3/26/2014 1 Kenneth A. Fox, M.D. Assistant Clinical Professor - UCSF Department of Medicine Chief – Department of Neurology Kaiser Permanente San Francisco A Practical Approach To Headache Overview Case Presentation Headache Emergencies Common Primary Headache Disorders/Treatment Medication Overuse/Rebound Occipital Neuralgia New Frontiers Case Wrap-Up Case Presentation 41F Obesity, Hypothyroidism, Depression Mod-severe, throbbing R frontal retro-orbital headache x 5d Associated sxs: N/V, photophobia, blurred vision, L hemisensory disturbance Took Ibuprofen 400mg q6 hours with incomplete relief Month prior, 3-4x/wk responsive to repeated dosing of Ibuprofen 400mg over a 24 hour period No triggers but gets “clusters” around menstrual cycle Headache Emergencies Generally Concerning Signs Thunderclap onset “Worst headache of my life” Progressive pain or associated symptoms Focal neurological signs/symptoms Narrow Differential Patients may possess unique qualifiers (eg. HIV, systemic cancer) Clinical components may overlap with benign syndromes
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K Fox HIheadache14 - UCSF CME K Fox... · Subarachnoid Hemorrhage Carotid/Vertebral Dissection Common Clinical Features Exquisite, pulsating anterior or posterior neck pain with radiation
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3/26/2014
1
Kenneth A. Fox, M.D.Assistant Clinical Professor - UCSF Department of Medicine
Chief – Department of NeurologyKaiser Permanente San Francisco
A Practical Approach ToHeadache
Overview
Case Presentation
Headache Emergencies
Common Primary Headache Disorders/Treatment
Medication Overuse/Rebound
Occipital Neuralgia
New Frontiers
Case Wrap-Up
Case Presentation
41F Obesity, Hypothyroidism, Depression
Mod-severe, throbbing R frontal retro-orbital headache x 5d
Associated sxs: N/V, photophobia, blurred vision, L hemisensory disturbance
Took Ibuprofen 400mg q6 hours with incomplete relief
Month prior, 3-4x/wk responsive to repeated dosing of Ibuprofen 400mg over a 24 hour period
No triggers but gets “clusters” around menstrual cycle
Headache Emergencies
Generally Concerning SignsThunderclap onset
“Worst headache of my life”
Progressive pain or associated symptoms
Focal neurological signs/symptoms
Narrow Differential
Patients may possess unique qualifiers (eg. HIV, systemic cancer)
Clinical components may overlap with benign syndromes
3/26/2014
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Headache Emergencies
Subarachnoid Hemorrhage
Atraumatic Subdural Hematoma
Carotid/Vertebral Dissection
Pituitary Apoplexy
Venous Sinus Thrombosis
Giant Cell Arteritis
Idiopathic Intracranial Hypertension
Subarachnoid Hemorrhage
Common Clinical Features
Thunderclap, severe holocranial headache
Nausea and light sensitivity are common
Nuchal rigidity/meningismus
Focal neurological symptoms (eg. 3rd Nerve Palsy)
Smaller/”sentinel” bleeds may not have neurological signs
Normal neurological examination except for papilledema
Neuroimaging unrevealing
Increased opening pressure on LP (>200mmH20)
Tx – large volume LP, diuretics, permanent shunting
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Primary Headache Disorders
Tension
Migraine
Trigeminal Neuralgia
Trigeminal Autonomic CephalgiasCluster
Hemicranial continua
Paroxysmal Hemicrania
SUNCT
Headache Patterns
Tension Headache
Recurrent bilateral pressing/tightening quality
Not aggravated by physical activity
Not preceded by aura or associated with N/V, sensory sensitivity, focal neurological symptoms
Muscle tenderness is a prominent feature
Most effective meds: Naproxen, Indomethacin, Ketorolac, Aspirin/Acetaminophen/Caffeine (muscle relaxants not validated)
Non-pharmacological measures include heat/ice, stress management, relaxation/meditation, exercise, sleep hygeine, biofeedback (*acupuncture has yet to be validated)
Migraine Headache
Recurrent pulsating head pain which is typically severe, unilateral, and aggravated by physical activity
Pain may be preceded by aura visual, focal neurological signs
Frequently accompanied by autonomic symptomsNausea ± vomiting, Diarrhea
Cochrane review - similar effectiveness with all 7 optionsMeta-analysis - most effective agents: Almotriptan, Eletriptan, RizatriptanIncreasing doses may be necessarySwitching agents is reasonable before abandoning classAvoid in patients with Hx CAD, stroke, hemiplegic+basilar migraine
Naproxen + Sumatriptan
2 replicate RCTs trials with >1k patients per trial
1:1:1:1 ratio groups (N500/S85, S85, N500, and Placebo)
Relief from mod-severe migraine pain at 2 hours
Combination conferred superior efficacy compared to placebo and either as monotherapy
No significant adverse events, save heart palpitations in a 58 year old woman
Complimentary mechanisms of action are thought to underlytherapeutic advantages
JAMA 2007
Migraine Prophylaxis: When do we start?
“An effective abortive strategy is the best prophylaxis”
Criteria*Occurrence 2-3x/mo or recurring attack affecting function
Duration > 48 hours
Common accompanying complex neurological symptoms
Inadequate relief, intolerance, overuse of abortive agents
Patient preference
*Ann. Int Med 2002
Migraine Prophylaxis: Setting Expectations
Establish “contract” of commitment
Utilize the lowest effective dose, preferably once daily to start
Trial for at least 8 weeks
Reduce or eliminate frequent use of abortive medication