Neurological lectures...Headaches http://yassermetwally.com http://yassermetwally.net

1. Classification of headaches
Professor Yasser Metwally
Primary headaches • Secondary headaches
OR Idiopathic headaches • OR Symptomatic headaches
– THE HEADACHE IS ITSELF – THE HEADACHE IS ON LY A
THE DISEASE SYMPTOM OF AN OTHER
UNDERLYING DISEASE
– NO ORGANIC LESION IN
THE BEACKGROUND – TREAT THE UNDERLYING
DISEASE!
– TREAT THE HEADACHE!

2. HISTORY AND EXAMINATIONS
SHOULD CLARIFY IF
• THE PATIENT HAS PRIMARY OR
SECONDARY HEADACHE
• IS THERE ANY URGENCY
• IN CASE OF PRIMARY HEADACHE ONLY THE
HEADACHE ATTACKS SHOULD BE TREATED
(„ATTACK THERAPY”), OR PROPHYLACTIC
THERAPY IS ALSO NECESSARY
(„PREVENTIVE THERAPY, INTERVAL
THERAPY”)

3. SECONDARY, SYMPTOMATIC
HEADACHES
• THE HEADACHE IS A SYMPTOM OF AN
UNDERLYING DISEASE, LIKE
– Hypertension
– Sinusitis
– Glaucoma
– Eye strain
– Fever
– Cervical spondylosis
– Anaemia
– Temporal arteriitis
– Meningitis, encephalitis
– Brain tumor, meningeal carcinomatosis
– Haemorrhagic stroke…

4. • Secondary headache disorders
Headache attributed to ...
5. head and/or neck trauma
6. cranial or cervical vascular disorder
7. non-vascular intracranial disorder
vascular
8. a substance or its withdrawal
9. infection
10. disorder of homoeostasis
11. disorder of cranium, neck, eyes, ears, nose,
sinuses, teeth, mouth or other facial or cranial
structures
12. psychiatric disorder
13. cranial neuralgias and central causes of facial
pain

5. Primary, idiopathic headaches
• Tension type of headache
• Migraine
• Cluster headache
• Other, rare types of primary
headaches

6. Treatment of tension type of
headache
• Acute, episodic form: NSAID drugs, 500-1000
mg ASA, paracetamol, or noraminophenazon
• Indication of prophylactic treatment tension
treatment:
type of headache in at least 14 days per moth

7. Prophylactic treatment of the
chronic tension type of headache
• Tricyclic antidepressants
• Guidelines:
 Start with low dose (10-25 mg) and increase the dose if
25
no beneficial effect after 1 weeks
1-2
 Maximal dose should not be more than 75 mg/day
 Change to other tricyclic antidepressant only after 6
6-8
weeks
 Ask the patient to use headache diary
 Use the tricyclic antidepressant for 6 months
6-9
 Decrease the dose gradually

8. Prophylactic treatment of the
chronic tension type of headache
First choice of drug:
amitryptiline (Teperin tabl, 25 mg)
• 1st week: 25 mg in the evening
• 2nd week: 50 mg in the evening
• 3rd week: 75 mg in the evening continuously
• Change to other drug (e.g. clomipramine) if no
beneficial effect within 6 weeks

9. Common side effects of
tricyclic antidepressants
• Anticholinergic side effects:
– Dry mouth
– Increased pulse rate
– Urinary retention (in prostate hyperplasia!!!)
– Increased intraocular pressure (glaucoma!!!)
• Sleepiness or hyperactivity
• Serotonine syndrome (do not use if the
patient takes SSRI drug)

10. If the patient does not tolerate the TCA
drugs, or cannot be administared
because of danger of interaction
• Anxiolytics (e.g.: alprasolam, clonazepam…)
• and selective antidepressants (e.g. SSRI)
• Change of lifestyle
• Psychotherapy, psychological treatments,
biofeedback, behavioral therapy, relaxation
methods

