Слайд 1Approach to Headaches
AIMGP Seminar
April 2004
Gloria Rambaldini
Слайд 2 mechanisms of headache
1. Traction or dilatation of intracranial or
extracranial arteries.
2. Traction of large extracranial veins
3. Compression, traction or
inflammation of cranial and spinal nerves
4. Spasm and trauma to cranial and cervical muscles.
5. Meningeal irritation and raised intracranial pressure
6. Disturbance of intracerebral serotonergic projections
Слайд 3Origins of Pain in the Head
Extra-cranial pain sensitive structures:
Sinuses
Eyes/orbits
Ears
Teeth
TMJ
Blood
vessels
Intra-cranial pain sensitive structures:
Arteries
Veins
Meninges
Dura
Слайд 4Classification of Headaches
PRIMARY - NO structural or metabolic abnormality:
Tension
Migraine
Cluster
SECONDARY –
structural or metabolic abnormality:
Extracranial: sinusitis, otitis media, glaucoma, TMJ ds
Inracranial:
SAH, vasculitis, dissection, central vein thrombosis, tumor, abscess, meningitis
Metabolic disorders: CO2 retention, CO poisoing
Слайд 5HISTORY
Headache Characteristics:
Temporal profile: acute vs chronic, frequency
Location and radiation
Quality
Alleviating and
exacerbating factors
Associated symptoms
Constitutional symptoms
PMH: HTN, DM, hyperlipidemia, smoking
Слайд 6RED Flags
New onset headache in a patient >50 y.o.
Sudden, worst
headache of one’s life
Morning headache associated with N/V
Fever, weight loss
Worsens
with valsalva maneuvers
Focal neurologic deficits, jaw claudication
Altered LOC
Hx of trauma, cancer or HIV
Слайд 7Physical Exam
Blood pressure
Fundoscopy
Auscultation for bruits in H/N
Temporal artery inspection and
palpation
Meningismus
Neurologic exam: motor, sensory, coordination and gait
Слайд 8MIGRAINE Headaches
Affects 15% of the general population
Female > Males
Family History
present in 70%
Pathophysiology: vascular vs neurologic
Precipitants: caffeine, chocolate, alcohol, cheese,
BCP/HRT, menses, stress
Слайд 9MIGRAINE Headaches
Diagnostic criteria:
1. 5 attacks in 6 months
2. Headaches lasting
4-72 h with >/= 2:
- unilateral
- pulsatile
- moderate to severe
in intensity
- aggravated by activity
3. Associated with >/= 1:
- nausea/vomiting
- photophobia/phonophobia
Слайд 10MIGRAINE Headaches
Subtypes:
Auras – visual or sensory
Scintillating scotoma
Fortification spectra
Ophthalmoplegic
CN III palsy
Vertbrobasilar
hemiplegic
Слайд 11Visual Auras: Patient drawings
Scintillating Scotomas
Progression of a typical aura over
30 minutes
BMJ 2002; 325:881-6
Слайд 12MIGRAINE: Acute Treatment
Mild attacks: NSAIDS +/- dopamine antagonists
eg. ASA 650-1300
mg q4h + metoclopromide 10 mg PO/IV
Moderate attacks:
NSAIDS (ibuprofen 400-800
mg PO q2-6h)
5-HT1 receptor agonists
Selective – sumatriptan 50-100 mg PO
Nonselective – ergot 1-2 mg PO q1h x 3
CMAJ 1997; 156: 1273-87
Слайд 13MIGRAINE: Acute Treatment
Severe & Ultra-severe attacks:
First line:
DHE 0.5-1 mg q1h
IM/SC/IV
sumatriptan 50-100 mg PO or 6 mg SC
Second line:
chlorpromazine
50 mg IM
Prochlorperazine 5-10 mg IV/IM
dexamethasone 12-20 mg IV
CMAJ 1997; 156: 1273-87
Слайд 14MIGRAINE: Prophylaxis
Consider if >/3 attacks/month, impaired quality of life:
B-blockers
Calcium channel
blockers
TCA (amitriptyline)
NSAIDS
Valproic acid
5HT2 Antagonists (methysergide, pizotyline)
CMAJ 1997; 156: 1273-87
Слайд 15TENSION Headaches
Most common type, typically brought on by stress, lasting
30 min to 7 d
Diagnostic Criteria >/= 2:
Pressing/tightening, non-pulsating
Mild-moderate
Bilateral
Not worsened
by ADLs
Photo or phonophobia (not coincident)
Not associated with N/V
Treatment: reassurance, NSAIDS
Слайд 16CLUSTER Headaches
Age of onset 25-50 y.o., M>F
Features:
Attacks clustered in time
(>5)
Severe unilateral, orbital or temporal pain
Lasting 15 min – 3
h
Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead/facial swelling, miosis, ptosis
Treatment:
Acute: O2, 5HT1 antagonists, DHE
Prophylaxis: Calcium Channel Blockers, ergots, Li
Слайд 17Medication Induced Headaches
Rebound headaches due to overuse of analgesics or
prophylactic meds
25% of patients referred to neurologists for ‘intractable’ headaches
have medication-overuse or medication-induced headaches
Слайд 18Giant Cell Arteritis
Chronic granulomatous vasculitis affecting the arteries originating from
the aortic arch
18/100 000 persons >50 y.o.
Features:
Headache 2/3 of patients
Fever, weight loss, malaise
Scalp tenderness
Jaw claudication
Diplopia
PMR related Sx (50% of GCA patients have PMR)
Слайд 19Giant Cell Arteritis
Physical Exam:
BP and pulse deficits in arms
Fundoscopy
Temporal Artery:
beaded , prominent , tender
H/N and subclavian bruits
MSK exam
Investigations:
Normocytic
normochromic anemia
ESR (typically > 50)
TA biopsy
JAMA 2002; 287(1): 92-101
Слайд 20Giant Cell Arteritis
Diagnostic Criteria – 3/5 (Sn 94%, Sp 91%)
Age
> 50 y.o.
New onset headache
TA tender +/- decreased pulse
ESR >
50
Bx: necrotizing granulomatous arteritis
Слайд 21Giant Cell Arteritis
Treatment:
Prednisone 40-80 mg PO od until symptoms
resolve and ESR normalizes
Once in remission decrease dose by 10%
q1-2w
Osteoporosis prevention: vitamin D and calcium +/- bisphosphonate
AIM 2003; 139:505-515
Слайд 22Case 1
A 28 y.o. woman is referred to you for
management of her headaches
Headaches are described as right-sided pounding, with
associated nausea and photophobia
Aggravated by activity
ASA and Tylenol have not provided relief
What next?
Слайд 23Case 2
A 72 y.o. woman presents with a four month
history of a bitemporal headache with aching and morning stiffness
of her shoulders
She has noted a low grade fever and some weight loss
What next?
Слайд 24Case 3
A 62 y.o. man is referred for new onset
headaches
For the last 4 weeks he has awoken with a
diffuse headache and nausea
What next?
