Neuro: 8:00 - 9:00 Scribe: Hillary Carney

Neuro: 8:00 - 9:00 Scribe: Hillary Carney

Friday, January 8, 2009 Proof: Dipesh Patel

Dr. Lopez Headaches Page 1 of 7

NOTE: Many of the slides he told us to read on our own. For these I copied directly from the slide.

I.  Introduction [S1]:

a.  So the first thing will be to answer this question: The following is a diagnostic criteria for tension-type headaches? answer: bilateral pain

II.  Overview [S2]

a.  In your practices you will find patients with headaches every so often. Sometimes patients who have headaches believe that it’s due to their eyesight. Many people believe that they have headaches because they need glasses. It’s not true, but people believe that. Some people also think headaches can be from their teeth.

III.  Tension-Type Headaches [S3]

a.  So tension-type headaches are the most common type of headaches that people have. If you go out to the street and ask the first one hundred people that go by, they will tell you that if they have headaches it will be a tension-type headache. It is the most common type of headache in the general population. We have here some types: Episodic tension type headaches—we have all had this type of headache sometimes. Episodic means every so often. Once in a blue moon. Infrequent would be less than six headaches days per month.

b.  Frequent means 10 or more headaches in a month.

c.  Chronic would be patients who have pain for three months in a row more days than not.

d.  The diagnostic criteria for tension-type headaches is defined by the IHS –international headache society- this society came up with the diagnostic criteria.

IV.  Tension-Type Headaches [S4]

a.  They can last from minutes to hours to the whole day. The pain may last between 30 minutes to a few hours. This is pain that by definition is short lived.

b.  The patient must have at least two of the following:

i.  The pain has to be bilateral not unilateral like in the case of migraines. And the pain has to be a very pressing or tight in quality.

c.  Many times I will ask patients if they feel like their head is being squeezed by a tight band. He asks them what is the pain like: is this a pulsating pain, a tight pain, a dull ache, or a sharp pain? And they say it’s really bad—intensity is important, but right now we are talking about the quality of pain. The patient usually says well it just hurts, so he has stopped asking this question.

d.  The pain has to be mild or moderate in intensity—and how do you define that?—those scales of 0 to 10 are worthless. So he asks his patients if 0 is no pain at all and 10 being severe pain the patients will say “well it’s a 12.” People will say well I’m special. He will usually ask instead—“is you pain enough to keep you out of work or school, and if so how many times do you miss work?” This will give you a good idea of how severe their pain is, and their response to your therapy. The patient may say “Well I have 6 headache days per month and out of those 4 on them are so severe that I cannot go to school.” And then after a few months they may tell him “well I have 3 headache days per month and only 1 of them is enough to interfere with my activities of daily living.” So then he knows that his therapy is working. So instead of asking them from 0 to 10 he may ask them how many days out of the month is your pain so severe as to keep you out of school or work? So that’s a way to quantify pain.

e.  The pain by definition should not be aggravated by routine physical activity. So those individuals that have tension-type headaches they can walk, go up and down stairs, go to school, the pain when they move around is not aggravated. That’s the difference between migraines and tension-type headaches.

V.  Tension-Type Headaches [S5]

a.  The patient should have both of the following :

i.  No more than one of photophobia, phonophobia, or mild nausea

ii.  neither moderate or severe nausea nor vomiting

b.  This is not very difficult to diagnose. So you ask somebody “do you have headaches?” and they say yeah, and you ask how often and they will tell you how often in a month and where the pain is. Then you ask, “do you have nausea and vomiting?” and they may say, “yeah I have nausea but not really vomiting.” Won’t complain of bright lights or noise making it worse. They can move around when they have headaches. You can ask “Is the pain severe enough to keep you in bed?” and they will usually say “No, not really.” So this is tension-type headache. Then of course if someone gets an MRI and it’s a brain tumor you cannot say this is a tension-type headache. It’s a brain tumor.

VI.  Migraine Prevalence [S6]

a.  Migraine on the other hand is the most common type of headache that we see in the neurology clinic because patients with tension-type headaches do they go to the doctor? No not usually. Most normal people don’t go to the doctor for minor illness or aches and little pains, but Migraine is the most common type of pain that comes to the neurologist because this is severe pain by definition. So about 12% of the general population has migraines. So in this room about 8 people have migraines in this class. It’s also three times more common in women. Unfortunately it’s more common when people are being productive.

VII.  Migraine Prevalence [S7]

a.  You see the statics here and you can read this on your own.

i.  There are nearly 30 million migraine sufferers in the United States1,2*

ii.  Migraine affects 17.1% of women3

iii.  Migraine affects 5.6% of men3

iv.  Migraine prevalence peaks between 25 and 55 years of age1,2

v.  These are the most productive years

vi.  1 in 4 households has at least 1 migraine sufferer2

VIII. Migraine Is a Highly Prevalent Medical Disorder[S8]

a.  Now this graph shows the prevalence of migraines. The thing you can see here is that it is more common in females, about three times more common. The important part here is that the pain from migraine never goes away completely in some people. So after menopause in females around age 50 the prevalence decreases but the pain never goes away altogether in some people. So you cannot tell people that you can cure them from the migraines. Migraines are not curable. Migraines are chronic, progressive, incurable disease. That’s what you have to tell patients. The best you can achieve in clinical practice is to make the pain less frequent and less severe, improve the patient’s quality of life.

