Chronic Daily Headaches
David V. Lardizabal, M.D.
Assistant Professor, Kirksville College of Medicine
Objectives
To learn the systematic approach in the diagnosis of chronic daily headaches
To present different cases of chronic daily headaches
Basic Components of the History
Onset
Location
Quality
Duration
Frequency
Associated Symptoms
Triggers
Relieving Factors
Medication: dose/frequency
General and Neurologic Examination
Case #1
A previously healthy 38 year old man presented with 4 month history of daily headache. The headache began gradually and without provocation. The pain was continuous and became progressively more severe and disabling. The headache was moderately intense holocranial pressure that lasted throughout the day and was not associated with gastrointestinal or autonomic symptoms.
Case #1 continued
He tried over-the-counter analgesics without relief prior to receiving acetaminophen with codeine from his family physician. A prior neurological examination and non-enhanced MRI of the head were unremarkable. His alleviating factors was “resting and relaxing” were the only thing that helped. His headache was improved when he is supine i.e. resting in bed, resting in the sofa, or mid-day naps. When he rises from bed, his headache would invariably intensity.
Diagnosis?
Diagnosis?
Case #2
15 year old boy has been having daily headaches for the past 6 months. It is a constant pressure. He has incontinence and difficulty in looking up. He has tried different analgesics without relief. He wakes up in the morning vomiting. The neurologic examination showed no upgaze and papilledema.
Diagnosis?
Diagnosis?
Case #3
18 year old female had a minor head trauma from an altercation. She has daily headaches and posterior neck pain for 2 weeks. She vomits daily. She has no nausea, light or sound sensitivity. Her neurological examination is normal. The CT scan was negative. She was told to have post-traumatic headache.
Diagnosis?
Diagnosis?
Lesson Number 1
Secondary Headaches should be vigilantly investigated in daily headache patients.
Neurologic Examination is important
CT is not the diagnostic test of choice
MRI with/without contrast should be performed in new daily headaches.
Secondary Chronic Daily Headaches
Post-Traumatic Headache
Cervical Spine Disorders
Headaches associated with Vascular Disorders; AVM; arteritis including GCA, dissection, subdural hematoma
Headache associated with Non-Vascular disorders (EBV, HIV, tumor)
TMJ, Sinus infections (sphenoid), Chronic CNS infections
Intracranial Hypotension or hypertension
Primary Chronic Daily Headaches
Definition of CDH
> 15 or more headache days
> 3 or more months
Chronic Daily Headaches
Duration of head pain
Autonomic Features
Medication History
Neurologic Examination
Duration of the Head Pain
More than 4 hours
Less than 4 hours
Autonomic Features
Eyelid swelling
Ptosis “drooping”
Miosis or Mydriasis
Conjunctival injection
Lacrimation “Tearing”
Rhinorrhea “runny nose”
Medication History
What are the medication used for abortive and/or prophylactic therapy?
What is the monthly consumption?
Case #4
23 year old woman presented for evaluation of intractable and disabling daily headache of 6 months duration. Her headache began 3 years ago, occurring one to 3 times per month. Initially, her headache were left temporal in location and were severe and throbbing and associated with prominent nausea and photo- or phonophobia.
Case #4 continued
Over the past 6 months, she has had a moderate intensity, diffuse, daily, and continuous headache with only mild photophobia and occasional nausea. To allow herself to function at school, throughout the past year, she escalated her abortive medication use, initially using 4 to 8 acetaminophen-aspirin-caffeine tablets daily and in the past 6 months, 4 to 8 perscription acetaminophen-caffeine-butalbital tablets daily.
Case #4 continued
Prophylactic therapy with tricyclic antidepressant and anticonvulsant was unhelpful. Her neurological examination and brain MRI were normal.
Case #4
Fulfills criteria for CDH
Normal MRI and exam
Secondary causes excluded.
Diagnosis?
Chronic Daily Headaches?
