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Subarachnoid Hemorrhage

23

Intracerebral Hemorrhage

24

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Corbett JJ, Mehta MP. Cerebrospinal fluid pressure in normal obese subjects and patients with pseudotumor cerebri. Neurology 1983;33:1386-8

37

39

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Coronal T140

��RNFL thickness: Depth difference between inner border of NFL & internal limiting membraneRNFL thickness: Depth difference between inner border of NFL & internal limiting membrane43

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44

45

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Mild grade ½ papilledema on OCT

46

Following disc edema over time with OCT

47

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Migraine Aura

59

6

CGRP: calcitonin gene-related peptide

NK: neurokinin A

SP: substance P

CGRP

NK

SP

5-HT1F5-HT1D

5-HT1B

Blood vessel

Trigeminal

nerve

MOA of triptans

CONSTRICTION

INHIBITION

Adapted from Goadsby et al. Neurol Clin. 1997.

Triptans: Proposed Mechanism

of Action

74

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Cost* of Triptan Dose

Ranging from highest to lowest price

Amerge 2.5 mg $16.64

Zomig 5 mg $15.09

Axert 12.5 mg $14.75

Maxalt 5 mg or 10 mg $14.35

Imitrex 50 mg $14.29

Imitrex 100 mg $13.74

Zomig 2.5 mg $13.27

Relpax 40 mg $12.64

*Prices are WAC from First DataBank, May 200380

IHS CLASSIFICATION

Episodic

Chronic

�� Cluster Cluster headacheheadache

�� Episodic (90%)Episodic (90%)

�� Chronic (10%)Chronic (10%)

�� Cluster period lasts Cluster period lasts

for more than one for more than one

year without year without

remission or remission or

remission lasts less remission lasts less

than 14 daysthan 14 days

�� Related syndromesRelated syndromesCephalalgia. 1988.

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EPIDEMIOLOGYEPIDEMIOLOGY

Predominantly male Predominantly male

((3.5 3.5 –– 7:1 7:1 male:femalemale:female ratio)ratio)

Mean age of onset (27 Mean age of onset (27 ––

31 years)31 years)

Prevalence Prevalence

(0.1% (0.1% –– 0.4%)0.4%)

Ekbom C et al. Ekbom C et al. HeadacheHeadache. 1978.. 1978.Swanson JW et al. Swanson JW et al. NeurologyNeurology. 1994.. 1994.Manzoni GC. Manzoni GC. CephalalgiaCephalalgia. 1997.. 1997.

Rare before the age of Rare before the age of

10 years10 years

130

GENETICSGENETICS

11stst--degree relatives have a degree relatives have a

14X increased risk14X increased risk

Five identical twin pairs with Five identical twin pairs with

100% concordance100% concordance

Positive family history in Positive family history in

7% of sufferers7% of sufferers

Russel MB. Russel MB. CephalalgiaCephalalgia. 1997.. 1997.

AutosomalAutosomal dominant disorder?dominant disorder?

131

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CIRCANNUAL PERIODICITY

Waldenlind E. Cluster Headache and Related Conditions. 1999.Kudrow L. Cephalalgia. 1987.

132

CIRCADIAN PERIODICITY11--3 attacks daily (up to 8 attacks/day)3 attacks daily (up to 8 attacks/day)

Peak time periodsPeak time periods

PMPMPMPMAMAM

REM sleepREM sleep

Trucco M, Waldenlind E. Trucco M, Waldenlind E. CephalalgiaCephalalgia. 1993.. 1993.

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ATTACK PROFILEATTACK PROFILE

Unilateral orbital / temporal severe pain Unilateral orbital / temporal severe pain

intensityintensity

Rapid onset (5 Rapid onset (5 –– 15 min) / short duration 15 min) / short duration

(45 (45 –– 90 min)90 min)

“Agitated” patient (pacing / “Agitated” patient (pacing /

restless)restless)

‘‘MigrainousMigrainous’ symptoms (nausea, ’ symptoms (nausea,

photophobia, photophobia, phonophobiaphonophobia, aura), aura)

134

AUTONOMIC FEATURESAUTONOMIC FEATURESAUTONOMIC FEATURESAUTONOMIC FEATURES

Conjunctival injection lacrimationConjunctival injection lacrimation

Nasal congestion / rhinorrheaNasal congestion / rhinorrhea

Partial Horner’s syndromePartial Horner’s syndrome

Facial flushing / sweating Facial flushing / sweating

edemaedema

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ASSOCIATED ASSOCIATED FEATURESFEATURESASSOCIATED ASSOCIATED FEATURESFEATURES

High alcohol / tobacco usageHigh alcohol / tobacco usage

Leonine facies (heavy facial Leonine facies (heavy facial

features)?features)?

Peau d’orange skin?Peau d’orange skin?

HazelHazel--colored eyes?colored eyes?

Duodenal ulceration?Duodenal ulceration?

Type A personality?Type A personality?

136

HYPOTHALAMUS ABNORMAL –

FUNCTION AND STRUCTURE

May A et al. Lancet. 1998; Nat Med. 1999.

Function Structure

139

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PERIODICITY DYSFUNCTIONAL

HYPOTHALAMIC PACEMAKER

CircannualCircannual and and ciradianciradian

rhythmicityrhythmicity

Seasonal predilection of Seasonal predilection of

cluster periodscluster periods

Altered Altered secretorysecretory circadian circadian

rhythms of rhythms of hypophysealhypophyseal

hormone systems hormone systems (melatonin, (melatonin,

testosterone, betatestosterone, beta--endorphin, betaendorphin, beta--lipotropinlipotropin, ,

cortisolcortisol, , prolactinprolactin))

Leone M, Bussone G. Leone M, Bussone G. CephalalgiaCephalalgia. 1993.. 1993.140

SURGICAL PROCEDURES

FOR CLUSTER HEADACHES

Autonomic (parasympathetic) Autonomic (parasympathetic)

pathway procedurespathway procedures

Sensory trigeminal pathway Sensory trigeminal pathway

proceduresprocedures�� Radiofrequency or glycerol Radiofrequency or glycerol rhizotomyrhizotomy

�� Gamma knife Gamma knife radiosurgeryradiosurgery

�� Trigeminal root sectionTrigeminal root section

�� OtherOther

OnofrioOnofrio BM, Campbell JK. BM, Campbell JK. Mayo Mayo ClinClin ProcProc. 1986.. 1986.Mathew NT, Hurt W. Mathew NT, Hurt W. HeadacheHeadache. 1988.. 1988.TahaTaha JM, JM, TewTew JM. JM. HeadacheHeadache. 1995.. 1995.

148

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Frequency, Time of Onset, and Duration of HypnicHeadache (n=19)

32%

32%

37%

63%

37%

32%

68%

0% 20% 40% 60% 80%

<30

30-…

>120

1-3 …

3-6 …

1-3 …

>4 …

Feature:Feature:

FrequencyFrequency

Time of onsetTime of onset

Duration (min)Duration (min)

Dodick DW, Mosek AC, Campbell JK, Cephalgia, 1998, 18:152-6155

Laterality, Quality and Severity of Hypnic Headache in 19 Patients

21%

74%

5%

42%

58%

32%

68%

0% 50% 100%

Severe

Moderate

Mild

Throbbing, sharp, pulsating or stabbing

Pressure, dull or boring

Unilateral

Bilateral

Feature:Feature:

LateralityLaterality

QualityQuality

Severity (1Severity (1--10 scale)10 scale)

Dodick DW, Mosek AC, Campbell JK, Cephalgia, 1998, 18:152-6

157