HEADACHES HEADACHES PBLPBL

STEVEN J. SCHEINER, M.D.Board Certified in Pain Medicine

Board Certified in NeurologyDiplomate, American Academy of Pain Management

Senior Physician, Pain Relief UnitDepartment of Anesthesiology and Critical Care

Hadassah Medical Center

IHS Classification ICHD-II

The International Classification of Headache Disorders. 2nd edition. The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–160Cephalalgia 2004; 24(Suppl 1): 9–160

Migraine without AuraMigraine without Aura At least 5 attacksAt least 5 attacks Headache attacks lasting 4-72 hours if untreated Headache attacks lasting 4-72 hours if untreated Has at least two of the following, but not weakness:Has at least two of the following, but not weakness:

1.1. unilateral locationunilateral location2.2. pulsating qualitypulsating quality3.3. moderate or severe pain intensitymoderate or severe pain intensity4.4. aggravation by or causing avoidance of routine aggravation by or causing avoidance of routine

physical activityphysical activity Has at least one of the following:Has at least one of the following:

1.1. nausea and/or vomitingnausea and/or vomiting2.2. photophobia and phonophobiaphotophobia and phonophobia

Not attributed to another disorderNot attributed to another disorderThe International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–160The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–160

Migraine with AuraMigraine with Aura At least two headache attacks that fulfill the At least two headache attacks that fulfill the

characteristics of migraine without auracharacteristics of migraine without aura Headaches usually follow the aura but may Headaches usually follow the aura but may

begin with it & last 4-72 hours if untreatedbegin with it & last 4-72 hours if untreated Has at least one of the following reversible Has at least one of the following reversible

symptoms (lasting 4-60 min) but no symptoms (lasting 4-60 min) but no weakness:weakness:

1.1. Positive or negative visual symptoms such as Positive or negative visual symptoms such as scintillating scotomas, blind spot (scotoma), scintillating scotomas, blind spot (scotoma), blurred vision, zigzag lines, homonymous blurred vision, zigzag lines, homonymous hemianopsiahemianopsia

2.2. Positive or negative sensory symptoms such Positive or negative sensory symptoms such as tingling or numbnessas tingling or numbnessThe International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–160The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–160

Aura Without HeadacheAura Without Headache

At least two attacks of symptoms At least two attacks of symptoms typical of auras, but not weakness, typical of auras, but not weakness, such as visual, sensory or speech such as visual, sensory or speech disturbances that resolve in 1 hour disturbances that resolve in 1 hour & are not followed by headache& are not followed by headache

The International Classification of Headache Disorders. 2nd edition. Cephalalgia The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–1602004; 24(Suppl 1): 9–160http://ihs-classification.org/en/02_klassifikation/http://ihs-classification.org/en/02_klassifikation/

Tension-Type Headache Tension-Type Headache (TTH)(TTH)

Subclassified by FrequencySubclassified by Frequency HA lasting 30 minutes to 7 daysHA lasting 30 minutes to 7 days Has at least two of the following:Has at least two of the following:

1.1. Bilateral locationBilateral location2.2. Mild or moderate pain intensity (may inhibit but Mild or moderate pain intensity (may inhibit but

not prohibit activity)not prohibit activity)3.3. Pressing/tightening (nonpulsating) qualityPressing/tightening (nonpulsating) quality4.4. No aggravation while climbing stairs or similar No aggravation while climbing stairs or similar

routine physical activityroutine physical activity Has both of the following:Has both of the following:

1.1. No nausea or vomiting (can have anorexia)No nausea or vomiting (can have anorexia)2.2. No more than one of photophobia and No more than one of photophobia and

phonophobiaphonophobia Not attributed to another disorderNot attributed to another disorderThe International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–160The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–160

Infrequent Episodic TTHInfrequent Episodic TTH

At least 10 episodesAt least 10 episodes Less than 1 day/month Less than 1 day/month (Average less than 12 days/year)(Average less than 12 days/year)

Frequent Episodic TTHFrequent Episodic TTH

At least 10 episodesAt least 10 episodes 1 or more days/month but less than 1 or more days/month but less than

