Workshop on Syndrome Recognition and Management HEADACHE Workshop on Syndrome Recognition and Management James J. Foody, MD, FACP Feinberg School of Medicine Northwestern University

Headache Workshop Goals Recognition of Several Headache Syndromes Management Strategies

Headache Classification Primary v Secondary Paroxysmal v Chronic Episodic v Recurrent Mild to moderate v Moderate to severe

What is This?

Case #1 CHARACTER THROBBING UNILATERAL QUALITY SEVERITY DISABLING ONSET MAXIMAL IN 1 HOUR DURATION HOURS RELIEF NSAID INADEQUATE FREQUENCY 2-4 PER WEEK CATAMENEAL

DIAGNOSIS #1 MIGRAINE

Migraine Morphology Diagnostic criteria for migraine without aura From:   Goadsby: BMJ, Volume 312(7041).May 18, 1996.1279-1283

Migraine Aura Spreading electrochemical depression across cortex Typically occurs 20-30 minutes before onset of head pain >80% migraineurs never experience aura Aura can occur w/o headache

Migraine Associations Colic in infancy Motion sickness Ice pick-like head pains “Freezer brain” Increased psycho-sensory sensitivity before migraine Increased appetite (especially for chocolate) Sleeplessness Burst of activity

Migraine Triggers Sleep deprivation/excess Caffeine ingestion or caffeine withdrawal Wine, especially red, & alcohol in general Fasting Sex hormones Most migraines have no trigger Strong familial pattern

Case #2 CHARACTER DULL BIFRONTAL QUALITY SEVERITY MODERATE ONSET UPON AWAKENING DURATION ALL DAY RELIEF FIORINAL INADEQUATE FREQUENCY DAILY

CHRONIC DAILY HEADACHE DIAGNOSIS #2 CHRONIC DAILY HEADACHE TRANSFORMED MIGRAINE

Chronic Daily Headache Rebound effect from analgesic Rebound headaches begin to overlap More analgesics due to more headaches Worst offenders: Caffeine Barbiturate combinations e.g Fiorinal Narcotics

Chronic Daily Headache Alternative Hypothesis Supraspinal pain regulatory pathways are dysfunctional Overuse of analgesics is associated, not causative At least 2/3 had prior typical migraine

Case #3 CHARACTER BORING UNILATERAL QUALITY SEVERITY DISABLING ONSET AWAKENS FROM SLEEP DURATION 10-20 MINUTES RELIEF SPONTANEOUS FREQUENCY 2-4 PER NIGHT FOR 10 NIGHTS

DIAGNOSIS #3 CLUSTER HEADACHE

Cluster Headache Clustering refers to calendar 80-90% affect males Never throbbing Always unilateral Often awaken 2-3 hours after falling asleep Alcohol invariable trigger during cluster

Case #4 CHARACTER SHARP WORST PAIN OF LIFE QUALITY SEVERITY DISABLING ONSET INTERCOURSE DURATION 20 MINUTES RELIEF SPONTANEOUS FREQUENCY ONCE

DIAGNOSIS #4 THUNDERCLAP HEADACHE

Thunderclap Headache No known cause Benign Triggers Exertion Sexual activity Weight lifting Prolonged Valsalva

Case #5 CHARACTER DULL BIFRONTAL QUALITY SEVERITY SOME DISABLING ONSET 6 MONTHS DURATION CONSTANT RELIEF NSAID / NARCOTIC FREQUENCY DAILY

CHRONIC DAILY HEADACHE DIAGNOSIS #5 CHRONIC DAILY HEADACHE TRANSFORMED MIGRAINE

“Sinus” Headache Pain from sinusitis is usually easily distinguishable Sinusitis can trigger migraine headache Migraineurs often give a family history of sinus headaches that are actually misnamed migraine

Bethany is a 26 year old woman c/o headache.   Case #1 Bethany is a 26 year old woman c/o headache. She has a headache every Saturday morning for the past 4 years. She reports more frequent headaches beginning 1 week before menses and lasting until the 2nd or 3rd day of menses. The headache gradually builds until it is at its maximum in an hour. It throbs, usually on the left side, although occasionally on the right or across the front of the head. She feels nauseated and vomits rarely. Social history: single, lives in Lincoln Park, condoms and diaphragm for contraception, works as attorney in large firm 6 days a week; no smoking; drinks alcohol only on Saturday night; sleeps from midnight-5:30 except sleeps until noon Sunday; drinks a Starbucks Venti latte every morning on the way to work and 2-3 cups coffee during the morning. Usually skips breakfast, eats light lunch. ROS Her mother said she had colic as an infant. She hates amusement parks. She cannot read in a car. FH: Her mother and father both get sinus headaches.

