HEADACHES

CHRONIC HEADACHE

Determining Its quality,severity ,location,duration,and time course as well as the conditions that produce

,exacerbate or relieve it

Ausculation-Palpation

Quality of cephalic pain in most patients is dull (not sharp localize)

Throbbing D.D Waxing&Waning

The most Intense headaches :

SAH-Meningitis—Migraine-Cluster-Tic doulourex

LOCATION OF HEADACHE

Supratentorial SOL:Frontotemporal

Infratentorial SOL:Occipitonuchal

Ear pain :Referal

Vertex or Biparietal :Sphenoid or ethmoid sinus disease or thrombosis of SSS

MODE OF ONSET &DURATION

SAH:Abrup

Meningitis:Hours or days

Ophthalmodynia :A few seconds

Ice pick headache:Seconds

Classic migraine:early morning

Cluster:Nightly

SOL: Any time of day or night

IICP :Worse in morning

Tension headache :Persists for weeks

RELATION OF HEADACHE TO CERTAIN BIOLOGIC EVENTS

Premenstural headache:Tension or

, Migraine

Cervical spine disease:First movement of the neck is painful

Eye strain headache

Alcohol-Exercise-Straining-Coughing-

e

MIGRAINE

CLINICAL FEATURES

90% <40 YEARS OLD

F >M

90% Familial History Positive

20% of Women 6% Men

MIGRAINE WITHOUT AURA

Prodormal Phase:

May awaken the subjects

May be unilateral

Lower half headache

Prefer dark &quiet room

Photophobia&phonophobia&osmopho

Nausea-vomiting(delayed)-diarrhea

Anorexia> Nausea

Blurred vision-Lightheadedness-

Epistaxis-subconjunctival hemorrhage

Fever-PAT (rarely)

Peak of pain :30min to several hours

Frequency&severity is extremly variabl

Status migrainosus = Hospitalization

Chronic daily headache=Attack at less than weekly

MIGRAIN WITH AURA

Aura=Transient visual,sensory,motor,or language disturbance

Headache is identical to common M

prodormal symptoms may be accured

Visual aura(most common) teichopsia

Homonymous field (white or colored)

Positive scotoma then negative scoto

Metamorphopsia

Photopsia--- Retinal migraine

Contralateral headache

Sensory aura(second most common)

Paresthesias(positive)numbness(neg)

Variable distibution 20-30min

DD:TIA-seizure

Language aura:dysphasia or aphasia

Alexia-agraphia-mild confusion

Weakness of the limbs or facial

Transient abdominal symptoms-disturbed mentation-dejavu

MIGRAINE AURA WITHOUT HEADACHE

TREATMENT & MANAGEMENT

Reassurance-lack of cure

Normal CT or MRI

Avoidance of trigger factors(caffeine-smoking-alcohol-reserpine-OCP-nifedipine-theophilline-estrogens)

Avoidance of fasting & insomnia

& tyramin

PHARMACOTHERAPYTriptansTriptans : mechanisms : 5 HT1 B : mechanisms : 5 HT1 B

agonists 5 HT1 D agonists have agonists 5 HT1 D agonists have beneficial effect on migraine associated beneficial effect on migraine associated

symptomssymptoms side effectsside effects : :

TinglingTingling Flash sensationsFlash sensations

Heaviness or pressure in neck or chestHeaviness or pressure in neck or chest

ContrandicationsContrandications : IHD , HTN , using ergo , : IHD , HTN , using ergo , peripheral vascular disease ,pregnancy , peripheral vascular disease ,pregnancy , lactation , hemiplegic migrainelactation , hemiplegic migraine,,Well toleratedWell tolerated : naratriptan almotriptan : naratriptan almotriptan, ,

Triptan +NSAIDSTriptan +NSAIDS Triptan + metoclopramideTriptan + metoclopramide ErgotsErgots : vasoconstrictors and vasodilators : vasoconstrictors and vasodilators

55– – HT receptors agonistsHT receptors agonists oral –rectal –parenteraloral –rectal –parenteral

dose : 2mg + caffeine repeat : after dose : 2mg + caffeine repeat : after 11 hour hour 1-2 mg rectally+analgesic orally1-2 mg rectally+analgesic orally

