tension and TACs Flashcards
MC type of HA
tension
Over 80% of adults experience TTHA periodically
* Also common in children and adolescents
forms of tension HA
what differentiates them?
- Episodic
- Chronic- (frequency > 15 days/month for 6 months)
most pts who have tension HA and medical care
- Most patients who suffer TTHA do not seek specific medical treatment
- Use OTC medications to combat symptoms
Infrequent episodic Tension Type HA: ICHD Diganostic Criteria
A. how many?
B. duration
C. greater/=2 of the following 4 characteristics:
D. Both of the following:
E. Not better accounted for by?
A. At least 10 episodes of headache occurring on <1 d/mo.and fulfilling criteria B-D
B. Lasting from 30 min to 7 days
C. greater/=2 of the following 4 characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or phonophobia
E. Not better accounted for by another ICHD-3 diagnosis
tension bi/uni
bilateral
Tension-Type Headache
Symptoms begin before the age of?
cranial location?
Associated with?
Occurs in relation to?
Symptoms begin before the age 20 years in 40% of patients.
No predilection for any particular cranial location-may involve the frontal, temporal, parietal, or occipital areas alone, or in combination
Associated with pericranial/cervical muscle tenderness-Studies have shown that patients with chronic TTH have a higher incidence of active TrPs in the upper trapezius, SCM, temporalis, as well as the suboccipitals and other posterior cervical muscles than in controls.
Occurs in relation to emotional conflict
tension and migraine HAs as a continuum
Most patients with TTH experience occasional very painful headaches often accompanied by migrainous symptoms.
Epidemiological characteristics of TTH patients not significantly different from migraine patients-
Migraine and TTH also share common triggers (stress, mental tension, fatigue, lack of sleep, and menstruation)
Suggests that these disorders are at two ends of a continuum and many people will experience both types over a lifetime
Non-pharmacological Management of tension HAs: caf/alc
initial result? protocol?
Decrease intake of caffeine and alcohol as well as any medications that have been chronically used by the patient for the headache
May at first increase the frequency and intensity of headaches
After 1-2 weeks the withdrawal should subside
Decrease Caffeine use by 25% every week so caffeine withdrawal headache should not occur
Non-pharmacological Management of tension HAs: stress
Strategies for coping with stress and muscular pain:
Relaxation therapy with EMG biofeedback
Hypnotherapy
Massage therapy and physical therapy
Increase physical activity especially outdoors
Deep breathing exercises
1 minute headspace mini breathing meditation: youtube
Calm app teaches mindfulness and meditation in 10 minute daily presentations
Psychotherapy for cognitive therapy and mindfulness exercises
Pharmacological Management Tension-type Headache:
* Rx class options
* usage frquency?
ANALGESICS: aspirin, acetaminophen
NSAIDs: indomethacin, ibuprofen, naproxen, ketoprofen
COMBINATION: aspirin &/or acetaminophen with caffeine (i.e. Excedrin Migraine)
MUSCLE RELAXANTS: diazepam, methocarbamol (Robaxin), cyclobenzaprine (Flexeril), carisoprodol, baclofen
Usage is on an as needed basis but typically limited time use
mild analgesics and tension HA
Judicious use of mild analgesics may be needed
No more than 2 days per week
adjunctive rx for tension HAs
best taken when?
Low dosages of a tricyclic antidepressant can be helpful in managing the headache
Best taken before bedtime because of their sedative effects
Examples:
Amitriptyline (Elavil),Nortriptyline (Pamelor), Doxepin, Desipramine
Trigeminal autonomic cephalalgias (TACs)
*All TACs are unilateral headaches accompanied by autonomic features
3.1 Cluster headache
3.2 Paroxysmal hemicrania
3.3 Short-lasting unilateral neuralgiform headache attacks
3.4 Hemicrania continua
3.5 Probable trigeminal autonomic cephalalgia
autonomic features of TACs
a) conjunctival injection and/or lacrimation;
b) nasal congestion and/or rhinorrhea;
c) eyelid oedema;
d) fore-head and facial sweating;
e) forehead and facial flushing;
f) sensation of fullness in the ear;
g) miosis and/or ptosis
Cluster headache
A. At least ? attacks fulfilling criteria B-D
B. pain quality/location? duration?
C. Either or both of the following:
1. greater/= 1 of the following ipsilateral symptoms or signs:
2. a sense of ?
