Everything you wanted to know about Headache but were afraid to ask
SNOOP ing around
Richard S. Sohn MD
Emeritus Professor of Neurology
Washington Universtity

Richard S Sohn MD has no potential or current conflicts of interest.

Disease Prevalence in the US Population
12%
7%
6%
5%
1%
Rheumatoid arthritis
Asthma Diabetes Osteoarthritis Migraine
Data from the Centers for Disease Control and Prevention, US Census Bureau, and the Arthritis Foundation.

Patients Presenting to PCPs with Episodic
Headache Most Likely Have Migraine n= 377 patients who returned diaries
Migrainous
18%
3%
Episodic Tension
Headache
3%
Other
Migraine
76%
Migraine/Migrainous is Common (94%);
Tension Headache is Rare
Newman et al. Poster presented at: The Diamond Headache Clinical Research and Educational Foundation Meeting;
July 16-20, 2002; Lake Buena Vista, Fla.

•
Differentiate troublesome from dangerous headaches
•
Recognize common headache syndromes
•
Effectively treat common headache syndromes

• Divide 13 general headings into 2 major groups
•
Primary headaches(benign headache disorders)
–
Migraine
– Tension type
–
Cluster
– Post traumatic
–
Medication overuse
– Other benign headaches
• Secondary headaches(headaches caused by another disease)

History and Physical
Red Flags
SNOOP
YES
NO
Diagnostic Tests
CT,MRI,LP,ESR
Primary Headache Disorders
 Migraine
 Tension-Type Headache
 Cluster Headache
 Other Disorders
Silberstein SD et al. Wolff’s Headache and
Other Head Pain 2001:6-26
Secondary Headache Disorders

SNOOP
•
S ystemic symptoms (fever, weight loss) or secondary risk factors (HIV, systemic cancer)
•
N eurologic symptoms or abnormal signs
(confusion, impaired alertness or consciousness)
•
O nset: sudden, abrupt, or split-second
• O lder: new onset and progressive headache, especially in middle-age > 50 (giant cell arteritis)
•
P revious headache history: first headache or different (change in attack frequency, severity or clinical features)
Silberstein SD et al. Wolff’s Headache and Other Head Pain 2001:6-26

Some causes of secondary headache
•
Intracranial masses
•
Infection
•
Trauma
•
Hemorrhage
•
Inflammation
•
Meningeal infiltration

•
Hypertension (except malignant )
•
Allergy
•
Refractive error

•
If the headaches are chronic
•
If the examinations are normal
•
NO STUDIES ARE NEEDED

Patient Description 41-year-old female school teacher
Chief Complaint Recurrent ‘sinus headaches’ that last 2 days
Character of Pain Patient described pain as pressure sensation involving the maxillary sinus region; no radiation of pain. Pain was moderate to severe ranging from 6-8 on a 1-10 scale.
Headaches would begin and end gradually
1-2 times per month Frequency
Symptoms
Headache Triggers
Patient complained about nasal congestion and runny nose. Patient denied any visual disturbances, fever, or joint pain. Upon probing, patient stated that she often felt sick to her stomach during her headaches and her headaches intensified when she bent over
Barometric pressure changes, cold, sleep disturbance
Medical History Headaches began in late teens without known precipitant and have recurred monthly since onset
Family History
Mother is also a longstanding ‘sinus headache’ sufferer
Physical Exam Normal
Test Results
Normal sinus CT scan
Past Treatments Sinus surgery with no change in her headaches. Also multiple courses of antibiotics. Decongestants seem to relieve pain slightly

Sinus headache is the most common misdiagnosis
Symptoms include
•
Dull ache located near the nose
• Pressure over the sinus cavities
• Thick, colored nasal discharge
•
OTCs can sometimes relieve the pain

Headache:
A Minor Criteria in AAO-HNS Sinusitis
Headache is a minor factor in the diagnosis of rhinosinusitis, according to AAO-HNS*
•
Major factors
•
Minor factors
Purulence in nasal cavity on exam Headache
Facial pain/pressure/congestion
† Fever (chronic)
Halitosis
Nasal obstruction/blockage/ discharge Fatigue
Fever (in acute only) Dental pain
Cough
Hyposmia/anosmia
Ear pain/pressure/fullness
* American Academy of Otolaryngology-Head and Neck Surgery, also adopted by the American College of
†
Allergy and Immunology Lanza et al. Otolaryngol Head Neck Surg 1997.117(pt 2): S1-S7
Facial pain/pressure alone does not constitute a suggestive history for rhinosinusitis in the absence of another major nasal symptom or sign.