IX.  Migraine Prevalence [S9]

a.  What happens in migraines is that it is a neurovascular problem. The problem starts in the brain stem—in the magnus raphe nucleus. It appears that there is a subset of neurons in the brain stem that are highly sensitive and that’s the way individuals are born. This is a genetic disease. So individuals are born with hyper excitable neurons and given the right circumstances such as stress, hormonal changes during adolescence, caffeine—there are multiple triggers— then the pain will appear but the patient is already pre-disposed to have migraines. He sometimes tells patients that you have migraines because it’s in your genes, this is your genetic makeup just like your nose and the color of your eyes.

b.  The brain cells cause the blood vessels in the meninges to open and be very porous—and certain substances will irritate the trigeminal nerve—and then those sensitive neurons will pick up those substances that I talked about—and then they will go from the brain stem to the thalami and then to the cortex.

X.  Prevalence of Migraine [S10]

a.  For migraines, patients have to have 5 or more episodes of the following—of course if the patient has only had 4 episodes you don’t tell them to go home and come back after the 5th episode.

XI.  Prevalence of Migraine: Age and Gender [S11] -Graph

XII.  Pathophysiology of Migraine [S12]- Picture

XIII. Migraine: IHS Diagnostic Criteria I [S13]

a.  In migraines, the pain lasts from 4 to 72 hours. This is a prolonged pain compared to the shorter pain of tension-type headaches. The pain is usually unilateral, usually throbbing. The pain is aggravated by movement. So patients with migraines will usually go to a quiet place and just take a nap or rest. The pain is usually moderate to severe. How do you know that it’s severe? The patient won’t be able to go on with their normal life.

XIV.  Migraine Diagnostic Criteria II [S14]

a.  Finally, the pain has to be associated with nausea and vomiting or photophobia or phonophobia. I hope you understand the difference between tension-type headaches and migraines. Tension-type is short term, less severe pain as compared to migraines. Migraines are longer, more severe pain and more dramatic. Patients don’t want lights. They don’t want anyone talking to them. They want to go to their rooms and take a nap.

XV.  Clinical Criteria for the Diagnosis of Trigeminal Neuralgia [S15]

a.  You can read this on your own. This is the criteria for trigeminal neuralgia. The pain is usually short, about 2 minutes, but it’s very severe, but fortunately it’s very short. You guys will remember that there are three divisions of the trigeminal nerve. Of course it follows that in one or more divisions of the trigeminal nerve the pain is very severe. It has a burning or stabbing quality. Between headaches the patients are perfectly fine. So provided that the person is not having the pain at that moment he or she looks fine. These headaches are precipitated by certain activities such as chewing. So sometimes when a patient is just chewing their food they can have one of these headaches. Sometimes when smiling or talking. Patients can actually lose weight because they don’t want to eat, because they can have this severe pain that disables them in many cases.

XVI.  Trigeminal Neuralgia [S16]

a.  So we have idiopathic trigeminal neuralgia where we get an MRI of the brain trying to find a reason, in the brain stem maybe or in the 5th nuclei, and there is nothing, not a stroke, not a tumor, or MS. We have to tell the patient that we don’t know why they are having this pain.

b.  Sometimes the patient is having vascular compression of the fifth cranial nerve and there is a loop of the posterior ciliary artery that can sometimes loop around the 5th cranial nerve root and compress it. Surgeons go in and decompress the nerve and put a piece of tissue, usually foam, between the nerve and the blood vessel so that every time the blood vessel pulsates it won’t touch the 5th cranial nerve root and many times that will cure people.

c.  If the MRI shows MS well then that’s the diagnosis. So those patients should get an MRI many times.

XVII.  MRI of the Brain [S17]

a.  The arrow is pointing to the root of the 5th cranial nerve. You have a picture here of the posterior ciliary artery wrapping around it. Again, if you find this in an MRI this is very fortunate for the patient because this can be treated surgically.

XVIII.  Cluster Headache [S18]

a.  Cluster headaches are usually unilateral with severe pain. It is the most painful condition known to women. I say for women because for us men everything is painful; we are wimps. In patients with cluster headaches the pain is around the orbit and in the temporal region. It’s not a facial pain. It’s a short pain, lasting 45-90 minutes, but very severe.

XIX.  Cluster Headache [S19]

a.  For some reason it appears about 90 minutes after they go to sleep. So you have here some statics about the epidemiology of these headaches. Fortunately, the majority of the patients have episodic pain, so the pain comes and goes. They may have a cluster of headaches lasting for let’s say 8 weeks, and they have pain every day and every night 3 or 4 episodes lasting 15-45 minutes of this pain. And then after two months the pain goes away and they are pain free for a year or two. Then again the pain comes back. It’s a repetitive thing that will happen once or twice a year sometimes or every 18 or 24 months or so. For some reason the pain appears around 90 minutes after they go to sleep.

b.  We also have chronic clusters. Which are fortunately in a minority of these patients. They have pain constantly. 10-20% have chronic cluster headaches—with no remissions or remissions lasting less than 1 month. For these patients alcohol brings on the pain. The pain usually starts about 90 minutes after they go to sleep because the pain seems to be associated with REM sleep. That happens in normal people about 90 minutes after you go to sleep-- that’s when people dream.

XX. Cluster Headache [S20]

a.  The typical guy that has cluster headaches is someone in their 40’s or 50’s and they look like the Marboro man—he’s this rugged cowboy, he’s tough, he has facial hair, rough looking man, and he smokes. He’s in his 40’s or 50’s and this is the typical person that has cluster headaches. They don’t have a cowboy hat probably, but they have an Alabama baseball cap instead. These patients are very difficult to treat.

XXI.  Paroxysmal Hemicrania vs Cluster Headaches [S21]

a.  Now we have another condition called paroxymsmal hemicranic. In paroxysmal hemicrania the pain is shorter. Remember in clusters the pain can go from 15-45 minutes sometimes longer. In paroxysmal hemicrania the pain is shorter and more frequent. In clusters the pain comes with a frequency of maybe 3 or 4 episodes every day, usually at night. With paroxysmal hemicranias, another primary type of headache, they may have up to 15 headaches a day.