Lesson Number 3
Chronic Daily Headache is a Symptom
It is NOT a Diagnosis
Migraine
Medication Overuse Headaches ( MOH)
Medication Overuse Headaches (MOH)
Simple analgesics
> 15 days for > 3 months
Opiods, Ergotamines, Triptans or Combination of medications
> 10 days/month > 3 months
Frequent/regular use 2-3 times per week
Lesson Number 4
Medication Overuse Headaches should be excluded or Treated before diagnosing Primary CDH disorders
What are the Primary Chronic Daily Headache Disorders?
Case #5
A 50 year old female has been complaining of right supraorbital pain for the past 1 year. The pain is brief, typically 15 minutes. It is stabbing, and electric-like. The attacks are sporadic and she can have 5 to 40 exquisitely painful episodes for 5 days every week. The neurologic examination is normal and MRI brain is normal.
Case #5 Continued
Anticonvulsants failed.
Microvascular Decompression failed
Gamma Knife Therapy failed.
What was the presumptive diagnosis in this case?
Case #5 continued
The patient had tearing, ptosis, and rhinorrhea on the same side of the pain.
Diagnosis?
This is not Trigeminal Neuralgia
Trigeminal Autonomic Cephalalgia
Chronic Paroxysmal Hemicrania
Case #6
50 year old woman. She has been having right sided headache for the past 10 years. It is a dull pain that last almost the whole day. She has no nausea, no photophobia, no phonophobia, or vomiting. At times, there are “stabbing” pains just above the eyebrow. She has tearing in the right eye and ptosis in these acute stabbing headaches. She has tried “all the headache medications made by man.” Her examination and MRI, LP were normal.
Lesson Number 5
The presence of autonomic features is an important differential
Chronic Paroxysmal Hemicrania (< 4 hrs HA)
Hemicrania Continua (> 4 hours HA)
Patients with CDH with autonomic features should be therapeutically tried with Indomethacin
Primary Variety
Headache Duration < 4 hours
Cluster Headache
Chronic Paroxysmal Hemicrania
SUNCT
Hypnic Headache
Criteria of Chronic Cluster
Attacks occurs for more than 1 year without remission or with remission lasting less than 1 month.
Frequency: one every second day to eight day.
Associated with one of:
Lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, miosis, eyelid edema, conjunctival injection, sense of restlessness or agitation during headache.
Hypnic Headache
Attacks of pain may be unilateral/bilateral and always occur after falling asleep.
15-180 minutes
15 times per month
None or one of the following:
Nausea, photophobia, phonophobia
Not attributable to another disorder
SUNCT
Short-Lasting Unilateral Neuralgiform Headache with Conjunctival injection and Tearing
At least 20 attacks
Unilateral moderately severe orbital or temporal stabbing or throbbing pain lasting 10-120 seconds
Not attributable to another disorder
At least one: nasal congestion, rhinorrhea, or eyelid edema.
Primary CDH
Headache Duration > 4 hours
Chronic Migraine
Chronic Tension-Type Headache
New Daily Persistent Headache
Hemicrania Continua (indomethacin responsive)
Chronic Migraine (CM)
“transformed migraine”
Migraine without aura with CDH features in the absence of medication overuse.
When CM is associated with medication oversue, only a diagnosis of probable Chronic mgraine and probable MOH.
Only after withdrawal of overused medications and the persistence of migraine on more than 15 days per month can a diagnosis of CM be made.
Chronic Tension-Type HA
Fulfills CDH definition
At least 2 of of the pain characteristics
Pressing/tightening quality
Mild to moderate severity
Bilateral location
No aggravation by walking stairs or similar routine physical activity
Historyof episodic TT HA
No vomiting, no more than one: nausea, photophobia
Does not meet criteria for NDPH or HC
New Daily Persistent Headache
Abrupt development (< 3 days) of headache that does not remit.
Summary
Chronic Daily Headache should be approached in a systematic manner
Secondary HA should be excluded
It must fulfill CDH definition
Do no over-medicate patients or educate them in avoiding overmedication
Always remember the associated symptoms; not just the pain
Thank You
DIHYDROERGOTAMINE PROTOCOL
DIHYDROERGOTAMINE PROTOCOL
DIHYDROERGOTAMINE PROTOCOL
David V. Lardizabal, M.D.
