Professional Documents
Culture Documents
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.
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
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.
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.
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
Unilateral
Pulsating
Moderately severe.
Aggravated by physical activity
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.
Migraine Prevention
Drug
Valproate
Amitriptyline
Propranolol
Prozac
Riboflavin
Gabapentin
ACE
Aspirin
Clonidine
Verapamil
Evidence
A
A
A
B
B
B
B
B
B
B
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.
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
Bilateral
Pressing/tight non pulsating quality
Mild/moderate intensity
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.