HEADACHE. as. MUDr. Rudolf Černý, CSc. doc. MUDr. Petr Marusič, Ph.D.

Transcription

1 HEADACHE as. MUDr. Rudolf Černý, CSc. doc. MUDr. Petr Marusič, Ph.D. Dpt. of Neurology Charles University in Prague, 2nd Faculty of Medicine Motol University Hospital

2 History of headache 1200 years B.C. Papyrus of Ebers description of migraine, compresive bandage 400 years B.C. Hippocrates description of migraine, visual symptoms 2nd century A.D. Galenos hemicrania = migraine 1930 Wollfe Vascular theory 1981 International Headache Society 1995 Triptans for migraine therapy

3 Epidemiology Long-life prevalence % Point prevalence (Do you have a headache today?) = 22% ; = 11 % HEADACHE 10 % of patients at GPs

4 Aetiology Mechanical and/or inflammatory extra- and intracranial arteries large intracranial veins and their shields meninges cranial and cervical spinal cord nerves skull, teeth and cervical structures Intracranial hypertension Spasm, inflammation or trauma of head and neck muscles

5 Classification IHS Primary headache disorders no other causative disorder Secondary headache disorders (ie, caused by another disorder) new headache occurring in close temporal relation to another disorder that is a known cause of headache coded as attributed to that disorder Cranial neuralgias, central and primary facial pain and other headaches

6 Diagnosis Medical History Headache Onset, duration, recurrence Distribution and other characteristics of pain Associated symptoms Another disorder that is a known cause of headache Neurological examination Investigations CT (Ag), MR (Ag), CSF

7 Classification IHS The primary headaches 1. Migraine 2. Tension-type headache 3. Cluster headache and other trigeminal autonomic cephalalgias 4. Other primary headaches

8 Migraine (without aura) A. At least 5 attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 h (untreated or unsuccessfully treated) C. Headache has at least 2 of the following characteristics: unilateral location pulsating quality moderate or severe pain intensity aggravation by or causing avoidance of routine physical activity (eg, walking, climbing stairs) D. During headache at least 1 of the following: nausea and/or vomiting photophobia and phonophobia E. Not attributed to another disorder

9 Migraine with aura A. At least 2 attacks fulfilling criteria B D B. Aura consisting of at least 1 of the following, but no motor weakness: fully reversible visual symptoms including positive and/or negative features fully reversible sensory symptoms including positive and/or negative features fully reversible dysphasic speech disturbance C. At least two of the following: homonymous visual symptoms and/or unilateral sensory symptoms at least one aura symptom develops gradually over 5 min and/or different aura symptoms occur in succession over 5 min each symptom lasts over 5 and less than 60 min D. Headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follows aura within 60 min E. Not attributed to another disorder

10 Treatment ACUTE Nonsteroid analgesics acetylsalicylic a., ibuprofen, paracetamol, Triptans selective agonists of 5-HT1D and 5-HT1B receptors Antiemetics metoclopramide, thietylperazine PROPHYLACTIC Anticonvulsants valproate, topiramate, gabapentin Beta-blockers propranolol, metoprolol Ca-channel blockers flunarizine, cinnarizine Lifestyle changes!

11 Tension-type headache Infrequent episodic TTH has very little impact on the individual and does not deserve much attention from the medical profession Frequent episodic TTH sufferers can encounter considerable disability that sometimes warrants expensive drugs and prophylactic medication Chronic TTH

12 Tension-type headache Infrequent episodic A. At least 10 episodes occurring on <1 d/mo (<12 d/y) and fulfilling criteria B-D B. Headache lasting from 30 min to 7 d C.Headache has at least 2 of the following characteristics: bilateral location pressing/tightening (non-pulsating) quality mild or moderate intensity not aggravated by routine physical activity D.Both of the following: no nausea or vomiting (anorexia may occur) no more than one of photophobia or phonophobia E. Not attributed to another disorder

13 Treatment ACUTE Nonsteroid analgesics acetylsalicylic a., ibuprofen, paracetamol, PROPHYLACTIC Gabapentin Antidepressants SSRI, SNRI, amitriptyline, Lifestyle changes, relaxation, aerobic sports, psychotherapy,

14 Cluster headache A. At least 5 attacks fulfilling criteria B-D B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting min if untreated C.Headache is accompanied by at least 1 of the following: ipsilateral conjunctival injection and/or lacrimation ipsilateral nasal congestion and/or rhinorrhoea ipsilateral eyelid oedema ipsilateral forehead and facial sweating ipsilateral miosis and/or ptosis a sense of restlessness or agitation D. Attacks have a frequency from 1/2 d to 8/d E. Not attributed to another disorder

15 Classification IHS Primary headache disorders no other causative disorder Secondary headache disorders (ie, caused by another disorder) new headache occurring in close temporal relation to another disorder that is a known cause of headache coded as attributed to that disorder Cranial neuralgias, central and primary facial pain and other headaches

16 Classical trigeminal neuralgia A. Paroxysmal attacks of pain lasting from a fraction of 1 sec to 2 min, affecting one or more divisions of the trigeminal nerve and fulfilling criteria B and C B. Pain has at least 1 of the following characteristics: intense, sharp, superficial or stabbing precipitated from trigger areas or by trigger factors C. Attacks are stereotyped in the individual patient D.There is no clinically evident neurological deficit E. Not attributed to another disorder

17 Differential diagnosis in headache History! Neurological examination Head CT/MRI Normal finding Primary headache? Secondary headache? neck, eyes, ears, nose, sinuses, teeth, mouth,? Cranial neuralgia or facial pain? Meningeal sy CSF Meningitis? SA haemorrhage? Focal finding MR, MR-Ag, US Tumour, Haematoma, AVM, Hydrocephalus, Dissection, Sinus thrombosis,?