HeadacheHeadache

ByWael Hamdy Mansy, MD

Assistant Professor of Clinical PharmacyKing Saud University

Classification of headachesClassification of headaches

Primary headachesPrimary headaches OR Idiopathic OR Idiopathic

headachesheadaches

– THE HEADACHE IS THE HEADACHE IS ITSELF THE DISEASEITSELF THE DISEASE

– NO ORGANIC LESION IN NO ORGANIC LESION IN THE BEACKGROUNDTHE BEACKGROUND

– TREAT THE HEADACHE!TREAT THE HEADACHE!

Secondary headachesSecondary headaches OR Symptomatic OR Symptomatic

headachesheadaches

– THE HEADACHE IS ON LY A THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER SYMPTOM OF AN OTHER UNDERLYING DISEASEUNDERLYING DISEASE

– TREAT THE UNDERLYING TREAT THE UNDERLYING DISEASE!DISEASE!

History and examination History and examination should clarify ifshould clarify if

Type of hedeache (1ry or 2ry).Type of hedeache (1ry or 2ry). Is any urgency?Is any urgency? In case of 1ry headache only the In case of 1ry headache only the

headache attacks should be treated headache attacks should be treated “attack therapy, or prophylactic therapy “attack therapy, or prophylactic therapy is also necessary.is also necessary.

SECONDARY, SYMPTOMATIC SECONDARY, SYMPTOMATIC HEADACHESHEADACHES

THE HEADACHE IS A SYMPTOM OF AN THE HEADACHE IS A SYMPTOM OF AN UNDERLYING DISEASE, LIKEUNDERLYING DISEASE, LIKE– HypertensionHypertension– SinusitisSinusitis– GlaucomaGlaucoma– Eye strainEye strain– FeverFever– Cervical spondylosis Cervical spondylosis – AnaemiaAnaemia– Temporal arteriitis Temporal arteriitis – Meningitis, encephalitisMeningitis, encephalitis– Brain tumor, meningeal carcinomatosisBrain tumor, meningeal carcinomatosis– Haemorrhagic stroke…Haemorrhagic stroke…

Primary, idiopathic Primary, idiopathic headachesheadaches

Tension type of headacheTension type of headache MigraineMigraine Cluster headacheCluster headache Other, rare types of primary Other, rare types of primary

headachesheadaches

Tension headacheTension headache

Renamed Renamed tension-type headachestension-type headaches by  by the the International Headache Society in  in 1988, are the most common type of 1988, are the most common type of primary primary headaches. .

The pain can radiate from the neck, back, The pain can radiate from the neck, back, eyes, or other muscle groups in the body. eyes, or other muscle groups in the body.

Tension-type headaches account for Tension-type headaches account for nearly 90% of all headaches. nearly 90% of all headaches. Approximately 3% of the population has Approximately 3% of the population has chronic tension-type headaches chronic tension-type headaches

Tension –type headaches can be Tension –type headaches can be episodic or chronic.episodic or chronic.

Episodic tension-type headaches occur Episodic tension-type headaches occur 15 days a month.15 days a month.

Chronic tension-type headaches 15 days Chronic tension-type headaches 15 days or more a month for at least 6 months.or more a month for at least 6 months.

Can last from minutes to days, months Can last from minutes to days, months or even years, though a typical tension or even years, though a typical tension headache lasts 4-6 hsheadache lasts 4-6 hs

Cluster headacheCluster headache

Nicknamed "Nicknamed "suicide headachesuicide headache", is a ", is a neurological disease that involves an neurological disease that involves an immense degree of pain. immense degree of pain.

"Cluster" refers to the tendency of "Cluster" refers to the tendency of these headaches to occur periodically, these headaches to occur periodically, with active periods interrupted by with active periods interrupted by spontaneous remissions. spontaneous remissions.

