1. Headaches Anne Mounsey M.D. Dept. of Family Medicine
Univ. of Virginia School of Medicine

2. Objectives
Learn how to distinguish life threatening headaches from benign headaches.
Learn management of migraine and chronic tension headache.

3. Causes of headaches. 2. Traction of large extracranial veins
1. Traction or dilatation of intracranial or extracranial arteries.
2. Traction of large extracranial veins
3. Compression, traction or inflammation of cranial and spinal nerves
4. Spasm and trauma to cranial and cervical muscles.
5. Meningeal irritation and raised intracranial pressure
6. Disturbance of intracerebral serotonergic projections

4. Pathophysiology of pain management in migraine
Cortical spreading depression activates the trigeminal and parasympathetic systems which causes vasodilatation and release of neuropeptides that cause inflammation.
Serotonin 5 HT receptors modulate the release of neurogenic peptides.
The goal of therapy is to prevent the neorogenic inflammation that occurs as a result of neuropeptide release. Triptans are 5 HT receptor agonists and block this release

5. Acute onset headache
Sufficient evidence from retrospective and prospective studies to support the association of an acute sudden onset headache with a vascular event.
Sudden onset headache is a red flag
Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache: Annals of Emerg Med 2002 (1):39.

6. Life Threatening causes of acute headaches.
Intracranial hemorrhage
Subdural hemorrhage
Subarachnoid hemorrhage.
Meningitis
Hypertensive encephalopathy.
Temporal arteritis in patient over 50. Red flag is the first and the worst.

7. Subarachnoid hemorrhage:causes
80% of non traumatic hemorrhages from ruptured saccular aneurysms.
Other causes: AV malformations, neoplasms, blood dyscrasias.
Commonest ages yrs.

8. Subarachnoid hemorrhage:risk factors.
Estimated that 5% of population have a berry aneurysm.
HTN
Smoking and alcohol
Sympathomimetic drugs
Polycystic kidney disease
Coarctation of the aorta
Marfans syndrome

9. Subarachnoid hemorrhage:useful signs and symptoms
Sudden onset of worst headache of life.
Worse on exertion eg valsalva, exercise.
75% of patients have nausea and vomiting.
50% of patients have meningism.
25% of patients have neck stiffness.
Linn F et al: Prospective study of sentinel headache in aneurysmal subarachnoid hemorrhage, Lancet 344:590, 1994.
Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage, J Neurosurg 25:219, 1966.
Subarachnoid hemorrhage (SAH) refers to extravasated blood in the subarachnoid space. The blood activates meningeal nociceptors, leading to diffuse occipital pain along with signs of meningismus. SAH accounts for up to 10% of all strokes and is the most common cause of sudden death from a stroke.[38] 20% of strokes are hemorrhagic, 80% are ischemic . Of the hemorrhagic strokes half are due to a subarachnoid hemorrahge and half due to intracerebral hemorrhage.Intracerebral hemorrhage is associated with HTN and AVM.

10. Risk factors for SDH
Age, alcohol, anticoagulation or anti-platelet treatment.
May be minimal trauma such as coughing
The signs and symptoms of brain compression may not appear until up to 2 weeks after the trauma..

11. Subdural hemorrhage Dull, mild generalized head pain.
Symptoms of chronic SDH may be subtle.
Up to 50% have altered level of consciousness
Headache is worse at night and same side as hematoma
On exam patient may have unilateral weakness and increased reflexes.

12. Hypertensive Encephalopathy
Associated with high blood pressure, nausea, vomiting and blurred vision
Usually associated with blood pressures of 200/130.
Headache diffuse and worse in the morning and subsides during the day.

13. Meningitis:useful signs and symptoms.
The absence of fever, neck stiffness and altered mental status in a patient with a headache virtually eliminates the diagnosis of meningitis.
In multiple studies the presence of neck stiffness on examination has a pooled sensitivity of 70%.
Does this adult patient have meningitis? Attia et al. JAMA 1999;281(2):
Fever is the most sensitive and then neck stiffness.Sensitivity is the proportino of paeple with the disease who have a positive result.

