Post-Concussive Headaches and Dizziness Louise M. Klebanoff, MD

Transcription

1 Post-Concussive Headaches and Dizziness Louise M. Klebanoff, MD Associate Professor and Vice Chairman for Operations Chief, General Neurology Department of Neurology

2 Disclosures: None

3 Introduction: Headaches Post-concussive headaches are a key feature of the more complex post-concussive syndrome Loss of consciousness is not required for the development of post-concussive headaches In most patients, post-concussive headaches occur within 7-10 days of injury and resolve within three months Up to 30% of patients report headaches continuing long after the injury Patients > 40 years old Patients with previous concussions

4 Historical Background Maty (1766): described persistent postconcussive symptoms following trauma Boyer, Dupuytren, Cooper (mid-19 th century): reported headache and other symptoms following closed head injuries Ericksen (1882): argued that mild head injury or concussion of the spine could result in severe disabilities due to damage to the central nervous system

5 Controversy Many symptoms of post-concussive syndrome were thought to be malingering Ericksen (1882): argued that head injury did not occur in the absence of obvious external injury Functional disorder neurosis Rigler (1981) Compensation neurosis Evidence of anatomic abnormalities is minimal The risk of post-concussive headaches does not appear to be correlated with the severity of the head injury

6 Few post-concussive headaches require surgical intervention

7 Red Flags Increasing headache frequency/severity Chronic daily headaches unresponsive to treatment Headaches always on the same side Headaches associated with seizures Headaches with an abnormal neurological examination Headaches precipitated by exertion, strain or positional changes Headaches that awaken the patient over time

8 Types of Post-Concussive Headaches Muscle tension type headaches Cervicogenic headaches Migraine headaches

9 Tension Type Headaches Duration 30 minutes 7 days Characteristics: Bilateral Pressing/tight (non-pulsatile) Mild-moderate intensity Not aggravated by routine physical activity No nausea or vomiting No photophobia or phonophobia

10 Cervicogenic Headaches Occur following injury to the muscles and soft tissues of the neck ( whiplash ) Nerves in the tissues and bones of the neck have branches that travel to the skull and scalp and cause headache Start in the neck, shoulders, back of the head Can travel anteriorly over the top of the head Neck movement or positioning can make the pain worse Range from mild to severe Usually no associated features

11 Migraine Headaches At least two of the following: Unilateral location Pulsatile quality Moderate-severe intensity Aggravated by routine exertion At least one of the following: Nausea and/or vomiting Sensitivity to light and noise Up to 31% of patients will have aura on some occasions

12 Migraine Pathophysiology Migraine is a primary disorder of the brain Migraine is NOT a caused by a primary vascular event Neurovascular headache: a disorder in which neural events result in the dilation of blood vessels which in turn results in pain and further nerve activation Basic Biological Problem: dysfunction of brainstem or diencephalic nuclei that are involved in the sensory modulation of craniovascular afferents Activation in the brainstem during migraine attacks has been detected with PET scanning

13 Post-concussive Headache Treatment No specific treatments of post-concussive headaches Patient education Lifestyle changes to avoid triggers Regular sleep (especially awakening time) Regular meals (no skipping, no sugar loading) Hydration Exercise Avoidance of peaks in stress/relaxation Avoidance of dietary triggers

14 Acute Headache Treatments Over the Counter Analgesics and NSAIDS: Important to treat early Important to treat with adequate dose 900 mg aspirin 1000 mg acetaminophen mg of naproxen mg ibuprofen Anti-nausea drugs (or drugs that increase gastric motility) may facilitate absorption of the primary drug Overuse must be avoided (< 2-3 days per week)

15 Analgesic Overuse Analgesic overuse MUST be avoided Analgesic overuse/rebound headaches can evolve into chronic daily headaches Prophylactic agents are NOT effective in the setting of analgesic overuse/rebound headaches Restrict use to 2-3 days per week

16 Acute Headache Treatments Avoid opiates Mask pain without suppressing the pathophysiological mechanism of the headache May leave the patient cognitively impaired Addiction risk Offer no advantages over more specific headache therapies

17 Acute Migraine Therapy: Triptans Selective pharmacology (activate serotonin 5-HT 1B/1D receptors) Established efficacy based on well-designed controlled trials Moderate side effect profile Tingling paresthesias Dizziness, flushing, neck pain or stiffness Well-established safety record Disadvantages: Higher cost Restricted use in setting of cardiovascular disease

