T1 SYMPOSIUM. Headaches and migraines (JG)(1).pptx

Headache symposium Module 202 Dr Jeban Ganesalingam Consultant Neurologist University Hospitals Sussex Contents and objectives Diagnosis of headaches. Common symptoms and how they relate to underlying pathophysiology. By the end of this lecture, the successful student should be able to: Describe...

Headache symposium Module 202 Dr Jeban Ganesalingam Consultant Neurologist University Hospitals Sussex Contents and objectives Diagnosis of headaches. Common symptoms and how they relate to underlying pathophysiology. By the end of this lecture, the successful student should be able to: Describe the pain sensitive structures within the brain. Distinguish primary vs secondary headaches. List the symptoms within the criteria for diagnose migraines. Identify the red flag symptoms that warrants further investigation. Why does it matter to know about headaches? • Estimated half of adult population has had at least one headache over the past year. • Lifetime prevalence is 96% • 15% of UK population have migraine • Third highest cause of disability • 25% of all OPD referrals to Neurology • 1-2% of all admissions to the ED What causes headaches? Pain sensitivity of cranial structures Pain sensitive Pain insensitive • Cranial venous sinuses with afferent veins • Arteries at the base of their brain and their major branches • Arteries of the dura • Dura near the base of the brain and large arteries • Dural Cranial and Extracranial nerves • All extracranial structures • Brain parenchyma • Ependyma • Choroid plexus • Pia • Arachnoid • Dura over convexity • Skull Neurotransmitter s • Neuromodulators • Seretonin • Dopamine • Glutamate • Oxytocin • Noradrenalin • Neuropeptides • CGRP (Calcitonin Gene Related Peptide) • PACAP • Orexin • Neurokinin A • Substance P CNS structures involved in modulating pain Number of brainstem nuclei involved in processing pain: Trigeminocervical complex Superior salivatory nucleus (autonomic) Locus Coeruleus (Noradrenalin) Dorsal Raphe nucleus (seretonergic) Hypothalamus (Orexin) Peripheral ganglion including: Trigeminal ganglion Clinical assessment Phenotype the headache • Presenting headache • Constant or episodic • Site: Unilateral or bilateral/holocranic • Headache load: Frequency/duration/severity • Character of pain: Throbbing, stabbing etc • Precipitating factor • Previous history of headaches • Any red flags? Headache classification Primary headach es Secondar y headach es ICHD Headache disorder 1 Migraine 2 Tension-type 3 Trigeminal autonomic cephalgias 4 Other primary headache disorders 5 ..attributed to trauma or injury to the head +/-neck 6 ..attributed to cranial or cervical vascular disorder 7 ..attributed to non-vascular intracranial disorder 8 ..attributed to a substance or its withdrawal 9 ..attributed to infection 10 ..attributed to a disorder of homeostasis 11 ..attributed to disorder involving the facial structures 12 ..attributed to a psychiatric disorder 13 Painful cranial neuropathies and other facial pains 14 Other headache disorders 99% of all primary headach es Primary vs secondary headache Are there any red flags present? Yes Secondary headache No Does the phenotype fulfil the criteria for migraines? No Another primary headache e.g Tension, Cluster attack Yes Migraine Red flags in clinical assessment • Age: Greater than 50 yrs • Onset: Thunderclap < 5mins, NDPH • Severity: “worst headache of their life” • Progression: Rapid or developing associated features. • Triggers: Provoked by valsalva, exercise, sex, postural change. • Systemic symptoms: Rash, weight loss, fever, neck stiffness. • Risk factors: HIV, Suspected malignancy, surgery, shunt in situ, inflammatory disorders, recent head injury. • Neurological signs: optic nerve swelling, hemiparesis, altered consciousness, visual field defect, cranial nerve palsies, seizures. • Raised ICP features: N&V, Position dependent, Visual obscurations, pusalatile tinnitus, worse with Valsalva maneouvres • It is the absence of RED FLAGs that give you confidence you are dealing with a primary headache. Primary vs secondary headache Are there any red flags present? Yes Secondary headache No Does the phenotype fulfil the criteria for migraines? No Another primary headache e.g Tension, Cluster attack Yes Migraine Diagnostic criteria for migraines A: At least five attacks1 fulfilling criteria B-D B: Headache attacks lasting 4-72 hr (untreated or unsuccessfully treated) 2;3 C: Headache has at least two of the following four characteristics: 1. unilateral location 2. pulsating quality 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs) D: During headache at least one of the following: 5. nausea and/or vomiting 6. photophobia and phonophobia E: Not better accounted for by another ICHD-3 diagnosis Primary vs secondary headache Are there any red flags present? Yes Secondary headache No Does the phenotype fulfil the criteria for migraines? No Another primary headache e.g Tension, Cluster attack Yes Migraine Headache types Pain > 4 hours No migrainous features Often bilateral Prefers to be still Pain > 4 hours +++ migrainous features Unilateral or bilateral Prefers to be still Pain < 4 hours Prominent autonomic symptoms Side-locked Migraines Migraine • Over 