11. Migraine: epidemiology
• Life-time prevalence 10%
time 10%-12%
• 1% chronic migraine (>15 days/months)
• Sex ratio 2.5 (f) to 1 (m); in childhood 1 to 1
• Mean frequency 1.2/month
• Mean duration 24 h (untreated)
• 10% always with aura, >30% sometimes with
aura
• 30% treated by physicians

12. Migraine: pathophysiology
Genetic disposition, hormonal influence
,
Activation of brainstem nuclei by trigger factors
Neurovascular inflammation of intracranial
vessels
Impaired antinociception
„Spreading Depression“ as mechanism of aura

13. Migraine classification
1.1 migraine without aura
1.2 migraine with aura
1.3 periodic syndromes in childhood
1.4 retinal migraine
1.5 migraine complications
1.6 probable migraine

14. Migraine
• WITHOUT AURA • WITH AURA +
– VISUAL
• Typical headache 2/4
– SENSORY
– Unilateralsi
– MOTOR
– Severe
– SPEECH DISTURBANCE
– Pulsating
before migraineous headache
– Physical activity
• AURA SYMPTOMS
aggravates
– USUALLY<1/2 HOUR
• Accompanying signs 1/2
– LESS THAN 1 HOUR
– Photophobia and
phonophobia
– Nausea, or vomitus

15. MIGRAINE WITH AURA
• DURING AURA: • DURING HEADACHE
– VASOCONSTRICTION – VASODILATION
– HYPOPERFUSION – HYPERPERFUSION
BUT: AURA SYMPTOM IS NOT CONSEQUENCE OF
VASOCONSTRICTION INDUCED HYPOPERFUSION
CUASE OF THE AURA: SPREADING DEPRESSION.
THE VASOCONSTRICTION AND HYPOPERFUSION ARE
CONSEQUENCES OF THE SPREADIND DEPRESSION
AURA
SPREADING DEPRESSION
VASOCONSTRICTION,
HYPOPERFUSION

16. IMPORTANT TO KNOW!
MIGRAINE WITH AURA
• IS A RISK FACTOR FOR ISCHAEMIC STROKE
– THEREFORE PATIENTS SUFFERING FROM
MIGRAINE WITH AURA
• SHOULD NOT SMOKE!!!
• SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!!
• THE PROPROTION OF PATENT FORAMEN
OVALE IN PATIENTS WITH MIGRAINE WITH
AURA IS ABOUT 50-55%! (IN THE POPULATION
55%!
IS ABOUT 25%).

17. Is there a relationship between
aura and patent foramen ovale
•?
• Paradoxic emboli theory is not likely
• Shunting of venous blood to the arterial side could be the
reason  no breakdown of certain neurotransmitters
(5HT) in the lung!
• Comorbidity could be also an explanation.
• However, closure of patent foramen ovale decreases the
frequency of migraine attacks.
• BUT! Migraine is a benign disease. Please do not
indicate closure of patent foramen ovale just because of
migraine with aura!

18. Treatment of migraine attack
• Try to sleep
• Antiemetics
• Analgetics
• Ergot derivatives
• Triptans

19. Treatment of migraine attack
I. Antiemetics
• 1. Metoclopramid (Cerucal tabl 10 mg)
– 10-20 mg per os
– 20 mg rectal
– 10 mg parenteral
• 2. Domperidon (Motilium tabl 10 mg)
– 10-20 mg per os

20. Treatment of migraine attack
II. Analgetics
1. ASA (Aspirin, Colfarit, etc)
– 500-1000 mg per os
– 500 mg parenteral (Aspisol i.v.)
2. Paracetamol (Rubophen, Panadol, etc)
– 500-1000 mg per os
3. NSAIDs
– Ibuprofen (Ibuprofen, Humaprofen, etc) 400
400-800 mg per os
– Diclofenac (Voltaren, Cataflam etc) mg per os
etc)50
– Naproxen (Naprosyn, Apranax) 250250-550 mg per os

