Headache

Mary D. Hughes, MD

Neuroscience Associates

Case 1

22 year old female presents with recurrent

headaches. She has had headaches for the past

3 years.

They start on the right side of her head and spread

across her forehead. She gets queasy and notes

that the light bothers her eyes during a headache.

She doesn’t drink Margaritas because she has

noticed that they trigger her headaches.

A “bad” headache – makes her lay her head down on her desk at work.

She gets milder ones about once a week that she treats with Tylenol.

PmHx – Normal Soc Hx: rare etoh, Recently separated

Fam Hx: Mother has migraines

PE: Normal

Adapted IHS Criteria for

Migraine with Typical Aura

A At least 2 attacks fulfilling criteria B B Aura consisting of at least one of the following, but no motor weakness: -Fully reversible visual symptoms including positive features (e.g.,

flickering lights, spots, or lines) and/or negative features (i.e., loss of vision) -Fully reversible sensory symptoms including positive features (i.e., pins

and needles) and/or negative features (i.e., numbness) -Fully reversible dysphasic speech disturbance C At least two of the following: -Homonymous visual symptoms and/or unilateral sensory symptoms -At least one aura symptom develops gradually 5 minutes or more and/or

different aura symptoms occur in succession over 5 or more minutes D Headache fulfilling criteria for migraine without aura beginning during the

aura or follows the aura within 60 minutes

Alice in Wonderland

Syndrome

• Lewis Carroll –

Migraineur? Or

addict?

• Distorted images

“I’m pretty brave, generally, only

today I happen to have a

headache.”

Tweedledum

Visual Scotoma

Adapted from IHS Criteria

for Migraine without Aura*

Headache Descriptions (Any 2)

Unilateral

Pulsatile quality

Moderate to severe pain intensity

Aggravation by or causing avoidance of routine physical activity

Associated Symptoms (Any 1)

Nausea and/or vomiting

Photophobia and phonophobia

*Must have 5 attacks fulfilling the above criteria and no signs of a secondary headache disorder. The headaches last 4–72 hours

Triggers

Anxiety

Stress

Lack of food or sleep

Exposure to light

Hormonal changes (in

women)

Genetics

Case 2

22 year old female presents with sinus headaches. She gets

pressure over her eyes and lights bother her.

She admits to being irritable during a headache. The sinus

pressure gets worse when she climbs stairs.

PmHx – negative SocHx: Student, No tobbacco or alcohol

Fam Hx: Negative for migraines

PE: Normal

Adapted IHS Criteria for

General Diagnosis of Episodic

TTH*

Headache Description (Any 2)

Associated Symptoms (Any 1)

Pressing or tightening Mild to moderate intensity Bilateral location No worsening with exertion

No nausea or vomiting Photophobia or phonophobia (1 allowed)

*Must have had >10 previous headache episodes and no evidence of a secondary headache disorder. Episodic TTH occur <15 days/month and CTTH occur >15 days/month. CTTH also allows the presence of mild nausea

Life Cycle of Migraines

Life Cycle of Migraines

Case 3

31 year old male presents with a severe headaches that wake him from sleep for the last two weeks. The pain is so intense that he “cries” and paces the room. His girlfriend states that he “hits his head” the pain is so severe. He remembers having headaches like this 2 years ago which lasted about a month and then disappeared.

PmHx: Neg SocHx: Smokes 1ppd, 1-2 beers/night

FamHx: Remembers his father having bad headaches

PE: normal

Adapted IHS Criteria for the

General Diagnosis of Cluster Headache*

Headache Description (All 4)

Severe headache

Unilateral

Duration of 15–180 min

Orbital, periorbital, or temporal location

Autonomic Symptoms (Any 2)

Rhinorrhea

Lacrimation

Facial sweating

Miosis

Eyelid edema

Conjunctival injection

Ptosis

*No evidence of a secondary headache disorder. Episodic cluster headaches occur for <1 year and chronic headaches occur for >1 year.

Characteristics of Primary

Headache Disorders

Migraine Tension-Type Cluster

Location Unilateral Bilateral Strictly Unilateral

Intensity Mod/Severe Mild/Moderate Severe

Duration 4-72 hrs 30 min-7 days 15 – 90 min

Quality Throbbing Pressing/Tightening Severe

Assoc. Symptoms

Yes No Yes - autonomic

Gender F > M F > M M > F

MSQ

Red Flags for a Secondary

Headache Disorder

A new or different headache

"Thunderclap" headache (peak intensity within seconds to minutes)

Worst headache ever

Focal neurologic signs or symptoms, such as papilledema, motor weakness, memory loss, papillary abnormalities, or sensory loss

Change in existing headaches

New onset headache after age 50

Headache associated with systemic symptoms (fever, weight loss, jaw claudication)

Migraine Comfort Signs

Positive family history of migraine

Headache related to menstrual cycle

Headaches preceded by typical aura

Headaches remaining periodic and stable over time

Normal physical and neurologic findings

Pain Relief

Pain Free

Risk of Reocurrance

Class A Established Efficacy Class B Probable Efficacy

Divaloproex sodium Amitriptyline

Sodium valproate Venlafaxine

Topiramate Atenolol

Metoprolol Naldolol

Propranolol Naratriptan(MRM)

Timolol Zolmitriptan (MRM)

Frovatriptan (MRM)

MRM = menstrual related migraine

ED algorthim

http

://effectivehe

althcare.ah

rq.go

v/

Institute of Medicine and

Comparative Effectiveness

Research

“Compare the effectiveness of

different treatment strategies on the

frequency and lost productivity in

people with chronic, frequent

migraine headaches”

Background

GHS employee claims data

Appropriate anti-migraine medication use is

associated with 26% decreased annual total health

care costs

GHS employee survey

40% with mild to severe headache

45% not satisfied with headache treatment

Utilization and treatment outcomes Utilization

Have you ever seen a health care provider in the last year for your

headaches? Yes, n(%)

259 (62.1)

Have you ever gone to emergency room in the last year because of your

headaches? Yes, n(%)

46 (8.6)

Have you had a CAT scan or MRI in the last year because of your

headache? Yes, n(%)

68 (12.7)

Has a health care provider ever told you that you have migraines? Yes, n(%) 339 (63.1)

Medication use, n(%)

Yes 415 (77.3)

OTC 329 (61.3)

Prescription drugs 247 (46.0)

High utilizers 89 (16.6)

Treatment optimization, n(%)

Yes 146 (27.2)

No 269 (50.0)

N/A 122 (22.7)

Impacts of Headache on

Treatment Optimization and

Productivity

Migraine/headache

– 18% of women and 6% men

– Most active employment period

• 25-55 years old

– Lost work productivity(absenteeism)

– Reduced efficiency (presenteeism)

Impacts of Headache on

Treatment Optimization and

Productivity

Total costs for migraine:

60%: indirect costs due to lost

productivity

40%: direct medical costs

Acknowledgements

• The study was funded by IAHC seed grant