Key Concepts
- Primary HA are classified as migraine, tension-type, or cluster and other trigeminal autonomic cephalagias.
- Pain because of trigeminaovascuular system of the brain.
- Migraine is further classified as a migraine with aura and migraine without aura.
- Short term goals is pain relief
- Long term is to stop HA
- Prophylaxis is indicated if headaches are frequent or severe, lead to significant disability, or require the use of pain-relieving medications two or more times per week.
- Primary HA are more common.
- Tension type/migraine, cluster, etc.
Epidemiology of Headache Disorders
- Tension - Type
Most common
- Muscle contraction is most significant factor in path. Pain. 1 year prev. 30-90%
- More common in adult females.
- Episodic or chronic.
- Cluster
- Most uncommon and severe. Genetic disposition.
Etiology and Pathophysiology of HA and disorders
Trigeminovascular system overactivity. Intracerebral vasoconstriction leads to neural ischemia and is followed by reflex extracranial vasodilation and pain. The pain experienced is likely due to over activity of the trigeminovascular system of the brain.
Cluster HA is cephalagias. Caused by sympathetic under-activity and parasympathetic Activation. Also Vasoactive peptide is released and neurogenic inflammation is seen.
Clinical presentation of headaches
Migraine headaches.
- Interferes with daily functioning.
- Include visual perception of flickering lights, spots, or wavey lines; partial loss of vision is a classic negative symptom of an aura.
Migraine without aura: unilateral pain, photot,phono,osmophobia. Need five or more attacks.
Migraine with aura: Visual symptoms, sensory, dysphasic speech, moderate or sever pain.
Visual sensory symptoms
One aura symptoms develops at least 5min prior or after
Duration of each symptom is 4-60min. Need 2 or more attacks.
Tension - Type Headache
- Tension types, usually reported to be mild to moderate, non pulsating and bilatera. Muscle palpitation in the fronto0temporal and parieto0occipital may identify localized tender points.
Pain. Mild or moderate not pulsating bilateral, no nausea or vomiting either photophobia or phonophobia lasts 30min-7days criteria for diagnosis: ten r more attacks fulfilling the above criteria occuring on average less than 1 day per month are necessary for diagnosis.
Cluster Headache
Pain associated with cluster headache differs from migraine and TTH in that it is severe, intermittent, and short in duration. Usually phappen at night but may occur in the day. Usually unilateral pain and not pulsatile like migranes. Aura is not a feature.
Clinical presentation and diagnosis of cluster headache. : unilateral pain, oribatal supraorbital temporal sharp and stabbing. Nasal congestion and or rhinorrhea eyelid edema. Lasts 2 sec to 19min. One or more per day more than half of the time. Twenty or more attacks fulfilling the above criteria are necessary for diagnosis.
Treatment: Pain relief
Urgent further evaluation if: new onset, sudden, severe, onset after 40years, stereotyped pattern, systemic signs, papilledema, cough, exertion, pregnancy, cancer, HIV, seizures.
Give headache diary.
Pharmacologic Therapy:
Migraine- Analgesics, Opiates, Triptans, and Ergotamines.
Tension type headache - OTC
Cluster tx. Same as migraine.
Migraine prevention: B blocker and timolol. Amitrtyptiline or tricyclics (sedation is SE so give at night). Valproic acid and topiramate indicated as well as gabapentin and lamotrigine. Methysergide (ergotamine derivative that impacts the sodium balance).
Tension prevention. Same as migraine, but tricyclics are mainstay of chronic therapy.
Cluster prevention. CCB verapamil is mainstay. 240-360mg perday.
In children:
Avoid aspirin. Give ibuprofen. Triptans only good if over 12.
Pregnancy:
HA more commmon in women than men. Estrogen levels responsible, HA common in pregnancy. Avoid therapy. Tylenol is safe unless in third trimester. Opioids are ok but can cause withdrawal. Antiemetics ok, corticosteroids ok. Triptans CONTRAINDICATED as well as ERGOTS.
Outcome evaluation. Monitor pts for relief of HA and lack of HA recurrence. Make journal and assess it.
Monitor SE
Acetaminophen: analgesic overuse can cause withrdawal
NSAIDS: GI distress or bleeding, and HTN/edema or renal dysfunction, CBC and Scr.
Opiates: sedation, constipation.
SRA (triptans): monitor pts for flushing, palpitations, chest pain, shortness of breath, recommend electrocardiography if symptoms persist.
Ergotamines: Cardiovascular complications
Prophylacitc meds:
Antiepileptics: dizziness, fatigue, nausea, paresthesias. Assess changes in weight
B-blockers: monitor for bradychardia, hypotension and fatigue.
CCB: monitor for bradychardia, edema. If GERD or constipation withdrawal
Tricyclic antidepressants: changes in vision, sedation, dry mouth, GI upset and orthostatic dizziness.
Primary Source: Pharmacotherapy: Principals and Practice by McGraw, Hill
