Information on Headaches

ROBERT HUGHES MD
NORTH COUNTRY ENT
OTORHINOLARYNGOLOGY
OTOLARYNGIC ALLERGY
HEADACHE
Migraine
Sinus and Allergy
Tension and Stress
and countless others
Trepanning
● Primitive man believed that head pain was the work
of evil spirits who invaded the body of unfortunate
individuals.
● If headache was caused by the invasion of evil
spirits, then letting the spirits out of the skull
should bring relief.
● Thus was born the surgical procedure known as
trepanning which dates back ten thousand years or
more.
Pacific,
Europe, North America and South America.
● Such procedures were found in the South
Imhotep- “the One Who
Walked in Peace”
● Vizier of a Pharaoh, lived about 2900 BC;
● He is credited with many accomplishments in many
fields and one of his activities seems to have been
that of a successful physician.
● He is one of the first medical men whose name is on
record and rose from the role of medical hero to
become God of Medicine.
● He began using simple surgery instead of
magic.
just
Sir William Osler tells us that Imhotep
was the:
!
● "..first figure of a physician to stand out clearly from
the mists of antiquity." Imhotep diagnosed and treated
over 200 diseases, 15 diseases of the abdomen, 11 of
the bladder, 10 of the rectum, 29 of the eyes, and 18 of
the skin, hair, nails and tongue. Imhotep treated
tuberculosis, gallstones, appendicitis, gout and
arthritis. He also performed surgery and practiced
some dentistry. Imhotep extracted medicine from
plants. He also knew the position and function of the
vital organs and circulation of the blood system. The
Encyclopedia Britannica says, "The evidence afforded
by Egyptian and Greek texts support the view that
Imhotep's reputation was very respected in early times.
His prestige increased with the lapse of centuries and
his temples in Greek times were the centers of medical
teachings." The Two Great Names in the
History of Greek Medicine
●Hippocrates-dominated the beginning
of a period of remarkable scientific
creativity, which lasted more than 700
years
●Galen—near the end of the period,
both furthered scientific knowledge
and crystallized it in an amazing
volume of written works. His influence
lasted for 1500 years/45 generations.
The Age of
Enlightment
HEADACHE
THEY CAN BE CHALLENGING
!
THEY CAN BE A CHALLENGE
The Role of
Otolaryngology
Headache is a common complaint in ENT
practices
ENT’s have both the Medical and Surgical
expertise
Define if it is Surgical (anatomical)
Specifically Manage if Medical
Perform Allergy Management (if applicable)
My Personal Opinion
Sinus Headache exists as a distinct entity
!
Allergic pathophysiology parallels the
vascular models used for migraine HA
!
Migraine/Tension/Sinus is a three way
continuum
!
Anatomical abnormalities can trigger
Migraines
!
Confusion in diagnosis a real issue today
WORRISOME HEADACHE RED FLAGS
“SNOOP”
!
!
!
Systemic symptoms (fever, weight loss) or !
Secondary risk factors (HIV, systemic cancer)
Neurologic symptoms or abnormal signs (confusion,
impaired alertness, or consciousness)
!
!
Onset: sudden, abrupt, or split-second
Older: new onset and progressive headache, especially in
middle-age >50 (giant cell arteritis)
!
Previous headache history: first headache or different
(change in attack frequency, severity, or clinical features)
How Common is
Migraine?
30,000,000 Americans
20% of women
7% of men at any given time
Most of us have some migraine
manifestations occasionally
Recognizing
Migraine
Pounding unilateral headache
Preceded by visual or other aura
Nausea, vomiting
Light and sound sensitivity
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Migraine Definition
IHS criteria: Migraine/aura (3 out of 4)
One or more fully reversible aura
symptoms indicates focal cerebral cortical
or brainstem dysfunction.
At least one aura symptom develops
gradually over more than 4 minutes.
No aura symptom lasts more than one
hour.
HA follows aura w/free interval of less than
one hour and may begin before or w/aura.
IHS Diagnostic criteria: migraine w/o
aura
HA lasting for 4-72 hrs
HA w/2+ of following:
Unilateral
Pulsating
Mod/severe intensity.
History, PE, Neuro exam show no
other organic disease.
!
At least five attacks occur
Aggravated by routine
physical activity.
During HA at least 1 of following
N/V
Photophobia
Phonophobia
What is migraine?