21. Treatment of migraine attack
III. Ergot derivatives
• 1. Ergotamin tartarate
– 2-4 mg per os, sublinguali or rectal
4
– 1 mg nasal spray
• 2. Dihydrergotamin (Neomigran) nasal spray
– no more available

22. Treatment of migraine attack
IV. Combinations in Hungary
• Migpriv:
– lizin-acetylsalicilate + metoclopramid
acetylsalicilate
• Quarelin:
– aminophenazon+coffein+drotaverin
• Kefalgin
– ergotamin tartarate+
atropin+coffein+aminophenazon

23. Treatment of migraine attack
V. Triptans
1. Sumatriptan (Imigran® 6 mg inj, 50 and 6 mg sc with autoinjector
100 mg tabl, Imitrex nasal spray, supp
supp, 50-100 mg per os,
Glaxo)
nasal spray 20 mg
2. Zolmitriptan (Zomig®, Zeneca) 2,5 – 5 mg
3. Naratriptan (Naramig®, Glaxo) 2,5 mg
4. Rizatriptan (Maxalt®, MSD) 5 – 10 mg per os
5. Eletriptan (Relpax, Pfizer) 20 – 80 mg per os
6. Frovatriptan (Smith-Kleine Beecham)
Kleine 2,5 mg per os
7. Avitriptan (Bristol-Myers Squibb) 75 – 150 mg
8. Alniditan (Janssen) 2 – 4 mg, nasal spray

24. The ideal triptan
• Effective
• Rapid onset
• No recurrence
• Good consistency
• Different applications
• Good tolerability
• No interactions
• Cheap

25. Attack treatment in emergency
Very severe migraine attack / status migrainosus:
• Triptan (sumatriptan 6 mg s.c.)
• Lysin-ASA 1,000 mg i.v.
• Metamizol 500-1,000 mg i.v.
• Antiemetics i.v.
• Steroids i.v.

26. Strategy of treatment of
migraine attacks
• Step care accross or within attacks
– 1: NSAID
– 2: ergot
– 3: triptan
• Stratified care
– do not go through all the steps, but drug can be
chosen depending on the severity of the attack

27. Prophylactic treatment of migraine
attacks
• Indication:
 2 or more attacks/month
 At least one long (>4 days) attack/month
• Start of prophyalactic treatment: gradually
• Duration of prophylactic treatment: 2-9 months
• Stop of prophylactic treatment gradually,
treatment:
within 4 weeks
• Use headache diary
• INFORM THE PATIENT ABOUT THE
PROPHYLACTIC TREATMENT!!!

28. Aims of prophylactic treatment
of migraine
• To decrease the frequency of attacks
• To decrease the intensity of the pain
• To increase the efficacy of attack therapy

29. Prophylactic treatment of migraine
• Beta-receptor-blockers (propranolol)
blockers
• Calcium channel blockers (flunarizine)
• Antiepileptics (valproic acid)
• Tricyclic antidepressants (amitriptyline)
• Topiramate (Topamax)
• Serotonin antagonists
• NSAID

30. Beta-receptor-blockers Use: hypertension, tachycardia
(propranolol 2x20-40 mg) Do not use: hypotension,
bradicardia,
heart conduction disturbances
Calcium channel blockers Do not use: obesity, maior depression
(flunarizine, 10 mg every evening) in the history
Side effects: provokes depression,
increases appetite, cause sleepiness
Tricyclic antidepressants Use: if tension type of headache is
amitryptiline, 10-75 mg every evening) present besides migraine
Do not use: see above
Antiepileptics Few side effects, but
(valproic acid, 2x300-500 mg) Pregnancy should be avoided

31. Other prophylactic treatment
of migraine
• Change of life-style
• Regular, not exhausting physical activities
• Cognitive behavioral therapy
• Regular sleeping
• Avoid the precipitating factors
• Acuouncture?

