Akuter Kopfschmerz Till Sprenger, MD Neurologie USB
Disclosure I have consulted for Biogen Idec, Novartis, Mitsubishi Pharmaceuticals, Eli Lilly, Genzyme and Allergan. I have received compensation for educational presentations and travel from Eli Lilly, Janssen Pharmaceuticals, Pfizer, Allergan and Bayer Schering.
Primary versus secondary headaches
4 cases of patients with trigeminal autonomic headache
34-yo woman referred for cluster HA work-up stabbing strictly right-sided periorbital HA for the last 3 days VAS 10/10, right-sided tearing and red-eye with pain Attack duration 2-3 hours Similar symptoms 1 year before, which improved spontaneously after a few weeks ENT exam non-contributory (including ultrasound of paranasal sinus) Used Metamizole 20 gtt, which seemed to help
Current medical history: for several months continuous left-sided Hemicrania (VAS 6-7/10) up to several times daily pain exacerbations with periorbital location (VAS 10/10) during the pain exacerbations swelling of the left eyelid, ptosis, lacrimation and runny nose exacerbations lasted approx. 30 min, sometimes several hours no response to therapeutic administration of O2 and sumatriptan nasal spray
This patient needs A) CT of the paranasal sinuses B) MRI of the brain C) Lumbar puncture D) No additional exams E) Psychotherapy
Exams are normal, this patient has A) Migraine B) Tension type headache C) Hemicrania continua D) New daily persistent headache E) Cluster headache
Hemicrania continua diagnostic criteria A) Headache for >3 months fulfilling criteria B-D B) All of the following characteristics: - unilateral pain without side-shift - daily and continuous, without pain-free periods - moderate intensity, but with exacerbations of severe pain C) At least one of the following autonomic features occurs during exacerbations and ipsilateral to the side of pain: - conjunctival injection and/or lacrimation - nasal congestion and/or rhinorrhoea - ptosis and/or miosis D) Complete response to therapeutic doses of indomethacin E) Not attributed to another disorder 1
45-year old woman with new onset continuous right V1 pain for the last two days with severe pain intensity Right sided cranial autonomic symptoms (lacrimation, red eye)
71 year-old man with strictly right-sided daily excruciating periorbital head pain attacks most severe between November and March, but occurring throughout the whole year with a frequency of 4 to 100 attacks per day Conjunctival injection and tearing during attacks
SUNCT/SUNA 3.3 Short-lasting Unilateral Neuralgiform headache attacks with or Conjunctival injection and Tearing or Cranial Autonomic symptoms Cohen et al., Brain 2006;129:2746 & ICHD-IIIβ
Pain/symptom phenotype Physical exam Primary headache diagnosis Clinical course, accompanying conditions Paraclinical tests, imaging
SNOOP
Lipton and Bigal 2006
International Classification of Headache Disorders-IIIβ I- Primary 1. Migraine 2. Tension-type headache 3. Trigeminal autonomic cephalalgias 3.1 Cluster headache 3.2 Paroxsymal hemicrania 3.3 SUNCT/SUNA 3.4 Hemicrania continua 4. Other Primary Headaches 4.1 Cough headache 4.2 Exercise Headache 4.3 Sexual activity headache 4.4 Thunderclap headache 4.5 Cold stimulus: external/ingestion 4.6 External pressure: compression/traction 4.7 Stabbing Headache 4.8 New Daily Persistent Headache II-Secondary 5. Trauma or injury to the head 6. Cranial or cervical vascular 7. Intracranial non-vascular 8. Substances 9. Infection 10. Homoeostasis 11. Disorder head, neck, eyes 12. Psychiatric III-Cranial neuralgias/facial pain - trigeminal neuralgia - trigeminal neuropathy - glossopharngeal neuralgia - nervus intermedius neuralgia - occipital neuralgia - Tolosa-Hunt - Burning Mouth Syndrome Cephalalgia 2013;33:629
Migraine - Symptoms Micieli G. Suffering in silence. In: Edmeads J, ed. Migraine: A Brighter Future, 1993:1 7
Migraine criteria ICHD II
Phases of migraine attacks Pre-HA Headache Post-HA mild Moderate to severe Prodrome Aura Headache Postdrome time
Attacks Migraine: The Attacks & the Disorder Premonitory symptoms Aura Pain unilateral throbbing movement worse Nausea Sensory sensitivity photophobia phonophobia osmophobia dizziness Postdrome Disorder Repeated attacks < 15 days/month: Episodic 15 days/month: Chronic Family history / Genetics Migraine markers Motion sickness Seeing stars when standing up Comorbidities Triggers (biology) Sleep: missing/excess Food: skipping meals Chemical: alcohol or nitroglycerin Weather Sensory: light, smells Hormonal Stress- relaxation Interictal symptoms
Migraine: Classification
Tension-Type Headache the IHS phenotype Episodic lasts 30 mins to 7 days Two of - pressing/tight pain - mild/moderate severity - bilateral - no aggravation by activity Both of - No nausea/vomiting - Photophobia or phonophobia, not both Chronic 15 days/month Two of - pressing/tight pain - mild/moderate - bilateral - no aggravation by activity Both of - No vomiting/severe nausea - Only one of photophobia or phonophobia, or nausea (Cephalalgia 2004;24 [suppl 1]:1-160)
Trigeminal Autonomic Cephalalgias (TACs)* 3.1 Cluster Headache a. Episodic b. Chronic 3.2 Paroxysmal Hemicrania a. Episodic b. Chronic 3.3 SUNCT (Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing)/SUNA 3.4 Hemicrania continua 3.4 Probable TAC *Goadsby & Lipton Brain 1997;120:193; Cephalalgia 2004; 24[Suppl 1]: 1-160 Cephalalgia 2013;33:629
Cluster headache as common as Multiple Sclerosis** Cluster headache Migraine sex male female unilateral 100% 66% duration 15-180mins 4-72hrs nausea 50% 80% Photophobia* 56% 85% exacerbation with No Yes movement family history Yes Yes aura 14% 30% *Unilateral in 4% migraineurs & 80% ECH (Irimia et al., Cephalalgia 2005; 25:856) **Ford et al., J Neurol 2002; 249:260-265
Cranial Autonomic Symptoms in Migraine compared to Cluster Headache Clinic-based study Cranial autonomic symptoms (CAS) in migraine - Less common, less prominent, less consistent, more bilateral % patients 100 80 60 40 20 0 lacrimation conjunctival injection nasal migraine cluster headache eyelid oedema Any CAS Lai et al., JNNP 2009;80:1116
Differential diagnosis according to headache duration
Landmark Study How often are physicians wrong when they diagnose nonmigraine in a patient complaining of primary headache? Prospective, open-label study Patients tracked for three months or six attacks Assigned IHS diagnoses by experts % Patients with non-migraine, Tepper et al., Headache 2004;44:856-864
Should migraineurs ever be scanned? History of migraine and normal examination (n = 897) -> 4 relevant abnormality on CT or MRI three tumours one AVM BUT Two of these (tumour and AVM) had seizures One papilloma choroid plexus one glioblastoma Alter et al., Neurology 1994;44:1353-1354
Reasons to consider neuroimaging in migraineurs Evans and Purdy 2006
Should patients with non-migraine headache be scanned? Non-migraine patients with normal examinations (n =1825; 2.4% abnormal) 21 tumours 6 AVMs 3 aneurysms 8 hydrocephalus Alter et al., Neurology 1994;44:1353-1354
Thank you very much for your attention.