neurological lectures...headaches
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Neurological lectures...Headaches http://yassermetwally.com http://yassermetwally.netTRANSCRIPT
Classification of Professor Yasser
• Primary headaches• OR Idiopathic headaches
– THE HEADACHE IS ITSELF THE DISEASE
– NO ORGANIC LESION IN THE BEACKGROUND
– TREAT THE HEADACHE!
••
Classification of headachesProfessor Yasser Metwally
Secondary headachesOR 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”)
HISTORY AND EXAMINATIONS SHOULD CLARIFY IF
THE PATIENT HAS PRIMARY OR SECONDARY HEADACHE IS THERE ANY URGENCYIN CASE OF PRIMARY HEADACHE ONLY THE HEADACHE ATTACKS SHOULD BE TREATED („ATTACK THERAPY”), OR PROPHYLACTIC THERAPY IS ALSO NECESSARY („PREVENTIVE THERAPY, INTERVAL
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, SYMPTOMATIC HEADACHES
THE HEADACHE IS A SYMPTOM OF AN UNDERLYING DISEASE, LIKE
Brain tumor, meningeal carcinomatosis
• Secondary headache disorders
Headache attributed to ...5. head and/or neck trauma6. cranial or cervical vascular disorder7. non-vascular intracranial disorder8. a substance or its withdrawal9. infection
10. 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
Secondary headache disorders
5. head and/or neck trauma6. cranial or cervical vascular disorder
vascular intracranial disorder8. a substance or its withdrawal
10. disorder of homoeostasis11. disorder of cranium, neck, eyes, ears, nose,
sinuses, teeth, mouth or other facial or cranial
cranial neuralgias and central causes of facial
Primary, idiopathic headaches
• Tension type of headache• Migraine• Cluster headache• Other, rare types of primary
headaches
Primary, idiopathic headaches
Tension type of headache
Other, rare types of primary
Treatment of tension type of headache
• Acute, episodic form:mg ASA, paracetamol, or noraminophenazon
• Indication of prophylactic treatmenttype of headache in at least 14 days per moth
Treatment of tension type of headache
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
Maximal dose should not be more than 75 mg/day Change to other tricyclic antidepressant only after 6
weeks Ask the patient to use headache diary Use the tricyclic antidepressant for 6 Decrease the dose gradually
Prophylactic treatment of the chronic tension type of headache
Tricyclic antidepressants
25 mg) and increase the dose if no beneficial effect after 1-2 weeksMaximal dose should not be more than 75 mg/dayChange to other tricyclic antidepressant only after 6-8
Ask the patient to use headache diaryUse the tricyclic antidepressant for 6-9 monthsDecrease 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
First choice of drug: amitryptiline (Teperin tabl, 25 mg)
1st week: 25 mg in the evening2nd week: 50 mg in the evening3rd week: 75 mg in the evening continuouslyChange 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)
Common side effects of tricyclic antidepressants
Anticholinergic side effects:
Urinary retention (in prostate hyperplasia!!!)Increased intraocular pressure (glaucoma!!!)
Sleepiness or hyperactivitySerotonine 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
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)
Psychotherapy, psychological treatments, biofeedback, behavioral therapy, relaxation
Migraine: epidemiology• Life-time prevalence 10%• 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: epidemiologytime prevalence 10%-12%
1% chronic migraine (>15 days/months)Sex ratio 2.5 (f) to 1 (m); in childhood 1 to 1Mean frequency 1.2/monthMean duration 24 h (untreated) 10% always with aura, >30% sometimes with
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: pathophysiology
, hormonal influenceActivation of brainstem nuclei by trigger factorsNeurovascular inflammation of intracranial
Impaired antinociception„Spreading Depression“ as mechanism of aura
Migraine classification
1.1 migraine without aura1.2 migraine with aura1.3 periodic syndromes in childhood1.4 retinal migraine1.5 migraine complications1.6 probable migraine
Migraine classification
1.1 migraine without aura1.2 migraine with aura1.3 periodic syndromes in childhood
1.5 migraine complications
Migraine• 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 +
– VISUAL– SENSORY– MOTOR– SPEECH DISTURBANCE
before migraineous headache• AURA SYMPTOMS
– USUALLY<1/2 HOUR– LESS THAN 1 HOUR
MIGRAINE WITH AURA• DURING AURA:
– VASOCONSTRICTION – HYPOPERFUSION
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 DEPRESSION
MIGRAINE WITH AURA• 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
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%!IS ABOUT 25%).
IMPORTANT TO KNOW! MIGRAINE WITH AURA
RISK FACTOR FOR ISCHAEMIC STROKETHEREFORE PATIENTS SUFFERING FROM
SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!!
PROPROTION OF PATENT FORAMEN IN PATIENTS WITH MIGRAINE WITH
55%! (IN THE POPULATION
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!
