Introduction to Clinical Neurology

Headache

Daniel Lowenstein, MD Andy Josephson, MD Wade Smith, MD, PhD

Dan Lowenstein, MD
! Robert B. and Ellinor Aird Professor of Neurology ! Director, UCSF Epilepsy Center ! Department of Neurology, UCSF School of Medicine ! Potential Conflicts of Interest !! None

Learning Objectives

Learning Objectives
o! Describe the major clinical features of migraine, tension

headache, cluster headache, and trigeminal neuralgia. primary headache disorders.

o! Explain the principles of acute and prophylactic therapy for o! Describe the clinical features of the worrisome headache. o! Describe the presentation and acute therapeutic

considerations for patients with giant cell (temporal) arteritis, tumor-associated headache with intracranial hypertension, and subarachnoid hemorrhage.

Introduction

The treatment of headache in 1200 BC

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From the World Health Organization (2012)

o! Global prevalence among adults of current headache disorder

(symptomatic at least once within the last year) is 47%.

o! Half to three quarters of the adults aged 1865 years in the world

have had headache in the last year and among those individuals, more than 10% have reported migraine. worlds adult population.

o! Headache on 15 or more days every month affects 1.74% of the o! Despite regional variations, headache disorders are a worldwide

problem, affecting people of all ages, races, income levels and geographical areas.

The most important question of all!

New

Old

Primary
Headache Disorders

! Migraine ! Tension-type ! Cluster ! Trigeminal neuralgia ! Tumor-associated ! Giant cell (temporal) arteritis ! Subarachnoid hemorrhage

Secondary
Headache Disorders

Primary Headache Disorders

hemicrania hemicranium hemigranea migranea mygrame migraine

Ty p i c a l c l i n i c a l f e a t u r e s o f ( c l a s s i c ) migraine with aura

o! Visual disturbances or other focal symptoms o! Hemicranial, throbbing, or dull/deep headache o! Nausea and vomiting o! Photophobia o! Sensitivity to noise o! Positive family history

Migraine

<--hours to 1-3 days-->"

Timeline of migraine and clues to pathogenesis

(from Andrew Charles, MD, David Geffen School of Medicine at UCLA)

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Pain pathways in migraine

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Ty p i c a l c l i n i c a l f e a t u r e s o f ( c o m m o n ) migraine without aura

o! Throbbing or dull/deep headache o! Nausea and vomiting o! Photophobia o! Sensitivity to noise o! Positive family history

Diagnostic criteria for migraine

(International Headache Society - 2005)

A.! At least 5 attacks B.! Attack lasts 4-72h C.! At least 2 of the following:
! ! ! ! ! ! ! ! ! Unilateral Pulsating Moderate or severe intensity Aggravation by or avoidance of routine activity Nausea Vomiting Photophobia Phonophobia Osmophobia

D.! Accompanied by at least two of the following:

E.! Not attributed to another disorder

Migraine therapy: Identification of precipitants

o! Stress o! Menstruation o! Oral contraceptives o! Glare o! Physical exertion, fatigue o! Lack of sleep o! Hunger o! Foods and beverages containing nitrite, glutamate, salt,

tyramine, etc.

o! Medications

Medical therapy of migraine " Abortive!

Aspirin " NSAIDs" Ergots" Triptan drugs:" Rizatriptan" Zolmitriptan" Almotriptan" Frovatriptan" Sumatriptan "

Prophylactic!
Ergots" NSAIDs" B-blockers" Tricyclic antidepressants" Ca++ channel blockers" Anticonvulsants" and more..." "

Tension-type Headache
(International Headache Society - 2005)

A.! Headache lasting from 30min to 7days (may be episodic or chronic) B.! At least 3 of the following:
! Bilateral ! Pressing/tightening (non-pulsating) quality ! Mild or moderate intensity ! Not aggravated by routine physical activity

C.! No nausea, vomiting, photophobia or phonophobia D.! Not attributed to another disorder

Treatment: J%$8;;(3#'#1838'%4(7&/';8C0'14(@J@4(DJ@TO;4( +0&588)+#7E4(#')(U&77.V(#'G)8L$8;;#'%;(&$(#'M0&C,G7;( !

Clinical features of cluster headache

o! Usually males, age 20-50 o! Unilateral, periorbital pain o! Circadian rhythmicity o! Unilateral autonomic symptoms o! Alcohol sensitivity o! Clustering of attacks

Cluster

<--hours-->"

Medical therapy of cluster headaches

o! Triptans o! Prednisone o! Ca++ channel blockers o! Ergots o! Oxygen o! Lidocaine o! Lithium

Trigeminal neuralgia

Clinical features of trigeminal neuralgia (tic douloureux)

o! Electric shock-like, staccato volleys of pain o! Presence of trigger sites o! Unilateral pain, V2/V3 >>> V1 o! No other neurologic deficit

<--minutes-->"

Therapy of trigeminal neuralgia

Medical
o! o! o! o!

Carbamazepine Lamotrigine Valproate Amitriptyline

Surgical
o! Decompression of vessel

over the nerve o! Selective ablation

W(

Secondary Headache Disorders

Features of the
! ! ! ! ! ! ! ! ! ! ! ! !

Wo r r i s o m e

Headache

First, worst, abrupt Onset age > 50 In setting of major medical illness Worse in AM or with Valsalva Nausea and vomiting Awakens from sleep Trauma or neurosurgery Progressive Seizure LOC Fever Stiff neck Abnormal neuro exam

Tumor-associated headache

o! Dull, non-throbbing o! Intermittent but slowly increasing o! Worsened by exertion or change in posture o! Disturbs sleep o! Associated with nausea and vomiting

Tumor-associated headache

Clinical features of giant cell (temporal) arteritis

F > M, age 50-85 (average 70)

Headache Temporal artery tenderness Jaw claudication Thickened or nodular temporal artery Visual symptoms Polymyalgia rheumatica ESR > 50mm/hr Hematocrit < 35% Abnormal liver function 85% 70 65 45 40 40 95 50 50

Giant cell (temporal) arteritis

Tr e a t m e n t o f g i a n t c e l l ( t e m p o r a l ) a r t e r i t i s

(for now!)

Clinical features of subarachnoid hemorrhage

o! Sudden, explosive, excruciating headache o! Neck stiffness o! Vomiting o! Changing level of consciousness

Subarachnoid hemorrhage

<--Minutes-->"

Subhyaloid hemorrhage

!uspect SAH $et CT is nega%ve# " must do LP#

Management of raised ICP

o! Intubate and hyperventilate (pCO2 = 25) o! Osmotic agents o! Raise head of bed o! Limit IV fluids o! Call a consultant (neurologist,

neurosurgeon, or neurointerventionalist)

Summary

Migraine Headaches"

Cluster headache"

Trigeminal neuralgia"

Giant cell (temporal)" arteritis"

Tumor"

Subarachnoid "