Common Headaches- Diagnosis and Treatment

Common Headaches- Diagnosis and Treatment Anjaneyulu Alapati,M.D Honorary Clinical Professor UAB School of Medicine Huntsville, AL

Headache-incidence

Headache- patterns Minutes - vascular Hours to days- infectious Weeks to months- inflammatory/neoplastic 6 months /years primary headaches

Common Headaches- causes

Headache-Brain Tumour

Headache-algorithm

Headache-treatment

Primary Headaches

Headache Case history 18 yr old female having intermittent throbbing moderate to severe headache, nausea, and light sensitivity. Frequency 2 per month, lasts for 2-4 hrs.duration 1-2 yrs 1. What is the diagnosis? 2. What work up you do? 3. How do you treat?

Common Migraine - criteria 5 attacks Headache attacks lasting for 4-72 hrs Headache has 2 of the following feature Pulsating Unilateral Moderate or severe pain Aggravation or causing avoidance of physical activity During headaches one of the following nausea/vomiting Photophobia or phonophobia.

Migraine- epidemiology General population- 12%. Females 18% and males 6%( 30 million Americans) History of episodic headache for more than 6 months- likelyhood of migraine is > 90% Screening questions 1. Has headache limited your activities for more than a day in the last 3 months 2. Are you nauseated or sick to your stomach during headache 3. Does light bother you when you have headache

Migraine and Psychiatric disorders Major Depression 34% Dysthymia 9% Bipolar 4% Panic Disorder 11% GAD 10% OCD 9% Phobia 40% Illicit Drugs 20% Nicotine dependence 33%

Migraine- mechanism

Migraine- acute treatment Mild to moderate- Tylenol, NSAIDS Moderate- Triptans Severe Toradol, Reglan, Imitrex Inj, DHE inj.

Triptans-Principles of Usage Limit to 2 tabs per week or in 24 hrs Pregnancy, Uncontrolled HTN, known cardiac disease contraindications Use with caution- males above 40 with risk factors or post menopausal women Watch for Serotonin syndrome when given with SSRI Caution with MAOI

Headache-Case history 30 yr old female having intermittent headaches preceeded by flashes of light. Unilateral predominantly. Lasts for 4-24 hrs. freeqency twice per week. Tried tylenol and advil. Diagnosis? How to treat?

Migraine- preventive therapy Beta Blockers- Propranolol, Metoprolol Anti epileptics- topamax, depakote Tricyclics- Elavil, Pamelar Calcium channel blockers- Verapamil,diltiazem Seratonin antagonists- Cyproheptadine,pizotifin, methysergide Indications- > 3 headaches per month or one disabling headache per month Duration of treatment- 6 months

Headaches- Case history 34 yr old male presented to ER with headache, facial droop, slurred speech and numbness in right arm Had similar history 2 yrs ago. Symptoms resolved in 6 hrs Stroke work up negative. MRI/MRA/Echo. Diagnosis Treatment

Complex or Complicated Migraines Exclusion diagnosis Vasospasm No smoking or BCP Treatment- Verapamil,diltiazem MRI may show small ischaemic areas or infarcts TEE may show PFO

Headaches- Case History 34 yr old female presents to office with recurrent headaches around the monthly periods. Lasts for 2-3 days with intense nausea. Could not go to work. Tried advil Diagnosis treatment

Menstrual Migraine Pure menstrual migraines -10% Menstrual related migraines-70-80% Miniprophylaxis Naproxen sodium -550 mg bid Frovatriptan-2.5 mg Naratriptan-1 mg p bid Zolmitriptan-2.5 mg TID Danazol Tamoxifen

Headaches- Case History 9 yr old child presented to Pediatrician with recurrent vertigo, nausea, vomiting. Lasts for 2-3 days. Work up negative. Diagnosois treatment

Childhood Migraines Vertigo,headaches Abdominal pain, cyclical vomiting. Preventive Meds- Cyproheptadine, beta blocker, topamax Acute treatment- NSAIDS, Imitrex

Headaches- Case history 36 yr old having new on set headache while having sex, headaches starts at the time of orgasm. Severe throbbing. Lasts for 30 mts to 1 hr. Diagnosis treatment

Coital headache Propranolol Diltiazem Indomethacin Types Preorgasm headache Orgasm headaches SECONDARY Causes Must be excluded

Headaches case history 24 yr old female with history of migraines presented to office with 2 weeks of intractable headaches. Intense nausea. Not able to keep any thing down. Photophobia. Went to ED twice. Had MRI and MRA of brain. Given demerol and phenergan with temporary relief Diagnosis Treatment

Status migrainicus DHE protocol 1 mg Q 8 hrs for 2 days after test dose IV Steroids I IV Depakote IV Chlorpromazine

Headaches- Case history 40 yr old female having right sided sharp headaches, lasting for 5-10 mts, happens 10-15 times a day. Duration- 1 year Mild lacrimation,redness of eye Diagnosis treatment

