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Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Is All Headache Pain The Is All Headache Pain The Same? Same?
Diagnostic and Treatment Diagnostic and Treatment PearlsPearls
Christy M. Jackson, MDChristy M. Jackson, MD
Director, Director, DalessioDalessio Headache CenterHeadache Center
Scripps ClinicScripps Clinic
International Classification of International Classification of Headache DisordersHeadache Disorders
Second Edition Jan 2004Second Edition Jan 2004
4 Primary Headache 4 Primary Headache CategoriesCategories
8 Secondary Headache 8 Secondary Headache CategoriesCategories
NewNew: Trigeminal : Trigeminal Autonomic Autonomic CephalalgiasCephalalgias
NewNew: Sub classification : Sub classification of TTHof TTH
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
ICHDICHD--2 Primary Headaches2 Primary Headaches
Lipton, RB, et.al. Neurology 2004;63:427-435
ICDH ICDH --2 Secondary Headaches2 Secondary Headaches
Lipton, RB, et.al. Neurology 2004;63:427-435
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Migraine PrevalenceMigraine Prevalence
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
0
5
10
15
20
25
30
0 20 30 40 50 60 70 80 100
Age (Years)
On
e Y
ear
Per
iod
Pre
vale
nce
(%
)
Females
Males
Migraine Prevalence Peaks in the 25Migraine Prevalence Peaks in the 25--55 Age 55 Age Range for Both GendersRange for Both Genders
Consulting PatternsConsulting Patterns
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
PCP/NonPCP/Non--specialists Lead the List of Healthcare specialists Lead the List of Healthcare Practitioners Consulted Prior to a Diagnosis of Practitioners Consulted Prior to a Diagnosis of
Migraine*Migraine*
9%
16%
24%
82%
Counseling
Alternative Medicine
HA Specialist
PCP/Non-specialist
*Categories Not Mutually Exclusive
Undiagnosed Migraine Sufferers Often Undiagnosed Migraine Sufferers Often Receive Other Medical DiagnosesReceive Other Medical Diagnoses
42%
32%
Sinus HA
Tension-type HA
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Sheftell FD. Managing Acute Pain October 1996;40-47
Reference: 6. Ophoff, R.A. et al.: Familial hemiplegic migraine and episodic ataxia type-2 are caused bymutations in the Ca2+ channel gene CACNL1A4, Cell 87:543-552, November 1, 1996
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Migraine Activity May Start in the Cortex with Migraine Activity May Start in the Cortex with Cortical Spreading DepressionCortical Spreading Depression
Welch M et al. Headache. 2005 Apr; 45 Suppl 1:S25-32. Van den Maagdenberg AM et al. Neuron. 2004;41:701-10.Lauritzen M. Brain. 1994;117:199–210.
Double click image to play video
Trigeminal Nerves Surrounding Trigeminal Nerves Surrounding MeningealMeningeal Blood Vessels are ActivatedBlood Vessels are Activated
Trigeminal nerve fibers in the Trigeminal nerve fibers in the meningealmeningeal blood vesselblood vessel
1
2 3
Bolay H et al. Nature Medicine. 2001;8:136-142. Williamson DJ, Hargreaves RJ. Microsc Res Tech. 2001;53:167-78.
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
NeurochemicalNeurochemical Release leads to Release leads to NeurochemicalNeurochemical ProductionProduction
KininsKinins start the process leading to prostaglandin synthesisstart the process leading to prostaglandin synthesis
KininsKinins facilitate the production of facilitate the production of cyclooxygenasescyclooxygenases
CyclooxygenasesCyclooxygenases convert convert arachidonicarachidonic acid to prostaglandinsacid to prostaglandins
Woolf CJ. Ann Intern Med. 2004;140:441-451.
