Ophthalmologic findings ; visual loss, ophthalmoparesisophthalmoparesis

– Mononeuropathies and peripheral neuropathiesMononeuropathies and peripheral neuropathies– TIA or strokeTIA or stroke– othersothers

Diagnosis of temporal arteritisDiagnosis of temporal arteritis

Based on clinical suspicion that is usually Based on clinical suspicion that is usually confirmed by laboratory testingconfirmed by laboratory testing

3 best test : westergren ESR, C-reactive 3 best test : westergren ESR, C-reactive protein(CRP), temporal artery biopsyprotein(CRP), temporal artery biopsy

Headache due to severe HTHeadache due to severe HT

Usually bioccipital throbbingUsually bioccipital throbbing Can be generalized or frontal throbbingCan be generalized or frontal throbbing Often present in the morning on awakeningOften present in the morning on awakening Diastolic BP usually elevated to 120 mmHg Diastolic BP usually elevated to 120 mmHg

or higheror higher

Headaches and neoplasmsHeadaches and neoplasms

Brain tumors are an uncommon cause of Brain tumors are an uncommon cause of headacheheadache

8% of patient with headaches and brain 8% of patient with headaches and brain tumors have a normal neurological tumors have a normal neurological examinationexamination

Papilledema is present in 40%Papilledema is present in 40% Headache related to size of tumor and Headache related to size of tumor and

amount of midline shiftamount of midline shift

Headaches and neoplasms Headaches and neoplasms (cont)(cont)

Most common location of headaches is Most common location of headaches is bifrontalbifrontal

Most of headache are intermittent with Most of headache are intermittent with moderate to severe intensitymoderate to severe intensity

‘‘classic’ brain tumor headache---severe, classic’ brain tumor headache---severe, worse in the morning, associated N/V---worse in the morning, associated N/V---occurs in a minority of patientsoccurs in a minority of patients

Headache and Headache and intracranial intracranial pressurepressure

Pseudotumor cerebriPseudotumor cerebri (idiopathic (idiopathic intracranial hypertension)intracranial hypertension)

– Neurological examination is normal except Neurological examination is normal except papilledema, visual loss, cranial nerve VI palsypapilledema, visual loss, cranial nerve VI palsy

– CSF pressure is increased (>20 cm H2O in CSF pressure is increased (>20 cm H2O in nonobese and >25 cmH2O in obese patient)nonobese and >25 cmH2O in obese patient)

– CSF analysis is normal except decreased CSF analysis is normal except decreased proteinprotein

– No hydrocephalus or mass lesionNo hydrocephalus or mass lesion– There are no other identifiable causesThere are no other identifiable causes

Pseudotumor cerebriPseudotumor cerebri

>90% of patients are young obese women>90% of patients are young obese women Usually Primary or idiopathicUsually Primary or idiopathic Secondary causes and associations Secondary causes and associations

– Intracranial massIntracranial mass– Obstruction of ventricular systemObstruction of ventricular system– Cerebral venous thrombosisCerebral venous thrombosis– Meningitis/ encephalitisMeningitis/ encephalitis– Medications : Vitamin A, Minocycline, Anabolic steroids, Medications : Vitamin A, Minocycline, Anabolic steroids,

Corticosteroid withdrawalCorticosteroid withdrawal

Clinical manifestation of Clinical manifestation of Pseudotumor cerebriPseudotumor cerebri

Headache Headache – Pulsatile, daily, continuousPulsatile, daily, continuous– Unilateral, bilateral, frontal, occipital Unilateral, bilateral, frontal, occipital

[ bifrontotemporal is the most common[ bifrontotemporal is the most common]]– Nausea/vomitingNausea/vomiting– Orbital painOrbital pain

PapilledemaPapilledema– Visual symptoms : transient visual obscuration, diplopia, Visual symptoms : transient visual obscuration, diplopia,

visual loss, cranial nerve VI palsyvisual loss, cranial nerve VI palsy

Diagnostic evaluation of Diagnostic evaluation of Pseudotumor cerebriPseudotumor cerebri

CT or MRI brain CT or MRI brain – Exclude tumor or hydrocephalusExclude tumor or hydrocephalus

