Headache

European Interactive Pain Course03.-07.09.07

Wednesday

Headache – Symptoms and

treatment


Headache and facial pain: diagnosis

History

Location

of pain

Character

of pain

First onset

Duration

of pain

Pain-free

intervals

Reasons

for

increase

or decrease

in symptoms

Triggering

factors

Concomitant

symptoms

Analgesic

history

Family

history

Family

stress

Social

history


Examples of patterns of pain for various types of headache

Migraine

Cluster headache

Chronic

tension

headache

Trigeminal

neuralgia

M D M D F S S M D M D F S S M D M D F S SM D M D F S S

M D M D F S S M D M D F S S M D M D F S SM D M D F S S

0

10

0

10

M D M D F S S M D M D F S S M D M D F S SM D M D F S S0

10

Attackendauer ~ 30 min/d

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

10

NRS

NRS

NRS

NRS


Headache and facial pain

Keeping a headache diary

Determine

the

type, frequency

and severity

of headache

Monitoring

of treatment

Download Kopfschmerzkalender: www.dmkg.de


Pathogenesis of migraine

Congenital

tendency towards

reaction

Congenital

tendency towards

reaction

Triggers:StressLight and noiseFoodstuffs, alcoholEffects

of weather

Hormone fluctuationsChanges

in sleeping-waking-rhythm

Triggers:StressLight and noiseFoodstuffs, alcoholEffects

of weather

Hormone fluctuationsChanges

in sleeping-waking-rhythm

Crossing

migraine

thresholdCrossing

migraine

threshold

Abnormal cerebral activityAbnormal cerebral activity

Abnormal vascular activity

Abnormal vascular activity

HeadacheHeadache

Aura symptomsAura symptoms

Vomiting

center disorder

Vomiting

center disorder

Central sensitization

Central sensitization


Migraine

Therapeutic regimen in acute migraine

ASA (1 g) or paracetamol (1 g) or ibuprofen (600 mg) or dipyrone (1 g)

After onset of effect of the anti-emeticgive ASA, paracetamol, ibuprofen or dipyrone

Metoclopramide or domperidone 20 mg orally or rectally

Start medicinal therapywith anti-emetic

treatmentafter 20 minutes

Orally: e.g. sumatriptan subcutaneously: 6 mg or25-100 mg rectally: 25 mg or

nasally: 20 mg

If pain relief is inadequate:administration of sumatriptan

No effect Side-effect:vomiting

Recurrence of headache

Repeat after 4 hours at the earliest (max.

300 mg/day)

Repeat after 2 hours at the earliest (max. 12 mg s.c./day or max.

50 mg supp./day or max. 40 mg nasally/day)

On recurrence of headacherepeat sumatriptan

administration

Source: DMKG 2000 Guidelines


Triptans – Onset of effect

Source: SPCs

SubstanceSubstance TrademarkTrademark FormulationFormulation DosesDoses Onset

of effectOnset

of effect

SumatriptanSumatriptan Imigran®Imigran®

s.c.orallynasallyrectally

s.c.orallynasallyrectally

6 mg50 –

100 mg

10 –

20 mg25 mg

6 mg50 –

100 mg

10 –

20 mg25 mg

10 –

15 min30 min15 min30 min

10 –


ZolmitriptanZolmitriptan Asco

Top®Asco

Top®

Asco

Top®Asco

Top®

orally

(SL tab.)nasallyorally

(SL tab.)

nasally2.5 mg

2.5 –

5 mg2.5 mg

2.5 –

5 mg60 min15 min60 min15 min

RizatriptanRizatriptan Maxalt

lingua®Maxalt®Maxalt

lingua®

Maxalt®orally

(SL tab.)

orallyorally

(SL tab.)

orally10 mg10 mg10 mg10 mg


NaratriptanNaratriptan Naramig®Naramig® orallyorally 2.5 mg2.5 mg 60 min60 min

AlmotriptanAlmotriptan Almogran®Almogran® orallyorally 12.5 mg12.5 mg 30 min30 min