15 days/month for at least 3 months 15 days/month for at least 3 months (12 or more days/year & less than (12 or more days/year & less than

180 days/year)180 days/year)

Chronic TTHChronic TTH

15 or more days/month for more 15 or more days/month for more than 3 monthsthan 3 months

(180 or more days/year)(180 or more days/year) Headache lasts hours or may be Headache lasts hours or may be

continuouscontinuous

Case # 1: Prof. Ben-HurCase # 1: Prof. Ben-Hur

Female age16 with Migraine Female age16 with Migraine History at ER History at ER

No feverNo fever Non Focal Neuro ExamNon Focal Neuro Exam No Meningeal Signs Per No Meningeal Signs Per

NeurologyNeurology Initially Tx with Analgesics & IV Initially Tx with Analgesics & IV

FluidFluid

Case # 1 ContinuedCase # 1 Continued

Headache Worsened Despite TxHeadache Worsened Despite Tx Patient Became Hyperactive & Patient Became Hyperactive &

Agitated with Increasing Pain Agitated with Increasing Pain Otherwise No Change in ExamOtherwise No Change in Exam Tx with DiazepamTx with Diazepam WBC 16 Attributed to Stress WBC 16 Attributed to Stress

ReactionReaction Final Disposition & DiagnosisFinal Disposition & Diagnosis

Red Flag # 1Red Flag # 1

Altered Mental Status w HeadacheAltered Mental Status w Headache Do Not Need Other FindingsDo Not Need Other Findings

Differential Dxs Include:Differential Dxs Include: Bacterial MeningitisBacterial Meningitis Encephalitis: Herpes is a Neuro Encephalitis: Herpes is a Neuro

EmergencyEmergency Fungal, Parasitic & Non InfectiousFungal, Parasitic & Non Infectious SAHSAH

#2 AECOM Med Student #2 AECOM Med Student HusbandHusband

Jacobi Hospital ERJacobi Hospital ER Mid 20s with New Moderately Mid 20s with New Moderately

Severe HeadacheSevere Headache Throbbing, No N/V/Photo/PhonoThrobbing, No N/V/Photo/Phono No Prior Headache HistoryNo Prior Headache History Non Focal Neuro ExamNon Focal Neuro Exam Responded to NSAID TxResponded to NSAID Tx DischargedDischarged

Case # 2 ContinuedCase # 2 Continued

Two Months Later Returns to ERTwo Months Later Returns to ER Headache RecurrenceHeadache Recurrence Similar to Initial Headache But Less Similar to Initial Headache But Less

SevereSevere Non Focal Neuro ExamNon Focal Neuro Exam Responded Well to a Different Responded Well to a Different

NSAIDNSAID DischargedDischarged

Case # 2 ContinuedCase # 2 Continued

Returns Again to ER in Three Returns Again to ER in Three MonthsMonths

Final Disposition & DiagnosisFinal Disposition & Diagnosis

Sentinel HeadachesSentinel Headaches

Proceed Aneurysmal SAH 20-50%Proceed Aneurysmal SAH 20-50% May be Self Limited or Relieved May be Self Limited or Relieved

by Analgesics or Triptansby Analgesics or Triptans Recognition Can Be LifesavingRecognition Can Be Lifesaving Mechanism: Tiny Bleed or Mechanism: Tiny Bleed or

Pressure on Pain Sensitive Pressure on Pain Sensitive Intracranial StructuresIntracranial Structures

Case # 3 Hadassah Pain Case # 3 Hadassah Pain ClinicClinic

Male Age 32 with Two Male Age 32 with Two Migraines/YearMigraines/Year

11stst Migraine in Childhood & + FH Migraine in Childhood & + FH Presents w 1 ½ Weeks of New Daily Presents w 1 ½ Weeks of New Daily

Headache Headache Throbbing, Very Mild N/Photo/PhonoThrobbing, Very Mild N/Photo/Phono Much Less Severe than Usual Much Less Severe than Usual