10mg metoclopramide10mg metoclopramide

Supp : chlorpromazine 25-100 mg or Supp : chlorpromazine 25-100 mg or prochlorperazine 25mg or supp : prochlorperazine 25mg or supp : acetaminophen acetaminophen Caution in : HTN , peripheral vascular Caution in : HTN , peripheral vascular diseasedisease

Contraindicated : IHD , pregnancy , Contraindicated : IHD , pregnancy , prolonged auraprolonged aura

Subcutaneous and Intranasal Serotonin (5-HT) Agonists

HEADACHE RESPONSE (%)*

DRUGDOSE (mg)

1 HR 2HR 4HR RECURRENCE OF HEADACHE'(%)

Di hydros rgo la mine

Subcutaneous 1 57 73 85 18

Intranasal 2 46 47-61 56-70 14

Sumatriptan

Subcutaneous 6 70 75 83 35-40

Intranasal 20 55 60 NA 35-40

Zolmitriptan

Intranasal 5 55 70 78 25

Oral Serotonin (5-HT) Agonists

HEADACHE RESPONSE (%)'

DRUG DOSE (mg) 1 HR 2HR 4 HR RECURRENCE OF HEADACHE(%)

Almotriptan 12.5 35 57 NA 23

Eletriptan 20.0 20 49 NA 30

40.0 30 60 NA 22

Frovatriptan 2.5 NA 42 61 10-25

Naratriptan 1.0 19 42 51 17-38

25 21 48 67

Rizatriptan 5.0 30 60 NA 30-35

10-0 37 67-77 NA

Sumatriptan 25 NA 52 68 35-40

50 NA 50 70

100 NA 56 75

Zolrmitriptan 2.5 38 64 75 31

5.0 44 66 77

Serotonin (5-HT) Agonists Used in Acute Migraine Treatment

MAY REPEAT DOSES

MAXIMUM DOSE

DRUG ROUTE(S) DOSEIF HEADACHE RECURS

PER 24 HR

Dihydroergotamine IV 0.5 ,1.0 mg 1 hr 3mg

)DHE-45( IM 0.5 ,1.0mg 1 hr 3mg

sc 0.5 ,I.Omg 1 hr 3mg

)Migranal( Nasal spray2mg

(0.5mg/spray )one spray in

3mg

each nostril, repeal in 15 min

Almotriptan (Axert) Oral 12.5mg 2hr 25 mg

Eletriptan (Replax)

Oral 20 ,40 mg 2hr 80mg

Frovatrrptan (Frova)

Oral 2.5mg

1 mg, 2.5mg*

2hr

4 hr

7.5 mg

Naratriptan (Amerge)

Oral 5mg

Rizatriptan (Maxalt)

Oral 5mg, lOmg' 2hr 30 mg

Sumatriptan (Imitrex)

Oral 25mg,

50mg, 100mg2hr 300 mg

SC 6mg 2hr 12mg

Intranasal 5 mg, 20 mg* 40 mg

Zolmitriplan (Zomig)

Oral 2.5mg*, 5mg 2hr 10 mg

10mg

Intranasal 5mg 2hr

Nonhormonal Prophylaxis for Menstrual MigraineCYCLIC (PERIMENSTURAL) DAYS -3THROUGH +3Nonsteroidal anti-inflammatory drugsNaproxen sodium 550 mg bidMefenamic acid 250 mg tidKetoprofen 75mg tid Triptans and ergotsSumatriptan 25mg tidNaratriptan 1.0 mg tid or 2.5 mg bidFrovatriptan 2.5 mg once dailyZolmitriptan 2.5mg bidErgotamine tartrate + caffeine (Wigraine) 1 mg qhs or bidDihydroergotamine 0.5-1.0mg (SC, IM, or intranasal) bid

NONCYCLIC (THROUGHOUT CYCLE) Tricyclic antidepressantsNortriptyline or amitriptyline 10-150 mg qhs Beta-blockerPropranolol or nadotlol 40-240 mg daily Calcium-channel blockerVerapamil 240-480mg daily AnticonvulsantDivalproex 250-500 mg bidTopamax 75mgqhs to 100mg bid Dopamine agonistsBromocriptine2.5-5.0mg tid OtherMagnesium 360-600mg daily