D. Frequency?
E. Not better accounted for?
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital
and/or temporal pain lasting 15-180 min (when untreated)
C. Either or both of the following:
1. 1 of the following ipsilateral symptoms or signs:
a) conjunctival injection and/or lacrimation; b) nasal congestion and/or rhinorrhea; c) eyelid oedema; d) fore-head and facial sweating; e) forehead and facial flushing; f) sensation of fullness in the ear; g) miosis and/or ptosis
2. a sense of restlessness or agitation
D. Frequency from 1-2x/ d to 8x/d for > half the time when active
E. Not better accounted for by another ICHD-3 diagnosis
episodic cluster
A. Attacks fulfilling criteria for 3.1 Cluster headache and occurring in bouts (cluster periods)
B. >/= 2 cluster periods lasting 7 d to 1 y (when untreated) and separated by pain- free remission periods of greater/= 1 month
chronic cluster
A. Attacks fulfilling criteria for 3.1 Cluster headache and criterion B below
B. Occurring without a remission period, or with remissions lasting <1 mo, for greater than/= 1 year
Cluster Headache
Brief attacks are:
provoked by?
frequently occur when?
Provoked by alcohol
Frequently occurs during sleep or napping times
During cluster how do pts act
During an attack, patients will characteristically pace, cry, scream, or pound their fists.
cluster demo
Primarily affects men (4:1) males: females ratio
Age of onset between 20-40
Cluster Headache
% of the patients have chronic symptoms.
HAs occur for how long?
Chronic form may evolve from?
10% of the patients have chronic symptoms.
HAs occur for years before termination or remission.
Chronic form may evolve from the episodic form or may have a chronic pattern from its onset
cluster etiology
Etiology and pathogenesis are unknown-
possible dysfunction of hypothalamus
cluster pain location? radiation?
Pain is usually centered behind or around the orbit or in the temporal area, BUT radiation to the teeth and jaws is common- some patients may seek dental treatment for the pain
Cluster Headache Abortive Treatment options
- 100% Oxygen at 7-10 l./min. for 15 min. using face mask is effective within 10-15 minutes in 60-70% of cases
- Sumatriptan (6 mg S.C. or nasal spray)
- DHE-45 (1.0 mg I.M. or I.V. or Migranol (intranasal)
- Intranasal administration of 1 ml of 4% topical Lidocaine
- Indomethacin (oral or rectal suppositories)- cluster headache MAY respond
Cluster Headache Treatment
Prophylactic Treatments for episodic cluster
Verapamil
Ergotamine
Lithium carbonate
Methysergide
Valproate
Prednisone
Cluster Headache Treatment
Prophylactic Treatments for chronic cluster
Verapamil
Lithium carbonate
Methysergide
Gabapentin
Hemicrania Continua:
Common in?
mc pain areas
type of pain
Age:
Common in women
Temporal or frontal pain is most common
Throbbing, aching, sharp, stabbing
Age: 10-77 y.o. (mean range= 35-49 years
Hemicrania Continua:
defined?
pain intensity?
Treatment:
A daily, continuous, strictly unilateral primary headache
The intensity of the pain may fluctuate but the headache never remits
Treatment: By definition, hemicrania continua remits with indomethacin medication
Hemicrania continua diagnostic criteria
A. side?
B. present for how long/ exacerbation?
C. Either or both of the following:
D. Responds absolutely to?
E. Not better accounted for?
A. Unilateral headache fulfilling criteria B-D
B. Present >3 mo, with exacerbations of moderate or
greater intensity
C. Either or both of the following:
1. greater/ = 1 of the following ipsilateral autonomic symptoms:
a) conjunctival injection and/or lacrimation; b) nasal congestion and/or rhinorrhea; c) eyelid oedema; d) fore-head and facial sweating; e) forehead and facial flushing; f) sensation of fullness in the ear; g) miosis and/or ptosis
2. a sense of restlessness or agitation, or aggravation of pain by movement
D. Responds absolutely to indomethacin
E. Not better accounted for by another ICHD-3 diagnosi
CPH Clinical characteristics
Many consider CPH a variant of?
Occurs primarily in?
Age range is?
Many consider CPH a variant of cluster headache
Occurs primarily in women 2:1
Age range is 37-42 (mean age = 34 years)
CPH:
Attacks may be precipitated by?
Pain location
Attacks may be precipitated by flexion and occasionally by rotation of the neck.
Pain is Chronic, unilateral and localized to the temple, forehead, ear, eye, or occipital region
CPH Clinical
Characteristics
pain described as?