Migraine without aura (MO)
Migraine with aura (MA)
At least five attacks fulfilling these
criteria:
•
•
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•
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Headache lasting 4–72 h
(2–48 h in children)
With at least two of:
unilateral location
pulsating quality
moderate/severe intensity
aggravated by activity
At least two attacks fulfilling
these criteria:
• At least three of the following:
–
–
–
one or more fully reversible
aura symptoms
gradually developing or
sequential aura symptoms
no one aura symptom lasts
longer than 1 h
headache shortly follows or accompanies aura
Accompanied by at least one of: –
nausea
vomiting
photophobia and/or • No evidence of organic disease
phonophobia
• No evidence of organic disease
Headache Classification Committee of IHS (1988)
Subtypes?
Classic
Atypical
Chronic Daily HA
Cluster HA
Transformed Migraine
Medication overuse HA
Chronic Tension type HA
More subtypes?
New Daily Persistent HA
Hemicranial continua
Hypnic Migraine
Paroxysmal Hemicrania
Neuralgiform HA
No Classification For SINUS HEADACHE
World prevalence of migraine:
A disorder of First World
Switzerland 13%
Denmark 10%
France 8%†
USA
12%
Italy 16%
Chile 7%
†Prevalence measured over a few years
Japan 8%
● 1-year prevalence
rates
Rasmussen
and Olesen (1994); Rasmussen (1995);
Population-based
●
Lipton et al (1994); Lavados and Tenhamm (1997); Sakai
and Igarashi (1997)
studies
•
Diagnosis depends on patient history
•
No specific tests or clinical markers
Diagnosis of
migraine
•
Positive diagnosis if attack history fulfils IHS criteria for migraine
•
Other pointers include:
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–
–
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•
family history of migraine
age of onset <45
presence of aura
menstrual association
Organic disease must be excluded
Cady (1999); Warshaw et al (1998)
Physiology
Vasospasm – Lance
Spreading Wave of Depression – Leao
Trigeminocentric
Allodynia
Vasospasm
I. Aura: Arteries Spasm
Visual and focal neurological symtoms
Pial and Occipital small artery branches
II. Headache: Compensatory Vasodilation
Pounding unilateral sick headache
III. Inflammation and muscle spasm: second
pain phase
Phases of Migraine
Vague Prodrome: psychic change and
cravings e.g. chocolate
Aura: Focal symptoms and vision
Headache: Throbbing unilateral pain
Inflammation: Prolonged phase and TTH
Postdrome
Migraine related stroke
Spreading Wave
Brainstem controls Cortical Activity
Epileptic like phenomenon that spreads over Cortex
Visual Phenomenon that spreads over surface of
brain like shimmering “C”
Cheiro-oral Jacksonian phenomena
Concurrence of migraine and epilepsy
Why epilepsy drugs work for migraine
Trigeminal Theory
Serotonin again
Trigeminal Afferents: sensory function of face
and meninges
Trigeminal efferents to vessels
Cause vessel spasm and sensitivity
This theory primarily explains action of
Triptans: 5-HT 1b,d agonists
Migraine Pathophysiology
Goadsby NEJM 346!
:257-70,2002
Neurovascular theory.
Abnormal brainstem responses.
Trigemino-vascular system.
Calcitonin gene related
peptide
Neurokinin A
Substance P
!
Extracranial arterial vasodilation.
Temporal
Pulsing pain.
Extracranial neurogenic inflammation.
Decreased inhibition of central pain
transmission.
Endogenous opioids.
Mechanism
Allodynia Theory
Migraine is a state of hypersensitivity
Light, sounds, smells, touch (head in
headache)
Need for dark room
Best preventives decrease sensitivity.
Anticonvulsants, tricyclics, beta and calcium
channel blockers
Each of these Theories explains some
migraine phenomena
Migraine Phenomena
Focal and paroxysmal onset of symptoms
Specific visual phenomena
Spreading numbness and moving visual phenomena and
sensory distortions.