MigraineMigraine

Case # 3 ContinuedCase # 3 Continued

At Shaare Zedek ER for 3 Days At Shaare Zedek ER for 3 Days Previous WeekPrevious Week

Negative CT of HeadNegative CT of Head Unsuccessful LPUnsuccessful LP D/C with Steroid Tapper for Status D/C with Steroid Tapper for Status

MigranosisMigranosis Disposition & DiagnosisDisposition & Diagnosis

Diagnosis Case # 3Diagnosis Case # 3

New Daily Persistent Headache New Daily Persistent Headache (NDPH)(NDPH)

PosttraumaticPosttraumatic in a very broad way in a very broad way As a result of viral meningitis As a result of viral meningitis This is a typical presentation of This is a typical presentation of

NDPH & more common than after a NDPH & more common than after a blow to headblow to head

Also seen after malarial meningitisAlso seen after malarial meningitis

IHS Classification ICHD-II

The International Classification of Headache Disorders. 2nd edition. The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–160Cephalalgia 2004; 24(Suppl 1): 9–160

Cluster HeadacheCluster Headache At least 5 attacks fulfilling the following:At least 5 attacks fulfilling the following: Severe or very severe unilateral orbital, supraorbital Severe or very severe unilateral orbital, supraorbital

and/or temporal pain lasting 15-180 minutes if untreated1 and/or temporal pain lasting 15-180 minutes if untreated1 Headache is accompanied by at least one of the following: Headache is accompanied by at least one of the following:

1.1. ipsilateral conjunctival injection and/or lacrimationipsilateral conjunctival injection and/or lacrimation2.2. ipsilateral nasal congestion and/or rhinorrhoeaipsilateral nasal congestion and/or rhinorrhoea3.3. ipsilateral eyelid edemaipsilateral eyelid edema4.4. ipsilateral forehead and facial sweatingipsilateral forehead and facial sweating5.5. ipsilateral miosis (pupillary constriction) and/or ptosisipsilateral miosis (pupillary constriction) and/or ptosis6.6. a sense of restlessness or agitationa sense of restlessness or agitation

Attacks have a frequency from one every other day to Attacks have a frequency from one every other day to 8/day8/day

Not attributed to another disorder Not attributed to another disorder The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–16024(Suppl 1): 9–160

Cluster HeadacheCluster Headache During part (but less than half) of the time-During part (but less than half) of the time-

course of cluster headache, attacks may be course of cluster headache, attacks may be less severe and/or of shorter or longer less severe and/or of shorter or longer duration & may also be may be less frequentduration & may also be may be less frequent

Acute attacks involve activation of the Acute attacks involve activation of the posterior hypothalamic grey matterposterior hypothalamic grey matter

Attacks usually occur in series (Attacks usually occur in series (cluster cluster periodsperiods) lasting for weeks or months ) lasting for weeks or months separated by remission periods usually separated by remission periods usually lasting months or years. However, about 10-lasting months or years. However, about 10-15% of patients have chronic symptoms 15% of patients have chronic symptoms without remissionswithout remissions

Cluster HeadacheCluster Headache In a large series with good follow-up, 27% of In a large series with good follow-up, 27% of

patients had only a single cluster periodpatients had only a single cluster period During a cluster period, and in the chronic During a cluster period, and in the chronic

subtype, attacks occur regularly and may be subtype, attacks occur regularly and may be provoked by alcohol, histamine or provoked by alcohol, histamine or nitroglycerinenitroglycerine

During the worst attacks, the intensity of pain During the worst attacks, the intensity of pain is excruciating & patients characteristically is excruciating & patients characteristically pace the floorpace the floor

Age at onset is usually 20-40 yearsAge at onset is usually 20-40 years For unknown reasons prevalence is 3-4 times For unknown reasons prevalence is 3-4 times

higher in men than in womenhigher in men than in women

Cluster Headache PlusCluster Headache Plus

Some patients have been described Some patients have been described who have both cluster headache and who have both cluster headache and trigeminal neuralgiatrigeminal neuralgia