The cause of the disease is currently The cause of the disease is currently unknown. It affects approximately 0.1% of unknown. It affects approximately 0.1% of the population, and men are more the population, and men are more commonly affected than women commonly affected than women

Migraine HeadacheMigraine Headache

PrevalencePrevalence

FamilialFamilial Young, healthy women; F>M: 3:1Young, healthy women; F>M: 3:1

– 17 – 18.2% of adult females17 – 18.2% of adult females– 6 – 6.5% adult males6 – 6.5% adult males

2-32-3rdrd decade onset… can occur sooner decade onset… can occur sooner Peaks ages 22-55.Peaks ages 22-55. ½ migraine sufferers not diagnosed.½ migraine sufferers not diagnosed. 94% of patients seen in primary care 94% of patients seen in primary care

settings for headache have migrainessettings for headache have migraines

Common Common misdiagnoses for misdiagnoses for migraine:migraine:– Sinus Headache (HA)Sinus Headache (HA)– Stress HAStress HA

Referral to ENT for Referral to ENT for sinus disease and sinus disease and facial pain.facial pain.

The International Headache Society (IHS) The International Headache Society (IHS) classifies migraine headache classifies migraine headache

The IHS defines the intensity of pain with The IHS defines the intensity of pain with a verbal, four-point scale:a verbal, four-point scale:

NumberNumber PainPain AnnotationsAnnotations

00 NONO

11 MildMild does not interfere with usual does not interfere with usual activities activities

22 ModerateModerate inhibits, but does not wholly inhibits, but does not wholly prevent usual activities prevent usual activities

33 SevereSevere prevents all activitiesprevents all activities

Migraine DefinitionMigraine Definition IHS Diagnostic criteria: migraine IHS Diagnostic criteria: migraine

w/o auraw/o aura– HA lasting for 4-72 hrsHA lasting for 4-72 hrs– HA w/2+ of following:HA w/2+ of following:

UnilateralUnilateral PulsatingPulsating Mod/severe intensity.Mod/severe intensity. Aggravated by routine Aggravated by routine

physical activity.physical activity.– During HA at least 1 of During HA at least 1 of

followingfollowing N/VN/V PhotophobiaPhotophobia PhonophobiaPhonophobia

IHS criteria: Migraine/aura (3 out IHS criteria: Migraine/aura (3 out of 4)of 4)– One or more fully reversible One or more fully reversible

aura symptoms indicates aura symptoms indicates focal cerebral cortical or focal cerebral cortical or brainstem dysfunction.brainstem dysfunction.

– At least one aura symptom At least one aura symptom develops gradually over more develops gradually over more than 4 minutes.than 4 minutes.

– No aura symptom lasts more No aura symptom lasts more than one hour.than one hour.

– HA follows aura w/free HA follows aura w/free interval of less than one hour interval of less than one hour and may begin before or and may begin before or w/aura.w/aura.

History, PE, Neuro exam show no other organic History, PE, Neuro exam show no other organic disease.disease.

At least five attacks occurAt least five attacks occur

Migraine mechanismMigraine mechanism Neurovascular theory.Neurovascular theory.

– Abnormal brainstem Abnormal brainstem responses.responses.

– Trigemino-vascular Trigemino-vascular system.system. Calcitonin gene related Calcitonin gene related

peptidepeptide Neurokinin ANeurokinin A Substance PSubstance P

Extracranial arterial Extracranial arterial vasodilation.vasodilation.– TemporalTemporal– Pulsing pain.Pulsing pain.

Extracranial neurogenic Extracranial neurogenic inflammation.inflammation.

Decreased inhibition of Decreased inhibition of central pain transmission.central pain transmission.– Endogenous opioids.Endogenous opioids.

Important role in Important role in migraine migraine pathogenesis.pathogenesis.

Mechanism of Mechanism of action in migraines action in migraines not well not well established.established.

Main target of Main target of pharmacotherapy.pharmacotherapy.