Assistant Professor, Kirksville College of Medicine
Objectives
To learn the systematic approach in the diagnosis of chronic daily headaches
To present different cases of chronic daily headaches
Basic Components of the History
Onset
Location
Quality
Duration
Frequency
Associated Symptoms
Triggers
Relieving Factors
Medication: dose/frequency
General and Neurologic Examination
Case #1
A previously healthy 38 year old man presented with 4 month history of daily headache. The headache began gradually and without provocation. The pain was continuous and became progressively more severe and disabling. The headache was moderately intense holocranial pressure that lasted throughout the day and was not associated with gastrointestinal or autonomic symptoms.
Case #1 continued
He tried over-the-counter analgesics without relief prior to receiving acetaminophen with codeine from his family physician. A prior neurological examination and non-enhanced MRI of the head were unremarkable. His alleviating factors was “resting and relaxing” were the only thing that helped. His headache was improved when he is supine i.e. resting in bed, resting in the sofa, or mid-day naps. When he rises from bed, his headache would invariably intensity.
Diagnosis?
Diagnosis?
Case #2
15 year old boy has been having daily headaches for the past 6 months. It is a constant pressure. He has incontinence and difficulty in looking up. He has tried different analgesics without relief. He wakes up in the morning vomiting. The neurologic examination showed no upgaze and papilledema.
Diagnosis?
Diagnosis?
Case #3
18 year old female had a minor head trauma from an altercation. She has daily headaches and posterior neck pain for 2 weeks. She vomits daily. She has no nausea, light or sound sensitivity. Her neurological examination is normal. The CT scan was negative. She was told to have post-traumatic headache.
Diagnosis?
Diagnosis?
Lesson Number 1
Secondary Headaches should be vigilantly investigated in daily headache patients.
Neurologic Examination is important
CT is not the diagnostic test of choice
MRI with/without contrast should be performed in new daily headaches.
Secondary Chronic Daily Headaches
Post-Traumatic Headache
Cervical Spine Disorders
Headaches associated with Vascular Disorders; AVM; arteritis including GCA, dissection, subdural hematoma
Headache associated with Non-Vascular disorders (EBV, HIV, tumor)
TMJ, Sinus infections (sphenoid), Chronic CNS infections
Intracranial Hypotension or hypertension
Primary Chronic Daily Headaches
Definition of CDH
> 15 or more headache days
> 3 or more months
Chronic Daily Headaches
Duration of head pain
Autonomic Features
Medication History
Neurologic Examination
Duration of the Head Pain
More than 4 hours
Less than 4 hours
Autonomic Features
Eyelid swelling
Ptosis “drooping”
Miosis or Mydriasis
Conjunctival injection
Lacrimation “Tearing”
Rhinorrhea “runny nose”
Medication History
What are the medication used for abortive and/or prophylactic therapy?
What is the monthly consumption?
Case #4
23 year old woman presented for evaluation of intractable and disabling daily headache of 6 months duration. Her headache began 3 years ago, occurring one to 3 times per month. Initially, her headache were left temporal in location and were severe and throbbing and associated with prominent nausea and photo- or phonophobia.
Case #4 continued
Over the past 6 months, she has had a moderate intensity, diffuse, daily, and continuous headache with only mild photophobia and occasional nausea. To allow herself to function at school, throughout the past year, she escalated her abortive medication use, initially using 4 to 8 acetaminophen-aspirin-caffeine tablets daily and in the past 6 months, 4 to 8 perscription acetaminophen-caffeine-butalbital tablets daily.
Case #4 continued
Prophylactic therapy with tricyclic antidepressant and anticonvulsant was unhelpful. Her neurological examination and brain MRI were normal.
Case #4
Fulfills criteria for CDH
Normal MRI and exam
Secondary causes excluded.
Diagnosis?
Chronic Daily Headaches?