Is there a relationship between aura and patent foramen ovale
Paradoxic emboli theory is not likelyShunting of venous blood to the arterial side could be the
no breakdown of certain neurotransmitters
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
Treatment of migraine attack
• Try to sleep• Antiemetics• Analgetics• Ergot derivatives• Triptans
Treatment of migraine attack
Ergot derivatives
Treatment of migraine attackI. 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 attackI. Antiemetics
1. Metoclopramid (Cerucal tabl 10 mg)
2. Domperidon (Motilium tabl 10 mg)
Treatment of migraine attackII. 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– Diclofenac (Voltaren, Cataflam etc)– Naproxen (Naprosyn, Apranax) 250
Treatment of migraine attackII. Analgetics
2. Paracetamol (Rubophen, Panadol, etc)
Ibuprofen (Ibuprofen, Humaprofen, etc) 400-800 mg per os Diclofenac (Voltaren, Cataflam etc)50 mg per osNaproxen (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
1. Ergotamin tartarate4 mg per os, sublinguali or rectal
2. Dihydrergotamin (Neomigran) nasal spray
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
acetylsalicilate + metoclopramid
aminophenazon+coffein+drotaverin
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, suppGlaxo)
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)
Treatment of migraine attack V. Triptans
50 and supp,
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
Kleine Beecham) 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
The ideal triptan
Rapid onsetNo recurrenceGood consistencyDifferent applicationsGood tolerabilityNo interactions
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
Very severe migraine attack / status migrainosus:
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
Strategy of treatment of migraine attacks
Step care accross or within attacks
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:• Stop of prophylactic treatment
within 4 weeks• Use headache diary• INFORM THE PATIENT ABOUT THE
PROPHYLACTIC TREATMENT!!!
Prophylactic treatment of migraine attacks
At least one long (>4 days) attack/month
Start of prophyalactic treatment: graduallyDuration of prophylactic treatment: 2-9 monthsStop of prophylactic treatment: gradually,
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
Aims of prophylactic treatment of migraine
To decrease the frequency of attacksTo decrease the intensity of the painTo 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
Prophylactic treatment of migraine
blockers (propranolol)Calcium channel blockers (flunarizine)Antiepileptics (valproic acid)Tricyclic antidepressants (amitriptyline)Topiramate (Topamax)
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?
Other prophylactic treatment of migraine
Regular, not exhausting physical activitiesCognitive behavioral therapy
Avoid the precipitating factors
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 and pregnancyMigraine without aura in >70% of women less frequent or absent (prognostic factor: menstrual
Significantly more manifestation of migraine
Acute treatment: paracetamol; NSAIDs in
Prophylaxis: magnesium, metoprolol,
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 I
Sex ratio 1:1 (boys with good prognosis)Abdominal symptoms often predominantSemiology of attacks as in adulthood except shorter duration of attacksShort 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
mg
• Prophylaxis:–Flunarizine 5-10 mg–Propranolol 80 mg
Migraine in childhood II
First choice: ibuprofen 10 mg/kgSecond choice: paracetamol 15 mg/kgThird choice: sumatriptan nasal spray 10-20
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• 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 sidein 45 degree
Treatment of cluster attackOxygen:7 liters/min 100% oxigén for 15 minutes
Effective in 75% of patients within 10 minutesSumatiptan 6 mg s.c., 50-100 mg per osErgot derivatives (lot of side effects)Anaesthesia of the ipsilateral fossa sphenopalatina)
1 ml 4% Xylocain nasal dropThe head is turned back and to the ipsilateral side
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 episodic form of cluster headache
Epizodic form: prednisolon
10. days daily 30 mg 15. days daily 20 mg 20. days daily 15 mg25. days daily 10 mg30. days daily 5 mg
• 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
Can be decreased after 2 weeks remissionControl of serum level is necessary
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)
3. Cluster headache and autonomic cephalgias
autonomic cephalgias
Cluster headacheParoxysmal hemicrania
syndrome(Hemicrania continua)
Headache of cervical origin• Lidocain infiltration• NSAID: 50-150 mg indomethacin, 20
piroxicam (Hotemin, Feldene), etc• Surgical methods (CV
vertebrae)• Other methods (physiotherapy, TENS)
Headache of cervical origin
150 mg indomethacin, 20-40 mg piroxicam (Hotemin, Feldene), etcSurgical methods (CV-CVII fusion of
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
the dose after 1-2 weeks to 10 mg!!! – Diagnosis: STA biopsy. – BUT Start the steroid before results of biopsy!!!– We, pain decrease
Arteriitis temporalisArteriitis temporalis (age>50y, We>50 mm/h)Autoimmune disease, granulomatose inflammation of
Pulsating pain, more severe at night
inflammation of internal maxillary arteryWeakness, loss of appetite, low fever, Danger of thrombosis of ophthalmic or ciliary artery!!!Amaurosis fugax may precede the blindness
60 mg methylprednisolone – decrease 2 weeks to 10 mg!!!
Start the steroid before results of biopsy!!!
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 ipsilateral abducent nerve and facial pain around the ear and forehead
Facial painsHunt syndrome (ophthalmoplegia
granulomatose inflammation in cavernous sinus, superior orbital fissure –
Gradenigo’s syndrome: otitis media –inflammation of apex of petrous bone – lesion of ipsilateral abducent nerve and facial pain around
Carotid dissection• After neck trauma, extensive neck turning• Neck pain• Horner’s syndrome• Diagnosis: carotid duplex, MRI
Carotid dissectionAfter neck trauma, extensive neck turning
Diagnosis: carotid duplex, MRI-T2