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The Northern Neuroscience Centre

Chiang Mai University

NNC CMU

Headache and Facial


Pain
Surat Tanprawate, MD

Assist. Prof. of Neurology and Headache Medicine


Chiang Mai Headache stUdy Group (CM-HUG)
The Northern Neuroscience Center, Chiang Mai University
Secondary headache Primary headache

Migraine
Neuralgias
TTH

TACs

Other
primary
headache
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
ICHD-III
• The International Classification of Headache Disorder
version III

1. Primary headache disorder

Migraine, TTH, TACs (CH, PH, SUNCT, HC), Other


primary headache

2. Secondary headache disorder

Headache attributed to ….

3. Cranial neuralgia
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Primary headache disorders
Migraine Tension-type Trigeminal Other primary
headache Autonomic headache
(TTH) Cephalalgias disorder
(TACs)
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Primary headache disorders
Migraine Tension-type Trigeminal Other primary
headache Autonomic headache
(TTH) Cephalalgias disorder
(TACs)
Migraine without aura Chronic migraine
Migraine with aura Complication of migraine
- Migraine with typical aura - Status migranosus
- Migraine with brainstem aura - Persistent aura without infarction
- Hemiplegic migraine - Migrainous infarction
- Retinal migraine - Migraine aura-triggered seizure

Episodic syndromes that may be associated with migraine


- Recurrent gastrointestinal disturbance (Cyclical vomiting syndrome, Abdominal
migraine )
- Benign paroxysmal vertigo
- Benign paroxysmal torticollis
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Primary headache disorders
Migraine Tension-type Trigeminal Other primary
headache Autonomic headache
(TTH) Cephalalgias disorder
(TACs)

Episodic tension-type headache Chronic tension-type headache


- Frequency (with/without
pericranial tenderness)
- Infrequency(with/without
pericranial tenderness)
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Primary headache disorders
Migraine Tension-type Trigeminal Other primary
headache Autonomic headache
(TTH) Cephalalgias disorder
(TACs)

- Cluster headache, CH (episodic/chronic)


- Paroxysmal hemicrania, PH (episodic/chronic)
- Short-listing unilateral neuralgiform headache attacks with conjunctival
injection and tearing, SUNCT (episodic/chronic)
- Hemicrania continua, HC
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Primary headache disorders
Migraine Tension-type Trigeminal Other primary
headache Autonomic headache
(TTH) Cephalalgias disorder
(TACs)

Primary cough headache Hypnic headache


Primary exercise headache
Primary headache associated with sexual activity
Primary thunderclap headache 

Primary stabbing headache
Cold-stimulus headache
External-compression headache Nummular headache 

External-traction headache New daily persistent headache (NDPH)
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Secondary headache disorders
• Headache attributed to • Headache attributed to infection
trauma or injury to the head
and/or neck • Headache attributed to disorder
of homoeostasis
• Headache attributed to
cranial or cervical vascular
disorder
• Headache or facial pain attributed
to disorder of the cranium, neck,
• Headache attributed to eyes, ears, nose, sinuses, teeth,
non-vascular intracranial mouth or other facial or cervical
disorder structure

• Headache attributed to a • Headache attributed to


substance or its withdrawal psychiatric disorder
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Chiang Mai University
NNC CMU
Painful cranial neuropathies, other
facial pains and other headaches
• Trigeminal neuralgia • Tolosa-Hunt syndrome

• Painful trigeminal • Paratrigeminal oculosympathetic


neuropathy (Raeder’s) syndrome

• Glossopharyngeal neuralgia • Recurrent painful ophthalmoplegic


neuropathy
• Occipital neuralgia
• Burning mouth syndrome (BMS)
• Optic neuritis
• Persisent idiopathic facial pain (PIFP)
• Headache attributed to
ischemic ocular motor nerve
palsy • Central neuropathic pain
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Chiang Mai University
NNC CMU
TTH vs Migraine (ICHD-III)
Migraine Tension-type headache
A. At least 5 episode of headache A. At least 10 episode of headache
B. Lasting from 4 hours to 72 days B. Lasting from 30 minutes to 7 days
C. At least two of the following four C. At least two of the following four characteristics
characteristics
1. bilateral location
1. unilateral location
2. pressing or tightening (non-pulsating)
2. pulsating quality quality
3. moderate or severe pain intensity 3. mild or moderate intensity
4. aggravated by or causing avoidance of 4. not aggravated by routing physical activity
routing physical activity such as walking or such as walking or climbing stairs
climbing stairs
D. Both of the following:
D. Both of the following:
1. no nausea or vomiting
1. nausea and/or vomiting
2. no more than one of photophobia or
2. photophobia and photophobia photophobia

