a short presentation on migraine n tt

1. Headache Review
Santosh K. Dhungana
JR Y1
Dept of GP& EM

2. scenario..
 28/ F from Siraha, presented to GOPD with-
◦ h/o repeated headaches, left sided
◦ 2-3 episodes/ month, lasting 30 mins to hrs
◦ Variable pattern
◦ Increased severity during menses
◦ Relieved by avoiding family members and
sleeping

3.  Gives h/o multiple treatments at various
centers
 All investigations- baseline, eye consult, CT,
EEG normal
 She was accompanied by her husband
 Has 3 children, lives in a joint family of 8
members
 Can’t speak Nepali

4. headaches..
 >10 mil doctor visits/ year, 2 mil ER visits in
US
 One of primary symptom perpetuated/
exaggerated for 1˚/2˚ gain
 Headache + backache-
◦ Leading cause of lost productivity and
absenteeism
◦ Loss of > $61 bil/ yr
 JAMA, Nov 12, 2003

5. why worry?
 a lot of people think headaches are
“normal”
 take OTC drugs-
◦ Suppress symptoms
◦ curtain on “danger signs”
 drug dependence
 ADRs esp NSAIDs and kidney

6. Classification
 Primary headaches-
 those in which headache and its associated
features are the disorder in itself
 secondary headaches-
 those caused by exogenous disorders
◦ the International Headache Society (IHS)

7. Primary vs Secondary
headaches
 Tension type 69%
 Migraine 16%
 Idiopathic stabbing
2%
 Exertional 1%
 Cluster
0.1% • Systemic infection
63%
• Head injury
4%
• Vascular disorders
1%
• SAH
<1%
OPD vs ER

8. anat and physio
 pain perception-
◦ a normal physiologic response mediated
by a healthy nervous system
 Pain occurs when
◦ peripheral pain receptors are stimulated in
response to tissue injury, visceral
distension or
◦ pain-producing pathways of the PNS/
CNS are damaged or activated
inappropriately

9. anat and physio
 few cranial structures are pain-
sensitive-
◦ the scalp
◦ middle meningeal artery
◦ dural sinuses
◦ falx cerebri
◦ proximal segments of the large arteries
 much of the brain parenchyma-no pain

10. clinical approach
 History
 A full description of the pain
 site /radiation/ quality/ severity/ frequency/
duration/ onset and offset
 precipitating factors
 aggravating and relieving factors
 associated symptoms

11.  physical examination
 Inspect
◦ Head/ temporal arteries/ eyes
 palpate
◦ temporal arteries/ the face and neck muscles
◦ the cervical spine/ sinuses
◦ teeth and TMJ
 signs of meningeal irritation and papilledema
 A mental state examination
◦ Mood/ anxiety /tension/ depression
 Eye examination
 Neurological examination
◦ sensation and motor power in the face and limbs and
reflexes

12. red flag
 "Worst" headache ever/ thunder clap
 First severe headache
 Abnormal neurologic examination
 Fever or unexplained systemic signs
 Vomiting that precedes headache
 Pain induced by bending, lifting, coughing
 Pain that disturbs sleep or presents immediately upon
awakening
 age > 55
 Headache with local tenderness- region of temporal
artery

13. secondary headache

14. some causes
 URTI/ sinusitis
 Meningitis, encephalitis, brain abscess
 Intracranial hemorrhage (SAH, epidural, subdural)
 Brain tumor (cerebral, pituitary)
 Temporal arteritis
 Glaucoma, refractive errors
 Ophthalmic herpes zoster
 Cervical spondylosis

15. infections
 URTI/ sinusitis
◦ Most common cause of headache
 Meningitis-
◦ Bacterial, TB, fungal
 Encephalitis-
◦ Viral
 brain abscess
◦ Immune status

16. infections
 Rule of thumb
◦ Acute, severe headache
with stiff neck + fever
 Kernig’s / brudzinki
 Meningococcal rashes
 Dx-
◦ Blood, CSF, x-ray, CT, MRI
 Tt-
◦ Urgent Abx
LP vs Abx- which first?