Lumbar punctureLumbar puncture– If the scans show no other explanation for papilledemaIf the scans show no other explanation for papilledema– Measure opening pressureMeasure opening pressure– CSF analysis should be normal except low protein level CSF analysis should be normal except low protein level

in some casesin some cases

Ophthalmologist consultationOphthalmologist consultation– Evaluate fundus, visual acuity, visual fieldEvaluate fundus, visual acuity, visual field

Management of Pseudotumor Management of Pseudotumor cerebricerebri

Treat causesTreat causes Treatment of idiopathic Pseudotumor cerebriTreatment of idiopathic Pseudotumor cerebri

– Lose weight for obese patientsLose weight for obese patients– Repeated LP to reduce pressure to 12-17.5 cm H2ORepeated LP to reduce pressure to 12-17.5 cm H2O– Medication for persistent headache Medication for persistent headache

drug for migraine headachedrug for migraine headache DiureticsDiuretics AcetazolamideAcetazolamide

– Surgical treatments for papilledema and headacheSurgical treatments for papilledema and headache Optic nerve sheath fenestrationOptic nerve sheath fenestration Lumboperitoneal shuntLumboperitoneal shunt

Low CSF pressure headacheLow CSF pressure headache

Most often due to Most often due to – Post LPPost LP– Spontaneous occurrenceSpontaneous occurrence– CSF shunt overdrainageCSF shunt overdrainage

Diagnostic evaluation of low CSF Diagnostic evaluation of low CSF pressure headachepressure headache

Repeat LP : opening pressure 0-7cmH2O or Repeat LP : opening pressure 0-7cmH2O or in normal rangein normal range

CSF analysis: normal or moderate, primarily CSF analysis: normal or moderate, primarily lymphocytic pleocytosis, RBC, elevate lymphocytic pleocytosis, RBC, elevate proteinprotein

MRI brain : diffuse meningeal enhancement MRI brain : diffuse meningeal enhancement with gadolinium or subdural fluid collectionwith gadolinium or subdural fluid collection

Intracranial hypotensionIntracranial hypotension

Post-Lumbar puncture headachePost-Lumbar puncture headache

Most common complication of lumbar punctureMost common complication of lumbar puncture Risk factors Risk factors

– FemaleFemale– Age 18-30 yearsAge 18-30 years– Lesser body mass indexLesser body mass index– Prior chronic or recurrent headachePrior chronic or recurrent headache– Prior PLPHPrior PLPH– Larger-diameter needle, perpendicular orientation of Larger-diameter needle, perpendicular orientation of

bevel, not reinsert the styletbevel, not reinsert the stylet

Clinical manifestation of PLPHClinical manifestation of PLPH

Bilateral, frontal, occipital, generalized pressure or Bilateral, frontal, occipital, generalized pressure or throbbing occurring in upright position and throbbing occurring in upright position and decreasing or resolving when supinedecreasing or resolving when supine

Worse with headache movement, coughing, Worse with headache movement, coughing, straining, sneezing, jugular venous compressionstraining, sneezing, jugular venous compression

Begins within 48 hrs or 72 hrsBegins within 48 hrs or 72 hrs Additional symptoms : neck stiffness, nausea, Additional symptoms : neck stiffness, nausea,

vomitingvomiting

Headaches caused by Vasoactive Headaches caused by Vasoactive substancessubstances

Dilation of intracranial vesselsDilation of intracranial vessels– Throbbing in nature and made worse by sudden head Throbbing in nature and made worse by sudden head

movementmovement ExamplesExamples

– AlcoholAlcohol– MarijuanaMarijuana– CocaineCocaine– Monosodium glutamate “Chinese restaurant syndrome”Monosodium glutamate “Chinese restaurant syndrome”– Nitrite and NitratesNitrite and Nitrates– Histamine headacheHistamine headache

Rebound headache : nicotine and caffeineRebound headache : nicotine and caffeine

Headache due to infection and Headache due to infection and inflammationinflammation