E. Not better accounted for by another ICHD-3 E. Not better accounted for by another ICHD-3
diagnosis diagnosis
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Chiang Mai University
NNC CMU
TTH or Migraine

Mild

Moderate

Severe
Aura
Unilateral
Vomiting
Bilateral

Photophobia Aggravated
by activity
Nausea

Throbbing

Pressure

Tension-type
Migraine
headache
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Chiang Mai University
NNC CMU

Approach to headache disorder


History taking and PE (possible localisation, cause)
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Chiang Mai University
Clinical Headache Syndrome NNC CMU

Criteria Character
- Red flag sign
- Symptoms -> cause
- Atypical feature for

primary headache

Primary headache Cranial neuralgia


Migraine, TTH, TACs, other
Secondary and other facial
primary headache disorder headache pain

International classification of headache disorder-III (ICHD) beta


The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Clues for secondary headache
“Red flag sign”
• Abnormal neurological exam; including papilledema,
stiffness of neck

• Age > 50

• Temporal profiles: sudden severe, worsening


headache

• Concurrent events: pregnancy, immunocompromise

• Provoking activity: exercise, cough, wake up from


sleep etc.
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Clues for primary headache
“Blue flag sign”

• Healthy young age

• Temporal profiles: chronic episodic, wax and wane

• Character: non-fixed site, alternate site

• Specific triggers: internal (sleep, anxiety,


menstruation), external (environment)
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Chiang Mai University

NNC CMU

Migraine
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Chiang Mai University
NNC CMU
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Chiang Mai University
NNC CMU
Food

Migraine Triggers
Sleep

Light

Noise
Periaqueductal gray matter (PAG), Cortical
spreading depression [CSD]
Nucleus raphe magnus (NRM)

Geoffrey A. Headache 2008.


The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Migraine is a disorder of sensory processing
Phases of Acute Migraine Attack

Prodromal Aura Headache Resolution


phase phase phase phase
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Chiang Mai University
NNC CMU
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Chiang Mai University
NNC CMU
Allostatic Load: Stress
Genetic Variant Load Triggers load

Migrane frequency
Migraine severity

> 15 days/month
called chronic
migraine
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Acute medication
• Use it early

• Start acute medication when pain is mild-moderate

• Use as strategic approach

• Mild: Non-specific medication: acetaminophen,


NSAIDs (Ibuprofen, Diclofenac, Naproxen etc)

• Moderate to severe: Specific medication -


triptans, ergotamine
Specific Acute Medication Target Serotonin receptor in the
Trigeminovascular System

• 5-HT1B: constricts the pain-


producing intracranial,
extracranial blood vessel in
the meninges

• 5-HT1D: presynaptically
inhibits trigeminal peptide
release and interfere with
central trigeminal nucleus
caudalis
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Chiang Mai University
NNC CMU

Potential targets for combined therapy include direct inhibition of


autonomous generation of activity in central trigeminovascular neurons plus
blockade of incoming nociceptive signals they receive from the meninges.

Burstein R and Jakubowski M Neurology 2005;64 (suppl2)


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Chiang Mai University
NNC CMU

Migraine prophylaxis
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Chiang Mai University
NNC CMU
Goals of Preventive Therapy

• Decrease attack frequency, intensity and duration

• Improve responsiveness to acute treatment

• Improve function in workplace and at home

• Reduce need for acute treatment


The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
When to consider migraine preventive treatment
• An estimated 38% of patients with migraine are appropriate
candidates for preventive therapy, but only 3% to 13% are taking
preventive medications

• Indication s for initiating preventive treatment

• Debilitating recurrent attacks that impair a patient’s daily


functioning and QoL

• Frequent attacks (> 4/months)

• Overuse of acute medications

• Acute medications are ineffective, not well tolerated, or


contraindications due to other medical comorbidities
Silberstein SD, et al Neurology 2012;78:1337-1345
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Criteria for Offering Preventive Migraine Treatment

Headache frequency, Days per Month


Headache-
related 2 3 4-5 6-10 11-14
impairment

None Consider Offer Offer

Some Consider Offer Offer Offer

Severe/Bed
Consider Offer Offer Offer Offer
rest

Lipton RB and Silberstein SD. Headache 2015, (Supp 2):103-22


The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Smile migraine app. MIGRAINE LEVEL
Migraine Status Analyzer
Analyze your migraine level with
guided treatment

We develop Migraine Level based on research on matching


: Migraine day/ pain severity and Disability Score (Headache Impact Test)
-> Generate algorithm ->
Make Migraine Level (Impact) UI Users Friendly
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Chiang Mai University
NNC CMU

Comparing the guideline

Which preventive therapy is the best?