Aura MechanismAura Mechanism Cortical spreading depressionCortical spreading depression

– Self propagating wave of neuronal and glial depolarization Self propagating wave of neuronal and glial depolarization across the cortexacross the cortex Activates trigeminal afferentsActivates trigeminal afferents

– Causes inflammation of pain sensitive meninges that Causes inflammation of pain sensitive meninges that generates HA through central/peripheral reflexes.generates HA through central/peripheral reflexes.

Alters blood-brain barrier.Alters blood-brain barrier.– Associated with a low flow state in the dural sinuses.Associated with a low flow state in the dural sinuses.

AurasAuras– Vision – most common Vision – most common

neurologic symptomneurologic symptom– Paresthesia of lips, Paresthesia of lips,

lower face and fingers… lower face and fingers… 22ndnd most common most common

– Typical auraTypical aura Flickering uncolored Flickering uncolored

zigzag line in center zigzag line in center and then peripheryand then periphery

Motor – hand and arm Motor – hand and arm on one sideon one side

Auras (visual, sensory, Auras (visual, sensory, aphasia) – 1 hraphasia) – 1 hr

ProdromeProdrome– Lasts hours to days…Lasts hours to days…

MIGRAINE WITH AURAMIGRAINE WITH AURA DURING AURA: DURING AURA:

– VASOCONSTRICTION VASOCONSTRICTION – HYPOPERFUSIONHYPOPERFUSION

DURING DURING HEADACHEHEADACHE– VASODILATIONVASODILATION– HYPERPERFUSIONHYPERPERFUSIONBUT: 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 DEPRESSIONAURA

VASOCONSTRICTION, HYPOPERFUSION

IMPORTANT TO KNOW! IMPORTANT TO KNOW! MIGRAINE WITH AURAMIGRAINE WITH AURA

IS A IS A RISK FACTOR FOR ISCHAEMIC STROKERISK FACTOR FOR ISCHAEMIC STROKE– THEREFORE PATIENTS SUFFERING FROM THEREFORE PATIENTS SUFFERING FROM

MIGRAINE WITH AURAMIGRAINE WITH AURA SHOULD NOT SMOKE!!!SHOULD NOT SMOKE!!! SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!!SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!!

THE THE PROPROTION OF PATENT FORAMEN PROPROTION OF PATENT FORAMEN OVALEOVALE IN PATIENTS WITH MIGRAINE WITH IN PATIENTS WITH MIGRAINE WITH AURA IS ABOUT AURA IS ABOUT 50-55%!50-55%! (IN THE (IN THE POPULATION IS ABOUT 25%).POPULATION IS ABOUT 25%).

Is there a relationship Is there a relationship between aura and patent between aura and patent

foramen ovaleforamen ovale ?? Paradoxic emboli theory is not likelyParadoxic emboli theory is not likely Shunting of venous blood to the arterial side Shunting of venous blood to the arterial side

could be the reason could be the reason no breakdown of no breakdown of certain neurotransmitters (5HT) in the lung!certain neurotransmitters (5HT) in the lung!

Comorbidity could be also an explanation.Comorbidity could be also an explanation.

However, closure of patent foramen ovale However, closure of patent foramen ovale decreases the frequency of migraine decreases the frequency of migraine attacks.attacks.

BUT! Migraine is a benign disease. Please do BUT! Migraine is a benign disease. Please do not indicate closure of patent foramen ovale not indicate closure of patent foramen ovale just because of migraine with aura!just because of migraine with aura!

Migraine SubtypesMigraine Subtypes Basilar type migraineBasilar type migraine

– Dysarthria, vertigo, Dysarthria, vertigo, diplopia, tinnitus, diplopia, tinnitus, decreased hearing, decreased hearing, ataxia, bilateral ataxia, bilateral paresthesias, altered paresthesias, altered consciousness.consciousness.

– Simultaneous bilateral Simultaneous bilateral visual symptoms.visual symptoms.

