EVALUATING THE PATIENT WITH CHRONIC HEADACHES Dr. Fallon Schloemer, DO Assistant Professor Department of Neurology Medical College of Wisconsin WHAT IS HEADACHE? 1 WHAT’S THE BIG DEAL? • Headache accounts for: • 4.4% of all consultations in general practice • 5% of all medical admissions to the hospital • 20% of neurology outpatient consultations • Migraine specifically affects over 20% of people at some point in their lives • 2% of the world has chronic migraine! • In Top 40 of conditions causing worldwide disability HEADACHE CLASSIFICATION SYSTEM • International Classification of Headache Disorders, Third (Beta) Edition (ICHD-3 beta) • Designed to provide diagnostic consistency for research purposes • Provides diagnostic criteria to guide treatment and management • Divided into 3 parts: • Part one: the primary headaches • Part two: the secondary headaches • Part three: painful cranial neuropathies, other facial pains and other headaches • Appendix 2 GENERAL HEADACHE EPIDEMIOLOGY • As many as 90% of all benign headaches fall under a few categories • Migraine • Prevalence: 18% in women and 6% in men • Tension-type • Prevalence: 38% (episodic), 2-3% (chronic) • Cluster • Prevalence: <1% • New daily persistent headache • Prevalence and incidence are unknown CHRONIC DAILY HEADACHE (CDH) • Is this a diagnosis??? • Descriptive term than encompasses several different specific headache diagnoses characterized by frequent headaches. • Long duration: chronic migraine, chronic tension-type, medication overuse, hemicrania continua, and new daily persistent headache • Short duration: chronic cluster, chronic paroxysmal hemicrania, hypnic headache, and primary stabbing headache • What defines “chronic”? • Frequency is 15 or more headaches per month for at least 3 months • Persistence of headache subtypes for at least one year without remission 3 EPIDEMIOLOGY OF CDH • Prevalence of chronic daily headache: 4% • Majority suffer from chronic tension-type, chronic migraine or medication overuse headache • Women>>Men • Burden: • Results in significant pain and suffering, reductions in quality of life, and enormous economic costs to society CASE • A 25 year-old female with history of migraine without aura since age 16. Until 1 year ago, was getting headaches 2-3 days per month, relieved with butalbital/aspirin/caffeine. • Over the past year, headaches have increased in frequency and her use of butablital/aspirin/caffeine has also increased. • She presents now with 25 headache days per month, 12 of which are severe. Severe headaches are described as right-sided, throbbing, with associated photophobia, phonophobia, and nausea. Headaches last most of the day. Triggers are stress and sleep deprivation. 4 CASE • On severe headache days, she took 4-6 tablets of her acute medications and on less severe days took 2 tablets. 25 days per month she was taking her combination analgesic. • Preventative therapy in the past included amitriptyline (stopped years ago due to sedation). • Family history is notable for mother and sister with migraine • Neurological exam including fundi and visual fields was normal. • Work-up with MRI and routine labs was normal. CASE • Diagnosis ? • Chronic Migraine with Medication Overuse 5 CHRONIC MIGRAINE • Previously listed as a complication of migraine, transformed migraine, chronic daily headache • >15 or more headache days/month for >3 months • The broader acceptance of the concept that migraine can be a chronic condition has led to increasing interest in the pathophysiology, epidemiology, and treatment of this condition • Migraine accounts >50% of the disability attributable to all neurological diseases • Cost to society in the USA alone >>$20 billion annually DIAGNOSIS OF CHRONIC MIGRAINE • Recognize the pattern: • How did the headaches originally develop? • Primary headache disorder (episodic migraine)increasing attack frequency no headache freedom • Headache starts one day and ever goes away New daily persistent headache • Important to rule out secondary causes Ther Adv Chronic Dis. 2015 May; 6(3): 115–123 6 DIAGNOSIS OF CHRONIC MIGRAINE • Recognize the disorder: • Commonest cause of recurrent, severe headache • 20% of women, 10% of men • Genetic basis with internal and external influences • Migraine and Greek word hemicrania ‘half of the head’ • Not everyone’s migraine has ‘read the textbook’ DIAGNOSIS OF CHRONIC MIGRAINE • Take a detailed history: • Accurate history taking is vital • Give patients time to describe attacks • Fill the gaps • It’s all in the history!! • Pattern of pain • Triggers or exacerbating factors • Nature of pain • Associated symptoms • Current and previous treatments • Other medical history and family history 7 DIAGNOSIS OF CHRONIC MIGRAINE • Investigate appropriately: • Driven by cultural myths • 1. Headaches are due to brain tumors • 2. Abnormal scan or blood test is needed • When to image?? • Abnormal exam • Papilledema on fundoscopic exam • Focal neurologic deficits • History of cancer • New onset headache >50 years old • Significant change in headache pattern/characteristics DIAGNOSIS OF CHRONIC MIGRAINE • Make a diagnosis: • Even if presumptive, make one • Reassurance is important • But doc, “Something is wrong up there.” 