10 million people in the UK have migraines • Third most common disease in the world • More prevalent in females than males Adapted from migraine trust website Phases of migraine Ref: Charles. Lancet Neurology 2018 Treatments for migraine • Lifestyle • Avoidance of triggers • Hydrate, reduce caffeine, alcohol • Regular meals • Good sleep hygiene • Exercise • Abortive treatments: • Triptans – Decrease CGRP release • NSAIDs – Decrease prostaglandin secretion • Paracetamol • Preventatives: • Antiemetics – Decrease Dopamine • Oral drugs centrally • Anti-hypertensives Modulate • Anti-epileptics neurotransmit • Antidepressants ters • Injectables • Botox – blocks release of neurotransmitters • CGRP antagonists – blocks CGRP Botox and migraines CGRP monoclonal antibody Co-morbidities • 5 times more likely to have depression • 20% of episodic migraineurs have depression • Bidirectional relationship • Anxiety/Depression comes first in a sub-group • Anxiety • Anxious about when next attack will occur • Feel helpless about the unpredictability of attacks • Frustrated that they can’t function and plan their lives. • Depression • Mirror common migraine symptoms – insomnia, loss of appetite, malaise • Therefore need to involve GP/Clinical Psychologist/Psychiatrist when appropriate Other primary headaches Tension Headache Chronic daily headache Tight vice/squeezing Frontal/occipital Usually bilateral Not severe Better on holiday! Treatment Non-drug- relaxation/yoga/massage Tri-cyclic antidepressants TMJ pain Cluster headaches Side-locked, < 4 hours, periodicity Can occur in bouts Agitation, Autonomic symptoms Patient video Secondary headaches Nature of the problem • Headaches (4.5%) and seizures are the 2 commonest neurological presentations to ED • Majority of headaches presenting to GP, OPD, ED don’t have a sinister cause • Migraines, tension are the majority • Secondary headaches: • 2.14% of presentations in Neuro OPD in 1 year, • 5.5% of presentations to ED in 1 year • Intracranial bleeds, infections • Malignant tumours: 0.1% of 2000 MRI scans, (Vernooij et al 2007) • Benign tumours: 1.6% of 2000 MRI scans, (Vernooij et al 2007) • Scan for reassurance: • Reduction in anxiety and low mood at 3 months but not sustained after 1 year. When to scan? ATYPICAL FEATURES OF A PRIMARY HEADACHE RED FLAGS Imaging of choice Plain CT scan MRI Brain • CTA (Intracranial +/-Extracranial) • CTV • CT with contrast • • • • With Gad MRA/MRV MRI TOF (does not involve contrast) Thin sections through area of interest • E.g Orbits, Trigeminal nerve, Pituitary, Hippocampus, Temporal lobe Other Investigations Lumbar puncture: • • • • • • • Cell count (infections) Protein – elevated in a variety of pathologies Glucose – low in bacterial infection Oligoclonal bands – positive in certain inflammatory conditions. Cytology – abnormal cells present in tumours Viral PCR – viral infections Opening pressure: Elevated in IIH and with other space-occupying lesions. Blood pressure Blood tests: ESR, CRP - infection/inflammation CSF dysregulation Idiopathic Intracranial Hypertension “benign intracranial hypertension” not benign ! – can cause permanent visual loss Risk - high BMI, certain drugs High pressure chronic headaches prominent visual obscurations Treatment Therapeutic LP (repeat if reqd) Acetazolamide Optic nerve fenes. L-Perit. shunt Enlarged blind spot, constricted fields, loss of visual acuity late Idiopathic intracranial hypertension Low pressure headache Headache worse on sitting/standing up. Relieved by lying down. Vascular Thunderclap headaches: Urgent CT If negative- needs LP at 12 hours after onset of headache to test for CSF Xanthochromia Patient video Neurovascular conflict Trigeminal neuralgia Neurovascular conflict Paroxysmal pain typically in the V2 and V3 dermatomes Triggered by touch, wind, talking, brushing teeth Other causes include Tumours, MS, saccular aneursyms Patient video Inflammation Temporal Arteritis (GCA) Age >50yrs Mean age 70yrs ?1% of >80yrs Female>males 25% PMR ESR >50, but 10% <30 Fever, Malaise Pain on brushing hair, unable to lie on pillow or wear glasses Jaw claudication Visual loss -50% if untreated – acute or transient (amaurosis like) May be sequential ~75% in 3/52 Infection Meningitis What is it? Inflammation of meninges. Causes: Infection (bacterial, viral, protozoal, fungal) Neoplastic Inflammatory (eg sarcoid, Behcets) Infection by: Blood, adjacent structures (nasopharynx), trauma/iatrogenic CSF in Diagnosis Rbc’s SAH Wbc’s ++++ Gluc Prot Pressure Others xanthochromia Bacterial meningitis ++++ N’s germs Malignant meningitis ++ L cells ++ L AFB’s TB meningitis Viral meningitis ++++ L’s Neoplastic Brain tumour Rarely present with headaches alone Malignant tumours: 0.1% of 2000 MRI scans, (Vernooij et al 2007) Benign tumours: 1.6% of 2000 MRI scans, (Vernooij et al 2007) Contents and objectives Diagnosis of headaches. Common symptoms and how they relate to underlying pathophysiology. By the end of this lecture, the successful student should be able to: Describe the pain sensitive structures within the brain. Distinguish primary vs secondary headaches. List the symptoms within the criteria for diagnose migraines. Identify the red flag symptoms that warrants further investigation.