PROPHYLACTIC TREATMENT

Beta blockers :Propranolol 80-240mg/d for 2-3months side effects (lethargy –depression -hypotension-bradycardia -impotence-insomnia-nightmare)-Group* C Timolol - Nadolol- Atenolol-Motoprolol

AntidepressantsAntidepressants: : AmitriptylineAmitriptyline: :

effect :blockade of noradrenaline uptake effect :blockade of noradrenaline uptake inhibition of serotonin re uptake inhibition of serotonin re uptake unknown unknown

Side effects :Side effects : morning drowsiness , morning drowsiness , dryness of the mouth , weight gain, dryness of the mouth , weight gain, tachycardia ,vertigo , constipation , tachycardia ,vertigo , constipation , B.M depressionB.M depression Group :D duration: 3monthsGroup :D duration: 3months

Phenelzine (MAOI)Phenelzine (MAOI): :

drug interactions : sympathomimetics , drug interactions : sympathomimetics , anticholinergic , TCA , anticholinergic , TCA , oppioids ( meperidine ) oppioids ( meperidine )

Side effects :Side effects : HTN , hallucinations , HTN , hallucinations , retention of urine , agitationretention of urine , agitation

Calcium channel blockersCalcium channel blockers: : mechanism :mechanism : unknown , vasoconstriction , unknown , vasoconstriction ,

prevention of platelet aggregation ,alteration in prevention of platelet aggregation ,alteration in release and reuptake of serotoninrelease and reuptake of serotonin..

Verapamil :Verapamil : 80-160mg TDS ,effective in classic 80-160mg TDS ,effective in classic migraine Side effects: migraine Side effects: vertigo ,constipation ,HF bradycardia ,V.F: half vertigo ,constipation ,HF bradycardia ,V.F: half life:2.8-4.7h form:tab:40-80mg FC tab:240mg life:2.8-4.7h form:tab:40-80mg FC tab:240mg ing:5mg / 2mg metabolism :liver excretion ing:5mg / 2mg metabolism :liver excretion :kidney group :C , :kidney group :C ,

flunarizine? nimodipine? Diltiazemflunarizine? nimodipine? Diltiazem??

Anticonvulsants :Anticonvulsants : mechanisms: unknown mechanisms: unknown Sodium channel inhibition, GABASodium channel inhibition, GABANa-valproateNa-valproate :dose: 500-1750mg/d :dose: 500-1750mg/d

Side effects: sedation , dizziness, appetite, Side effects: sedation , dizziness, appetite, BT,BT, LFT, hair loss LFT, hair loss,,

Group :D Form :tab 200-500mgGroup :D Form :tab 200-500mg syrup 200mg /5cc HL :6-16 hsyrup 200mg /5cc HL :6-16 h

GabapentinGabapentin : relative well tolerated : relative well tolerated side effects : side effects : dizziness ,sedation ,depression , ataxia , dizziness ,sedation ,depression , ataxia , fatigue , leukopenia dose:900-fatigue , leukopenia dose:900-2400mg/d cap: 100- 300-400 mg HL:5-2400mg/d cap: 100- 300-400 mg HL:5-

7h contraindication <12 years group:C7h contraindication <12 years group:C

TopiramateTopiramate : mechanisms : Ca channel blocker , : mechanisms : Ca channel blocker , GABAGABA

Dose : 15-25 mg/d 75-200 mg/d Form: Dose : 15-25 mg/d 75-200 mg/d Form: tab : 25-50-100-200 mgtab : 25-50-100-200 mg

Side effectsSide effects : sedation cognitive problems , : sedation cognitive problems , paresthesia , weight loss, ataxia , paresthesia , weight loss, ataxia ,

depressiondepression Group :CGroup :C

HL : 21h excretion: kidneyHL : 21h excretion: kidney

Serotonergic agentsSerotonergic agents: : 11((methysergidemethysergide

Side effects: retroperitoneal fibrosis Side effects: retroperitoneal fibrosis 1/1000 pulmonary and heart valve 1/1000 pulmonary and heart valve fibrosis ,nausea, leg pain, abdominal fibrosis ,nausea, leg pain, abdominal cramp ,agitation, hallucinationcramp ,agitation, hallucination