They should receive both diagnosesThey should receive both diagnoses The importance of this observation is The importance of this observation is

that both conditions must be treated that both conditions must be treated for the patient to be headache freefor the patient to be headache free

Cluster Headache & Other Cluster Headache & Other Trigeminal Autonomic Trigeminal Autonomic

Cephalalgias (TAC)Cephalalgias (TAC) 3.1 G44.0 Cluster headache (15-180 min. & 1-8/day)3.1 G44.0 Cluster headache (15-180 min. & 1-8/day) 3.1.1 G44.01 Episodic cluster headache3.1.1 G44.01 Episodic cluster headache 3.1.2 G44.02 Chronic cluster headache3.1.2 G44.02 Chronic cluster headache 3.2 G44.03 Paroxysmal hemicrania (1-45 min. & 1-40/day)3.2 G44.03 Paroxysmal hemicrania (1-45 min. & 1-40/day) 3.2.1 G44.03 Episodic paroxysmal hemicrania3.2.1 G44.03 Episodic paroxysmal hemicrania 3.2.2 G44.03 Chronic paroxysmal hemicrania3.2.2 G44.03 Chronic paroxysmal hemicrania 3.3 G44.08 Short-lasting unilateral neuralgiform headache 3.3 G44.08 Short-lasting unilateral neuralgiform headache

attacks with conjunctival injection and tearing (SUNCT) attacks with conjunctival injection and tearing (SUNCT) (15-600 sec. & 1/day-30/hour)(15-600 sec. & 1/day-30/hour)

3.4 G44.08 Probable TAC3.4 G44.08 Probable TAC 3.4.1 G44.08 Probable cluster headache3.4.1 G44.08 Probable cluster headache 3.4.2 G44.08 Probable paroxysmal hemicrania3.4.2 G44.08 Probable paroxysmal hemicrania 3.4.3 G44.08 Probable SUNCT3.4.3 G44.08 Probable SUNCT

Other Primary HeadachesOther Primary Headaches

4.1 G44.800 Primary stabbing headache4.1 G44.800 Primary stabbing headache(secs-3 min. & any frequency)(secs-3 min. & any frequency)

4.2 G44.803 Primary cough headache4.2 G44.803 Primary cough headache 4.3 G44.804 Primary exertional headache4.3 G44.804 Primary exertional headache 4.4 G44.805 Primary headache associated 4.4 G44.805 Primary headache associated

with sexual activitywith sexual activity 4.4.1 G44.805 Preorgasmic headache4.4.1 G44.805 Preorgasmic headache 4.4.2 G44.805 Orgasmic headache4.4.2 G44.805 Orgasmic headache 4.5 G44.80 Hypnic headache (15-30 min. & 4.5 G44.80 Hypnic headache (15-30 min. &

1-3/night)1-3/night) 4.6 G44.80 Primary thunderclap headache4.6 G44.80 Primary thunderclap headache 4.7 G44.80 Hemicrania continua4.7 G44.80 Hemicrania continua 4.8 G44.2 New daily-persistent headache4.8 G44.2 New daily-persistent headache

Primary Thunderclap Primary Thunderclap HeadacheHeadache

The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–16024(Suppl 1): 9–160

Secondary Causes of Secondary Causes of Thunderclap HeadacheThunderclap Headache

The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24(Suppl 1): 9–16024(Suppl 1): 9–160

SAH “The Worst HA of My SAH “The Worst HA of My Life”Life”

Usually Sudden Onset with Usually Sudden Onset with ExertionExertion Sentinel HAs proceed aneurysmal Sentinel HAs proceed aneurysmal

SAH 20-50%SAH 20-50% Recognition of these Has can be Recognition of these Has can be

lifesavinglifesaving Thunderclap onset lasting hours-Thunderclap onset lasting hours-

daysdays Meningismus tends to be absentMeningismus tends to be absent

Summary of Crucial Red Summary of Crucial Red FlagsFlags

Altered Mental StatusAltered Mental Status Sudden OnsetSudden Onset Focal Neurological SignsFocal Neurological Signs SeizuresSeizures