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Chiang Mai University
NNC CMU
Concept of using preventive medication

• Stratified treatment, and consider comorbidities

• Start low, go slow

• Wait time for highest efficacy with tolerable side


effect

• Right duration (4-6 months, but can be over year)

• Close monitor with headache diary, and disability


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Chiang Mai University
NNC CMU
Preventive medication class
• Standard preventive medication

• AEDs

• Anti-depressants

• Anti-hypertensive

• B-blockers, CCB, ACEI

• Supplementary and Hormonal: Magensium, Vit B2, Co-Enz Q10,


Estrogen

• Specific preventive medication: anti-CGRP therapy


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NNC CMU
Chiang Mai University

Explain patient expectation

Monthly reduction migraine


frequency during 26-week
double-blind treatment with
topiramate 100 mg/day

Bussone G, Int J Clin Pract 2005;59:961-968


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Chiang Mai University
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Duration of Therapy
4-6 months
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1 month 4-6 months


Drug titration Duration

Start Evaluation Stop

When should we start? When should we When should we


severity evaluate? stop?
frequency
acute med use 4 wks-8 wks-4 mo-6 mo 4-6 months

What should we start? What should we How to stop?


type of migraine evaluate? slow tapering off with
efficacy frequency maintain lowest dose if
comorbidity impact headache occurs
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Chiang Mai University
NNC CMU

Pathophysiological model for TTH


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Chiang Mai University
NNC CMU
Model of stress and tension-type headache

Diffuse noxious inhibitory control (DNIC) Cathcart S et al. Cephalalgia


2010;30(10):1250–1267
Treatment
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Chiang Mai University
NNC CMU
Treatment of TTH
• Pharmacologic vs Non-pharmacologic therapy

• Abortive vs Preventive therapy


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Chiang Mai University
NNC CMU
Abortive therapy-analgesic drugs
Level of
Substance Dose
recommendation
Ibuprofen 200 - 800 mg A

Ketoprofen 25 mg A

ASA 500 -1000 mg A

Naproxen 375 - 550 mg A

Diclofenac 12.5 - 100 mg A

Paracetamol 1000 mg A

Caffeine comb. 65 - 200 mg B

Bendtsen L. et al. Eur J of Neurol 2010;17:1318-1325


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NNC CMU
Chiang Mai University

Prophylactic treatment
Level of
Drugs Dose
recommendation

Amitrtyptyline 30-75 mg A

Mirtazapine 30 mg B

Venlafaxine 150 mg B

Clomipramine 75-150 mg B

Maprotiline 75 mg B

Mianserin 30-60 mg B
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Chiang Mai University
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Headache syndrome
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Chiang Mai University
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After history taking, think about specific character of
headache syndrome
“Common headache syndrome”

• Thunderclap headache • Headache aggravated • Headache response


by specific activities to Indomethacin
• Headache caused (changing position,
awakening from sleep exercise, cough) • Featureless headache
• Short / ultra short lasting
• Headache with • Recurrent wax and
headache
transient neurological wane headache with
deficit • Headache with cranial migrainous features
autonomic features
• Fixed side headache • Chronic headache
(side locked • New Daily Persistent with normal-neuro
headache) Headache (NDPH) imaging
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Chiang Mai University
NNC CMU
Basic data Female 75 y.o.

Headache Occiput, temporal,


characters bilateral
Localization - diffuse, IIP
Photophobia,
Cause - vascular nausea
Associated features

Clinical headache syndrome


Lying down, neck - “Thunderclap headache”
Triggers
flex

DDx…Duration, First onset, peak at


the onset with
progression
constant pain, 5 day

PE Normal

Ix CT brain, LP
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Causes and Clues
• Subarachnoid haemorrhage (SAH)

• clues: stiffness of neck, abnormal CSF

• Cerebral venous sinus thrombosis (CVST) (10% of CVST)

• clues: sign of IICP, seizure, focal neurological deficit -> MRI,


CTV brain

• Pituitary apoplexy

• clues: acute headache, ophthalmoplegia, diminished visual


acuity, alter mental status, MRI brain (may miss by CT)

DW Dodick. J. Neurol. Neurosurg. Psychiatry 2002;72;6-11


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Chiang Mai University
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Causes and Clues
• Cervicocephalic arterial dissection

