International Headache Society (IHS) Classification of Headaches
• PRIMARY HA’s (Benign HA disorders):
- Migraine (with or without aura)
- Chronic Migraine
- Tension type
- Cluster HA
- Post-traumatic HA – Drug rebound HA
- Other
• SECONDARY HA (Headaches that are a sign of organic disease)
Headache History Part 1
• Need good general health history
• HEADACHE HISTORY: – How many types of HA? – Frequency a) Previous b) Current c) Mode of increase: gradual or sudden
• PAIN: – Intensity – Location – Duration – Impact of exertion
• PRODROME: – Changes in energy levels, mood, appetite – Fatigue – Muscle aches – Aura
• ASSOCIATED SYMPTOMS: – Nausea – Vomiting – Anorexia – Photophobia – Phonophobia – Diarrhea – Stuffy/Runny Nose – Watery eyes – Ptosis/Miosis – Dizziness – Behavior a) Retreats to dark room b) Paces c) Rocks
Headache History Part 2
• TRIGGERS: – Hormones (menstrual cycle, OC’s, HRT) – Diet – Stress – Environmental changes – Sensory stimuli
• CURRENT AND PREVIOUS MEDICATIONS TRIED:
– For both prophylactic and abortive therapy
– Dosages
– Effectiveness
– Side effects
• GOOD MEDICATION/ SURGICAL HISTORY: – Co-morbidities a) Sleep disturbance, Mood disturbance – Other medications – Head Trauma – Previous LOC – Seizure D/O – Allergies
• FAMILY/ SOCIAL HISTORY: – Family illnesses a) IncludingHA’s – Habits – Occupation
Headache Exam
• GOOD GENERAL EXAMINATION: – Vital signs (particularly BP/Pulse) – Cardiac Status – Extracranial structures – ROM & presence of pain in C-spine
• NEUROLOGICAL EXAM: – Neck flexion – Presence of bruits over the head and neck – Optic fundi, pupils, visual fields – Thorough cranial nerve exam – Motor power in limbs – Muscle reflexes – Plantar responses – Sensory exam – Coordination – Gait
Worrisome Signs
• SIGNS WHICH MAY INDICATE HA OF PATHOLOGICAL ORIGIN (SecondaryHA):
– “Worst HA”
– Onset of HA after age 50
– Atypical HA for patient
– HA with fever
– Abrupt onset (max. intensity in sec. to min.)
– Subacute HA with progressive worsening over time
– Drowsiness, confusion, memory impairment
– Weakness, ataxia, loss of coordination
– Paresthesias / Sensory loss / Paralysis
– Abnormal medical or neurological exam
When a Brain is insulted, it does 3 things:
1) Swell
2) Bleed
3) Seize
Diagnostic Evaluation
• Lab testing (appropriate for variant or atypical forms) • Neurodiagnostic tests • Other WSR, TSH, CBC, glucose -CT, MRI/MRA, EEG, L.P., arteriogram -Dental, ENT, allergy evaluation
To Image or Not to Image
- As a general rule, many physicians (including neurologists) believe that any person with HA should have a ONE-TIME, thorough neuroimaging study (CT head with and w/o contrast or MRI of the head).
- Clearly, any patient with a “WORRISOME HISTORY” or abnormal examination needs an urgent imaging study and perhaps even an L.P. and possibly arteriogram. (Remember: CT CAN MISS 5-10% OF SUBARACHNOID HEMORRHAGES and an L.P. MAY BE NEEDED if the CT is NORMAL!)
Primary HA Disorders
1) COMMON Migraine
– (migraine without aura)
2)CLASSIC Migraine
– (migraine with aura)
(Consider CHRONIC migraine)
3) TENSION-Type HA
4) CLUSTER HA
Common Migraine
- Intensity: MODERATE TO SEVERE
- Disability: Inhibits or prohibits daily activities; pain aggravated by activity
- Age of onset: late teens to early 20’s; prevalence PEAKS between 35-40 YEARS!!!!
- Gender ratio F:M = 3:1!!!!!!!
- Frequency: 1-4 attacks per mo. (occ infreq.) – but 14 days or fewer per month
- Duration: 4 to 72 hr, usually 12-24 hr.
- Location: UNILATERAL OR BILATERAL
- Description: THROBBING/ SHARP/ PRESSURE
- Prodrome: Mood changes, myalgias, food cravings, sluggishness, excessive yawning
- Postdrome: Fatigue, irritability, “fog”
- Behavior: RETREAT TO DARK, QUIET ROOM
• Aura: NONE!!!!!
– Note: 80-90% of migraine sufferers DO NOT experience an aura!!!