Lesson Number 3
Chronic Daily Headache is a Symptom
It is NOT a Diagnosis
Migraine
Medication Overuse Headaches ( MOH)
Medication Overuse Headaches (MOH)
Simple analgesics
> 15 days for > 3 months
Opiods, Ergotamines, Triptans or Combination of medications
> 10 days/month > 3 months
Frequent/regular use 2-3 times per week
Lesson Number 4
Medication Overuse Headaches should be excluded or Treated before diagnosing Primary CDH disorders
What are the Primary Chronic Daily Headache Disorders?
Case #5
A 50 year old female has been complaining of right supraorbital pain for the past 1 year. The pain is brief, typically 15 minutes. It is stabbing, and electric-like. The attacks are sporadic and she can have 5 to 40 exquisitely painful episodes for 5 days every week. The neurologic examination is normal and MRI brain is normal.
Case #5 Continued
Anticonvulsants failed.
Microvascular Decompression failed
Gamma Knife Therapy failed.
What was the presumptive diagnosis in this case?
Case #5 continued
The patient had tearing, ptosis, and rhinorrhea on the same side of the pain.
Diagnosis?
This is not Trigeminal Neuralgia
Trigeminal Autonomic Cephalalgia
Chronic Paroxysmal Hemicrania
Case #6
50 year old woman. She has been having right sided headache for the past 10 years. It is a dull pain that last almost the whole day. She has no nausea, no photophobia, no phonophobia, or vomiting. At times, there are “stabbing” pains just above the eyebrow. She has tearing in the right eye and ptosis in these acute stabbing headaches. She has tried “all the headache medications made by man.” Her examination and MRI, LP were normal.
Lesson Number 5
The presence of autonomic features is an important differential
Chronic Paroxysmal Hemicrania (< 4 hrs HA)
Hemicrania Continua (> 4 hours HA)
Patients with CDH with autonomic features should be therapeutically tried with Indomethacin
Primary Variety
Headache Duration < 4 hours
Cluster Headache
Chronic Paroxysmal Hemicrania
SUNCT
Hypnic Headache
Criteria of Chronic Cluster
Attacks occurs for more than 1 year without remission or with remission lasting less than 1 month.
Frequency: one every second day to eight day.
Associated with one of:
Lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, miosis, eyelid edema, conjunctival injection, sense of restlessness or agitation during headache.
Hypnic Headache
Attacks of pain may be unilateral/bilateral and always occur after falling asleep.
15-180 minutes
15 times per month
None or one of the following:
Nausea, photophobia, phonophobia
Not attributable to another disorder
SUNCT
Short-Lasting Unilateral Neuralgiform Headache with Conjunctival injection and Tearing
At least 20 attacks
Unilateral moderately severe orbital or temporal stabbing or throbbing pain lasting 10-120 seconds
Not attributable to another disorder
At least one: nasal congestion, rhinorrhea, or eyelid edema.
Primary CDH
Headache Duration > 4 hours
Chronic Migraine
Chronic Tension-Type Headache
New Daily Persistent Headache
Hemicrania Continua (indomethacin responsive)
Chronic Migraine (CM)
“transformed migraine”
Migraine without aura with CDH features in the absence of medication overuse.
When CM is associated with medication oversue, only a diagnosis of probable Chronic mgraine and probable MOH.
Only after withdrawal of overused medications and the persistence of migraine on more than 15 days per month can a diagnosis of CM be made.
Chronic Tension-Type HA
Fulfills CDH definition
At least 2 of of the pain characteristics
Pressing/tightening quality
Mild to moderate severity
Bilateral location
No aggravation by walking stairs or similar routine physical activity
Historyof episodic TT HA
No vomiting, no more than one: nausea, photophobia
Does not meet criteria for NDPH or HC
New Daily Persistent Headache
Abrupt development (< 3 days) of headache that does not remit.
Summary
Chronic Daily Headache should be approached in a systematic manner
Secondary HA should be excluded
It must fulfill CDH definition
Do no over-medicate patients or educate them in avoiding overmedication
Always remember the associated symptoms; not just the pain
Thank You
DIHYDROERGOTAMINE PROTOCOL
DIHYDROERGOTAMINE PROTOCOL
DIHYDROERGOTAMINE PROTOCOL
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