14. Signs of Meningism.
In a prospective study of young adult patients Kernigs sign had a sensitivity of 9% and a specificity of 100%.
Brudzinskis sign has not been evaluated since the original report .
Uchihara T, Tsukagoshi H. Headache 1991;31:
Specificity is number of people without the disease who have a negative test result.

15. Can response to therapy aid diagnosis?
No meta-analyses or RCTS to support or refute using response to therapy as an indicator of underlying pathology.
Case reports exist of patients whose headaches have significantly improved with analgesia and then subsequently died from an intracranial hemorrhage.
Bottom line: Level C recommendation that response to therapy should not be used as the sole diagnostic indicator of the etiology of the headache.
Case reports of patients presenting with headaches to the ER that have responded wel to ketoralac (toradol) and been discharged and then found dead at home secondary to intra cerebral hemorrhage, SAH,

16. Acute H/A: Factors in history associated with abnormality on neuroimaging.
Headache waking patient up.
Headache worsening with valsalva
Subjective sensory disturbance.
Rapidly increasing headache.
However the absence of these does not rule out positive findings on neuroimaging.
Annals of Emergency Medicine: Vol 39:1:Jan 2002.
Loss of headache free period. Above findings increase the probability of abnormal findings on neuroimaging but have very wide confidence intervals

17. Level B recommendations:
Clinical Policy of the ACEP for management of patients presenting with acute onset headache.
Level B recommendations:
Patients with headache and abnormal neuro exam should undergo an emergent non contrast CT.
Patients presenting with an acute sudden onset headache should be considered for an emergent CT scan.
HIV patients with a new headache should have urgent neuroimaging
Emergent means done at once to exclude life threstening condition. Urgent means arranged prior to disharge. HIV patinets have high incidence of space occupying lesions.

18. Clinical Policy of ACEP cont.
Level C recommendation:
Patients over 50 with a new headache should be considered for urgent neuroimaging.
Emergent means done immediately
Urgent means scan appointment is arranged prior to discharge and included in disposition.
Annals of Emergency Medicine: Vol 39:1:Jan 2002.

19. Migraine: IHS criteria
5 attacks of
Headache lasting 4-72 hours.
Must be associated with nausea or vomiting or photophobia and phonophobia
Must have 2 of the following
Unilateral
Pulsating
Moderately severe.
Aggravated by physical activity

20. Sinus H/A vs. Migraine Summit study.
Prospective multi center observational study of 2,991 patient with self diagnosed or physician diagnosed sinus headache. Using the IHS migraine criteria 80% of them had migraine.
Schreiber CP, et al. Archives of Internal Medicine. In publication
To diagnose sinus headache must have purulent discharge on suction or spontaneous and simultaneous onset of headache and sinusitis and abnormal xray, CT or transillumination.

21. Phases of migraine
Premonition: eg hunger, energy surges, irritability.
Prodrome: aura.
Headache phase
Postdrome.

22. Migraine Treatment Drug Level of Evidence Tylenol B NSAIDS A Triptans
Fiorinal
Midrin
Opiates
DHE
Steroids C
NSAIDS, A for ibuprofen, B for naproxen. A for aspirin.
Dihydroergotamine is S/C or a spray.More side effects than triptans.all triptans are A.

23. Triptans
Meta-analysis of 53 studies showed all the oral triptans are effective and well tolerated.
Rizatriptan 10mg, eletriptan 80mg amd almotriptan 12.5 mg were the most effective.
40-80% two hour headache response.
Give as early as possible in migraine attack.
Nasal spray or S/C injection may be more effective.
Oral triptans in acute migraine:a meta-analysis of 53 trials. Ferrari MD. Lancet. 358 (9294): Nov 17.
Treat early. Higher dose more effective. Nasal spray and SC more effective. For mild h/a 75% pain free at 2 hrs. for severe 50%. Try different triptans. Combine with NSAID

24. Percentage of patients with two hour headache response for each treatment ((bars are 95% confidence interval of the percentage)

25. NNT for headache response at 2 hours

26. Consider prevention when: US Headache consortium guidelines.
Interferes with patients daily routine.
>2/week
Acute medications ineffective or contraindicated.
Presence of uncommon migraine conditions
Hemiplegic migraine
Basilar migraine
Migraine with prolonged aura.