Sinus Features of Headache May Hide the Presence of Migraine
Symptoms at Screen in 2424 subjects with Migraine (IHS 1.1/1.2)
98%
Moderate/Severe Pain
Pulsing/Throbbing
Worsened by Activity
Sinus Pressure
Sinus Pain
Nausea
Photophobia
Phonophobia
Nasal Congestion
Unilateral
Rhinorrhea
Watery Eyes
Aura
Itchy Nose
Vomiting
29%
27%
25%
40%
38%
67%
73%
79%
57%
63%
89%
85%
84%
82%
Migraine Symptoms
Sinus Symptoms
0% 20% 40% 60% 80%
Adapted from Schreiber et al. Poster presented at: American Headache Society Meeting; June 21-23, 2002.
Seattle, Wash. Data on file, GlaxoSmithKline.
100%

Migraine Can Be Triggered by Weather
Physical Exertion
Skipping Meals
Weather Changes
Changes in Sleep
Strong Odors
Menstruation
Stress
0%
% of Migraine Patients with Triggers
45%
45%
46%
52%
55%
(n = 69)
68%
72%
10% 20% 30% 40% 50% 60% 70% 80%
Scharff et al. Headache 1995; 35:397-403

Because Pain Can Be Felt in All Regions of the Trigeminal Nerve, a Diagnosis of
Sinus Headache is Often Given

Cranial Parasympathetic Nervous System
Extends into the Sinus Cavities and Tear Ducts

Migraine Pain Can Be Bilateral and
Nonthrobbing
41% of migraine patients had bilateral pain
50% of the time, pain was nonthrobbing
Lipton et al. Headache.
2001;41:646-657.
Pryse-Phillips et al. Can Med Assoc J. 1997;156(9):1273-1287.

• Tension headache is another common misdiagnosis
• Symptoms include
– Dull steady ache
– Physical activity does not worsen pain
–
Nausea, photo/phonophobia are not usually present
–
Vomiting never present
– Patients have likely tried OTCs and failed
Cady et al. Headache Free . 1993;36-38.

Stress is the Most Frequently Reported
Trigger of Migraine
% of Migraine Patients with Triggers
80%
70%
60%
50%
72%
68%
55%
52%
40%
30%
20%
10%
0%
Stress Menstruation Strong Odors n = 69
Scharff et al., Headache 1995; 35:397-403
Changes in
Sleep
46% 45% 45%
Weather
Changes
Skipping Meals Physical
Exertion

Patients with Migraine by IHS Criteria
Have Symptoms Commonly Associated with
Tension Headache
100%
87%
80%
59%
60%
57%
51%
37%
40%
20%
0% n =412
Stiffness/ Tightness in
Neck /Shoulders
Occipital/Cervical
Pain
Tenderness in neck muscles
Patient Report of
Tension or Stress
Patients with one or more TTH characteristics
Adapted from Smith, et al. Poster presented at American Headache Society, June 21-23,
2002, Seattle, Wash.

Neck Pain Can Occur in all Phases of Migraine
100% 92%
75%
61%
50% 41%
25%
0% n=108
Prodrome Headache
Phases of Migraine
Postdrome
Kaniecki et al. Poster presented at: 10th IHC; June 29-July 2, 2001; New York, NY.

In the Presence of Neck Pain
Tension Headache is Frequently Diagnosed
100%
82%
80%
60%
40%
20%
18%
0% n=108
No Yes
Previous Diagnosis of Tension Headache
Kaniecki et al. Poster presented at: 10th IHC; June 29-July 2, 2001; New York, NY.

Trigeminal Nucleus Caudalis Relays Pain
Signals to Higher-Order Neurons in the Thalamus and Cortex

Many facets of migraine

One Nerve Pathway, Multiple Symptoms,
Multiple Manifestations of Migraine

•
Nucleus and tractus solitarius are near by

Family history
Fever
Nasal discharge
Disabling
Menstrual association
“Sinus” Tension
Yes
No
Clear/None
No
No
Migraine
No
No
Yes
Yes

•
Moderate to severe
•
Unilateral
•
Throbbing
•
2 to 4 hours
•
Associated symptoms
–
Nausea and vomiting
–
Sensory hypersensitivity

Pre-HA Headache Post-HA
Mild
Moderate to Severe
Headache Premonitory/
Prodrome
Aura
Early Intervention
Time
Postdrome

90%
85%
80%
75%
70%
65%
60%
Complete
Pain Relief
No
Recurrence
Rapid
Onset
No Side
Effects
Relief of
Associated
Symptoms