Chronic Paroxysmal Hemicrania Indomethacin 25 mg po tid for 48 hrs to 1 week. Slowly could go up to 100 mg po tid Topamax/neurontin Occipital nerve block

Headaches-Case history 42 yr old male,alcoholic,waking up from sleep with right periorbital headaches. Duration 4-6 weeks. Associated with redness of the eye with lacrimation.nasal stuffiness, ptosis. Diagnosis Treatment

Cluster Headaches Thank You Q & A

Cluster Headaches Acute treatment -100% Oxygen 12L/min Imitrex Inj/DHE Inj steroids Preventive Meds- Lithium, verapamil

Headaches- Case history 40 yr old with history of depresssion, fibromyalgia having frequent headaches, bifrontal, dull, diffuse.mild to severe.no nausea or sensitivity to light. Diagnsois Work up treatment

Chronic Daily Muscle contraction headaches Headache occuring on > 15 days /months for >3 months Episodic or continuous Not meeting criteria for migraine Treatment-tricyclics/muscle relaxers/neurontin/anti depressants.

Chronic daily headaches- comorbid Psychiatric conditions Total Number of Pts 260 Depression 57% Panic attacks 30% Dysthymia 11% Generalized anxiety 8%

Headaches- Case history 42 yr old female presents with history of migraines since she was a teenager. Now having more frequent headaches, more or less daily. Wakes up from sleep with headache. Nausea. On abortive medication. Takes advil and excedrin migraines 3-4 times a day. Diagnosis treatment

Rebound Headaches(MOH) Detoxification Start on daily preventive medications Educate the pt Do not use butalbital or opiods for acute treament of migraines either occasionally or periodically Behavioral therapy Risk for Rebound Headaches Butalbital as little as 5 days per month Opiods as little as 8 days per month Tryptans NSAIDS as little as 10 days per month

Botox Inj for Chronic Migraines Chronic migraines lasting > 15 days a month Not responding to two Preventive medications.

Chronic Migraine- Botox therapy

Secondary Headaches

Red Flags for secondary Headaches( SNOOP) Systemic symptoms Secondary risk factors-hiv, Cancer Neurological symptoms or signs Onset- abrupt or split second Old age Pattern Changes/progressive

Headache-Diagnosis

Indications for Neuro Imaging (AAN) Headaches worsens with Valsalva Maneuver Patient wakes up from sleep with headache New onset headache in elderly person Change in character of Headaches Headache with focal neurological findings or Papilloedema Worst headache in life time Progressive Headaches

Headaches- Case history 32 yr old female, obese having daily headaches for 4 weeks. Bifrontal, visual obscurations, tinnitis. Transient loss of vision twice. Exam- Papilloedema. Diagnosis Work up treatment

Psudo Tumour Cerebri

Pseudotumour cerebri(benign Intracranial hypertension). MRI of brain with and with out contrast MRV of brain LP -high Opening pressure with normal CSF findings Treatment Diamox/Topamax Repeated LP s Weight loss Shunt surgery Optic Nerve Sheath Fenestration Frequent eye checks for Visual fields

Headaches- Case History 54 yr old male presented to ED with worst headache. Intense nausea, brief loss of consciousness. Neck pain, blurred vision. Exam: photophobia, Neck stiffness. Diagnosis Work up Treatment

SAH and aneurysm

SAH and aneurysm(thunderclap Headaches) CT scan of Brain with out contrast CT angio. LP if CT scan shows no haemorrhage Arteriogram. Treatment-Clipping, coiling

Headaches and Case history 65 year male having right temporal headaches with blurred vision. History of malaise, muscle stiffness. Examination- tenderness in the right temporal area.. Diagnosis Work up Treatment.

Giant Cell arteritis

Giant Cell arteritis- ACR Criteria Age above 50 Newly onset localized headache Temporal artery tenderness or decreased pulse ESR >50 Positive temporal artery biopsy Treatment Prednisone 40-80 mg IV methyl Prednisone for 3 days if visual symptoms followed by oral steroids Methotrexate

Headaches- case history 42 year old female presented with dull headache starts in the neck and goes in to bifrontal area, dizziness. blurred vision. Mostly on sitting and walking, gets better on lying down. Diagnosis Work up treatment

Sagging Brain Syndrome

Sagging Brain Syndrome

Low pressure headaches(sagging brain syndrome) Spontaneous. Symptoms like post LP headaches Diagnosis- MRI of brain - meningeal enhancement, cerebellar herniation LP- low opening pressure Myelogram to find out the CSF leak.(tarlov cyst) Treatment- Blood patch, caffeine, theophylline,surgery for CSF leak

Headaches- Case History 70 yr old male wakes up from sleep daily with neck pain, occipital headache, dull and sharp pain.mild nausea. Some times referred to frontal area. Neck and shoulders stiffness Cervicogenic headaches Treatment- Physical therapy, muscle relaxants

Thank You Q & A