27. Migraine Prevention Drug Evidence Valproate A Amitriptyline
Propranolol
Prozac B
Riboflavin
Gabapentin
ACE
Aspirin
Clonidine
Verapamil

28. Episodic Tension Type Headache.
IHS Criteria
Tension type headaches < 15 per month.
Lasts 30 mins to 7 days
No nausea or vomiting
No photophobia and phonophobia (1 ok)
Headache has at least 2 of the following criteria:
pressing/tightening
Bilateral
Mild-moderate
Not aggravated by physical activity.
75% of patinets with migraine have neck pain.

29. Causes of TTH
Some evidence that like migraine caused by serotonin imbalance but to a lesser extent than migraine.
This would indicate that similar treatments would work.
Some evidence that TTH in migraneurs is a lesser version of their migraine. So triptans may work.

30. Treatment of TTH
Simple analgesia:ibuprofen is more effective than acetaminophen.
Combine analgesics with a sedating anit-histamine eg diphenhydramine.
Limit treatment to 2 days a week to prevent rebound headaches.
Amitriptyline up to 100mg qd or nortriptyline up to 75mg qd . Tizanidine is an alpha2 adrenergic agonist that inhibits the release of norepinephrine. Increase dose of NSAIDA to max. Limit teartment to 2 days a week to avoid rebound. Can use ssris and TCAs for prevention.

31. Chronic Daily Headache
Affects 4-5% of the population.
Definiton: head pain for at least 4 hours for more than 15 days/month.
Often develops from an episodic headache disorder either migraine or episodic tension type headache
Includes chronic tension type headache(CTTH) and chronic daily migraine
Chronic tension type headache is the most common. Patients with chronic daily migraine have a past history of episodic migraine. Typically as the headaches come more frequently the associateds ymptoms of photophobia, phonophobia. Nausea and vomiting become less severe and less frequent.

32. Chronic Tension Type Headache.
Develops from episodic tension type headaches
The most common form of CDH.
Familial tendency.
Medication rebound headache may be a factor in the transformation of episodic headache to CDH.

33. Chronic Tension Type Headache
Affect women more than men
Most common in middle age
Stress is often a trigger
Average duration is 4-13 hours.
When see a patinet with CDH ask what their has were like before they became constant ie did they have episodic has before.ask about analgesic use.

34. Treatment of CTTH.
Treating each headache increases the frequency and severity of the headaches.
Reserve medications for worse than usual headache.
Expert opinion: treat 2 headaches a week.
Frequent headache sufferers are at risk of developing analgesic overuse or drug rebound headaches. Expert opinion: limit headache medication to 2 days per week.

35. Prevention of CTTH Tricyclic antidepressants. Stress management
Tizanidine
SSRIs:prozac
Anticonvulsants:gabapentin and topiramate.
Acupuncture

36. Rebound Headaches. IHS criteria.
Headache for 15 days/month with at least one of the following characteristics and 2,3 and 4.
Bilateral
Pressing/tight non pulsating quality
Mild/moderate intensity
Simple analgesic use >15 days a month for 3 months
Headache has increased during analgesic use
Headache resolves or reverts to previous pattern within 2 months after discontinuation of analgesia.

37. Rebound headaches
Most significant factor in their development is the lack of awareness by physicians and patients. “Prevention better than cure”
Triptans, all analgesics and ergotamines have been associated with medication rebound headaches.
Most significant factor in their development is the lack of awareness by physicians and patients.

38. Rebound headaches
If patient is unable to tolerate abrupt cessation of medication may need to titrate down over 2 weeks.
May need inpatient treatment to successfully withdraw
Various regimes including tizanidine, daily triptans, steroids and parenteral DHE have been used.
Most significant factor in their development is the lack of awareness by physicians and patients.