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Primary
Headache
11-13
..59
.
(13
.)
Diagnosis
of
headache
a
great
challenge
Believe
it
or
not?
Treatment
of
Diabetes,
HT
and
DLP
is
easier
than
treating
HA
Outline
Primary
vs.
secondary
headache
Significance
of
refractory
primary
headache(RH)
Definition
&
Diagnosis
strategy
of
RH
RH
mimickers
Comorbidity
hasnt
to
be
ignored
True
Primary
RH
Conclusion
SNOOP
headache
disorders**
-pattern
change:
a
significant
increase
in
the
number
and
severity
of
attacks*
Continuum
(Minneap
Minn)
2012;
18(4):
783-95.
Defining
the
Refractory
Primary
Headache
Term of use
Chronic Daily Headache(CDH)
15 days a month, > 3 months
Refractory
Headache/
Migraine?
Born
of
RHSIS
2000:
IHS
formed
The
Refractory
Headache
Special
Interest
Section
of
the
American
Headache
Society
(RHSIS)
Refractory
headache
Primary
Type
of
headache
Secondary
Type of therapy
Refractory
migraine
TTH
CH
Other
primary
headache
e.g.
Post
traumatic
headache
(PTH),
intracranial
hypo/
hypertension,
MOH,
neuralgia
(2)
Exclude
chronic
headache
other
than
migraine
Chronic
daily
headache
(CDH)
Exclude
secondary
CDH
(1)
Primary
CDH
Already
modify
triggers/life
style
modification
Chronic
migraine
(CM)
(4)
(5)
without
MOH
Significant
disability
(MIDAS
>
11)
Term of use
Pharmacologic
refractoriness
The Definition of RM
- Diagnosed migraine
- Still having headache even if they avoided trigger, and
modified life style
- No response to...
: 3/4 of preventive migraine drug class (beta-blocker, antidepressant, TCAs, CCB)
: NSAIDs, combined analgesics, triptans
- No Medication overused headache
Case
example
A
45
years-old
with
history
of
episodic
migraine
characterized
by
alternate
side
throbbing
headache
with
triggered
by
hot
weather
and
associated
with
photo-/phonophobia
6
months,
the
headache
has
become
constant
diffuse
and
dull
aching
pain
with
photophobia,
and
nausea
without
vomiting
The
neurologist
diagnosed
as
transform
migraine
RH
mimics
Physician
may
mis-diagnose
when
refractory
headache
has
normal
neuro-imaging
and
no
obvious
neurological
symptoms
arteritis
Secondary headache(cont)
72%
of
pts
report
at
least
1
trigger,
and
100%
reported
at
least
1
trigger
after
shown
a
specific
list
of
triggers
Daily
life
style
Daily
triggers
Daily
headache
Non-Migraine
Migraine
Co-morbidity of Migraine
Cardiac
Mitral
valve
prolapse
Myocardial
infarction
Patent
foramen
ovale
Immunologic
Allergies
Neurologic
Essential
tremor
Positional
vertigo
Seizure
disorder
Psychologic
Anxiety
disorder
Depression
Manic
disorder
Panic
disorder
Pulmonary
Asthma
Vascular
Hypertension
Stroke
Other
Fibromyalgia
syndrome
Irritable
bowel
syndrome
Raynauds
phenomenon
Refractory
migraine
Refractory
TTH
Refractory
CH
Refractory
other
primary
headache
Headache
triggered
by
certain
activity
(sleep,
cough,
exercise,
sexual
activity)
-
usually
non-
refractory,
and
self
limited
New
daily
persistent
headache
(NDPH)
Nummular
headache
-
refractory
Case
example
A
woman
with
persistent
headache
for
3
years
She
remember
the
onset
of
headache
exactly
MRI
+
MRA
brain
-
normal,
complete
neurological
exam,
LP-normal
No
headache
progression,
but
still
there
High
disability
Not
response
to
any
medication
Headache diary
Refractory CH
Treatment
option
Combination,
Other
preventive
medication,
Inpatient
infusion
therapy,
Botulinum
toxin
injection,
ONS
DHE
infusion
therapy,
ONS
Refractory TTH
Multimodal therapy
155 U
Frontalis:
4
x
5
U
Procerus: 1 x 5 U
Temporalis:
8
x
5
U*
Occipitalis:
6
x
5
U*
Corrugator:
2
x
5
U
Cervical
paraspinals:
4
x
5
U
Trapezius:
6
x
5
U*
Combination therapy
Parenteral
Regimen
Dihydroergotamine
(0.251
mg
IV
or
IM,
t.i.d.)
Diphenhydramine
(2550
mg
IV
or
IM,
t.i.d.)
Various
neuroleptics
(e.g.,
chlorpromazine
2.510
mg
IV,
t.i.d.)
Ketorolac
(10
mg
IV,
t.i.d.;
30
mg
IM,
t.i.d.)
Valproic
acid
(250750
mg
IV,
t.i.d.)
Magnesium
sulfate
(1
gram
IV,
b.i.d.)
Intravenous
(IV)
steroids
(LOS
>
3
days;
mean
of
international
centre
=
13
day)
Conclusion
Diagnostic
strategy
Exclude
chronic
headache
other
than
migraine
Chronic
daily
headache
(CDH)
Exclude
secondary
CDH
Primary
CDH
Already
modify
triggers/life
style
modification
Chronic
migraine
(CM)
without
MOH
Significant
disability
(MIDAS
>
11
Refractory migraine
Bio-psycho-social
model
of
Primary
headaches
Gene
Env. factors
CHANGES
Headache syndromes
co-morbidity