Nausea, vomiting “sick” headache
Pounding unilateral or bilateral pain
Psychic changes
Light and sound sensitivity even between attacks
Effectiveness of triptans
Effect of anticonvulants
Role of serotonin
Some Dicta
Any paroxysmal headache is likely to be
migraine unless proven otherwise
“Sinus” headaches and “tension” headaches
are almost always migraine headaches
First ever severe headache or sudden
“thunderclap” headaches may be SAH
Treatment
Effective treatment of attack
Prevention
Address comorbidities
Mechanisms for treatment
Trigeminal nerve
INHIBITION
5-HT1D 5-HT1F
triptan
CGRP
NK
SP
CONSTRICTION
5-HT1B
CGRP
calcitonin gene
related peptide
NK
neurokinin A
SP
Blood
vessel
substance P
Adapted from Goadsby (1997)
Acute Attack
Triptans:
sumatriptan, zolmitriptan, almotriptan, naratriptan, frovatriptan,
elitriptriptan, riaztriptan
NSAID’s
Fioricet
Midrin (isometheptane, chlorphenoxazone, apap
OTC: Caffeine, apap, phenacitin, asa
Ergots: Caffergot, DHE nasal, injected
Narcotics
Depacon
Consider
Combinations
Triptan + NSAID
Triptan + anti-nausea
Unconventional agents
Phenergan, Compazine alone or in
combination. Zyprexa or atypicals
We don’t have enough alternatives
Triptan worries
Not released under age 18
If you even suspect CAD don’t use or get proper
exclusionary tests.
Man or woman of a certain age
Smoker or other risk factors
Cerebrovascular disease or complicated migraine
- contraindicated
Watch for overuse. These are rescue medicines
Prophylaxis
Anticonvulsants: topiramate, valproate, Keppra,
gabapentin
Tricyclics
Amitriptylene, nortriptylene, trazodone
Beta Blockers
Timolol, propranolol, nadolol
Calcium channel blocker – verapamil
ACE inhibitors
SSRI’s
Atypicals
Preventive therapy
Consider if pt has more than 3-4 episodes/month.
Reduces frequency by 40 – 60%.
Breakthrough headaches easier to abort.
Beta blockers
Amitriptyline
Calcium channel blockers
Lifestyle modification.
Biofeedback.
Botox
51% migraineurs treated
had complete
prophylaxis for 4.1
months.
38% had prophylaxis for
2.7 months.
Randomized trial showed
significant improvement in
headache frequency with
multiple treatments.
Conclusions
Migraine is common but unrecognized.
Keep migraine and its variants in the
differential diagnosis.
Chronic Daily
Headache: When to
suspect sinus disease
“Sinus HA” Differential dx
• Acute rhinosinusitis (ARS)
• nasal and facial pain, nasal congestion and purulent
nasal drainage.
• Chronic rhinosinusitis (CRS)
• nasal drainage, congestion and facial pressure
• Migraine
“Sinus HA” work up
• Neurologists and internists utilize the
International Headache society guidelines
• Otolarynologists utilize the AAO-HNS
rhinosinusitis categories and criteria
• History
• Examination, including endoscopic
• Radiologic examination
AAO-HNS Rhinosinusitis Categories
• Acute rhinosinusitis (the patient has symptoms present for less
than 4 weeks)
• Subacute rhinosinusitis (the patient has symptoms present for
more than 4 weeks, but less than 12 weeks)
• Chronic rhinosinusitis (the patient has symptoms present for
greater than 12 weeks)
• Recurrent acute rhinosinusitis (the patient has more than 4
acute episodes over 1 year)
• Acute exacerbation of chronic rhinosinusitis (the patient
develops an acute infection, with new acute symptoms,
superimposed over a chronic infection, with a constant
baseline level of symptoms)
AAO-HNS Rhinosinusitis
Criteria
• Major Factors
• Purulence in nasal cavity on
examination
• Facial pain/pressure
• Nasal obstruction/blockage
• Fever (acute only)
• Hyposmia/anosmia
• Nasal discharge/purulence
• Discolored postnasal
drainage
•
•
•
•
•
•
•
•
Minor factors
Headache
Fever (all nonacute)
Halitosis
Fatigue
Dental pain
Cough
Ear pain/pressure/fullness
Nasal/facial pain
!
• Nasal mucosa is not uniformly pain sensitive
• Ostia are more sensitive
• Rhinosinusitis often affects >1 sinus; multiple
pain regions = diffuse pain
Nasal/facial pain
• Nasal sensation poorly
represented within the
brain
• Nasal sites refer pain to
surface structures
Maxillary Sinus
• Maxillary division of 5th cranial
nerve (V2)
• Posterior superior alveolar
• Infraorbital
• Anterior superior alveolar
• Stimulating the maxillary sinus
ostia will produce referred pain at
the posterior nasopharynx, posterior
teeth, zygoma, and temple.