32. Migraine and pregnancy
• Migraine without aura in >70% of women less
frequent or absent (prognostic factor: menstrual
migraine)
• Significantly more manifestation of migraine
with aura
• Acute treatment: paracetamol; NSAIDs in
second trimenon
• Triptans not allowed
• Prophylaxis: magnesium, metoprolol,
(fluoxetine)

33. Migraine in childhood I
• Prevalence 5%
• Sex ratio 1:1 (boys with good prognosis)
• Abdominal symptoms often predominant
• Semiology of attacks as in adulthood
except shorter duration of attacks
• Short sleep very effective

34. Migraine in childhood II
• Acute treatment:
–First choice: ibuprofen 10 mg/kg
First
–Second choice: paracetamol 15 mg/kg
Second
–Third choice: sumatriptan nasal spray 10
Third 10-20
mg
• Prophylaxis:
–Flunarizine 5-10 mg
–Propranolol 80 mg

35. Treatment of cluster attack
• Oxygen:7 liters/min 100% oxigén for 15 minutes
– Effective in 75% of patients within 10 minutes
• Sumatiptan 6 mg s.c., 5050-100 mg per os
• Ergot derivatives (lot of side effects)
• Anaesthesia of the ipsilateral fossa sphenopalatina)
– 1 ml 4% Xylocain nasal drop
– The head is turned back and to the ipsilateral side
in 45 degree

36. Prophylactic treatment of the
episodic form of cluster headache
• Epizodic form: prednisolon
• Treatment:
– 1-5. days 40 mg
– 6-10. days daily 30 mg
10.
– 10-15. days daily 20 mg
15.
– 16-20. days daily 15 mg
20.
– 21-25. days daily 10 mg
25.
– 26-30. days daily 5 mg
30.
– nothing

37. Prophylactic treatment of the
chronic form of cluster headache
• Lithium carbonate
• Daily 600-700 mg
• Can be decreased after 2 weeks remission
• Control of serum level is necessary
(0,4 - 0,8 mmol/l)

38. 3. Cluster headache and
trigemino-autonomic cephalgias
autonomic
• Trigemino-autonomic cephalgias
autonomic
(TAC)
–Cluster headache
Cluster
–Paroxysmal hemicrania
Paroxysmal
–SUNCT-syndrome
syndrome
–(Hemicrania continua)
(Hemicrania

39. Headache of cervical origin
• Lidocain infiltration
• NSAID: 50-150 mg indomethacin, 20
150 20-40 mg
piroxicam (Hotemin, Feldene), etc
• Surgical methods (CV(CV-CVII fusion of
vertebrae)
• Other methods (physiotherapy, TENS)

40. Arteriitis temporalis
• Arteriitis temporalis (age>50y, We>50 mm/h)
• Autoimmune disease, granulomatose inflammation of
branches of ECA
– Unilateral headache
– Pulsating pain, more severe at night
– Larger STA
1/3 jaw claudication  inflammation of internal maxillary artery
–
– Weakness, loss of appetite, low fever,
– Danger of thrombosis of ophthalmic or ciliary artery!!!
– Amaurosis fugax may precede the blindness
– Treatment: steroid – 45-60 mg methylprednisolone – decrease
60
the dose after 1-2 weeks to 10 mg!!!
2
– Diagnosis: STA biopsy.
– BUT Start the steroid before results of biopsy!!!
– We, pain decrease

41. Facial pains
• Tolosa-Hunt syndrome (ophthalmoplegia
Hunt
dolorosa) – granulomatose inflammation in
cavernous sinus, superior orbital fissure –
Treatment: steroid
• Gradenigo’s syndrome: otitis media –
inflammation of apex of petrous bone – lesion of
ipsilateral abducent nerve and facial pain around
the ear and forehead

42. Carotid dissection
• After neck trauma, extensive neck turning
• Neck pain
• Horner’s syndrome
• Diagnosis: carotid duplex, MRI
MRI-T2