• Treat early
•
Appropriate drug,dose, formulation
• Migraine specific agents
–
Temporarily disabling headache(stratified care)
–
No response to general agents
•
Non-oral in patients with vomiting
•
Offer rescue medication
• Guard against medication overuse

Pain-free Results with Sumatriptan
SUM40274/275
Treating when pain was mild
70%
60%
50%
57%
*
68%
61%
*
*
27% *
22%
†
50%
*
40%
30% 30%
Placebo
Sumatriptan 50 mg
Sumatriptan 100 mg
14%
29%
20%
10%
0%
Baseline 1 hour 2 hours 4 hours
Individual results may vary. If pain returns, a second dose may be taken after 2 hours.
* P < 0.001 vs placebo
†
P <0.05 vs placebo
Winner et al. Platform Presented at: American Headache Society Meeting; June 21-23, 2002; Seattle, Wash.
Data on file, GlaxoSmithKline.

•
Early pain free response
•
Less recurrence
•
Prevents progression of the attack
•
Limits disability
•
Less need for multiple doses of medication and rescue medication
•
May prevent progression to chronic daily headache

•
Its not really a migraine
•
It will go away by itself
•
My old medicine will work just fine

•
Its not really a migraine WRONG
•
It will go away by itself WRONG
•
My old medicine will work just fine
WRONG

•
Tingling
•
Warmth
•
Flushing
•
Chest discomfort
•
Sleepiness
•
Dizziness

• Hemiplegic or basilar migraine
•
Uncontrolled hypertension
• Use of MAOi’s except naratriptan,eletriptan,frovatripran and almotriptan
•
Use within 24 hours of an ergot or other triptan
•
Pregnancy category C
• Coronary disease and peripheral artery disease suspected or confirmed

• Migraine significantly interferes with daily routine despite acute treatment
•
More than 3 headaches a month, or 2 a week
• Acute treatments fail, are contraindicated, or produce unacceptable side effects
• Patient preference
•
Hemiplegic or basilar migraine
•
Migraine with prolonged aura

• Regular sleep and meals
•
Regular exercise
•
Hydration
•
Decaffination
•
Elimination of triggers
• Supported by class A studies
– Relaxation training with or without thermal biofeedback
–
EMG biofeedback
–
Cognitive behavioral therapy

• Beta blockers
– propranolol*, timolol*, atenolol,metoprolol,nadolol
•
Calcium channel blockers
– verapamil, flunarizine (not inUS) diltiazem
•
Antidepressants
– amitriptyline, desipramine,nortriptyline, MAOi’s
•
Antiepileptic drugs
– valproate*, topiramate*, zonisamide
•
Memantine
•
*=FDA approved for migraine prevention.

•
Preprogrammed
•
Follow the pain
•
Literature is controversial
•
Thought to work by uptake into proximal neurons, blocking secondary transmission, not by neuro-muscular blockade

Occipital nerve injection and/or stimulation
•
Thought to work by decreasing input to trigeminal system by decreasing spinal sensory input
•
Literature is controversial

JAMA, 285:2216-2222, 2001

•
Attempts to define menstrually associated migraine in the literature have included:
–
Menstrually associated migraine (MAM)
• Occur at other phases of the cycle
•
60-70% of female migraine patients
–
True menstrual migraine (TMM)
• Exclusively with menses
• 7-10% of female migraine patients

Supplement
Progesterone
–
Headaches on time
–
Vaginal bleeding delayed
Estrogen
– Headache delayed or avoided
–
Vaginal bleeding on time

•
Start a day or two prior to menses
•
Continue throughout the menstrual period
•
To reduce or eliminate hormone induced headaches

• Naratriptan (Amerge®) 1 mg BID
• Summatriptan (Imitrex®) 25 mg TID
• Rizatriptan (Maxalt®) 10 mg BID
• Zolmatriptan (Zomig®) 2.5 mg BID
• Frovatripatn (Frova ®) 2.5 mg daily
•
EXPENSIVE

• NSAID’s
–
Naproxyn 250 BID
–
Ibuprofen 400 BID
– etc
•
Cox II inhibitor
–
Celebrex 100 mg daily

•
Active oral contraceptive 28/28
•
Estrogen supplement
–
Estradiol patch 0.05 mg
–
Estradiol oral 1mg
–
Conjugated Equine Estrogen.625 mg

•
Secondary
•
Transformed Migraine or Tension type
–
Medication overuse
–
Additional diagnosis
• Medical
•
Psychiatric
•
New Onset Daily Headache