17. empirical therapy
 Preterm infants to infants <1 month
◦ Ampicillin + cefotaxime
 Infants 1–3 mo
◦ Ampicillin + cefotaxime or ceftriaxone
 Immunocompetent children >3 mo and adults
<55
◦ Cefotaxime, ceftriaxone or cefepime + vancomycin
 Adults >55 and adults of any age with
alcoholism or other debilitating illnesses
◦ Ampicillin + cefotaxime, ceftriaxone or cefepime +
vancomycin

18. head injury
 Skull/ scalp
 intracranial
◦ Concussion
◦ Contusion
◦ Hemorrhage- subdural, epidural
 Dx-
◦ Local examination, neurological, x-ray, CSF, CT,
MRI
• Px- GCS, Hunt and Hess scale
 Tt-
◦ General-ABCs, BP
◦ Urgent referral for ICU/ operative measures

19. SAH
 Life threatening, 40% die before tt
 Features-
◦ Sudden onset
◦ Occipitalgeneralised
◦ Pain, neck stiffness
◦ vomitting LOC
◦ Kernig’s +
◦ “sentinel headache”
 Dx-
◦ CT
◦ LP if CT negative- frank blood vs xanthochromia
 Mgmt- airway, BP
◦ Medical and surgical intervention

20. Grade Hunt-Hess Scale WFNS Scale
1 Mild headache, normal mental status,
no cranial nerve or motor findings
GCS score 15, no
motor deficits
2 Severe headache, normal mental
status, may have cranial nerve deficit
GCS score 13–14, no
motor deficits
3 Somnolent, confused, may have
cranial nerve or mild motor deficit
GCS score 13–14,
with motor deficits
4 Stupor, moderate to severe motor
deficit, may have intermittent reflex
posturing
GCS score 7–12, with
or without motor
deficits
5 Coma, reflex posturing or flaccid GCS score 3–6, with
or without motor
deficits

21. brain tumors
 5-10 per 100,000
 Age- 2 peaks
Children <10yrs
 Medulloblastoma
 Astrocytoma
 Glioma- brain stem
Age- 35- 60
• Meningioma
• Pituitary adenoma
• Mets from lung
• Glioma- cerebral
Inv- CT, MRI

22. temporal arteritis
 AKA GCA, cranial arteritis
◦ Persistent unilat throbbing headache
◦ Over temporal and scalp
◦ Localized cord like thickening
◦ w or w/o loss of pulsation of temporal artery
◦ blurring of vision- danger sign!
 Patho-
◦ Type of collagen disease
◦ Causes inflammation of extra-cranial vessels

23.  Dx-
◦ unilateral intermittent headache in 50 yr+ F>M
◦ fever
◦ Lab- high ESR, anemia
◦ Biopsy of STA (focal involvement)
◦ MRI best
 Tx-
◦ steroids
◦ Important to prevent blindness
◦ Prednisolone 50mg bid for 2-4 weeks
◦ Dose adjustment guided by CRP and ESR level
◦ May need 1- 2 yrs to resolve

24. glaucoma
 Chronic elevation of IOP-
◦ Optic neuropathy
◦ Painless vs acutely painful
 Dx-
◦ IOP measurement
◦ Cupping
 Tx-
◦ topical adrenergic agonists, cholinergic agonists,
beta blockers, PG analogues, Laser

25. cervical spondylosis
 Pain over nape of neck (-itis)
 Palpable tenderness
 Dx-
◦ clinical, x-ray, CT
 Tx-
◦ NSAIDs, physio

26. post spinal headache
 Cause- low ICP d/t CSF leak
 Severe with N/ V
 Tx-
◦ Bed rest
◦ Caffeine
◦ Blood patch
 AMDA experience

27. primary headaches

28. some causes
 Tension type
 Migraine
 Idiopathic stabbing
 Exertional
 Cluster

