Transcript Document

What Type of Headache do I
have?
David M. Biondi, DO
Director, Headache Management Programs
Spaulding Rehabilitation Hospital
Consultant, Massachusetts General Hospital
Instructor in Neurology, Harvard Medical School
Boston, MA
Headache in the Population
• 99% of women and 93% of men have had
headache during their lifetime
• 25% of women and 8% of men in the United
States have had migraine headache
• 18% of women and 6% of men have had migraine
over the previous year
• Prevalence is highest between age 25 – 55 years
• An estimated 30 million have migraine and up
to 10 million have chronic daily headache (> 15
headache days per month) in the U.S.
Headache History
• Headache attacks
– How it begins
• Precipitating event, illness, injury
• Headache attack descriptions
– Frequency and patterns
• Any significant changes
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–
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–
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Location
Time to peak intensity
Duration
Quality and intensity
Warning symptoms and aura
Associated symptoms and level of disability
Triggers and aggravating or relieving factors
Tension Headache or Migraine?
Tension-type Headache or Migraine?
Migraine is 6.3x more common than TTH
80
70
TTH is 1.5x
more common
than migraine
TTH is 3.3x
more common
than migraine
75
60
Population
50
Percent 40
(%)
30
40
Waiting Room
44
29
20
10
12
Significant
Headaches*
12
0
Tension-Type Headache
Migraine
* People who want to talk to the doctor about their headaches or who
have headaches that interfere with daily activities.
Lipton RB et al. Neurology. 2003;61:375-385.
Episodic Tension-type Headache
A. Number of days with such headache < 180/year (<15/month)
B. Headache lasting from 30 minutes to 7 days
C. At least 2 of the following:
• Pressing/tightening (non-pulsating) quality
• Mild or moderate intensity (may
inhibit, but does not prohibit activities)
• Bilateral location
• No aggravation by walking stairs
or similar routine physical activity
D. Both of the following:
• No nausea or vomiting (anorexia may occur)
• Photophobia and phonophobia are absent, or one but not
the other is present
E. At least 10 previous headache episodes fulfilling these criteria
F. No evidence of organic disease
Migraine Without Aura
A. Headache lasting from 4 to 72 hours
B. At least 2 of the following
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Unilateral location
Pulsating quality
Moderate or severe intensity
Aggravation by routine physical activity
C. At least 1 of the following:
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Nausea and/or vomiting
Photophobia and phonophobia
D. At least five attacks fulfilling these criteria
E. No evidence of organic disease
Tension-type Headache or Migraine
Mild
Moderate
Severe
Unilateral
Bilateral
Photophobia
Nausea
Aura
Vomiting
Aggravated
by Activity
Throbbing
Pressure
Tension-Type
Migraine
© 2002 Primary Care Network
Migraine Aura
• Positive Neurological Symptoms
– Reversible brain/neurological symptoms
• Visual flashes, spots, or zig-zag lines
• Traveling tingling sensations
– Gradual development over >4 minutes
– Resolves within 1 hour
• Negative Neurological Symptoms
– Reversible brain/neurological symptoms
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•
•
•
Visual blind spots
Numbness
Speech or word finding problems
Trouble thinking
– Resolves within 1 hour
“Even My Hair Hurts”
(allodynia)
• Cutaneous allodynia
– “Hair hurts”
– Painful when:
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Shaving
Combing hair
Touching scalp
Resting head on pillow
Pulling hair back (wearing
a ponytail)
• Wearing eyeglasses or
contact lenses
• Wearing hat or head band
• Other painful events
– Water hitting head or
face while showering
– Breathing through nose
especially cold air
– Cooking over a hot
stove
– Rubbing the neck or
shoulders
– Hanging head down or
bending over
Neck Pain During Migraine
• Prevalence
– 75% of subjects
• Descriptions
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69% - tightness
17% - stiffness
5% - throbbing
5% - other
82% had previously been
given a diagnosis of
tension-type headache
Kaniecki R. Neurology. 2002;58(Suppl 6):S15-S20.