18 Acute Migraine Therapy: Triptans Sumatriptan (Imitrex) Naratriptan (Amerge) Rizatriptan (Maxalt) Zolmitriptan (Zomig) Almotriptan (Axert) Eletriptan (Relpax)

19 Preventive Therapies Consider preventive therapies when: Headaches significantly interfere with daily routine despite acute treatment Acute medications fail, are contraindicated or cause troublesome adverse events Acute medications are overused The patient has frequent (> 2 per week) headaches Patient preference

20 Preventive Therapies Medication Options: Antiepileptic drugs Antidepressants Beta-blockers General rules: start low, go slow Remind patients that this takes time About 2/3 of patients given a prophylactic agent will have a 50% reduction in headaches Mechanism of action: modifies brain sensitivity

21 Preventive Therapies Amitriptyline (Elavil) Dose: mg at bedtime Side effects: drowsiness, dry mouth, constipation Nortriptyline (Pamelor) may be better tolerated Gabapentin (Neurontin) Dose: mg daily Side effects: tiredness, dizziness

22 Preventive Therapies Divalproex (valproate) (Depakote) Dose: mg BID Side effects: drowsiness, weight gain, tremor, hair loss, fetal abnormalities, hematologic and liver abnormalities Topiramate (Topamax) Dose: mg daily Side effects: confusion, paresthesias, weight loss Selective serotonin reuptake inhibitors Dose: depends on specific agent Side effects: anxiety, insomnia, sexual dysfunction

23 Preventive Therapies Verapamil Dose: mg daily Side effects: constipation, leg swelling, atrioventricular conduction disturbances Beta-adrenergic-receptor antagonists: Propranolol (Inderal) Dose: mg BID Metoprolol (Lopressor) Dose: mg/day Side effects: fatigue, postural dizziness Contraindications: asthma

24 Behavioral and Physical Therapies Consider behavioral or physical treatments: Patient preference Poor tolerance of medications Medical contraindications to medications Insufficient or no response to medications Pregnancy, planned pregnancy or nursing History of long-term, frequent or excessive use of analgesics or acute therapies Significant stress or deficient stress-coping skills

25 Behavioral and Physical Therapies Relaxation training Hypnotherapy Cognitive-behavioral therapy Physical therapies: Acupuncture TENS Occlusal adjustment Cervical manipulation (not chiropractic manipulation Occipital Nerve Block Botox

26 Nutraceutical Treatments Magnesium Dose: mg/day Side effects: diarrhea Riboflavin (Water-soluble vitamin B2) Dose: mg/day Side effects: bright yellow-orange urine

27 Nutraceutical Treatments Feverfew (member of the daisy family) Dose: 125-mg daily Side effects: GI idsturbance Butterbur (Petasites hybridus) Dose: 75-mg twice a day Side effect: burping Coenzyme Q10 Dose: 150-mg/day Side effects: infrequent GI distress, skin reactions

28 Dizziness Following Concussion Poor equilibrium Feeling off-balanced Light-headedness Giddiness/floating Disorientation Vertigo: Environment swims Whirling/Spinning To-and-fro Up-and-down

29 Benign Positional Vertigo Recurrent momentary episodes of vertigo brought on by changes in head position - Neck extension - Rolling over in bed - Arising from bed - Bending down Vertigo starts after a latency, builds to a peak and then subsides after about 1 minutes

30 Benign Positional Vertigo Positional testing: Lay patient down quickly from a seated position with the head and neck extended to one side Vertigo with rotatory nystagmus Pathophysiology: Otoconia (calcium carbonate crystals) in the posterior semicircular canal ampulla, displaced from utricle and saccule

31 Vertigo - Treatment Vestibular therapy Labyrinthe suppressants: Meclizine Diazepam Surgical intervention: Section of the posterior ampullary nerve Obliteration of the posterior semicicrular canal

32 Conclusions Headache and dizziness are key components of the postconcussive syndrome The pathophysiology is not well-understood Detailed neurological history will help establish the headache type and guide treatment A careful neurological examination will exclude ominous causes of headache and dizziness Therapies include: Medications for acute and preventive treatment of headache Physical therapy for cervicogenic headache and vertigo Supportive care Patient and practitioner education and patience

33 Thank you!