Headache: An Approach for Family Practice 2024 PDF

Headache An approach for Family Practice Ghadeer Fatani, MD, ABPN Objectives Identify different types of headaches. Identify red flags of headaches and when the patient needs emergent evaluation and intervention. Able to obtain a thorough history and examination related to...

Headache An approach for Family Practice Ghadeer Fatani, MD, ABPN Objectives Identify different types of headaches. Identify red flags of headaches and when the patient needs emergent evaluation and intervention. Able to obtain a thorough history and examination related to the headache type. Identify headache work ups and common management. Headache 99.9% of people with headaches have no signs of tissue damage Injuries to the brain itself does not cause pain- it causes altered brain functions However the membrane and the blood vessels of the brain are very sensitive. pain that the headache is causing, it's not because it's really a ecting the brain. Brain itself doesn't sense the pain. brain parenchyma and veins around actually doesn't feel the pain. Skull and blood vessels react to the pain generating receptors. So when we have vasoconstriction, we get pain  Headache Headache is one of the most frequent reasons for which patients seek medical attention A classification system for headache disorders has been established by the International Headache Society. The most recent version,lastedition International Classification of Headache Disorders, 3rd edition, divides headache disorders into primary headaches (in which the headache and associated features constitute the disorder itself) and secondary headaches (in which the headache is due to a serious underlying disorder). why do they use this society? Because they are very thorough and when you go to their website, you will nd that all headaches are properly divided by site, symptoms ,treatment,. Usually, a secondary is more dangerous than the primary. So, if there is secondary headaches, you have to address what's the cause of the headache then order to treat the headaches.  Headache: ICHD-3 Classification Primary second meanhypotentionornypertention.tnos.pt present and withheadaches the isbloodpressure cause fluctuation 1 The appendix, they added it to the third edition. Those are the headaches that are not still proven and we don't have su cient data to deal with. Headache: Diagnosis Wedonthaveanyworkupfor Depends almost entirely on the patients story Tests, scans etc rarely helpful. Why do we sometimes do neuroimaging for other workups? To exclude the secondary causes. It's not really to diagnose, it's merely to exclude the causes of the headaches.  You have to ask which side is it unilateral or bilateral is it one side or alternating. Headache: History alternating> migraine “‫يجيه بالجهه اليمني ووقت ثاني باليسار‬ Onset: abrupt versus insidious; age of onset; context in which headache began (eg, recent head or neck trauma including head/neck surgeries, systemic illness, pregnancy/postpartum) Timing: chronicity, duration, and frequency of headache attacks; time to maximal intensity; diurnal versus nocturnal Quality: sharp, dull, pressure-like, throbbing, aching, stabbing, lancinating, burning Laterality: unilateral versus bilateral; side-locked versus alternating Location: retro-orbital, frontal, temporal, occipital Severity: visual analog pain scale; disability and interference with routine activity Change: difference in pattern from prior headaches Associated symptoms: sensitivity to stimuli (eg, light, noise, smell, movement); nausea/vomiting; visual changes; numbness/tingling of the face or extremities; focal motor weakness; impairment of speech; light-headedness/vertigo; cognitive dysfunction Cranial autonomic features: lacrimation, conjunctival injection, eyelid edema, ptosis, pupillary changes; nasal congestion or rhinorrhea; aural fullness or tinnitus Aura: Visual, sensory etc Premonitory features: symptoms that precede headache attacks, hours to days prior (eg, yawning, sleepiness, increased thirst, changes ftp.frneaataines.ae in bowel/bladder pattern, neck stiffness); typically a feature of migraine Postdrome: symptoms that follow headache attacks, typically lasting 1 to 2 days (eg, inability to concentrate, fatigue, mood alterations); TEtypically a feature of migraine Identifiable triggers: menstrual cycle; skipping meals; lack of sleep or oversleeping; stress; altitude or barometric changes; positional change (lying down vs standing up); Valsalva maneuvers or physical exertion; alcohol; caffeine; cigarette smoke Family history: of primary headache disorders; cerebral aneurysm; brain tumor or malignancy 7 Primary Headache Disorders side they have headaches. When they have a headache, they have a focal neurological de cit usually a weakness they will present as weakness on right side or left side or whatever. Stroke‫صعب تفرق بينه وبني ال‬ Primary Headache Disorders Tension-type Headache Frequency chronic often daily Pain mild-moderate pressure, tightness Duration 30 mins - 7 days Location both sides whole head and neck Pressurelike be mythrobbing likeTightbandaroundhead Symptoms no light / sound sensitivity no aura Typical patient : any involvethened Typical patient : any Tension-type headache Now thought to be due to increased brain sensitivity to normal sensory inputs also one of the primary headaches.we don't have real cause or it's idiopathic. However, it's now thought that it's just increased brain sensitivity to sensory part. Few