HIV and headacheHIV and headache– Cryptococcal meningitis, neurosyphilis, Cryptococcal meningitis, neurosyphilis,

tuberculous meningitis, toxoplasmosis, CMV tuberculous meningitis, toxoplasmosis, CMV encephalitis, tumors, sinusitis, medications, encephalitis, tumors, sinusitis, medications, primary headacheprimary headache

Brain abscessBrain abscess Meningitis and encephalitisMeningitis and encephalitis Drug-induced aseptic meningitisDrug-induced aseptic meningitis : :

NSAIDs, ATBs, vaccines, others,…NSAIDs, ATBs, vaccines, others,…

Metabolic disorders and Metabolic disorders and headacheheadache

FeverFever HypoxiaHypoxia HypercapniaHypercapnia HypoglycemiaHypoglycemia DialysisDialysis High altitudeHigh altitude Decompression sicknessDecompression sickness Hyperventilation syndromeHyperventilation syndrome

Primary HeadachePrimary Headache

MigraineMigraine Tension-type headacheTension-type headache ClusterCluster

Headache typeHeadache type MigrainesMigraines Tension-typeTension-type ClusterCluster

Age at onsetAge at onset 10-4010-40 20-5020-50 15-4015-40

LocationLocation HemicranialHemicranial BilateralBilateral Unilateral peri/retro-Unilateral peri/retro-orbitalorbital

durationduration Several hours to 3 Several hours to 3 daysdays

30 min to 7days+30 min to 7days+ 30-120 min30-120 min

Frequency/timingFrequency/timing VariableVariable VariableVariable 1-8/day, nocturnal 1-8/day, nocturnal attacksattacks

severityseverity Moderate to severeModerate to severe Dull ache may Dull ache may wax/wanewax/wane

ExcruciatingExcruciating

qualityquality Throbbing, steady Throbbing, steady acheache

Band-like pressureBand-like pressure Boring, piercingBoring, piercing

Associated Associated featuresfeatures

N/V, N/V, photo/phono/osmophphoto/phono/osmoph

obia, scotoma, obia, scotoma, neurologic deficitsneurologic deficits

Generally noneGenerally none Ipsilateral Ipsilateral conjunctival conjunctival

injection, lacrimation, injection, lacrimation, nasal congestion, nasal congestion,

rhinorrhea, miosis, rhinorrhea, miosis, facial sweatingfacial sweating

Migraine headacheMigraine headache

Age- And Gender-specific Age- And Gender-specific Prevalence Of MigrainePrevalence Of Migraine

Age- And Gender-specific Age- And Gender-specific Prevalence Of MigrainePrevalence Of Migraine

Lipton RB, Stewart WF. Lipton RB, Stewart WF. NeurologyNeurology. 1993.. 1993.

Mig

rain

e P

reva

lenc

e (5

)M

igra

ine

Pre

vale

nce

(5)

Migraine Without AuraMigraine Without Aura

Migraine without auraMigraine without aura

AA. . At least 5 attacks fulfilling criteria BAt least 5 attacks fulfilling criteria B--DD

BB. . Headache attacks lasting 4-72 hours Headache attacks lasting 4-72 hours ((untreated or unsuccessfully untreated or unsuccessfully treatedtreated))

CC. . Headache has at least 2 of the following characteristicsHeadache has at least 2 of the following characteristics::

- - UnilateralUnilateral location location

- - PulsatingPulsating quality quality

- - Moderate or severeModerate or severe pain intensity pain intensity

- - Aggravation byAggravation by or causing avoidance of routine or causing avoidance of routine physical activity physical activity ((eg, walking or climbing stairseg, walking or climbing stairs))

DD. . During headache at least 1 of the followingDuring headache at least 1 of the following::

- Nausea and- Nausea and//or vomitingor vomiting

- Photophobia and phonophobia- Photophobia and phonophobia

EE. . Not attributed to another disorderNot attributed to another disorder

  

Migraine With AuraMigraine With Aura

Typical aura with Migraine Typical aura with Migraine headache(1)headache(1)

AA. . At least 2 attacks fulfilling criteria BAt least 2 attacks fulfilling criteria B--DD

BB. . Aura consisting of at least 1 of the following, but no motor Aura consisting of at least 1 of the following, but no motor weaknessweakness::