Inflammation Activates Pain Receptors Inflammation Activates Pain Receptors Leading to Pain TransmissionLeading to Pain Transmission
Inflammation and Inflammation and vasodilationvasodilation sensitize peripheral sensitize peripheral meningealmeningealpain receptors and lead to pain transmissionpain receptors and lead to pain transmission
Pain Receptors transmit signals to the trigeminal ganglion and Pain Receptors transmit signals to the trigeminal ganglion and the TNCthe TNC
When the TNC transmits pain signals to thalamus & cerebral When the TNC transmits pain signals to thalamus & cerebral cortex, the patient first feels paincortex, the patient first feels pain
Silberstein SD. Cephalalgia. 2004; 24(suppl 2):2-7. Bolay H et al. Nature Medicine. 2002;8:136-142Goadsby PJ et al eds. Pathophysiology of Headache in Wolff’s Headache and Other Pain. 7th ed. Oxford: Oxford University Press; 2001:62.Hargreaves RJ, Shepheard SL. Can J Neurol Sci. 1999;26(suppl3):S12-19
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Integrative Approaches to Integrative Approaches to Headache ManagementHeadache Management
Evidence Based usage of supplementsEvidence Based usage of supplements RiboflavinRiboflavin
MagnesiumMagnesium
PetadolaxPetadolax
Coenzyme Q10Coenzyme Q10
BiofeedbackBiofeedback
AcupunctureAcupuncture
Physical TherapyPhysical Therapy
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Lipton & Stewart. Cephalalgia. 1997;17(18):53-59
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Acute Management
Mostly migraine cases, some cluster
Outpatient vs Inpatient strategies
Infusion Centers will obviate the need for UCC or ER evaluation
Outpatient Strategies
Status Migrainosis
Intractable Cluster
Severe Muscle Contraction Pain
Trigeminal Neuralgia
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Status Migrainosis
Classical definition is unremitting migraine for more than 72 hours
Prednisone taper of 60 mg initially with 5 or 10 day taper
Toradol injection, nasal spray or tablets Triptan injectable if not tried already with
antinauseant Occipital Nerve Block Infusion center or admission
New Options for Migraine New Options for Migraine TreatmentTreatment
CalcitoninCalcitonin Gene Receptor Protein (CGRP) Gene Receptor Protein (CGRP) Inhibitor Inhibitor –– TelcagepantTelcagepant
Occipital Nerve StimulationOccipital Nerve Stimulation
SumatriptanSumatriptan Air InjectorAir Injector
SumatriptanSumatriptan patchpatch
ToradolToradol nasal spray nasal spray -- SprixSprix
DHE Inhalation ApparatusDHE Inhalation Apparatus--LevadexLevadex
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
New Options for Migraine Prophylaxis
Namenda
Savella
Botulinum Toxin 155-195 units every 3 months
Hypotheses:MechanismsHypotheses:Mechanisms of of Botox A in HeadacheBotox A in Headache
May reduce May reduce pericranialpericranial muscular tension and muscular tension and contractionscontractions
May directly affect sensory nerves May directly affect sensory nerves –– possibly possibly reducing reducing neuropeptideneuropeptide release release
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Dosing of BTX-A in Headache FDA recommendations for 155FDA recommendations for 155--190 units Botox A190 units Botox A
Fixed site of 31 standard sites usedFixed site of 31 standard sites used
Every 12 weeksEvery 12 weeks
Fixed-SiteFollow-the-Pain
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Cluster Headache TreatmentCluster Headache Treatment
Acute TherapyAcute Therapy High Flow High Flow
OxygenOxygen
TriptanTriptan
DHEDHE
Suppressant Suppressant TherapyTherapy SteroidsSteroids
IndomethacinIndomethacin
Ca Channel BlockerCa Channel Blocker
LithiumLithium
TopiramateTopiramate
WarfarinWarfarin
**WarfarinWarfarin for Refractory Cluster Headache, for Refractory Cluster Headache,
Hakim, S Headache 51:5, 713Hakim, S Headache 51:5, 713
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Tension Type Headache TreatmentTension Type Headache Treatment
Acute:Acute: NSAIDSNSAIDSTramadolTramadolLocal heat/coldLocal heat/coldValiumValium
Preventive:Preventive: TCATCANSAIDSNSAIDSPhysical TherapyPhysical TherapyTMJ analysis TMJ analysis ––
