Essential in headache

disorder
Surat Tanprawate, MD, MSc(Lond.), FRCP(T)
Headache Clinic, Department of Medicine
Chiangmai University
Facebook page: openneurons
The headache topics you
should know
1. International Classification of Headache Disorder-III
(ICHD-III)
2. Common headache disorder
1. Update evidence for migraine management
Secondary headache
Neuralgias
Primary headache
Migraine
TACs
TTH
Other
primary
headache
The Headache Classification
Classification of Headache Disorder
International Classification in Headache Disorder (ICHD)
ICHD-I: 1988
ICHD-II: 2004
IHC, Boston 2014: ICHD-III Beta version
Jes Olesen, MD, PhD University
of Copenhagen, Glostrup
Hospital, Denmark
http://www.ihs-classification.org/
Migraine
without aura
ICHD-III beta
Component
Algorithm approach
Headache complaint
History taking + Physical exam
Primary
headache
disorder
diagnosed by
ICHD-III Beta
criteria
Alarming s/s, Red
flag signs
S/S of
secondary
headache
Investigation to
detect serious
cause of
secondary
headache
Headache
attributed to .
Mixed headache
- Primary + Primary
- Primary +
Secondary
- Secondary +
secondary
Normal neurological
examination
Abnormal neurological
examination
Focal neurologic s/s
other than typical visual
or sensory aura
Papilledema
Temporal
profile
Concurrent
event
Provoking
activity
Age
Age> 50
Sudden onset
-SAH, ICH, mass
lesion (posterior
fossa)
Worsening
headache
-Mass lesion, SDH,
MOH
Pregnancy, post
partum
-Cerebral vein
thrombosis, carotid
dissection, pituitary
apoplexy
Headache with
cancer, HIV,
systemic illness
(fever, arteritis,
collagen vascular
disease)
Neck stiffness
Triggered by cough,
exertion or Valsava
-SAH, mass lesion
Worse in the
morning
-IICP
Worse on changing
position to upright
-Low CSF pressure
The headache topics you
should know
1. International Classification of Headache Disorder-III
(ICHD-III)
2. Common headache disorder
1. Primary headache disorder
Migraine, TACs, Other primary headache
2. Medication overuse headache (MOH)
Practical point of migraine
diagnosis
Primary headache disorder characterized by
recurrent headache accompanying with specific
phenomena...nausea/vomiting, aura,
photophobia/phonophobia
Migraine diagnostic criteria
A. 5 attacks fulfilling B-D (2 attacks for migraine with aura)
B. 4-72 hours (untreated/unsuccessfully treated)
C. 2/4 of following headache characters
1. unilateral
2. pulsating quality
3. moderate/severe pain intensity
4. aggravated by/cause avoid routine physical activity
D. 1/2 of following symptoms during headache
E. No other disorder
Classic migraine
(Migraine with aura)
The different phases of a migraine attack
Premonitory
symptoms
Premonitory
symptoms
prevalence =
87%-33%
Predictability of
headache at 72 hrs:
72%
Werner JB. Cephalalgia 2012. 33(13) 11171121
Somatosensory aura: Cheiro-oral numbness
Zig-zag lines (fortification)
Zig-zag lines in migraine aura
Visual Aura
Mosaic Illusion
Olomouc (c.1757) bastion fortress in today's
Czech Republic
Body distortion in Migraine
Pain characteristics and location of the acute migraine
attack: A study of 1283 migraine patients
Time of headache: morning in 18.7%, afternoon 13.5%, evening 4.0%,
during night 9.4%, and "anytime" 54.3%
Headache character: throbbing (73.5%), aching (73.8%), pressure
(75.4%), and stabbing (42.6%)
Headache increased by activity: 90.2% of patients
Headache location: eyes (67.1%), temporal (58.0%), and frontal
(55.9%), diffusely (17.5%) and vertex (24.1%)
Hemi-cranial location: 66.6% of patients,
Kelman L. Headache 2006 Jun;46(6):942-53.
Kelman L. Headache 2005 Sep;45(8):1038-47.
Genetic
Environmental
and factor
Cause
Pathophysiology of
acute migraine
Pathophysiology of episodic
and chronic migraine
- Genetic
: FHM, TREK

-Trigger factor
Pathophysiology
- Aura
- vasodilatation
- neurogenic inflammation
- peripheral and central
sensitization
- Trigemino vascular system
Neurotransmitter
- Serotonergic system
- Dopaminergic system
Structural and functional
brain change
- Brain stem activation
Clinical: chronic and transform
migraine, allodynia, neck pain