92%
100%
80%
61%
60%
41%
40%
20%
0%
Prodrome
Postdrome
Migraine
Phase
Migraine Pain Intensity
and Disability
9% Function Normally
>75% Report Severe to
Extremely Severe Pain
50
40
53%
Severe
Impairment
or Bed Rest
Required
39%
Some
Impairment
Patients 30
(%)
20
10
0
Mild
Moderately
Severe
Severe
Extremely
Severe
Lipton RB et al. Headache. 2001;41:638-645.
Dilemmas in Diagnosing Migraine
• Visual aura
– only 15-20% of migraineurs
• Head pain can be non-throbbing
– in ~40% of patients
• Head pain can be bilateral
– in ~ 43% of patients1
• Sinus pain and pressure, stuffiness, rhinorrhea &
weather association is often present
– in up to 97% of migraine attacks2
• Neck pain is often present
– in up to 75% of migraine attacks3
1. Data on File. GlaxoSmithKline.
2. Cady RK, et al. Poster presented at:10th IHC; June 29-July 2, 2001; New York NY.
3. Kaniecki RG, et al. Poster presented at:10th IHC; June 29-July 2, 2001; New York NY.
Sinus Headache or Migraine?
Myth
Headaches that are triggered by weather or
are associated with sinus symptoms are not
migraines.
Fact
 Up to 50% of migraine patients report their
headaches are influenced by weather1
 45% of migraine patients report sinus
symptoms including2
– Lacrimation
– Nasal congestion
– Rhinorrhea
1. Raskin NH. Headache. 2nd ed. New York: Churchill Livingstone; 1998.
2. Barbanti P et al. Cephalalgia. 2001;21:295.
Headache:
A Minor Criteria in AAO-HNS Sinusitis
Headache is a minor factor in the diagnosis of
rhinosinusitis, according to AAO-HNS*
• Major factors
– Purulence in nasal cavity on
exam
– Facial pain/pressure/congestion*
– Nasal obstruction/blockage/
discharge
– Fever (in acute only)
– Hyposmia/anosmia
• Minor factors
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Fever (chronic)
Halitosis
Headache
Fatigue
Dental pain
Cough
Ear pain/pressure/fullness
* Facial pain/pressure alone does not constitute a suggestive history for
rhinosinusitis in the absence of another major nasal symptom or sign.
* American Academy of Otolaryngology-Head and Neck Surgery Lanza et al. Otolaryngol Head Neck Surg 1997.117(pt 2): S1-S7.
“Sinus Symptoms” Are Common in
the Presentation of Migraine
97%
89%
85%
Moderate/Severe Pain
Pulsatile
Worsened by Activity
84%
82%
79%
Sinus Pressure
Sinus Pain
Photophobia
67%
63%
Phonophobia
Nasal Congestion
40%
38%
Runny Nose
Watery Eyes
29%
27%
Aura
Itchy Nose
“Sinus” Symptoms
25%
Vomiting
N = 2424
IHS Migraine Symptoms
0%
20%
40%
60%
80%
Schreiber C. Poster presented at: American Headache Society Meeting; June 21-23, 2002;Seattle, WA.
100%
“Sinus” Headache in Primary Care
Migraine w/o or
with Aura
82%
IHS 1.1, 1.2
8%
Migrainous
IHS 1.7
n=2520
10%
Other
0%
20%
40%
60%
Percentage of Subjects
Source: SUMMIT Study
80%
100%
One Nerve Pathway:
Multiple Symptoms of Migraine
Summary
• Tension-type headaches are very common in the
general population
• Migraine headaches are also common but are more
common than tension-type headaches in medical
clinics because of greater severity and disability
• True “sinus headaches” are uncommon
• Sinus symptoms and neck pain are very common
symptoms of migraine
• Most cases of recurrent “sinus headaches” are
migraine especially if there is a family history of
recurrent or chronic headaches