• Pressure within the maxillary sinus
itself produces a sense of vague
fullness in the face
Frontal Sinus
• Ophthalmic branch of 5th
cranial nerve (V1)
• Frontal recess irritation is felt
as pain in the inner canthal
region, anterior zygoma, and
molars.
• Local irritation within the
frontal sinus itself is felt as
mild pain at the same
approximate frontal
location.
Anterior Ethmoid
• Ophthalmic division (V1)
• Anterior ethmoid nerve off
nasociliary
• Also supplies the anterior
septum, turbinates, ostiomeatal
complex
• Pressure in the region of the
anterior ethmoid cells results
in fairly intense pain in the
ipsilateral eye behind the
inner canthus and radiates to
the maxilla, canine, and
bicuspid regions
Posterior Ethmoid and Sphenoid
• Maxillary division (V2)
• Posterior ethmoid nerve
• Posterior septum, parts of superior and
middle turbinates
• Ophthalmic division (V1)
• Greater superficial petrosal nerve
• Pressure in the region of the posterior
ethmoid cells results in intense pain in the
ipsilateral eye near the lateral canthus, the
lateral nose, canine, and cuspid regions.
• Sphenoid sinus irritation produces severe
deep head pain with some pain over the
ipsilateral eye, upper teeth, and coronal
suture region
Migaine
• Underdiagnosed condition
• Physicians will label 50% of subjects meeting IHS
criteria as having migraine
• Patients will label their symptoms as sinus related 90%
of the time when they actually meet the IHS criteria
for migraine
• Nasal symptoms often accompany migraine which
clouds the diagnosis
Migraine theory
• Sensitization of neural pathways
• Sterile inflammation of intracranial vessels trigeminovascular system
• Serotonin (5-hydroxytryptamine) receptors
• Epiphenomenon from autonomic discharge
• Vascular engorgement
• Other nasal symptoms
Migraine
• Usually unilateral, pulsating nature
• Pain rated as moderate to severe
• Lasts 4 to 72 hours
• 17% of females, 6% of males
• Nausea, vomiting, photophobia or phonophobia
• With or without aura (visual scotoma)
Migraines - triggers
!
!
•
•
•
•
Stress
Menses
OCP
Infection
• Trauma
• Vasodilators
• Wine
• Aged cheeses
Migraine v sinus pain
• ARS can cause facial pain per IHS and AAOHNS
• Straight-forward diagnosis
• Not a source of constant/daily pain
• CRS not accepted as a cause of pain per IHS
• Otolaryngologists feel CRS may be associated with
pain, but not the chief complaint
CRS and pain
• Pain described as dull and pressure-like in the
bilateral periorbital areas
• Pain worst in the morning
• Pain improves during the day
• Pain tends to last for days
• Pain not associated with nausea, vomiting,
phonophobia, and photophobia
CRS and pain
• Additional nasal symptoms present
• Subjective: nasal drainage, obstruction, and
congestion
• Objective: nasal inflammation and
mucopurulence
• Improvement with topical anesthetics or
decongestants
• CT sinus displays mucosal thickening
• Pain/pressure tends to improve after surgery
What CT sinus findings are
important?
• Maxillary sinus mucocele without boney erosion is not
usually important
• Mucoceles in other sinuses are important
• Air-fluid levels usually indicate an acute infection
• Partial or complete opacification should lead one to
consider an otolaryngic exam
• Location of thickening important:
• Ostiomeatal complex = confluence of sinus drainage
• Peripheral thickening with patent sinuses of lesser importance
Other nasal and pain
• Mucosa to mucosa contact points
• Enlarged turbinates
• Paradoxically curved middle turbinate
• Concha bullosa (aerated middle turbinate)
• Septal spur
• Barosinusitis
• Vacuum pain d/t barometric pressure changes
SURGICAL TREATMENT FOR
RHINOSINUSITIS
SEPTAL SURGERY
TURBINATE SURGERY
SINUS SURGERY FOR VENTILATION AND
DRAINAGE
SINUS SURGERY FOR POLYPOSIS
POLYPS
Conclusion
• “Sinus headache” may actually represent
migraine
• Nasal/facial pain or headache is often
associated with CRS
• Careful assessment of Hx, PEX, endoscopy, CT
will help to identify
• Other selected nasal anatomy may produce
chronic pain
• Surgery may alleviate the pain associated with
CRS and other anatomic variants
ALLERGY MANAGEMENT OF THE
CHRONIC HEADACHE PATIENT
When is immunotherapy indicated
How does one define the allergy headache
patient from the surgical or the TRUE
Migraine
Can CT Scans help?