- Fully reversible - Fully reversible visual symptomsvisual symptoms including positive including positive features features ((eg, flickering lights, spots or lineseg, flickering lights, spots or lines) ) andand//or or negative features negative features ((ie, loss of visionie, loss of vision))

- Fully reversible - Fully reversible sensory symptomssensory symptoms including positive including positive features features ((ie, pins and needlesie, pins and needles) ) andand//or negative features or negative features ((ie, ie, numbnessnumbness))

- Fully reversible - Fully reversible dysphasic speechdysphasic speech disturbance disturbance

Typical aura with Migraine Typical aura with Migraine headache(2)headache(2)

CC. . At least two of the followingAt least two of the following::

- Homonymous visual symptoms and- Homonymous visual symptoms and//or unilateral sensory or unilateral sensory symptomssymptoms

- At least one aura symptom develops gradually over >- At least one aura symptom develops gradually over >/=/=5 5 minutes andminutes and//or different aura symptoms occur in or different aura symptoms occur in succession over >succession over >/=/=5 minutes5 minutes

- Each symptom lasts >- Each symptom lasts >/=/=5 and <5 and </=/=60 minutes60 minutes

DD. . Headache fulfilling criteria BHeadache fulfilling criteria B--D for “Migraine without aura” D for “Migraine without aura” begins during the aura or follows aura within 60 minutesbegins during the aura or follows aura within 60 minutes

EE. . Not attributed to another disorderNot attributed to another disorder  

Visual AuraVisual Aura

Aura-NumbnessAura-Numbness

1. Prodrome1. Prodrome

2. Aura2. Aura

Phases of Migraine AttackPhases of Migraine Attack

3. Headache3. Headache

4. Postdrome4. Postdrome

Migraine TreatmentMigraine Treatment

Reassure and educate patient Reassure and educate patient Identify and remove triggersIdentify and remove triggers

Start a wellness program : exercise, balanced Start a wellness program : exercise, balanced meals, adequate sleep, smoking cessation meals, adequate sleep, smoking cessation

pharmacotherapypharmacotherapy

physical therapyphysical therapy

psychological therapypsychological therapy

Migraine TriggersMigraine Triggers

Stress and emotionStress and emotion

Hormonal changesHormonal changes

DietDiet

Environmental factorsEnvironmental factors

Too much or too little sleepToo much or too little sleep

Physical factorsPhysical factors

Acute vs Preventive Acute vs Preventive TherapyTherapy

Acute (Abortive)Acute (Abortive) : : Taken after attack has Taken after attack has begun to relieve pain and disability and stop begun to relieve pain and disability and stop progressionprogression

Preventive Therapy : Preventive Therapy : Taken daily to reduce Taken daily to reduce attack frequency, severity, and durationattack frequency, severity, and duration

Acute Migraine MedicationsAcute Migraine Medications Non-specificNon-specific

– NSAIDs : naproxen, ibuprofenNSAIDs : naproxen, ibuprofen– Combination analgesics : Combination analgesics :

acetaminophen/aspirin/caffeineacetaminophen/aspirin/caffeine– Neuroleptics/antiemetics : Neuroleptics/antiemetics :

metoclopramide, prochlorperazinemetoclopramide, prochlorperazine

Specific Specific – Ergotamine/DHE Ergotamine/DHE – Triptans : sumatriptan, Triptans : sumatriptan,

zolmitriptanzolmitriptan– CGRP antagonist :olcegepant, CGRP antagonist :olcegepant,

MK-0974MK-0974

Non-specificNon-specific– NSAIDs : naproxen, ibuprofenNSAIDs : naproxen, ibuprofen– Combination analgesics : Combination analgesics :

acetaminophen/aspirin/caffeineacetaminophen/aspirin/caffeine– Neuroleptics/antiemetics : Neuroleptics/antiemetics :

metoclopramide, prochlorperazinemetoclopramide, prochlorperazine

Specific Specific – Ergotamine/DHE Ergotamine/DHE – Triptans : sumatriptan, Triptans : sumatriptan,

zolmitriptanzolmitriptan– CGRP antagonist :olcegepant, CGRP antagonist :olcegepant,