consider Botox for consider Botox for massetermasseterdystoniadystonia
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
CervicogenicCervicogenic HeadacheHeadache
Side Locked, older population or in history of Side Locked, older population or in history of traumatrauma
Originates at base of skull and travels up over Originates at base of skull and travels up over scalp to eyescalp to eye
May become May become pulsatilepulsatile
Does not meet criteria for migraineDoes not meet criteria for migraine
Responds to occipital nerve blocks, Responds to occipital nerve blocks, indomethacinindomethacin
Characteristics of Medication Overuse Headache
Diffuse, bilateral headache every day, aggravated by physical or mental exertion
Waking with early morning headache
Restlessness, nausea, forgetfulness, depression
Medication withdrawal symptoms when meds missed
Tolerance to abortive medications
Lack of efficacy in many preventive medications
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Infusion Center
Added to the Dalessio Headache Center this year
Locations at TP, RB and CV
Entry requires eval by one of our MDs or NPs
Same day infusion of a cocktail of options
Infusion Cocktail
IV fluids
IV Magnesium one gram
IV Valproic Acid 500mg
IV Decadron 10 mg
IV Compazine or Reglan
IV Toradol 30-60 mg
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Inpatient Strategies
Medication Overuse Headache largely vs Status Migrainosis
DHE Protocol
IV Reglan
IV Steroids, especially if triptan withdrawal
Clonidine if indicated for opiate withdrawal
Phenobarbitol if indicated for butalbitalwithdrawal
DHE Protocol
Initial test dose of 0.5 mg IV with Reglan as premedication for nausea
Follow up dosing of 0.2-1.0 mg every 8 hours for 2-3 days
As outpatient, patient will continue DHE as a subcutaneous injection three times daily for one week, then taper over 3 weeks
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Patient Presentation
35 year old female
Presents to office after having been seen in Urgent Care twice in past week for headache, treated and sent home
CT Brain normal, LP with WBC of 10, otherwise normal
BP: 134/80, HR 80, AF, Weight 150, Height 5’6”
History
No prior history of recurrent headache episodes
No family history of headache
Mild postural and exertional component to pain
Global, non pulsatile with no features of photo or phonophobia
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Differential Diagnoses Secondary Headache Meningitis/Encephalitis PseudotumorMass lesionAneurysm SubduralVasculitisMedication reactionChiari IOther
Primary HeadacheNew Onset Daily Persistent HeadacheMedication Overuse Headache
Work Up
ImagingMRI/MRA Brain
Laboratory testingCBC
Chemistry panel
ESR, CRP, ANA, RPR
PTT
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
MRI Brain
Cortical Infarct
Gyral enhancement
Clinical Update
MRI tech tells nurse patient had shaking of her left arm during MRI
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Next Step: What is the definitive test?
Carotid Ultrasound
MRV
Brain Biopsy
EEG
MRV Images
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
CT scan
Cerebral Venous ThrombosisMain Neurologic Signs
and SymptomsHeadache 89%
Papilledema 28%
Generalized seizures 30%
Focal seizures 20%
Mental Status disorder 30%
Mean age 39 years
3:1 female to male ratio
Is All Headache Pain the Same? Diagnostic and Treatment Pearls Christy M. Jackson, MD
Evaluation CT Brain less sensitive
MRI Brain is best noninvasive tool
MRV is widely used in place of conventional angiography
CSF exam useful if meningitis/encephalitis is expectedMay also be therapeutic if elevated ICP present
LabsCBC, ESR,ANA,PTT, procoagulant workup (Pro C,
S, Antithrombin III, Factor V Leiden, Antiphospholipid Ab, Lupus Anticoagulant)
Management Anticoagulation with heparin should be started as
soon as possible Safe, even in the case of hemorrhagic conversions of
bland venous infarcts PTT maintained at 2x control until headache
resolves, focal deficits stabilize and mental status normalizes
Local thrombolysis may be necessaryMaintenance on warfarin 3-6 months or indefinitely
if procoagulant state found Seizure management ICP management with acetazolamide, diuretics