Anatomical: PAG, central
sensitization
episodic
constant
episodic become chronic
acute on chronic
Evolution of Migraine
Migraine is considered as a chronic
disorder with episodic attacks (CDEA)
No
migraine
LFEM
0-9 days of
headache/month
HFEM
10-14 days of
headache/month
Chronic
Migraine
Factor for Migraine progression
Conceptualized of clinical course of migraine
- Attack frequency
- Obesity
- Medication overuse
- Stressful life event
- Caffeine overuse
- Snoring
- Other pain
syndrome
- Gene
- Age/Sex
- Triggers
Bigal and Lipton Neurology 2008;71;848-855
The effective treatment for migraine
1.Non-pharmacologic + Pharmacologic therapy
2.Pharmacologic therapy: acute and prevention
1.Right drug-evidence based
2.Right dose-dose recommended
3.Right duration-4-6 months
Indication for preventive
treatment in migraine
Recurring migraine that significantly interferes with quality of
life
Frequency of migraine attacks > 1/weeks
Frequency of acute medication use > 2/week
Failure of, contraindication to, or trouble AE from acute
medication
Uncommon migraine: hemiplegic migraine, basilar migraine,
prolonged, disabling or frequent aura, or migrainous cerebral
infarction
Pract Neurol 2007; 7: 383393
Non-specific
medication
Ever S, Afra J. Eur J Neurol 2009, 16:968-981
Migraine- specific medication
(Imigran)
(Zomig)
(Relpax)
Ergotamine/C
affeine
1 mg/100 mg
Caffeine
B
ER situation
Acute migraine attack
Valproic acid 300-800 mg iv
Chlorpromazine 25 mg
Ketorolac 60 mg im
Magnesium sulfate 1000 mg iv
Metoclopamide 10 mg iv
Tramadol iv
Status migrainosus
Dexamethasone 10 mg iv
Refractory case
Haloperidol 5 mg iv
Occipital nerve block
Ever S, Afra J. Eur J Neurol 2009, 16:968-981
Shrestha M. Arch Intern Med. 1996;156:1725-1728
Pamela D et al. J Head and Face Pain. 2005;45(7):899-903
Bigal ME. Cephalalgia 2002. 22(5):345-353
Evers, S et al. European Journal of Neurology 2009, 16: 968981
Triptans
(Imigran)
(Zomig)
(Relpax)
Sumatriptan 2.5
Zolmitriptan
Eletriptan
3.3
1.0-2.0
Time to peak plasma(h)
Level A: established as effective
Should be offered to patients requiring
migraine prophylaxis
Level B: probably effective
Should be considered for patients requiring
migraine prophylaxis
Vivalproex/sodium valproate 400-1000 mg/d
Metoprolol




47.5-200 mg/d
Petasites (butterbur)

50-75 mg bid
Propranolol 120-240 mg/d
Timolol 10-15 mg/d
Topiramate 25-200 mg/d
Amitryptyline



25-
150 mg/d
Fenoprofen




200-600 md tid
Feverfew 50-300 mg bid
Histamine 1-10 ng sc 2/wk
Ibuprofen 200 bid
Ketoprofen 50 mg tid
Magnesium 600 mg
Naproxen/naproxen sodium 550 mg bid
Riboflavin 400 mg/d
Venlafaxine 150 mg/d
Atenolol 100 mg/d
Level C: possible effective
May be considered for patients requiring
migraine prophylaxis
Level U: conflicting or inadequate
evidence
Insufficient data to support or refute use for
migraine prophylaxis
Candesartan 16 mg/d
Carbamazepine


600 mg/d
Clonidine

0.75-0.15 mg
bid
Guanfacine 0.5-1 mg/d
Lisinopril 10-20 mg/d
Nebivolol 5 mg/d
Pindolol




10
mg/d
Flubiprofen 200 mg/d
Mefenamic acid 500 mg/d
Coenzyme Q10 100 mg tid
Cyproheptadine 4 mg/d
Acetazolamide

Hyperbaric
oxygen
Aspirin Indomethacin
Bisoprolol Nicardipine
Coumadin Nifedipine
Cyclandelate Nimodipine
Fluoxetin Omega-3
Fluvoxamine Picotamide
Gabapentin Verapamil
Clonazepam Montelukast
Lamotrigine Nabumetone
Acebutolol Oxcarbazepine
Telmesartan
Medication-overuse
headache (MOH)
Diagnostic criteria:
A. Headache occurring on >15 days per month in a
patient with a pre-existing headache disorder
B. Regular overuse for >3 months of one or more
drugs that can be taken for acute and/or
symptomatic treatment of headache
C. Not better accounted for by another ICHD-3
diagnosis.
ICHD-III beta
1) Patients with MOH should be offered advice and teaching to
encourage withdrawal treatment. (B)
2) Abrupt vs tapering withdrawal : No evidence
For the overuse of analgesics, ergotamine
derivatives, or triptans, abrupt withdrawal is recommended.
For the overuse of opioids, benzodiazepines, or
barbiturates, tapering down of the medication should be
offered. (good practice point)
3) Type of withdrawal: success, relapse rate:
Inpatient = outpatient (A)
Ever S and Jensen R. Eur J Neurol 2011. 18:1115-1121
4) Inpatient withdrawal treatment in patient with
- opioid, benzodiazepine, or barbiturate overuse
- severe psychiatric
- medical comorbidity
- failure of a previous outpatient withdrawal treatment
(good practice point)

5) Individualized preventive medication should be started
at the first day of withdrawal treatment or even before if
applicable. (C)
Ever S and Jensen R. Eur J Neurol 2011. 18:1115-1121
6) Topiramate 100 mg (up to 200 mg maximum) per
day is probably effective in the treatment of MOH. (B)

7) Corticosteroids (at least 60 mg prednisone or
prednisolone) and amitriptyline (up to 50 mg) are
possibly effective in the treatment of withdrawal
symptoms. (good practice point)
Ever S and Jensen R. Eur J Neurol 2011. 18:1115-1121
Thank you