EletriptanEletriptan Relpax®Relpax® orallyorally 40 mg40 mg 30 min30 min

FrovatriptanFrovatriptan Allegro®Allegro® orallyorally 2.5 mg2.5 mg 2 h2 h


Ferrari MD et al (THE LANCET 2001)

Large metaanalysis

of 53 randomised

double-blind controlled studies

in a total of 24,089 patients

The

parameters

analysed

included: Pain relief

at 2 hours

RecurrenceTolerability

versus

100mg sumatriptan

Oral triptans in acute migraine treatment


The differences between triptans

are small, but relevant for the

individual patient

Compared with placebo, the response rate of all triptans

is 79-89%

Oral triptans in the treatment of acute migraine

Ferrari MD et al (THE LANCET 2001)


Sumatriptan:Long-standing

experience, well tolerated, good effect

(variety

of

formulations)Zolmitriptan:A good alternative in many

patients; no weaknesses; well tolerated

Rizatriptan (10mg):Somewhat

shorter

time to Cmax

Naratriptan: Very

well tolerated, but

weaker

and slower

Almotriptan:Good effect

and well tolerated

Eletriptan (80mg): Good effect, less

recurrence, less

well tolerated

Frovatriptan*:Long elimination

half-life

Orale triptans in acute migraine treatment

*) not

in the

Ferrari protocol

(THE LANCET 2001) Ferrari MD et al (THE LANCET 2001)


Pharmacological treatment of migraine attacks Triptan contraindications

Vascular disease

Coronary arteries, brain arteries, peripheral blood vessels

Pregnancy and lactation

Dangerous interactions with ergotamines

are possible; comedication must therefore be avoided

Age <18 (except sumatriptan) or >65

Basilar migraine, familial hemiplegic migraine

Limitations on use:

Comedication

with SSRIs


Pharmacological treatment of migraine attacks Triptans

Side effects:

Fatigue, exhaustion

Vertigo

Flush, pressure, tightness

neck and chest

Tingling / paresthesia

involving the head or extremities

Heaviness in the limbs


A – No riskB – No evidence of increased

riskC – Risk cannot be ruled outD – Definite evidence of

increased riskX - Absolute risk

Drugs for treating headache during pregnancy

Active drug substance CategoryParacetamol

B

Caffeine

BMetoclopramide

B

Metoprolol

BMagnesium

B

Fluoxetine

BIbuprofen

and NSAIDs

B/D in 3rd trimester

Aspirin

C/D in 3rd trimesterTriptans

C

Flunarizine

COther

beta-blockers

C

Amitriptyline

CValproate

D/X

Ergotamines

XFrom

Evers


Migraine prophylaxis

Drug therapy – key drugs:

Metoprolol

or propranolol

Flunarizine

Valproic

acid

Amitriptyline

Topiramate

Naproxen premenstrually


Migraine prophylaxis

Non-pharmacological therapy

Antistress techniques

Relaxation

techniques

Biofeedback

Endurance

sports

Acupuncture


Part 1: The primary headaches

Migraine

Tension-type headache

Cluster headache and other trigeminal autonomic cephalalgias

Other primary headache disorders

The International Classification of Headache Disorders



Lifetime prevalence of 80%

Headache duration: 30 min –

7 days

2 characteristics:Bilateral location

pressing/tightening

(non- pulsating) quality

mild or

moderate intensity

not

aggravated

by

routine physical

activity

such as

walking

or

climbing

stairs

2 characteristics:no nausea

or

vomiting

(anorexia

may

occur)

no more

than

one

of photophobia

or

phonophobia

2 + 2 = Tension-type headache



Episodic TTH:At least 10 episodes

occurring

on <15 days

per month

for

at

least 3 months

Chronic TTH:Headache

occurring

on ≥15 days

per month

on average

for

more

than

3 months


Congenital

predisposition

Poor

physical

posture Psychosocial

triggers:Everyday

stressInterpersonal conflictChronic

feeling

of inability

to cope

Tense

muscles

Disorder

of brain

metabolismCentral sensitization

Headache

Tension-type headache model

Travell/Simons. Trigger

Point Flip Chart. Lippincott

Williams & Wilkins (1996)