Severe to very severe pain in what %
what is common during attacks
Throbbing, stabbing or boring pain
Severe to very severe pain in 88-93%
Restlessness is common during attacks
Paroxysmal hemicrania
A. At least ? attacks fulfilling criteria B-E
B. pain quality, location, and duration?
C. greater/ = 1 of the following ipsilateral symptoms or signs:
D. Frequency?
E. Prevented absolutely by?
F. Not better accounted for ?
A. At least 20 attacks fulfilling criteria B-E
B. Severe unilateral orbital, supraorbital and/or temporal pain lasting 2-30 min
C. greater/= 1 of the following ipsilateral symptoms or signs:
1. conjunctival injection and/or lacrimation
2. nasal congestion and/or rhinorrhoea
3. eyelid oedema
4. forehead and facial sweating
5. forehead and facial flushing
6. sensation of fullness in the ear
7. miosis and/or ptosis
D. Frequency >5/d for > half the time
E. Prevented absolutely by therapeutic doses of
indomethacin
F. Not better accounted for by another ICHD-3 diagnosis
Episodic paroxysmal
hemicrania
A. Attacks fulfilling criteria for 3.2 Paroxysmal hemicrania and occurring in bouts
* B. >/ = 2 bouts lasting 7d to 1 yr. (when untreated) and separated by pain-free remission periods of >/=1 mo
Chronic paroxysmal
hemicrania
A. Attacks fulfilling criteria for 3.2 Paroxysmal hemicrania
* B. Occurring without a remission period, or with remission periods lasting <1 mo, for >/=1 yr.
mc paroxysmal
hemicrania
Chronic paroxysmal
hemicrania
66-88%
Paroxysmal Hemicrania Treatment
Absolute responsiveness of CPH to indomethacin is part of the diagnostic criteria: 25mg 3x/day up to 50mg 3x/day
Long lasting remissions have been observed
Short-lasting unilateral neuralgiform headache attacks diagnostic criteria
A. At least ? attacks fulfilling criteria B-D
B. pain quality, location, duration?
C. >/=1 of the following symptoms/signs?
D. Frequency?
E. Not better accounted for?
A. At least 20 attacks fulfilling criteria B-D
B. Moderate or severe unilateral head pain, with
orbital, supraorbital, temporal and/or other
trigeminal distribution, lasting 1-600 sec and
occurring as single stabs, series of stabs or in a saw-
tooth pattern
C. >/=1 of the following ipsilateral cranial autonomic
symptoms or signs: 1. conjunctival injection and/or
lacrimation; 2. nasal congestion and/or rhinorrhoea;
3. eyelid oedema; 4. forehead and facial sweating;
5. forehead and facial flushing; 6. sensation of
fullness in the ear; 7. miosis and/or ptosis
D. Frequency >/=1/d for > half the time when active
E. Not better accounted for by another ICHD-3 diagnosis
Short-lasting unilateral neuralgiform
headache attacks with conjunctival injection
and tearing (SUNCT) criteria
Attacks fulfilling criteria for 3.3 Short-lasting
unilateral neuralgiform headache attacks
B. Both of conjunctival injection and lacrimation
(tearing)
SUNCT VS Trigeminal Neuralgia (TN)
* demographics
* features
* location
* refactory
TN more common in females, SUNCT in Males
Autonomic features (Conjunctival injection/tearing) MUST be present in SUNCT, less common in TN
Pain Location: Typically ocular area in SUNCT; V1 TN is very rare
TN has a REFRACTORY PERIOD
SUNCT
Treatment
Lamotrigine
Gabapentin
Topiramate
IV Lidocaine
Referral to Specialists for Diagnosis & Headache Management:
1. PRIMARY REFERRALS:
3. Secondary referral for pain management once diagnosis is made:
- PRIMARY REFERRALS:
- Family doctor or Neurologist (American Headache Society website)
- Orofacial Pain Specialist or Pain Management Medical Team
- Secondary referral for pain management once diagnosis is made:
- Psychotherapist
- Acupuncturist
You SHOULD REFER your patient with facial pain and headache within what time frame if pain is not managed?
You SHOULD REFER your patient with facial pain and headache within 2 weeks of your initial treatment if the pain is not being managed and to get a proper diagnosis and treatment
what TAC can present with tooth pain?
cluster
what Ha form can mimic mastiscory pain similar to TMD?
tension
What TACs respond to indomethicin
CPH/PH
hemicraania continua
cluster may respond
