Hoofdpijn – casuistiek

9 - 10 - 07

Prof. Dr. Koen PaemeleireDr. Phyllis Van Walleghem

Casus 1

34-jarige dame CDH sinds een 2-tal jaarhoofdpijn meest uitgesproken ’s ochtendssporadisch wazig zicht+ 10-tal kgKNO obesitas; bilateraal papiloedeemNMR hersenen inclusief venografie normaal

headache (94%) transient visual obscurations or blurring (68%) pulse synchronous tinnitus (58%) pain behind the eye (44%) double vision (38%) visual loss (30%) pain with eye movement (22%)

AM PM

What are the typical symptoms of IIH?

‘Benigne’ intracraniële hypertensie

Papiloedeem

What causes IIH ?

> women in the childbearing yearsstart or worsen during a period of weight gain

mimics

7.1 Headache attributed tohigh cerebrospinal fluid

pressure

©International Headache Society 2003/4ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

7.1 Headache attributed tohigh cerebrospinal fluid pressure

7.1.1 Headache attributed to idiopathicintracranial hypertension (IIH)

7.1.2 Headache attributed to intracranialhypertension secondary to metabolic, toxic or hormonal causes

7.1.3 Headache attributed to intracranialhypertension secondary to hydrocephalus

7.1.1 Headache attributed to IIH

©International Headache Society 2003/4ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

7.1.1 Headache attributed to IIH

A. Progressive headache with ≥1 of the following characteristics and fulfilling criteria C and D:

1. daily occurrence2.diffuse and/or constant (non-pulsating) pain3.aggravated by coughing or straining

B. Intracranial hypertension

C. Headache develops in close temporal relation to increased intracranial pressure

D.Headache improves after withdrawal of CSF to reduce pressure to 120-170 mm H2O and resolves within 72 h of persistent normalisation of intracranial pressure

7.1.1 Headache attributed to IIH

©International Headache Society 2003/4ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

7.1.1 Headache attributed to IIH

B. Intracranial hypertension fulfilling the following criteria:1. alert patient with neurological examination that either is normal or

demonstrates any of the following abnormalities:a) papilloedemab) enlarged blind spotc) visual field defect (progressive if untreated)d) sixth nerve palsy

2. increased CSF pressure (>200 mm H2O [non-obese], >250 mm H2O [obese]) measured by lumbar puncture in the recumbent position or by epidural or intraventricular pressure monitoring

3. normal CSF chemistry (low CSF protein acceptable) and cellularity4. intracranial diseases (including venous sinus thrombosis) ruled out

by appropriate investigations5. no metabolic, toxic or hormonal cause of intracranial hypertension

Casus 2

42-jarige man acuut opgetreden hoofdpijnklachtenheffen van een boomstronkblanco voorgeschiedenis, FA migraine +5-tal minuten crescendo tot 10/10 discrete nauseaKO: discrete terminale nekstijfheid

Thunderclap headache

Definitie

Ernstige hoofdpijn met plots begin en maximum intensiteit < 1 minuut na beginBij 2/3 ernstige onderliggende pathologie, meest frequent vasculair

SecundairVasculair Subarachnoidale hemorrhagie

Ongeruptureerd aneurysmaIntracerebrale bloedingIschemisch CVACerebrale veneuze sinusthromboseArteriële dissectie (carotis/vertebralis; intra- en extracranieel)CNS angiitisReversibele benigne CNS angiopathieHypofysaire bloeding

Niet-vasculair Colloid cyste derde ventrikel(spontane) LiquorhypotensieAcute sinusitis (in het bijzonder met barotrauma)(Pre-) eclampsiePhaeochromocytomaAcute arteriële hypertensie (oa medicamenteus-geïnduceerd: MAOI)Meningo-encefalitisIntermittente hydrocefalieAcuut glaucomaCervicaal (oa Nervus occipitalis major neuralgie)Idiopathische intracraniële hypertensie

PrimairMet trigger

Primary cough headachePrimary exertional headachePrimary headache associated with sexual activity

Zonder triggerPrimary thunderclap headache (per exclusionem; controversieel)‘Crash’ migraine (per exclusionem)Cluster headache

DD Thunderclap headache

Anamnese en klinisch onderzoek

Labo – infuus

Bij elke patiënt direct 1. CT hersenen A< 12 uur bij niet-traumatische SAH sensitiviteit 98 %2. CT angiografie circulus van Willisbij vermoeden dissectie: CT angiografie halsvaten!3. CT hersenen B 30 % empty delta sign bij CVST