29. tension type headache
 Aka muscle contraction headache
 Symmetrical
 Last for hours and recur daily
 “tight band”/ heavy wt on top of head sensation
 “invisible pillow” sign
 More common in females (75%)
 Onset: after rising, gets worse during day
 Aggravating factors: stress, overwork
 Relieving factors: alcohol

30. IHS criteria
 At least 10 episodes
 Each episode lasting 30 mins to 7 days
 2 of the following 4
◦ Non-pulsating
◦ mild- mod intensity
◦ b/l location
◦ not ˄ by routine activity
 Both of-
◦ No N/ V
◦ No photo/ phonophobia
 Lasting <15 days/ month (<180 days/ yr)
 Dx of exclusion

31. mgmt
 patient education
 massage
 stress reduction
◦ relaxation therapy
◦ yoga or meditation classes
 Analgesics- paracetamol, aspirin

32. migraine
 Greek word meaning ‘pain involving half the head’
 Very common (1 in 10 person)
 F>M
 Peak age 20- 50 yrs
 Many types-
◦ Common
◦ Classic
◦ Complicated
◦ Unusual subtypes-
 Hemiplegic, basilar, retinal, migranous stupor,
ophthalmoplegic, status migrainosus

33. classical features
 Radiation: retro-orbital and occipital
 Quality: intense and throbbing
 Frequency: 1 to 2 per month
 Duration: 4 to 72 hours (average 6 - 8 hours)
 Onset: paroxysmal, often wakes with it
 Offset: spontaneous (often after sleep)
 Precipitating factors: tension, stress (commonest)

34. common migraine- IHS
criteria
 The patient should have had at least five of
these headaches
 The headaches last 4 - 72 hours
 The headache must have at least two of
these-
◦ unilateral location
◦ pulsing quality
◦ moderate or severe intensity, inhibiting or
prohibiting daily activities
◦ headache worsened by routine physical activity
 The headache must have at least two of
these-
◦ nausea and/or vomiting
◦ photophobia and phonophobia

35. classic migraine- IHS criteria
At least two attacks,
including at least 3 of the following
◦ reversible brain symptoms (cortical or brain stem)
◦ gradual development over 4 minutes
◦ aura duration less than 60 minutes
 visual 25% (scintillation, scotoma, hemianopia)
 sensory (unilateral paraesthesia)
◦ headache follows aura in less than 1 hour

36. migraine- triggers
• Foodstuffs - chocolate, oranges, tomatoes, citrus fruits, cheeses, gluten sensitivity (possible)
• Alcohol - especially red wine
• Drugs - vasodilators, oestrogens, monosodium glutamate, nitrites (‘hot dog’ headache), indomethacin, OCP
• Glare or bright light
• Emotional stress
• Head trauma (often minor), e.g. jarring - ‘footballer's migraine’
• Allergen
• Climatic change
• Excessive noise
• Strong perfume
Endogenous
• Tiredness, physical exhaustion, oversleeping
• Stress, relaxation after stress - ‘weekend migraine’
• Exercise
• Hormonal changes - puberty - menstruation
- climacteric
- pregnancy
• Hunger
• Familial tendency
• ? Personality factors
Practically any thing can trigger a migraine
headache!

37. the Migraine Disability assessment test

38. management- acute attack
 Start as soon as you suspect
 Complete rest in dark room
 Cold-pack
 Avoid triggering factors

39. medical management
• First line
 paracetamol or Dispirin 600-900 mg + metoclopramide
10mg
 Paracetamol (in children)
 NSAIDs
• Alternative -Ergotamine (helps about 80% of
patients)
◦ oral
 Ergotamine 1 mg + caffeine 100 mg –Migril/ Cafergot
 2 tabs stat
 Repeat after 1 hr if necessary (max. 6 per day)
◦ Inhaler- 1 puff stat, repeat in 5 mins (max 6 puffs/
day)
◦ P/R-ergot 2mg + caffeine 100mg
◦ i/m- Dihydroergotamine 0.5-1.0 mg (give perinom