Does Tension Headache require different
treatment plans
Maybe we need to
rethink headache
OTOLARYNGIC
ALLERGY
ALLERGIC RHINOSINUSITIS
Hypersensitivity Reactions
(Gell & Coombs)
Type I
(allergic rhinitis, asthma, immediate onset food reactions)
Type II
Stimulating Antibody Reaction
(Graves’ disease)
Type VI
Delayed, Cell Mediated
(TB, poison ivy)
Type V
Immune Complex
(serum sicknesss, delayed onset food reactions, glomerulonephritis)
Type IV
Cytotoxic
(hemolytic anemia, Hashimoto’s)
Type III
Immediate
Antibody Dependent Cell Cytoxicity (transplant rejection)
Sinus & Allergy
Health Partnership
Rhinosinusitis
A Collaborative Initiative of the:
American Academy of Otolaryngic Allergy
American Academy of Otolaryngology- Head & Neck
Surgery
American Rhinologic Society
Acute Community-Acquired
Bacterial Rhinosinusitis
•
•
•
•
250 M Americans affected
Average of 3-4 viral URIs/year
1 Bn cases of viral RS/year
0.5% - 2% go on to acute bacterial
maxillary disease
National Ambulatory Medical Care Survey, National Center for Health Statistics.
Rhinosinusitis -vsSinusitis
The inflammatory process which causes
sinusitis is also associated with inflammation
of the nasal passages
•
•
•
Rhinitis typically precedes sinusitis
Sinusitis without rhinitis is rare
Mucus membranes of the nose and sinuses are
contiguous
Symptoms of nasal discharge and nasal obstruction are
prominent
in Neck
sinusitis
Lanza D, Kennedy D. Adult rhinosinusitis
defined. Otolaryngol Head
Surg
1997;117(suppl):S1-S7.
Implications of
Recent Knowledge
• The maxillary sinus was classically
considered the major focus of the
disorder
• Most maxillary sinusitis is now
known to be secondary to disease
in the ostiomeatal complex (OMC)
• Even minor swelling in a critical
area can result in ostial obstruction
and significant symptoms
Ostiomeatal
Complex
Obstruction in this small
area (from edema, thick
secretions, polyps or a
concha bullosa) can block
drainage from the anterior
ethmoid, maxillary & frontal
sinuses
Normal Anatomy of
Paranasal Sinuses
Paradoxic Middle Turbinate
Middle
turbinate
Nasal
Septum
Obstruction
of portion of
middle
meatus
Courtesy of H
Stammberger
Factors Predisposing to
Bacterial Rhinosinusitis
• Viral Upper Respiratory Infection
• Allergic Rhinitis
• Anatomic Ostiomeatal Obstruction
• Air Pollution
• Nasal Polyposis
• Medication effects
• Pregnancy
• Other Causes
Rhinosinusitis -vsAllergic Rhinitis
Infection
Nasal Obstruction/
Congestion
Thick Nasal Discharge
Cough/Irritability
Pressure With Pain
Toothache
Fever
Allergy
Nasal Obstruction/Congestion
Thin, Watery Discharge
Paroxysmal Sneezing
Itchy, Runny Nose
Seasonal or Perennial (can
increase sinusitis incidence)
Other Allergic Symptoms
(conjunctivitis, otitis, laryngitis)
Types of Rhinosinusitis: Temporal Courses
• Acute - Up to 4 wks, with total resolution of
symptoms
• Subacute - Longer than 4 wks but less than 12 wks
• Recurrent Acute - 4 or more RS episodes/year, with
resolution of symptoms between episodes
• Chronic - 12 weeks or more of signs and symptoms
Lanza D, Kennedy D. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997;117(suppl):S1-S7.
• Acute Exacerbations of Chronic Rhinosinusitis
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