LP - direct bij vermoeden meningo-encefalitis- na ≥ 12 uur tot max 24 uur bij vermoeden SAH als CT negatief

Thunderclap headacheUitwerking op spoedopname

Subarachnoidale bloeding

CT MRA DSA

Casus 3

55-jarige man recidiverende bruuske hoofdpijnklachten Re hemicranieel45-tal minuten tot 2 uur duren frequent ’s ochtends of na het dutten 10/10 zeer ongeduriglacrimatie en ptosis Re oog

Cluster hoofdpijn

Migraine

CTTH

Episodische cluster hoofdpijn

Hersentumor

Tijd (maanden)

0 3 6 9 12

0

2

4

6

8

10

00:00 6:00 12:00 18:00 24:00time

VAS score

pain

inte

nsity

Cluster hoofdpijn

Hypothalamic activation in cluster headache attacks

May et al., Lancet 1998;351:275-278

A. ≥ 5 attacksB. Severe unilateral (supra-)orbital and/or

temporal pain lasting 15-180 minsC. Attacks accompanied by at least one of-

1. Conjunctival injection and/or lacrimation2. Nasal congestion and/or rhinorrhoea3. Eyelid oedema4. Forehead/facial sweating5. Miosis and/or ptosis6. A sense of restlessness or agitation

D. Frequency: 1/2 d - 8/dE. Not attributed to another disorder

Cephalalgia 2004; 24[Suppl 1]: 1-160)

Cluster hoofdpijn

Casus 4

42-jarige damemigraine zonder aura sinds jarenonder controle met topiramaatEcho cor: patent foramen ovale? associatie van PFO en migraine.

Patent foramen ovale en migraine

Prevalence of PFO

17-23% of the population (autopsy)25.6% transoesophageal echo (TEE)

Seib, 1934; Meissner et al, 1999;

PFO and migrainehigh prevalencehigh chance of overlap

PFO and Migraine with Aura

PFO 48% Migraine + auraPFO 23% Migraine – auraPFO 20% Controls

Anzola et al, Neurology, 1999

Migraine with aura higher prevalence of PFOMost likely inherited in a dominant way

PFO closure

Improvement of migraine with aura afterPFO closure can be due to

Spontaneuos course of the disease (age)Placebo effectIntake of aspirinRegression to the mean

PFO closure and Migraine

MIST Analysis

primary endpoint for the complete elimination of headache was not achieved

however using more conventional migraine trial endpoints significant differences were found

MIST 50% Reduction in Headache Days

42

23

0

5

10

15

20

25

30

35

40

45

50

% of patients with 50% reduction

ImplantSham

p=.038

MIST Serious Adverse Events

chest pain

brainstem strokeatrial fibrillation

nose bleedretroperitoneal bleed

anemiapericardial effusion

incision site bleedtamponade

sham groupimplant group

Closure of PFO and Migraine

With two exceptions retrospective dataOne negative randomised trial (missed primary endpoint)

PFO closure: potentially dangerous procedure

Up to now there is no scientific evidence from properly conducted trials that closure of PFO leads to a reduction of migraine frequency that would justify

the risk of the procedure

Casus 5

Wat past niet bij de diagnose van migraine ?

geassocieerde klachten van foto- en fonofobievisuele klachten voor starten van de aanvalrusteloosheidpositieve familiale anamnese voor migraine

A) n ≥≥≥≥ 5

B) 4 - 72 h

C) 1.

2.

3. ++ / +++

4. ����

1. + ֠֠֠֠

2.

2/4

1/2

unilateral

pulsating

photo- & phonophobia

nausea ± vomiting

D)

Cephalalgia (2004), Suppl 1, 24, 1-152

±±±± aura

Diagnostische criteria migraine

Casus 6

Een migraine aura duurt volgens de criteria

<10 min per aura symptoom<1 uur per aura symptoom<1 uur voor alle aura symptomen <24 uur per aura symptoom

Diagnostische criteria aura

1.2.1 Typical aurawith migraine headache

©International Headache Society 2003/4ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

1.2.1 Typical aurawith migraine headache

A. At least 2 attacks fulfilling criteria B–D

B. Aura consisting of ≥1 of the following, but no motorweakness:

1. fully reversible visual symptoms including positive and/or negative features

2. fully reversible sensory symptoms including positive and/or negative features

3. fully reversible dysphasic speech disturbance

1.2.1 Typical aurawith migraine headache

©International Headache Society 2003/4ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