SNOOP
•
S ystemic symptoms (fever, weight loss) or secondary risk factors (HIV, systemic cancer)
•
N eurologic symptoms or abnormal signs
(confusion, impaired alertness or consciousness)
•
O nset: sudden, abrupt, or split-second
• O lder: new onset and progressive headache, especially in middle-age > 50 (giant cell arteritis)
•
P revious headache history: first headache or different (change in attack frequency, severity or clinical features)
Silberstein SD et al. Wolff’s Headache and Other Head Pain 2001:6-26

SNOOP
•
Yes
–
Order appropriate studies
–
Specific treatment
•
No—Medication overuse likely

•
Daily or nearly daily dull generalized headache
•
Aggravation by mild physical or mental activity
•
Waking with early morning headache
•
Depression, restlessness, nausea, forgetfulness, aesthenia
•
Medication withdrawal symptoms
•
Ineffectiveness of migraine specific abortive meds
•
Ineffectiveness of preventive meds

•
Use of multiple pain pills
•
Frequent calls for refills
•
Doctor shopping
•
Creative reasons for early refills

•
Stop all abortive medications
•
Teach proper symptomatic medication use
•
Teach non pharmacologic preventive measures
•
Start prophylactic medication
•
Reasonable expectations

•
Are not always because of medication overuse.
•
A trial off abortive meds is worth a try.

•
More common in men
•
Periorbital, sharp penetrating severe, repetitive
•
Dysautonomia
–
Lacrimation
– Conjuntival injection
–
Nasal congestion and rhinorhea
•
Tend to pace

•
High flow oxygen
•
Triptans
•
DHE
•
Prednisone
•
Verapamil
•
Lithium

•
Temporal artery often enlarged and tender
•
Risks
–
Stroke
–
Blindness
•
Association with polymyalgia rheumatica
–
Stiff painful joints
– Anemia
–
Jaw claudication

•
Elevated ESR
•
Biopsy
–
Long segment
–
Skip areas

•
Prednisone
–
Start as soon as possible because of risk of stroke and blindness
–
Biopsy will remain positive for several days on prednisone
•
Start 60 to 80 mg daily
•
Titrate down depending upon ESR

Remember the neck

•
New headache following a head injury
–
Structural?
–
Post concussive syndrome ?

SNOOP
•
S ystemic symptoms (fever, weight loss) or secondary risk factors (HIV, systemic cancer)
•
N eurologic symptoms or abnormal signs
(confusion, impaired alertness or consciousness)
•
O nset: sudden, abrupt, or split-second
• O lder: new onset and progressive headache, especially in middle-age > 50 (giant cell arteritis)
•
P revious headache history: first headache or different (change in attack frequency, severity or clinical features)
Silberstein SD et al. Wolff’s Headache and Other Head Pain 2001:6-26

SNOOP
•
Yes
–
Order appropriate studies
–
Specific therapy
•
No---Post concussive syndrome likely

Postconcussive syndrome
•
Dizziness
• Fatigue
• Irritability
• Poor concentration
• Poor memory
•
Insomnia
•
Personality change
•
Poor stress tolerance
• Low mood
• Anxiety
• Trouble thinking
• Headache
Jason laRue

•
Shear forces
–
Axonal injury (role of DTI ?)
– As likely with “minor” or “significant” injury
•
Injury to nearby structures
–
Neck
–
Jaw
–
Scalp

•
30 to 80% had headache at 3 mos
•
8 to 35% at one year
•
Approx 1/3 are unable to return to work
•
Older age, higher education, higher income and higher socioeconomic standing are good prognostic indicators
Combination of multiple studies

All treatment is symptomatic
•
Headache by type
–
Migraine
–
Tension type
•
Mood
•
Anxiety
Encourage activity and social interaction

The 2W rule
If you take ANYTHING for headache relief 2 or more days a week for 2 weeks in a row, call your doctor

• Migraine is a neurobiologic disorder
•
Migraineurs have a reduced threshold for headache
•
Migraine has a genetic basis
•
Migraine can be managed not cured
– Reasonable expectations
–
Ongoing process
•
Migraine should be categorized along with other chronic conditions like asthma, diabetes, arthritis and hypertension

• S.D. Silberstein, et al.
…Migraine prevention in adults... Neurology:April 24, 2012 78:1337-
1345
• Migraine Treatment Guidelines from The
Medical Letter
• February 1, 2011 (
Issue 102 ) p.
7

•
Differentiate troublesome from dangerous headaches
•
Recognize common headache syndromes
•
Effectively treat common headache syndromes