– No muscular weakness.No muscular weakness. Retinal or ocular Retinal or ocular

migrainemigraine– Repeated monocular Repeated monocular

scotomata or blindness scotomata or blindness < 1 hr< 1 hr

– Associated with or Associated with or followed by a HAfollowed by a HA

Migraine SubtypesMigraine Subtypes

Menstrual migraineMenstrual migraine Hemiplegic Hemiplegic

migrainemigraine– Unilateral motor and Unilateral motor and

sensory symptoms sensory symptoms that may persist that may persist after the headache.after the headache.

– Complete recoverComplete recover Familial hemiplegic Familial hemiplegic

migrainemigraine

Migrainous vertigoMigrainous vertigo Vertigo – sole or prevailing symptom.Vertigo – sole or prevailing symptom. Benign paroxysmal vertigo of childhood.Benign paroxysmal vertigo of childhood. Prevalence 7-9% of pts in referral dizzy and Prevalence 7-9% of pts in referral dizzy and

migraine clinics.migraine clinics. Not recognized by the IHSNot recognized by the IHS Diagnosis (proposed criteria)Diagnosis (proposed criteria)

– Recurrent episodic vestibular symptoms of at least Recurrent episodic vestibular symptoms of at least moderate severity.moderate severity.

– One of the following:One of the following: Current of previous history of IHS migraine.Current of previous history of IHS migraine. Migrainous symptoms during two or more attacks of Migrainous symptoms during two or more attacks of

vertigo.vertigo. Migraine-precipitants before vertigo in more than 50% of Migraine-precipitants before vertigo in more than 50% of

attacks.attacks.– Response to migraine medications in more than 50% Response to migraine medications in more than 50%

of attacksof attacks

Clinical manifestationsClinical manifestations

Clinical manifestationsClinical manifestations– Lateralized in severe Lateralized in severe

attacks – 60-70%attacks – 60-70%– Bifrontal/global HA – 30%Bifrontal/global HA – 30%– Gradual onset with Gradual onset with

crescendo pattern.crescendo pattern.– Limits activity due to its Limits activity due to its

intensity.intensity.– Worsened by rapid head Worsened by rapid head

motion, sneezing, straining, motion, sneezing, straining, constant motion or constant motion or exertion.exertion.

– Focal facial pain, cutaneous Focal facial pain, cutaneous allodynia, GI dysfunction, allodynia, GI dysfunction, facial flushing, lacrimation, facial flushing, lacrimation, rhinorrhea, nasal rhinorrhea, nasal congestion and vertigo…congestion and vertigo…

Precipitating factorsPrecipitating factorsstressstresshead and neck head and neck infectioninfectionhead trauma/surgeryhead trauma/surgeryaged cheeseaged cheesedairydairyred winered winenutsnutsshellfishshellfishcaffeine withdrawalcaffeine withdrawalvasodilatorsvasodilatorsperfumes/strong odorsperfumes/strong odorsirregular diet/sleepirregular diet/sleeplightlight

TreatmentTreatment

AbortiveAbortive– SteppedStepped– StratifieStratifie

dd– StagedStaged

PreventivPreventivee

Abortive TherapyAbortive Therapy Reduces headache Reduces headache

recurrence.recurrence. Alleviation of symptoms.Alleviation of symptoms. AnalgesicsAnalgesics

– Tylenol, opioids…Tylenol, opioids… AntiphlogisticsAntiphlogistics

– NSAIDsNSAIDs VasoconstrictorsVasoconstrictors

– CaffeineCaffeine– SympathomimeticsSympathomimetics– SerotoninergicsSerotoninergics

Selective - triptansSelective - triptans Nonselective – ergotsNonselective – ergots

MetoclopramideMetoclopramide

Abortive care strategiesAbortive care strategies SteppedStepped

– Start with lower level drugs, then switch to more specific Start with lower level drugs, then switch to more specific drugs if symptoms persist or worsen.drugs if symptoms persist or worsen.

Analgesics – Tylenol, NSAIDs…Analgesics – Tylenol, NSAIDs… Vasoconstrictors – sympathomimetics…Vasoconstrictors – sympathomimetics… Opioids (try to avoid) - ButorphanolOpioids (try to avoid) - Butorphanol Triptans – sumatriptan (oral, SQ, nasal), naratriptan, Triptans – sumatriptan (oral, SQ, nasal), naratriptan,

rizatripatan, zomatriptan.rizatripatan, zomatriptan.– Limited by patient compliance.Limited by patient compliance.