1.2.1 Typical aurawith migraine headache

C. At least two of the following:

1. homonymous visual symptoms and/or unilateral sensory symptoms

2. at least one aura symptom develops gradually over ≥5 min and/or different aura symptoms occur in succession over ≥5 min

3. each symptom lasts ≥5 and ≤60 min

D.Headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follows aura within 60 min

E. Not attributed to another disorder

Casus 7

17-jarige jongedame

hoofdpijnaanvallen sinds PO contraceptivumaanvallen 2-tal dagen

kloppende hoofdpijnklachten nausea en braken

sporadisch vooraf visuele klachtenmoeder en tante migraine

blanco voorgeschiedenis

rookt ± 15-tal sigaretten/dag

> MA> Posterior circulatie>Jonge ♀ (< 35-45 jaar)

Overall M RR 3MA RR 4-9M+smoking RR 10M+OC RR 16M+OC+smoking RR 34

Migraine as a risk factor for ischemic stroke

Migraine-roken-pil

Migraine met aura en de pil

Alternatives to COC are recommended forwomen with migraine with aura and additionalrisk factors for stroke (including smoking)

Migraine since COCconsider change to progestogen-only ornonhormonal contraception

Migraine without aura, aura appears: stop COC

Casus 8

50-jarige man hevige hoofdpijnunilateraal kloppend sporadisch nausea en brakenfoto- en fonofobieverhoogde mechanosensitiviteitmedicatie: ASA en ACE-inhibitorvoorgeschiedenis: CABG behandeling

Triptanen en coronair lijden

Contra-indicaties triptanen

angor, AMIcoronaire vaatspasmen (Prinzmetal)ischemische cardiomyopathie

TIA, CVA

Perifere vaataandoeningen

Ongecontroleerde hypertensie

Acute behandeling migraine

Step1: NSAID’s (naproxen, ibuprofen, diclofenac)

Step 2: triptanen

Paracetamolbij contra-indicatie NSAID als step 1zwakke evidentie

Gastroprokineticum

Casus 9

39-jarige manblanco voorgeschiedenis hoofdpijnklachten sinds 2-tal maanddagelijks, voornamelijk naar de avondholocranieelsporadisch discrete nauseana platte bedrust verbetert de hoofdpijnna arthroscopie van de linker kniesporadisch paracetamol of Apranax

Inte

nsite

it

Tijd

0

2

4

6

8

10

00:00 06:00 12:00 18:00 23:55

cm H20

am pm

Liquor hypotensie syndroom

Pachymeningeale aankleuring

MR/CT myelografie - RISA

Casus 10

21-jarige jongedame hevige unilaterale aangezichtspijnkortdurend (seconden), schietend, hevig Re kaak met uitstraling naar de tandenTandheelkundig normaalKNO normaal

Trigeminus neuralgia

Trigeminus neuralgie

Etiologie

Classical: ± vasculaire loopSymptomatic:

multiple sclerosis (2%)RIPvasculair: aneurysma eadental pathology/procedures

Paroxysmale pijn fractie seconde tot 2 minuten

Trigeminaal gebied (> Va,b) Unilateraal Triggers: wassen, scheren, spreken,

poetsen,kauwen, wind, rokenTic douloureuxTendens spontane remissie

Trigeminus neuralgie

NMR hersenen + verloop N trigeminus (CISS) + Gd

Vasculaire loop

Medicamenteuze behandeling:

Carbamazepine ea.

Chirurgische behandeling

Glycerol rhizotomy

Microvasculaire decompressie

Trigeminus neuralgie

Microvasculaire decompressie

Glycerol rhizotomy

Casus 11

Welke bewering is juist over cluster headache ?

verapamil eerste keuze aanvalsbehandelingfrequente positieve familiale anamnese CHeen passagère syndroom van Horner kan aanvallen duren gemiddeld 2- tot 3-tal dagen

Partieel Horner syndroom

Acute behandeling cluster hoofdpijn

Established– Sumatriptan 6 mg SC– Oxygen: 100% @ 7-12 L/min 15-20 min

Short term(methyl)prednisolonemethysergideergotamineGON injectionDHE 1mg 8hrly iv

Long termverapamillithiummethysergideneuromodulators

GabapentinTopiramate

melatoninsurgery

Preventieve behandeling CH

GON infiltratie