• clues: ipsilateral forehead headache, ipsilateral horner’s


syndrome, delay focal neurological deficit

• Acute hypertensive crisis

• clues: bilateral dull aching severe headache, evidence of


end organ damage, severe high BP

• Spontaneous intracranial hypotension (14% of SIH))

• clues: headache on changing position, low ICP, Imaging


shows tonsillar descent, meningeal thickening
DW Dodick. J. Neurol. Neurosurg. Psychiatry 2002;72;6-11
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Chiang Mai University
NNC CMU
Primary thunderclap headache (PTCH)
A) Severe head pain fulfilling criteria B and C

B) Both of the following characteristics:

1) sudden onset, reaching maximum intensity in < 1 min

2) lasting from 1 h to 10 days

C) Does not recur regularly over subsequent weeks or


months

D) Not attributed to another disorder (normal cerebrospinal


fluid and normal brain imaging are needed)
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Chiang Mai University
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Thunderclap
headache attributed
to reversible cerebral
vasoconstriction
(THARCV)

Precipitating factors
- sexual intercourse,
exertion, angiography,
sneezing, exposure to cold Valenca MM et al. J Headache Pain 2008 9:277–288
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Chiang Mai University
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Basic data Male 55 y.o.

Headache Occiput, temporal,


characters bilateral
Localization - diffuse
Cause - primary (hypnic
Associated features Nausea
headache), secondary…
Clinical headache syndrome
Sleep, occur only at - “Headache during sleep”
Triggers
night

DDx…Duration, Recurrent for 5


years, nearly every
progression
night

PE Normal

Ix CT brain, LP Normal MRI brain, LP


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Chiang Mai University
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Headache caused awakening from sleep/early


morning headache
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Chiang Mai University
NNC CMU
List of headache caused awakening from sleep

• Secondary headache • Primary headache


disorder disorder

• Increase intracranial • Hypnic headache


from any causes esp.
tumor • Nocturnal migraine/
early morning migraine
• Cervicogenic headache

• Medication overused • Chronic Tension-type


headache headache

• Obstructive sleep apnea • Cluster headache


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Chiang Mai University
NNC CMU
Headache attributed to
intracranial neoplasm

ICHD-iii 2014
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Chiang Mai University
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Headache aggravated by specific activities


(changing posture, exercise, cough)
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Chiang Mai University
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Basic data Male 37 y.o.

Headache Occiput, temporal,


characters bilateral

Localization - diffuse
Associated features Nausea
Cause - Orgasmic, secondary…
ClinicalTriggers
headache syndrome
Orgasm - “Headache triggered by
sexualDuration,
activity” 2 months, new
progression onset

DDx… PE Normal
Normal MRI + MRA brain
LP - normal
Ix MRI + MRA brain
Pascual J. J Headache Pain 2008
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Chiang Mai University
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Primary vs Secondary cough headache
Location Age
Secondary cough
headache began earlier
(40 vs 20 Y.O.)

Duration
Secondary headache
was lasted longer
Location of pain in primary and (5 years vs 11 months)
secondary cough headache
Pascual J. J Headache Pain (2008)
9:259–266
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Chiang Mai University
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Cough headache with posterior occupying lesion

Arachnoid cyst Dermoid tumor Meningioma


Pascual J. J Headache Pain (2008) 9:259–266
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Chiang Mai University
NNC CMU
Headache triggered by changing posture

Triggers

Cervicogenic headache, posterior


Changing posture fossa lesion, tension-type
headache, myofascial pain

Increase intracranial pressure (of


Postural change (related to
any causes), intraventricular lesion,
gravitational)
intracranial hypotension (CSF leak)

Migraine, primary exertional


headache, intracranial lesions,
Activities
extracranial/vascular lesion with
inflammation
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Chiang Mai University
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Headache attributed to CSF pressure
(increased/low)

• Increase CSF pressure • Low CSF pressure (<6


(>25 cm) cm)

• idiopathic intracranial • spontaneous


hypertension (IIH) intracranial
hypotension
• secondary to metabolic,
toxic, hormonal causes • post-dural puncture
headache
• secondary to
hydrocephalus • CSF fistula headache
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Chiang Mai University
NNC CMU
Conditions that may
produce intracranial
hypertension and
masquerade as
idiopathic intracranial
hypertension
Friedman DI et al. Neurology 2002
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Chiang Mai University
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the MRI brain of 45 years-old patient with headache while changing


position showing thickening of pachymeninges and low CSF pressure
Thank you