Headache Assignment. Headache Assignment

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1 Headache Assignment Download International Classification of Headache Disorder 2 nd Edition from: The file is protected and cannot be printed as it is. Tools to remove the protection are available on the internet. Headache Assignment Read 1.1 Migraine without aura Typical aura with migraine headache Examples of secondary headache (headache, facial pain and neuralgia) 1

2 Objectives Describe primary headache (1-4) Describe secondary headache (5-14) Describe how to diagnose migraine with/without aura Give examples of secondary headaches INTERNATIONAL CLASSIFICATION of of HEADACHE DISORDERS 2nd 2nd (ICHD-II) edition edition INTERNATIONAL CLASSIFICATION (ICHD-II) ICHD-II. Cephalalgia 2004; 24 (Suppl 1) International Headache Society 2003/4 2

3 Classification Part 1: Primary headache disorders Part 2: Classification Secondary headache disorders Part 3: Cranial neuralgias, central and primary facial pain and other headaches ICHD-II. Cephalalgia 2004; 24 (Suppl 1) International Headache Society 2003/4 Primary or secondary headache? Primary or secondary headache? Primary: no other causative disorder ICHD-II. Cephalalgia 2004; 24 (Suppl 1) International Headache Society 2003/4 3

4 Primary or secondary headache? Secondary (ie, caused by another disorder): Primary or secondary headache? new headache occurring in close temporal relation to another disorder that is a known cause of headache coded as attributed to that disorder (in place of previously used term associated with) ICHD-II. Cephalalgia 2004; 24 (Suppl 1) International Headache Society 2003/4 Classification Part 1: The primary headaches 1. Migraine Classification 2. Tension-type headache 3. Cluster headache and other trigeminal autonomic cephalalgias 4. Other primary headaches ICHD-II. Cephalalgia 2004; 24 (Suppl 1) International Headache Society 2003/4 4

5 Classification Part 2: The secondary headaches 5. Headache attributed to head and/or neck trauma Classification 6. Headache attributed to cranial or cervical vascular disorder 7. Headache attributed to non-vascular intracranial disorder 8. Headache attributed to a substance or its withdrawal 9. Headache attributed to infection ICHD-II. Cephalalgia 2004; 24 (Suppl 1) International Headache Society 2003/4 Classification Part 2: The secondary headaches 10.Headache attributed to disorder of homoeostasis Classification 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures 12. Headache attributed to psychiatric disorder ICHD-II. Cephalalgia 2004; 24 (Suppl 1) International Headache Society 2003/4 5

6 Classification Part 3: Cranial neuralgias, central and primary facial pain and other headaches Classification 13. Cranial neuralgias and central causes of facial pain 14. Other headache, cranial neuralgia, central or primary facial pain ICHD-II. Cephalalgia 2004; 24 (Suppl 1) International Headache Society 2003/4 Origin of Head Pain Except brain tissue, meninges, blood vessels and cranial vault including CN V, VII, IX, X are pain sensitive Upper cervical nerve roots and nerves, muscles of the nape and neck refer Occipital nerves refer to the frontal area 12 6

7 Cerebral Cortex Thalamus Blood vessels & Painsensitive structures CN V Midbrain S T N Pons MO Stress Sight Smell Sound CN VII, IX, XI, Cervical nerves Cervical cord 13 Referred Pain Superficial structure: local (sinusitis) Deep structure: ill-defined (myocardial infarction) Somatic afferent Visceral afferent 2nd order neuron 14 7

8 Tips Understand the IHS classification Look for pattern Look for underlying pathology Look for precipitating factors 15 Questions to Ask Your Patients Pattern Onset Location Frequency Duration Severity Prodrome/aura Associated symptoms Sleep habits Precipitating factors Emotional factors Relationship profile Family history Seasonal relationship Menstruation Medical history Surgical history Allergy Previous investigation Past treatment and responses Present medication 16 8

9 Diagnostic Criteria: Common Migraine (Migraine without aura) A. At least 4 attacks fulfilling B-D B. Headache attacks lasting 4-72 hours C. Headache has at least two of the following characteristics: 1. Unilateral location 2. Pulsating quality 3. Moderate or severe intensity 4. Aggravation by exertion 17 D. During headache at least one of the following: 1. Nausea and/or vomiting 2. Photophobia and phonophobia E. At least one of the following 1. History, physical and neurological examinations do not suggest one of the disorders listed in History and/or physical and/or neurological examination do suggest such disorder, but is ruled out by appropriate investigations 3. Such disorder is present, but migraine attacks do not occur for the first time in close temporal relation to the disorder 18 9