effective treatments : we are trialling a non-drug treatment usually depends on the severity of the headache and the frequency. if it is stress related, we do some lifestyle modi cations. If so painful take some analgesic Avoid use alot analgesic with pt wit chronic headache b.c it can cuse overuse headache due to medication. it's okay, two per week. It's okay to use two doses per day, however not more than two times per week. Migraine we have an episodic and chronic. Frequency 8-14 days/month- episodic Pain 15 and more- chronic moderate - severe Duration pulsating, throbbing Location 4 hrs - 3 days swap usually one sided (but side can Symptoms alternate between attacks) aura nausea, vomiting sensitive to light, sound, smells Diagnostic Criteria for Migraine Typical Migraine Patient Onset often as child / teenager / young adult but can start at any age 2-3 x more common in women than men Typical patient : young woman (15% of all young women) Migraine cause Cause unknown but strongly inherited Many effective treatments Triggers Foods : spices, wine , chocolate, citrus Food additives : monosodium glutamate Sleep : both too much and too little Stress : mainly offset Female hormones : fluctuating or falling oestrogen Migrainous Aura it Migrainous Aura Migrainous Aura  Treatment of Migraine Once a diagnosis of migraine has been established, it is important to assess the extent of a patient’s disease and level of functional impairment A headache diary also helps assess disability as well as the frequency of abortive medication use. followup3 6month Patient education is an important aspect of migraine management. Set realistic goals. Also, patients should be reassured that migraine is generally not associated with serious or life-threatening illnesses. In patients who have migraine with aura, there is an increased risk of stroke, myocardial infarction, and all-cause cardiovascular mortality, although the absolute risk of these events is low. If it hemiplegic migraine this may increased risk of cerebrovascular accident. hemiplegic migraine actually mechanism is like stroke. That's why it causes one-sided weakness. However, they actually regain and they come back to normal.So theoretically, they have a risk actually to have stroke.More than the normal population. Treatment of Migraine Identifying and avoiding specific headache triggers. A regulated lifestyle is important, including a healthy diet (with a regular eating schedule), exercise, routinized sleep patterns, avoidance of excess caffeine, and minimizing acute changes in stress levels (such as through biofeedback, meditation, or yoga). Lifestyle modifications that are effective in reducing headache frequency should be maintained on a routine basis because these provide a simple, cost-effective approach to migraine management. If these measures fail to prevent an attack, abortive pharmacologic measures are then needed. Abortive Migraine Treatment Abortive migraine therapy should be considered in patients with severe headache episodes regardless of frequency. Triptans: First-line therapy with Level A evidence. Mechanism of action: Agonists at 5HT-1B (meningeal blood vessel constriction) and 5HT-1D (prevents nociceptive neuropeptide release). MI Contraindicated in patients with a history of CAD, stroke, hemiplegic migraine and migraine with brainstem aura. Common side effects: drowsiness, a sensation of warmth, paresthesias, dizziness, and nausea.  Fast Acting Triptans Sumatriptan m..ec Zolmitriptan Rizatriptan Almotriptan Eletriptan. Slow Acting Triptans Naratriptan Frovatriptan Has the longest half-life (25h) and used often in patients for menstrual- related migraines.  Triptans are contraindicated in the presence of a past medical history of coronary artery disease, ischemic stroke, and peripheral vascular disease due to the risk of precipitating vasospasm. They are also contraindicated in hemiplegic migraine and migraine with brainstem aura. calcium channel brokers. They release peptide when they have vasoconstriction.This peptide is what causes an increase in sensation or pain sensation. So they found a way to make the antagonist, CGRP antagonists (Rimegepant, Ubrogepant):1bortivemaintenancetreatment Mechanism of action: Inhibition of CGRP receptors. Side effects may include nausea, tiredness and dry mouth. Avoid ubrogepant strong CYP3A4 inhibitors NSAIDs: ibuprofen, ketorolac, naproxen, flurbiprofen, diclofenac Anti-emetics: prochlorperazine, metoclopramide, promethazine with usually NSAIDs Paracetamol Acute Treatment of Migraine Attacks Acute Treatment of Migraine Attacks Preventive Treatments for Migraines Its depend on patient severity and frequency and also clinical judgment. preventive‫كل ماكان اكثر االفضل ابدا ال‬ Patients who experience an increasing frequency of migraine attacks, or attacks that are poorly responsive to acute medications, warrant preventive therapy. In general, preventive treatments should be considered for patients with four or more migraine days a month; however, the decision of when to start a preventive agent may also depend on the severity and duration of attacks, response to acute therapy, and patient preference. It’s not cure attack or stop, it its helpfully ,it will be shorter and less.  Beta Blockers First line euseita.ie Metoprolol (level A evidence) most common because its Propranolol (level A evidence) non selective beta blocker Timolol (level A evidence) It does not a ect the heart Nadolol (level B evidence) Atenolol (level B evidence) Should be avoided in patients with asthma and Raynaud’s phenomenon.  