MK-0974MK-0974

Migraine PreventionMigraine Prevention Classes of preventive drugs:Classes of preventive drugs:

– Antiepileptics : topiramate, valproate, Antiepileptics : topiramate, valproate, gabapentin gabapentin

– Tricyclic antidepressant : amitryptyline, Tricyclic antidepressant : amitryptyline, nortriptylinenortriptyline

– SNRI : venlafaxine, duloxetineSNRI : venlafaxine, duloxetine

– Beta-blockers : propanololBeta-blockers : propanolol

– Calcium channel blockers : flunarizineCalcium channel blockers : flunarizine

– Other treatment : magnesium, riboflavin, co-Other treatment : magnesium, riboflavin, co-enzyme Q10, feverfew, butterbur root, botulinum enzyme Q10, feverfew, butterbur root, botulinum toxin toxin

– No efficacy : nimodipine, clonidine, fluoxetineNo efficacy : nimodipine, clonidine, fluoxetine

Tension-type HeadacheTension-type Headache

TensionTension--type headache type headache ((TTHTTH))

-- Headache lasting from 30 minutes to 7 daysHeadache lasting from 30 minutes to 7 days-- Headache has at least 2 of the following characteristicsHeadache has at least 2 of the following characteristics::

- - BilateralBilateral locationlocation- - PressingPressing//tighteningtightening ((nonnon--pulsatingpulsating) ) qualityquality- - Mild or moderateMild or moderate intensity intensity- Not aggravated by routine physical activity such as - Not aggravated by routine physical activity such as walking or climbing stairswalking or climbing stairs

-- Both of the followingBoth of the following::- No nausea or vomiting - No nausea or vomiting ((anorexia may occuranorexia may occur))- No more than one of photophobia or phonophobia- No more than one of photophobia or phonophobia

-- Not attributed to another disorderNot attributed to another disorder  

TTH managementTTH management

Simple analgesic : acetaminophen, aspirin, Simple analgesic : acetaminophen, aspirin, NSAIDsNSAIDs

Behavioral approach : relaxationBehavioral approach : relaxation Triptans in pure TTH are not helpfulTriptans in pure TTH are not helpful For chronic TTH : amitryptylineFor chronic TTH : amitryptyline

Cluster HeadacheCluster Headache• Severe unilateral painSevere unilateral painAssociated with Associated with lacrimation, sweating, lacrimation, sweating, ptosis, conjunctival ptosis, conjunctival injection, and eyelid injection, and eyelid edemaedema• May be precipitated May be precipitated by alcohol, histamine, by alcohol, histamine, or nitroglycerineor nitroglycerine

Cluster HeadacheCluster Headache

A. At least 5 attacks fulfilling criteria B-DB. Severe or very severe unilateral orbital, supraorbital and/or

temporal pain lasting 15-180 minutes if untreatedC. Headache is accompanied by at least 1 of the following:

- Ipsilateral conjunctival injection and/or lacrimation- Ipsilateral nasal congestion and/or rhinorrhea- Ipsilateral eyelid edema- Ipsilateral forehead and facial sweating- Ipsilateral miosis and/or ptosis

A sense of restlessness or agitationD. Attacks have a frequency from 1 every other day to 8/dayE. Not attributed to another disorder

Treatment of Cluster Treatment of Cluster HeadacheHeadache

Acute treatmentAcute treatment

100% Oxygen inhalation100% Oxygen inhalationRapid acting DHERapid acting DHESumatriptan subcutaneouslySumatriptan subcutaneously

Cluster Headache Preventive Cluster Headache Preventive TreatmentTreatment

Short-termShort-term– Prednisolone 1 mg/kg/d tapering over 21 daysPrednisolone 1 mg/kg/d tapering over 21 days– VerapamilVerapamil– Greater occipital nerve injectionGreater occipital nerve injection

Long-termLong-term– verapamilverapamil– LithiumLithium– TopiramateTopiramate– GabapentinGabapentin– melatoninmelatonin

Thank you for your Thank you for your attentionattention