10 Aura 19 Aura A. Takes many form B. Migraine with aura = 1/3 total migraine cases C. In MA, first attack associated with aura = 40%, aura with every attack = 20% D. 57% has aura before headache E. Most auras last less than 30 minutes F. Most headache follows within 30 minutes G. 75% has single aura but combinations do occur H. Small blind dots > flashes of light > blind spot > foggy vision I. No association between headache side and aura side Queiroz LP, Rapoport AM, Weeks RE et al. Headache Mar; 37(3):

11 Migraine with Aura A. At least 2 attacks fulfilling B. B. At least 3 of the following 4 characteristics: 1.One or more fully reversible aura symptoms indicating focal cerebral cortical and/or brainstem dysfunction 2.At least one aura symptom develops over more than 4 minutes, or 2 or more symptoms occur in succession 3.No aura symptoms last more than 60 minutes. If more than 1 aura symptom is present, accepted duration is proportional increased 4.Headache follow aura with a free interval of less than 60 minutes. (It may also begin before or simultaneously with the aura) 21 Migraine with Aura C. At least one of the following 1. History, physical and neurological examinations do not suggest one of the disorders listed in groups History and/or physical and/or neurological examination do suggest such disorder, but is ruled out by appropriate investigations 3. Such disorder is present, but migraine attacks do not occur for the first time in close temporal relation to the disorder 22 11

12 Differential Diagnoses A. Transient Ischemic Attack B. Seizure C. Hypoglycemia D. Syncope E. Etc. 23 Case Study year-old man, unilateral headache, onset at age 12. Duration of headache 12 hours, very severe with aura of twinkling lights, worsening when straining or working. Associated symptoms include nausea, vomiting, phonophobia, photophobia. Sleep may result in free of headache when waking up. Precipitating factors include chocolate, cheese. 2. Frequency of 4-6 times a year

13 Treatment A. Pharmacological ~ A. Preventive treatment B. Abortive treatment B. Non-pharmacological ~ 25 Preventive ~ A. Beta blockers: Propranolol, Timolol, Nadolol, Metoprolol, Atenolol B. Calcium channel blockers: Verapamil, Diltiazem, Nicardipine, Nifedipine, Nimodipine C. Antiepileptic drugs: Sodium valproate, Gabapentin D. NSAIDs: Fenoprofen, Flurbiprofen, Ketoprofen, Naproxen, Nabumetone, Oxaprozine E. Antidepressants:Protriptyline, Desipramine, Amitriptyline, Doxepin, Nortriptyline, Imipramine F. Serotonin reuptake inhibitors: Fluoxetine, Sertraline, Paroxetine, Nefazodone, Venlafazine G. Others: Barbiturate, Cyproheptadine 26 13

14 Abortive ~ A. OTCs: Aspirin-Acetaminophen-Caffeine combinations, Ibuprofen B. Glucocorticoids: Dexamethasone, Prednisone, Methylprednisolone C. NSAIDs:Ibuprofen, Diclofenac, Ketaprofen, Ketorolac, Flurbiprofen, Meclofenamate, Naproxen Sodium D. Others: Almotriptan, Dihydroergotamine, Ergotamine tartrate, Frovatriptan, Isometheptene mucate-dichloralphenazone- Acetaminophen combination, Naratriptan, Rizatriptan, Sumatriptan, Zolmitriptan 27 Non-pharmacological ~ A. Precipitating factors B. Preventive exercise C. Massage during attack D. Acupuncture during attack E. Relaxation techniques 28 14

15 Medication and Substance Abuse 1. Chemicals 2. Foods 3. Anti-infective agents 4. Cardiovascular agents 5. Gastrointestinal agents 6. Analgesics 7. Pulmonary agents 8. Endocrine agents 29 Chemicals & Foods Alcohol Cocaine Monosodium glutamate Tyramine-vasoactive amines Sodium Nitrite Processed meats and fish Food coloring Preservatives 30 15

16 Anti-infective agents Amphotericin B Azithromycin Fluconazole Trimethoprim-Sulfamethoxazole (Septra, Bactrim) 31 Cardiovascular agents Calcium Channel Blockers (Nifedipine) Reserpine Methyldopa Nitroglycerin Dipyridamole (Persantine) Quinidine Digoxin 32 16

17 Gastrointestinal Agents Ondansetron (Zofran) Ranitidine (Zantac) Cimetidine (Tagamet) 33 Analgesics and Anti-Inflammatory agents Propoxyphene Pentazocine Corticosteroids NSAIDs (associated with Rebound Headache) Diclofenac (Voltaren) Indomethacin (Indocin) 34 17

18 Pulmonary Agents Aminophylline Theophylline Pseudoephedrine (Sudafed) 35 Endocrine Agents Danazol Oral Contraceptive CNS Agents Levodopa Amantadine Benzodiazepines Methylphenidate (Ritalin) 36 18

19 Chemical Withdrawal Alcohol Withdrawal Barbiturate withdrawal Caffeine withdrawal Narcotic withdrawal Ergotamine withdrawal 37 19