Anti-epileptic Drugs Topiramate (level A evidence): One of the most common first-line therapies. Side effect profile includes calcium phosphate stones, paresthesias, cognitive symptoms, fatigue, and weight loss. (Level A evidence) Risk for cleft lip and low birth weight if used during pregnancy. Valproic acid (level A evidence): Adverse effects include ataxia, sedation, tremor, nausea/vomiting. Monitor liver enzymes. Should be avoided during pregnancy. or bearing age folic acid ‫ولو بدانا معاهم بهالفتره نعطيه مع‬ alley ftp.a.tientifharecs Gabapentin (level U evidence): May be helpful for comorbid neuropathic pain management ,usually use it for tremor, RLS, and neuropathy. numbness ,tingling it’s work for headache Side effects include dizziness and sedation. Avoiditwhith Patient young  We use it if we have another reason. Antidepressants its improved mood Tricyclic antidepressants (TCAs): Very good with agitated pt or pt cant relax have alot of stress. Adverse effects may include anticholinergic side effects (dry mouth, constipation, weight gain, orthostatic hypotension, and sedation). Amitriptyline (level B evidence) Nortriptyline (metabolite of amitriptyline; less side effects) Imipramine Protriptyline (level U evidence; less sedation; may be activating) SSRIs/SNRIs Venlafaxine (level B evidence) Duloxetine Fluoxetine (level U evidence) Botox injections (temporary procedure ,6month) CGRP Inhibitors 1bortivemaintenancetreatment CGRP antagonists: Novel (approved 2018) class of monoclonal antibody medications for migraine prevention. The antibodies block CGRP, which is an important vasoactive peptide involved in the migraine cascade. First drug developed specifically for migraine prevention. Once monthly injections: Fremanezumab (can also be given quarterly) Erenumab (side effect of constipation) Glacanezumab Quarterly IV infusion Eptinezumab oral oronceerry6month *very expensive  Nutraceuticals If the patient does not want chemicals Magnesium (oxide, citrate, sulfate) Coenzyme Q10 Riboflavin (Vitamin B2) Inlargdotearound400 600 may use it with kids  1s Preventive Treatments for Migraines  1 Preventive Treatments for Migraines Medication overuse headache Headache made WORSE by pain killers Only occurs in people who already had headache Mainly due to codeine-containing medicines or stronger morphine- like drugs Need to stop responsible medicines : easier said than done We are trialling a new treatment for this If they stop taking the medication, they su er from headaches, and if they continue taking it, they have to increase the dose every time. Usually this patient opioid use.Or addicted to using medication. Either reduce it gradually until it stops or stop using it completely.. Trigeminal Autonomic Cephalalgias weblog The TACs describe a group of primary headaches including cluster headache, paroxysmal hemicrania (PH), short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)/short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA), and hemicrania continua (HC). Cluster Headache Frequency clusters – every time each year or season; then free Pain excruciating penetrating, boring continuous, non-throbbing 15mins-3 hrs; same clock time each day (2am); several episodes / day Duration Location ALWAYS the same side Symptoms watering eyes nasal stuffiness, runny nose inmate red eye, swollen eyelids sweating Typical patient : middle aged male smoker Cluster Headache  ssamebutdiftrentin IP.EE hiahehmfIEina adf.nlhdinepisodic TACs oneside oneside oneside iiiitma ifi if At the same time and in the same season ae Triptans as saiasnosticannner.n.io Anticonvulsant: Trigeminal Neuralgia VERY short (72 hours, it is considered status migrainosus, and warrants aggressive treatment. Intravenous infusion of antiemetics, ketorolac, valproic acid, magnesium, and steroids can be tried. Dihydroergotamine (DHE): Multi-day in-hospital infusion to break status migrainosus. Contraindications: peripheral vascular disease, coronary artery disease, severe hypertension, angina, recent triptan use within 24 hours, pregnancy, severe liver disease. Obtain an EKG before administering. Some experts use a half-sized “test dose” as the first dose to monitor for potential cardiac side effects. These are those that come in the emergency and the headache is very severe. And they need more e ective and immediate treatment. Usually they use IV medication Secondary Headache  DIAGNOSIS AND TESTING Detailed History and Examination Preliminary Diagnosis NO Primary Headache? YES Secondary Headache Atypical Features Diagnostic Testing  The Best 2 Tools We Have History Headache onset Duration Location Severity and Quality Associated Features Aggravating Factors Exam General exam! Neurologic exam Headache Red Flags (SNOOP4) sudden with standing or sitting. with intracranial hypotension headache J References ELAN D LOUIS; STEPHAN A MAYER. Merritt’s Neurology. Philadelphia: Wolters Kluwer Health, 2022. v. Fourteenth editionISBN 9781975141226. Disponível em: https://search-ebscohost- com.sdl.idm.oclc.org/login.aspx?direct=true&db=nlebk&AN=3322879 &site=eds-live. Acesso em: 9 set. 2023. BILLER, J. Practical Neurology. [Place of publication not identified]: Wolters Kluwer Health, 2017. v. Fifth editionISBN 9781496326959. Disponível em: https://search-ebscohost- com.sdl.idm.oclc.org/login.aspx?direct=true&db=nlebk&AN=1780873 &site=eds-live. Acesso em: 9 set. 2023. American Academy of Neurology: Continuum.