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

Unilateralis
Severe
Pulsating
Physical activity
aggravates

Accompanying signs 1/2

Photophobia and
phonophobia
Nausea, or vomitus

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

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 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%! (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

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)

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, tachycardia

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

Use: if tension type of headache is

present besides migraine
Do not use: see above
Few side effects, but
Pregnancy 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
Acupuncture?

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% 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)
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
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