StratifiedStratified– Adjusts treatment according to symptom intensity.Adjusts treatment according to symptom intensity.

Mild – analgesics, NSAIDsMild – analgesics, NSAIDs Moderate – analgesic plus caffeine/sympathomimeticModerate – analgesic plus caffeine/sympathomimetic Severe – opioids, triptans, ergots…Severe – opioids, triptans, ergots…

– Severe sx treatment limited due to concomitant GI sx’s.Severe sx treatment limited due to concomitant GI sx’s. StagedStaged

– Bases treatment on intensity and time of attacks.Bases treatment on intensity and time of attacks.– HA diary reviewed with patient.HA diary reviewed with patient.– Medication plan and backup plans.Medication plan and backup plans.

Preventive therapyPreventive therapy

Consider if pt has more than 3-4 Consider if pt has more than 3-4 episodes/month.episodes/month.

Reduces frequency by 40 – 60%.Reduces frequency by 40 – 60%. Breakthrough headaches easier to abort.Breakthrough headaches easier to abort. Beta blockersBeta blockers AmitriptylineAmitriptyline Calcium channel blockersCalcium channel blockers Lifestyle modification.Lifestyle modification. Biofeedback.Biofeedback.

BotoxBotox

51% migraineurs treated 51% migraineurs treated had complete had complete prophylaxis for 4.1 prophylaxis for 4.1 months.months.

38% had prophylaxis for 38% had prophylaxis for 2.7 months.2.7 months.

Randomized trial Randomized trial showed significant showed significant improvement in improvement in headache frequency headache frequency with multiple with multiple treatments.treatments.

ConclusionsConclusions

Migraine is common but Migraine is common but unrecognized.unrecognized.

Keep migraine and its variants in the Keep migraine and its variants in the differential diagnosis.differential diagnosis.

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2004; 62 (5) Supplement 2: S2-S8.2004; 62 (5) Supplement 2: S2-S8.2.2. Bailey, BJ. Head and Neck Surgery – Otolaryngology 3rd Edition. 2001. Pgs. 221-235.Bailey, BJ. Head and Neck Surgery – Otolaryngology 3rd Edition. 2001. Pgs. 221-235.3.3. Bajwa, ZH, Sabahat, A. Pathophysiology, Clinical Manifestations, and Diagnosis of Bajwa, ZH, Sabahat, A. Pathophysiology, Clinical Manifestations, and Diagnosis of

Migraine in Adults. Up To Date online. 2005.Migraine in Adults. Up To Date online. 2005.4.4. Lipton, RB, Stewart, WF, Liberman, JN. Self-awareness of migraine: Interpreting the Lipton, RB, Stewart, WF, Liberman, JN. Self-awareness of migraine: Interpreting the

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9.9. Avnon, y, Nitzan, M, Sprecher, E, Rogowski, Z, and Yarnitsky, D. Different patterns of Avnon, y, Nitzan, M, Sprecher, E, Rogowski, Z, and Yarnitsky, D. Different patterns of parasympathetic activation in uni- and bilateral migraineurs. Brain. 2003; 126: 1660-parasympathetic activation in uni- and bilateral migraineurs. Brain. 2003; 126: 1660-1670.1670.

10.10. Stroud, RH, Bailey, BJ, Quinn, FB. Headache and Facial Pain. Dr. Quinn’s Online Stroud, RH, Bailey, BJ, Quinn, FB. Headache and Facial Pain. Dr. Quinn’s Online Textbook of Otolaryngology Grand Rounds Archive. 2001. Textbook of Otolaryngology Grand Rounds Archive. 2001. http://www.utmb.edu/otoref/Grnds/HA-facial-pain-2001-0131/HA-facial-pain-2001.doc

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