Headaches

Anne Mounsey M.D.

Dept. of Family Medicine Univ. of Virginia School of Medicine

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

Causes of headaches.
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

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.

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.

Life Threatening causes of acute headaches.

Intracranial hemorrhage
Subdural hemorrhage Subarachnoid hemorrhage.

Meningitis Hypertensive encephalopathy.

Subarachnoid hemorrhage:causes
80% of non traumatic hemorrhages from ruptured saccular aneurysms. Other causes: AV malformations, neoplasms, blood dyscrasias.
Commonest ages 40-60 yrs.

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

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.

Risk factors for SDH

Age, alcohol, anticoagulation or antiplatelet 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..

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.

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.

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):175-181

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;31:167-171.

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.

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.

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

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.

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
1. 2. 3. 4. Unilateral Pulsating Moderately severe. Aggravated by physical activity

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

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

Migraine Treatment
Drug Tylenol NSAIDS Triptans Fiorinal Midrin Opiates DHE Steroids Level of Evidence B A A A B A B C

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):1668-75. 2001 Nov 17.

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

NNT for headache response at 2 hours

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.

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

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:
a. b. c. d. pressing/tightening Bilateral Mild-moderate Not aggravated by physical activity.

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.

Treatment of TTH
Simple analgesia:ibuprofen is more effective than acetaminophen. Combine analgesics with a sedating anithistamine eg diphenhydramine. Limit treatment to 2 days a week to prevent rebound headaches.

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.

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.

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.

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.

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

Rebound Headaches. IHS criteria.

Headache for 15 days/month with at least one of the following characteristics and 2,3 and 4.
a. b. c. 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.

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.

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.