Associated Symptoms of a Common Migraine
• MOST COMMON: – Nausea (90%) – Vomiting (33%) – Photophobia – Photophobia
• LEAST COMMON: – Diarrhea – Conjunctival injection – Stuffy nose – Lacrimation – Miosis – Ptosis
Classic Migraine
• AURA:
– Usually lasts 15-30 MIN., but sometimes longer.
– Commonly VISUAL SYMPTOMS (e.g. scintillations, scotoma – often hemianopic), BUT CAN BE ANYTHING NEUROLOGICAL
Chronic Migraine
- Many patients with EPISODIC MIGRAINE will ultimately develop CHRONIC MIGRAINE.
- H/o headaches consistent with migraine, now with headache 15 OR MORE DAYS PER MONTH , headache lasting 4 HOURS OR LONGER, for a period of at least 3 MONTHS, not attributed to another disorder.
What Causes Migraines?
- The most widely discussed theory is that migraine is caused by “NEUROGENIC INFLAMMATION.”
- The trigeminal nerve becomes activated, releasing neuropeptides, causing painful neurogenic inflammation within the meninges, with subsequent effect on the dural vasculature (vasodilation, plasma protein extravasation, and mast cell degranulation).
Tension- Type Headache
- Intensity: MILD TO MODERATE
- Disability: May inhibit, but DOES NOT PROHIBIT DAILY ACTIVITIES
- Age of onset: Variable; generally peak incidence 20-40 yr.
- Gender ratio F:M = 3:2
• Frequency:
– EPISODIC Type: 15 days/month
a) ??? Analgesic Rebound HA’s
• Duration:
– EPISODIC Type: SEVERAL Hours
– CHRONIC Type: ALL DAY, waxing and waning
- Location: BIFRONTAL, BIOCCIPITAL, neck, shoulders, band-like
- Description: DULL, ACHING, SQUEEZING, PRESSURE
- NO PRODROME OR AURA
- Behavior generally not affected
Cluster Headaches
- Intensity: SEVERE, EXCRUTIATING
- Disability: Prohibits daily activities
- Age of onset: 20’s to 50’s
- Gender ratio F:M = 1:6!!!!!!!!!
- RECENT ASSOCIATION WITH OBSTRUCTIVE SLEEP APNEA!!!!!!!!!!
• Monthly Frequency
– EPISODIC Type: 1 or more attacks/day for 6-8 wk.
– CHRONIC Type: several attacks per week without remission
- Duration: 30 minutes to 2 hr.
- Location: 100% UNILATERAL; generally ORBITOTEMPERAL!!!!!
- Description: Nonthrobbing, excruciating, sharp, boring, PENETRATING
- Prodrome: may include brief mild burning in ipsilateral inner canthus or internal nares
- NO AURA!!!
- Behavior: FRENTIC, PACING, ROCKING
• Associated Symptoms:
– IPSILATERAL PTOSIS, MIOSIS, CONJUNCTIVAL INJECTION, LACRIMATION, STUFFER OR RUNNY NOSE
Headache Triggers
• HORMONES:
– Menses, ovulation, HRT, OC’s
• DIET:
– Alcohol (esp. beer, red wine), chocolate, aged cheeses, MSG, aspartame, caffeine, nuts, nitrates/nitrites, citrus fruits, others
• CHANGES:
– Weather, seasons, travel, altitude, schedule, sleep pattern (too little, too much, or change from usual pattern),
diet, skipping meals
• STRESS:
– Let down periods, times of intense activity, major life change / stress
• SENSORY STIMULI:
– Bright or flickering lights, odors
Acute Treatment of Migraines
- OTC analgesics
- NSAID’s – e.g. Naproxen, Ketorolac, Diclofenac
- Isometheptene (Midrin)
- Butalbital (Fiorinal, Fioricet)
- Opioids – e.g. demerol, morphine, codeine, oxycodone, hydrocodone
- DHE nasal spray
• TRIPTANS (5HT1 agonists): – Sumatriptan (Imitrex) – Zolmitriptan (Zomig) – Naratriptan (Amerge) – Rizatriptan (Maxalt) – Almotriptan (Axert) – Frovotriptan (Frova)
Contraindications to Triptan Usage
– Documented or strong risk factors for ischemic heart disease, other cardiovascular, cerebrovascular or peripheral vascular disease, Raynaud’s syndrome, uncontrolled HTN, hemiplegic or basilar migraine, severe renal or hepatic impairment, use within 24 hr. of tx. with ergotamines, MAOI’s, or other 5-HT1 agonists.
Triptans
- NARATRIPTAN (Amerge) 1mg, 2.5mg.–one tablet at onset of HA; may repeat x 1 in 2hr. if needed (max=10mg in 24 hr). Onset of action = 60 min. Longest half-life of triptans and fewest side effects. Contraindicated in pt’s with severe hepatic or renal impairment.