Migraine Treatment (1) Eliminate triggers Regular sleep patterns Stabilize caffeine Decrease alcohol Look for cycling with menses

Migraine Treatment (2) Triptans Dihydroergotamine intranasal Sumatriptan intranasal or subcutaneous Rizatriptan transbuccal Zolmitriptan transbuccal Dihydroergotamine intranasal

Case #2   Nancy is a 42 year old woman c/o headache. She has a headache most of the time for the past 6 months. She had intermittent headaches since menarche. They responded to ibuprofen until the past year. The headaches became as frequent as 2-3 per week. She saw a doctor who prescribed Fiorinal. The headaches initially responded to Fiorinal, but gradually became worse and daily. She awakens with a dull bifrontal headache almost every day. By midmorning the pain is worse and involves her neck. She takes 6-8 Fiorinal every day. She avoids caffeine, alcohol, and chocolate.

Chronic Daily Headache Treatment Treat underlying migraine Trigger avoidance Triptan or dihydroergotamine Preventive Divalproex (Depakote) Amitriptyline

Case #3 Diane is a 35 year old woman c/o headache. She was well until 10 days ago when she awoke at 2 AM with extreme pain behind the right eye. She describes the pain as boring like a drill, lasting for 10 minutes. The same pain returned an hour later, accompanied by right eye tearing and watery unilateral rhinorrhea. She reports 2-4 nearly identical episodes for 8/10 past days. She went to an ER the second night, but the headache had passed. She was given a prescription for Tylenol #3, which she took once and vomited. She admits to rare headaches in the past, which are not remarkable. She fell from a horse on vacation 2 years ago with a brief loss of consciousness. She was hospitalized for observation for 1 night. She takes no medications. She is married, no children, no contraception, works as an accountant, lives in Downers Grove in her own home. FH Her brother committed suicide at age 39. He had disabling headaches that she thinks were similar to hers.

Cluster Headache Treatment High-flow inhaled oxygen Triptan injection or intranasal 4% lidocaine 1 mL in ipsilateral nostril

Case #4 Stu is a 49 year old man c/o headache. While engaged in sexual intercourse with his wife this morning, he developed the sudden onset of the worst headache of his life. The pain was sharp, constant, in the back of the head, radiating through the vertex, maximal at onset, lasted for 20 minutes and remitted completely. He could only lie still during the headache. He did not take any medication. He is apprehensive now but feels otherwise perfectly well. PH He has a 10 year history of hypertension, controlled on HCTZ 25 mg and atenolol 50 mg daily. His cholesterol was 245 six months ago. He is trying to exercise and lose weight in order to avoid more medication. He admits to very rare mild headaches. PE Height 6 feet; weight 249 pounds dressed. BP 140/85, pulse 62 regular. Heart, lungs, and neurological exam are completely normal.

Thunderclap Headache Clinical emergency to R/O subarachnoid hemorrhage CT w/o contrast highly sensitive & specific for subarachnoid hemorrhage LP mandatory if CT is negative MRA if suspect cerebral venous sinus thrombosis or arterial dissection Headache is benign and infrequently recurs

Case #5 Marianne is a 38 year old woman c/o headache. She started having sinus headaches as a teenager. She has been on antibiotic therapy innumerable times. Her sinuses always hurt, sometimes worse than others. The pain is dull & bifrontal. She began taking ibuprofen +/- Vicodin. She feels they help a little and takes at least some every day. Headaches are daily for at least 6 months. PMH Recent CT scan of the sinuses show mucosal thickening and air fluid levels. She underwent a right Caldwell-Luc procedure (maxillary antrostomy) 4 years ago. She was diagnosed with Hashimoto disease last year and takes levothyroxine 75 mcg daily. SH She is single. She is not sexually active and has never taken OCP. She misses 3-4 days of work each month. She is an office manager who lost her last job because of absences. She is afraid she will lose this job also. She likes her job and has excellent performance appraisals except for absences. PE Height 5’ 4”; weight 262 pounds. Blood pressure 150/90, pulse 72, temperature 37.1. Mild percussion tenderness both maxillary and frontal sinus areas. Funduscopy and neurological exam are completely normal.

Pearls (1) Find the best dose of a triptan Treat only two headaches a week Do not use oral medications if nausea occurs; gastroparesis is part of migraine Always use preventive therapy if > 5 headaches in a month for chronic daily headache

Pearls (2) “Sinus” headache is really migraine “Tension-headache” if it exists, is mild by definition. People do not spend money to see doctors for mild conditions. Methysergide works well for menstrual migraine

Pearls (3) Always tell migraine patients that they do not have a brain tumor or Get an imaging study