Treatment of acute tension-type headache

Paracetamol, conventional NSAIDs

or metamizole

Combination of 250 mg acetylsalicylate, 250 mg paracetamol und 65 mg caffeine

Flupirtine

100-300 mg

Topical application of peppermint oil



Treatment of chronic tension-type headache

Keeping a headache calendar

(www.dmkg.de

or www.americanheadachesociety.org)

Pharmacological

prevention

Non-pharmacological

prevention

Combination

of pharmacological

and non-pharmacological strategies

(Holroyd

et al. 2001)



Pharmacological prevention

Tricyclic

Antidepressants (amitriptyline, doxepin, imipramine,…)

Other antidepressants (mirtazapine, venlafaxine,…)

Valproate, gabapentin, topiramate

Tizanidine

Botulinum

toxin injections are ineffective in the therapy of

chronic TTH (Evers et al. 2002)


Tension headache

Non-pharmacological prevention

Regular

physical

activity/sports

Avoid/stop

smoking/caffeine

abuse

Adopt

a regular

lifestyle

(sleep, regular

meals, etc.)

Relaxation

techniques

/ biofeedback

Stress mangement

training

Intractable

cases:

Multimodal headache

program


Multimodal treatment program for patients with chronic headache

Erlangen program:

8 patients

in a group

Duration: 8 weeks

(twice

weekly, 3 –

9 pm)

Neurologist, psychologist, exercise

therapist

Particular

treatment

elements:

stress management

training, education,

exercise

sessions, PMR-training, biofeedback therapy


Multimodal treatment program for patients with chronic headache

B. Gunreben et al.: Effectiveness of an intensive multidisciplinary treatment programme for headache. Headache (2009)

A 20h-programm is

not superior

to standard

care

The

intensive (96h)- therapy is

highly

effective

for

patients

with

chronic headaches

and succeeds

the

20h-programm and standard

care


Part 2: The secondary headaches

Headache attributed to trauma

Headache attributed to vascular disease

…

Headache attributed to a substance or its withdrawal



Part 2: The secondary headaches

Headache attributed to trauma

Headache attributed to vascular disease

…

Headache attributed to a substance or its withdrawal

Medication-overuse headache (MOH)



Medication-overuse headache

IHS- Criteria

Headache

present

on 15 or

more

days/ month

Regular

overuse

for

≥3 months

of one

or

more

drugs

that

can

be taken

for

acute

treatment

of headache

Headache

has developed

or

markedly

worsened

during

medication overuse

Headache

resolves

or

reverts

to its

previous

pattern

within

2

months

after

discontinuation

of overused

medication



Prevalence

of 1 -1,5% (2,6% in women

in 0,2% in men)

First periodic (e.g. migraine), then permanent

“chameleon”, characteristics

shifting

from

migraine-like

to those

of

tension-type

headache

Overuse

is

defined

in terms

of duration

(≥3 months

and treatment days

per week

(on 2 or

more

day

each

week)

MOH can

occur

in headache-prone

patients

when

acute

headache medications

are

taken

for

other

indications



Pathogenesis (presumed)

Genetic

predisposition?

Medication induces changes in serotonergic/dopaminergic

synapses

Disinhibition

of the supraspinal

and trigeminal nociceptive

system


DMKG recommendation

Do not

take

any

headache

or

migraine

medicine

for

longer

than

3 days

in succession

or

on more

than

10 days

per month


Treatment

Abrupt substance

withdrawal

for

at least 14 days

(opioids, benzodiazepines, barbiturates

must

be

tapered)

During

withdrawal: prednisone

100 mg for

5 days, adequate hydration, long

lasting

NSAIDs

(Naproxen

500 mg)

Concurrent

pharmacological

treatment

of causative

headache disorder

(amitriptyline, topiramate)

Supportive

behavioural

therapy

(high rate of relapse

-

38% in the

first

year)



Take-Home Messages Headache

The

IHS-Classification

distinguishes

between primary and secondary headaches (headache

as a symptom

of an underlying

disease)