- ZOLMITRIPTAN (Zomig)2.5, 5.0mg.–one tablet at onset of HA; may repeat x 1 in 2hr. if needed (max=10mg in 24 hr). Onset of action = 30-60 min. Low dose recommended in pt’s with hepatic impairment.
• SUMATRIPTAN (Imitrex)
– 25, 50, 100 mg tablets–may take up to 100mg as single dose and repeat x 1 in 2hr. (max = 200mg in 24 hr). Onset of action: 30-60 min.
– 5, 10, 20 mg NS–one spray in one nostril at onset of HA; may repeat x 1 in 2hr. if needed (max= 40 mg
– 6 mg inj.–one injection SQ at onset of HA; may repeat in 1hr. x 1 if needed (max=12mgin24hr) Onset
of action: 10 min.
- RIZATRIPTAN (Maxalt) 5, 10 mg tablets/ MLT–may take one tablet at onset of HA; may repeat x 1 in 24hr. if needed, max. dose = 20 mg in 24 hr. (Note: use 5 mg in patients on propranolol; max. dose = 10 mg in 24 hr.)
- ALMOTRIPTAN (Axert)6.25, 12.5 mg tablets–may take one tablet at onset of HA; may repeat x 1 in 24hr. if needed, max. dose = 25 mg in 24 hr.
- FROVATRIPTAN (Frova) 2.5 mg tablets – may take one tablet at onset of HA; may repeat x 1 in 2 hr. if needed, max. dose = 7.5 mg in 24 hr.
- REMEMBER: If one triptan doesn’t work, try another! Consider nasal spray or injectable if needed.
DHE Protocol (Raskin Protocol)
- Metoclopromide or prochloperazine 10 mg IV over 60 sec. Wait 5 min. to allow distribution.
- Give DHE 0.5 mg IV over 60 sec. Wait 3-5 min.
- May repeat 0.5 mg IV if no relief. May repeat every 8 hr. for short-term use.
- SAME GENERAL CONTRAINDICATIONS AS TRIPTANS
- Side effects: chest pressure, anxiety, speeding or dissociation of thoughts, nausea.
Adjustive Agents in Migraine
• If nausea/ vomiting are a major feature of migraine, considering an antiemetic (often before analgesic medication)
– E.g. metoclopramide, prochlorperazine
- If insomnia is a major feature of migraine, consider a sedative/ hypnotic (e.g.diazepam or temazepam) or major tranquilizer (e.g. thorazine) to help the patient “SLEEP OFF” the migraine.
- A Prednisone taper can sometimes be used to break the cycle of a prolonged migraine or several weeks of frequent migraines.
Preventive Treatment of Migraine
• In general, if the patient is experiencing one or more HA’s per week, consider preventive medication in attempt to decrease the frequency and severity of HA.
• ANTIDEPRESSANTS:
– TCA’s (e.g. amitriptyline, nortriptyline)
– SSRI’s (e.g. fluoxetine, sertraline, escitalopram)
– MAOI’s (e.g. Phenelzineu)
- Beta- Blockers (e.g.propranolol)
- Calcium Channel Blockers (e.g.verapamil)
- Anticonvulsants (e.g. Topiramate, Valproic Acid, Gabapentin)
- Ergot alkaloids (ergotamine + phenobarbital)
- NSAID’s (e.g. ASA, naproxen)
- Muscle relaxants (e.g.tizanidine)
- Methysergide (Sansert)
Preventative Treatment of Chronic Migraine
- Many of the typical medications used for PREVENTION of EPISODIC migraine will also work for chronic migraine (e.g. propranolol, amitriptyline, topiramate, valproic acid).
- BOTOX INJECTIONS – only FDA-approved treatment for chronic migraine 155 units injected into 31 different sites, repeated every 3 months.
a) May see some IMPROVEMENT after 1st treatment, but need MULTIPLE TREATMENTS over 9-12 months to really determine if working. Studies have shown 70-80% improvement.
b) MINIMAL SIDE EFFECTS – typically mild, temporary ptosis; rarely can see widespread effect, ineffectiveness d/t antibody formation.
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Introduction to Pharmacology Lecture (Dr. Segars)24
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Introduction to Pharmacokinetics Lecture (Dr. Segars)47
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Introduction to Pharmacodynamics Lecture (Dr. Konorev)23
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Introduction to Biotransformation, Pharmacogenomics, and Clinical Drug Trials Lecture (Dr. Kruse)28
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TEST #3 Fitzpatrick Pharm of Seizures and Epilepsy63
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TEST #3 Fitzpatrick Opioid and Analgesics44
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TEST #3 Hon Headache33
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TEST #3 Hon Stroke21
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TEST #3 Hon Multiple Sclerosis14
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TEST #3 Hon Seizures and Syncope0
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TEST #3 Disorders of Equilibrium (Dr. Sachen)32
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TEST #3 Stupor and Coma (Dr. Sachen)62