40. ◦ Sumatriptan (a serotonin receptor agonist)-Migratan
 Oral
 50 - 100 mg at the time of prodrome
 repeat in 2 hours if necessary
 max 300 mg/24 hours
 Nasal spray
 10-20 mg per nostril (max 40mg/ day)
 Subcutaneous
 6mg stat
 Repeat 1 hrly (max 12 mg/ day)

41.  Severe attack – red flag
 Review for other causes – SAH, CVA, drug abuse
 Meds-
◦ Dihydroergotamine 0.5-1.0 mg +perinom 10 mg i/m
◦ Or sumatriptan 6mg s/c
◦ Or dihydroergotimine 0.5 mg + perinom 10 mg i/v
 No ergot if triptan used within 6 hrs!
 No triptan if ergot used within 24 hrs!

42. prophylaxis
 When?
◦ 2 or more attacks/ month
◦ Disturbing daily activity
 What?
◦ Propanolol 40mg bid/ tds (max 320 mg)
◦ TCA- amitriptylin 10mg hs (50-75 mg
maintainance)
◦ Pizotifen 0.5- 2.0 mg hs
◦ Cyproheptadin
◦ Nifedipine
◦ Naproxen
◦ Gapapentin
◦ Sod. valproate

43.  How long?
◦ Try single drug for at least 2 months
◦ No set time frame for termination of treatment
 Add TCA (amitriptyline) to others
 Alternatives medicines-
◦ herbal, homeopathy, chiropratice, naturopathy,
relaxation, massage

44. choice of initial drug
 if low or normal weight - pizotifen
 if hypertensive - a beta-blocker
 if depressed or anxious - amitriptyline
 if tension - a beta-blocker
 if cervical spondylosis - naproxen
 food-sensitive migraine - pizotifen
 menstrual migraine - naproxen or ibuprofen

45. transformed migraine
 progressive increase in frequency of migraine
attacks until the headache recurs daily.
 The typical migraine features become modified-
resembles that of tension headache but with the
unilateral situation of migraine
 Analgesic abuse can transform episodic migraine
into chronic daily headache

46. cluster headache
 AKA migrainous neuralgia
 Paroxysmal cluster of unilateral headache during
nights
 Rhinorrhea/ lacrimation/ red eye/
 Hallmark- predictable cyclical nature- “alarm clock
headache”
 Male: female = 6:1
 No visual problem
 No nausea

47. mgmt
 Acute
◦ 100% oxygen inhalation
◦ Sumatriptan 6mg s/c or 20 mg intranasal
◦ Ergot inhalation
◦ Perinom 10 mg + dihydroergotamine 0.5 mg i/v
◦ Greater occipital nerve block
 Prophylaxis
◦ Ergotamine
◦ Prednisolone 50 mg x 10 days then lower
◦ Lithium 250mg bd
◦ Verapamil

48. other causes of headache
 Mixed headache
 Drug rebound headache
 Hypertension headache
 Pseudotumor cerebri
 Cough and extertional
 Gravitational

49. Coming back to the case
 Female
 Unilateral headache (but prolonged duration)
 Isolation and sleep helps
 Examination and inv- Normal
?

50.  Stopped all meds
 Started on TRIAD
 Followed up for 3 consecutive OPD days..
 Lost to follow up

51.  Medication alone not enough
 Non-pharmacological tt, pt education
 Language/ education barrier

52. the children and elderly
 Children
• Intercurrent infections
• Psychogenic
• Migraine
• Post-traumatic
 Elderly
• Cervical dysfunction
• Cerebral tumour
• Temporal arteritis
• Subdural haemorrhage

53. references
 John Murtagh's General Practice, 4th Edition
 Harrison's Principles of Internal Medicine, 18th Ed
 An introduction to clinical emergency medicine- Mahadevan
 uptodate 19.3
 Diagnosis and management of headache in adults: summary
of SIGN guideline
BMJ 2008; 337

54. thank you