Göbel. Die Kopfschmerzen. Springer (2004)

A thorough

history and examination is

needed for

an accurate

headache

diagnosis

The

most

common

headache

dignoses

are migraine, tension-type headache and

medication-overuse headache


Take-Home Messages Headache

Migraine

attacks

can

be

treated

with

a combination

of antiemetics and

classical analgetics in an adequate dose. If

pain

is

not

reliefed properly, triptans should

be

administered

TTH can

be

treated

with

classical

analgetics

in an adequate dose

Drug treatment

should

not

exceed

10 days/month

For chronic

headache: combination of pharmacological and non-

pharmacological strategies



Headache Classification Subcommittee of the International Headache Society

2nd Edition 2003Cephalalgia 2004; 24 (Suppl 1): 1-160.

www.ihs-classification.org


Part 1

Primary headache disorders

Part 2

Secondary headache disorders

Part 3

Cranial

neuralgias, central

and primary

facial

pain

and other headaches




Migraine







Migraine

Tension type headache





Concomitant symptomsConjunctival

injection, miosis,

ptosis, lacrimation, rhinorrhoea

Concomitant symptomsConjunctival

injection, miosis,

ptosis, lacrimation, rhinorrhoea

CharacteristicsVery painful, restlessness,unilateral, periorbital, temporal

CharacteristicsVery painful, restlessness,unilateral, periorbital, temporal

AttacksDuration: 15-180 min1–8 / 24 h, at night, same time

AttacksDuration: 15-180 min1–8 / 24 h, at night, same time

Clusters1-3 months (episodic CH)

No remission (chronic CH)

Clusters1-3 months (episodic CH)

No remission (chronic CH)

Cluster Headache


Cluster Headache

Trigger factors

Alcohol

Nitroglycerin

Histamine

Relaxation, but also physical strain

High altitudes

Flickering lights


Cluster Headache

Pathogenesis (presumed)

Genetic component?

Activation

of the

posterior

hypothalamic

grey

matter

Non-septic inflammation

in the cavernous sinus and

in the region of the superior ophthalmic vein

Chronobiologic

disease?

Symptomatic: process of midline-structures


Cluster Headache

Treatment of attacks

Inhalation of 100% oxygen (10l/min for 20 min via face mask)

Triptans

(Sumatriptan

s.c./nasal spray, Zolmitriptan

nasal spray)

Intranasal lidocaine

Treatment


Cluster Headache

Prophylactic treatment

Verapamil

(>320 mg daily)

Steroids (Prednisone 100 mg daily, tapered over 10 to 12 days)

Lithium, Topiramate, Gabapentin, Valproat, Melatonin, Triptans

Occipital nerve block (steroids and anaesthetics)

Implantation of an occipital nerve stimulator

Deep brain stimulation of the hypothalamus


Part 1


Part 2


Part 3

Cranial

neuralgias, central

and primary

facial

pain

and other headaches



Part 1


Part 2


Part 3

Cranial neuralgias, central

and primary

facial

pain

and other headaches



Trigeminal neuralgia

SymptomsVery intense painStrictly unilateral in the region of one or several branches of the trigeminal nerveSudden attacks of shooting, electric shock-like painDuration of the attacks: seconds to minutesUp to 200 attacks/dayTypical trigger mechanisms such as swallowing, talking, chewing, cleaning teeth, etc.Develops usually in mid to late life



Classical trigeminal neuralgiaNot attributed to another disordercompression

of the

trigeminal

root

by

tortuous

or

aberrant

vessels

Symptomatic trigeminal neuralgiaLesions of brainstem, neoplasm (neurinoma

of the acoustic

nerve), inflammation (e.g. multiple sclerosis)



MedicationAnticonvulsants (carbamazepine, oxcarbazepine, gabapentin,…)NSAIDs

and opioids

are ineffective

SurgeryMicrovascular

decompression of the trigeminal nerve

Gamma-knife

radiosurgery

(radiation

of the

nerve root)Percutaneous

treatment

(destruction

of the

gasserian

ganglion)

Headache

Documents

Transcript of Headache