8 PATHOPHYSIOLOGY OF MIGRAINE • Activation of Trigeminovascular system • Innervates the meninges, and provides sensory innervation to the intracranial vessels • Upon stimulation: • dilatation of the meningeal blood vessels • release of neuropeptides – Substance P, NO, neurokinin A and CGRP, a potent vasodilator • Plasma protein extravasation and sterile neurogenic inflammation • Reactive impulses to travel back to the brainstem to the trigeminal nucleus caudalis and pain modulation centers (peri-aqueductal gray, locus ceruleus) • This information travels via the thalamus to cortex causing central pain perception, central sensitization Headache Continuum August 2012 MIGRAINE WITHOUT AURA • A. At least five attacks fulfilling criteria B–D • B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) • 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 (e.g. walking or climbing stairs) • D. During headache at least one of the following: • 1. nausea and/or vomiting • 2. photophobia and phonophobia • E. Not better accounted for by another ICHD-3 diagnosis. Cephalalgia 2013;33(9):629-808 9 MIGRAINE WITH AURA • A. At least two attacks fulfilling criteria B and C • B. One or more of the following fully reversible aura symptoms: • 1. Visual • 2. Sensory • 3. Speech and/or language • 4. Motor • 5. Brainstem • 6. Retinal • C. At least two of the following four characteristics: • 1. At last one aura symptom spreads gradually over >5 minutes, and/or two or more symptoms occur in succession • 2. Each individual aura symptom lasts 5-60 minutes • 3. At least one aura symptom is unilateral • 4. The aura is accompanied, or followed within 60 minutes, by headache • D. Not better accounted for by another ICHD-3 diagnosis, and TIA has been excluded Cephalalgia 2013;33(9):629-808 PHASES OF MIGRAINE 10 PREMONITORY PHASE (PRODROME) • Occurs hours to days before headache • Occurs in ~60% of migraineurs • Consists of psychological, neurologic, or general symptoms in various combinations • Depression, euphoria, irritability, hyperactivity, fatigue • Photophobia, phonophobia, hyperosmia • Stiff neck, cold feeling, increased thirst, increased urination, anorexia, diarrhea, constipation • Food cravings AURA • Comprised of focal neurologic phenomena that precede or accompany an attack • Occurs in 20% • Develop slowly over 5-20 minutes and last <60 minutes • Usually visual • Headache follows 80% of the time and usually begins within 60 mins • Migraine aura status can rarely occur 11 THE AURAS – WHAT ARE THEY? • Visual: scotoma; photopsia or phosphenes; geometric forms; fortification spectra; objects may rotate, oscillate, or shimmer; brightness appears often very bright • Visual Hallucinations or Distortions: metamorphopsia; macropsia; zoom or mosaic vision • Sensory: paresthesia, often migrating, often lasting for minutes, and can become bilateral • Olfactory hallucinations • Motor: weakness or ataxia • Language: dysarthria or aphasia • Delusions and Disturbed Consciousness: déjà vu, multiple conscious trance-like states VISUAL AURAS 12 HEADACHE • Unilateral, throbbing, moderate-severe, aggravated by routine activity • Radiate • Stabbing • Onset can vary, but often gradual • Usually lasts 4-72 hours • Patients prefer to lie down in a dark, quiet room • Scalp tenderness may prevent this allodynia HEADACHE ASSOCIATED PHENOMENA • Anorexia or food cravings • Nausea (90%) and vomiting (1/3), Diarrhea (16%) • Gastroparesis (Poor Gastric motility) • GI distress and poor absorption of meds • Photophobia (sensitive to light) • Phonophobia (sensitive to sound) • Lightheadedness and vertigo • Premonitory/Prodrome symptoms can continue • Blurry vision, nasal stuffiness, sweating • Neck pain/discomfort (59-61%) • Sinus pain/pressure (33-44%) 13 POSTDROME • Following the headache, patient may have impaired concentration or may feel tired, washed out, irritable, and listless • Some feel unusually refreshed or euphoric • Muscle weakness and aching • Anorexia or food cravings can occur COMPLICATIONS OF MIGRAINE • Status migrainosus • A debilitating migraine attack lasting for more than 72 hours • Persistent aura without infarction