66 months after 4 weeks stop restart U/A months after 4 weeks stop restart U/A + Cr . CT or MRI of abdomen ,CXR+ Cr . CT or MRI of abdomen ,CXR

Dose: 2mg /d 7-10 days 6-8mg/dDose: 2mg /d 7-10 days 6-8mg/d

22 ( (CyproheptadineCyproheptadine : antibradykinin, : antibradykinin, antiplatelet aggregation, serotonin antiplatelet aggregation, serotonin

antagonist ,minor role in adultsantagonist ,minor role in adults

Side effectsSide effects: weight gain drowsiness : weight gain drowsiness group: B tab: 4mggroup: B tab: 4mg

breast feeding contraiadicoted breast feeding contraiadicoted RiboflavinRiboflavin dose: 400mg/d dose: 400mg/d

Group :AGroup :A

Mg supplementationMg supplementation : dose : 600 mg/d : dose : 600 mg/d Side effectsSide effects : diarrhea, DTR , : diarrhea, DTR , hypotension , cardiac block , hypotension , cardiac block , respiratory paralysis . respiratory paralysis . Contraindication : heart block Contraindication : heart block vial : 10-20 -50 % Group : Dvial : 10-20 -50 % Group : D

HL : 0.5 -4 hHL : 0.5 -4 h

AspirinAspirin : 325 mg : 325 mg NSAIDSNSAIDS : :

BotulinumBotulinum : release of proinflammatory : release of proinflammatory

and vasodilating neuropeptide block of and vasodilating neuropeptide block of glutamate glutamate

DoseDose : 100 units beginning of effect after 7- : 100 units beginning of effect after 7- 10 days persists to 3 months 10 days persists to 3 months

Imipramine-Desipramine-NortriptylineImipramine-Desipramine-Nortriptyline Fluoxetine&SertralineFluoxetine&Sertraline ? ?

STATUS MIGRAINOSUS

Fluid replecement-Correction of electrolyte imbalance-- Suppression

of vomiting

DHE&Antiemetics TID

Dexamethasone or Prednisolone

20 mg QID --- taper 2-3 days

Tention Type Headache The most common almost always mild-rare CCTH

Criteria for diagnosis : lasts from 30

min to a week and has 2 or more

fallowing 1)bilateral 2)pressure

nonpulsatile3)mild to moderate

4(not aggravated by routin activity

TTH unassociated with nausea and vomiting

can have photophobia or phonophobia but not

both—tension and stress are associated

Treatment : NSAIDS- butalbital +analgesics

Preventive therapy: TCA-mirtazapine-topiramate-venlafaxine-tizanidine -botulinium toxin

SSRIs not effective

CLUSTER HEADACHE

Episodic type:1-3 attack of periorbital pain

each day for 4-8 weeks- pain free interval

one year Chronic form :attacks are similar

there are no sustained remission

M/F=8/1 no hereditary prevalence =69/100000

Age= 20-50y

Clinical features : periorbital( temporal or

maxillary) pain without warning reach crescendo 5min-sever and deep-nonflactuating

rarely pulsatile-strictly unilateral usually same

side-lasts 30 min to 2 hours-homolateral

lacrimation,red eye, nasal stuffiness and ptosis

nausea is uncommon-alcohol provokes attack

in 70% on-off vulnerability to alcohol is

pathognomonic

Treatment :the most satisfactory treatment is

prevention”

lithium 600-900 mg/d particulary chronic form

prednisone 10days ;beginning 60 mg daily for

7days and rapidly tapering

melatonin9 mg HS occasionally

ergotamine 1mg is most effective when given

1-2hours before a single nocturnal attack

..……Treatment:

occipital nerve stimulation-hypothalamic S

Treatment of attack : oxygen inhalation

10 lit/min for 15 min – intranasal lidocaine

4%topical or 2%viscous-sumatriptan 6mg

shorten attack 10-15 min