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The Northern Neuroscience Centre

Chiang Mai University

NNC CMU
Headache Clinical Case Seminar
COME ACROSS THE DIAGNOSTIC PITFALL

Surat Tanprawate, M.D., MSc(Lond.), F.R.C.P(T)


CMU Headache Study Group,
The Northern Neuroscience Centre/Division of Neurology
Faculty of Medicine, Chaing Mai University

RCPT 2016 PATTAYA

Headache adventure

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU
What is your diagnosis?

A. Vestibular migraine
B. Migraine with brainstem aura
C. Migraine with BPPV
D. Headache attributed to brainstem TIA

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU
Hx taking and PE

Feature suggest
serious secondary
headache
Red flag sign

Feature suggest
other secondary
headache

Feature suggest
primary
headache
Blue flag sign

Yellow flag sign


Grouping
Clinical headache syndrome
Headache in Special Circumstances
Diagnosis
Primary headache vs Secondary headache vs Cranial neuralgia

The Northern Neuroscience Centre


Chiang Mai University

Age > 50 (first onset)

NNC CMU
Healthy young age

Side locked headache

Headache after trauma/neck Temporal profiles: chronic,


injury
episodic, complete wax and
wane

Morning headache

Abnormal neurological exam; Character: non-fixed/


including papilledema,
alternated site or mild
stiness of neck
bilateral

Headache non-response to
medication

Temporal profiles: sudden


Specific triggers: internal
Headache with TACs
severe, worsening headache (sleep, anxiety, menstruation), characters
external (environment)
Concurrent events:
pregnancy,
immunocompromise,
systemic symptome
Provoking activity: exercise,
cough, wake up from sleep,
postural headache etc.

Headache response to
migraine specific medication

Grouping
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Chiang Mai University
Clinical headache
syndrome

NNC CMU

Headache with vestibular symptoms

Primary headache disorder

Vestibular migraine

Migraine with brainstem aura

Hemiplegic migraine

Primary headache with Neuro-otologic disorder (BPPV/


Menneires disease/etc)

Secondary headache disorder - brainstem lesion esp.


TIA

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU

New diagnostic criteria of Vestibular migraine


(A1.1.6) : ICHD-III Beta version 2013
A. At least five episodes fulfilling criteria C and D

B. A current or past history of 1.1 Migraine without aura or 1.2 Migraine with aura

C. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72


hours
D. At least 50% of episodes are associated with at least one of the following three migrainous
features:

1. headache with at least two of the following four characteristics: unilateral location,
pulsating quality, moderate or severe intensity, aggravation by routine physical activity

2. Photophobia/phonophobia

3. Visual aura

E. Not better accounted for by another ICHD-III diagnosis or by another vestibular disorder

ICHD-III Beta 2013

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU

Vestibular symptoms in vestibular migraine (defined by Barany Society)

Vertigino/dizziness character
a) spontaneous vertigo:
(i) internal vertigo (a false sensation of selfmotion)
(ii) external vertigo (a false sensation that the
visual surround is spinning or flowing)

Vertigo duration
10% seconds

30% lasting minutes

30% hours

30% several days

b) positional vertigo, occurring after a


change of head position
c) visually induced vertigo, triggered by a
complex or large moving visual stimulus;
d) head motion-induced vertigo, occurring
during head motion
e) head motion-induced dizziness with
nausea (dizziness is characterized by a
sensation of disturbed spatial orientation
Stolte B, Holle D et al. Cephalalgia. 2015 Mar;35(3):262-70

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU

Mechanisms involved in the pathophysiology of


vestibular migraine
Inherited brain excitability
Thalamocortical
processing

Trigemino-vascular reflex
Trigeminal pain pathway
activation

Amygdala
Insula

CGRP-Substance P-Neurokinin A
Emotional
response

Cognitive/
perceptive
changes

Spatial
memory
changes

Vasodilation of inner ear


blood vessels

Cochlea/vestibular hypersentitivity

Vestibular dysfunction
Sensorimotor response: eye, head, gait

Espinosa Sanchez JM et
al. Front in Neurol
2015;6(12): 1-6

The Northern Neuroscience Centre


Chiang Mai University

Migraine with brainstem aura

Vestibular migraine

NNC CMU

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU

Vestibular migraine treatment

Few studies

acute; zolmitriptan

anti-vertigo agent: promethazine, dimemhydrinate,


meclozine

prophylactic;

nortriptylline, verapamil, metoprolol, topiramate,


flunarizine, valproic acid, lamotrigine

CAI: acetazolamine

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU

A case example of migraine with brain stem aura

A patient with recurrent headache for 2 years with


associated neurological symptoms

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU

Practical point in migraine diagnosis

Typical migraine
- migraine without aura
- migraine with typical aura
(Typical aura: duration: 5-60 minutes,
visual symptoms, sensory symptoms
+/- speech symptoms, occurs in
succession , gradual onset, and slow
progression)

Atypical migraine
- migraine atypical aura (brainstem aura,
hemiplegic aura, prolonged aura)
- aura without headache (late-life
migraine accompaniments)
- migraine complication: migralepsy,
migraine infarct

Treatment guideline in episodic migraine in adults

Flunarizine is available in EU

AAN/AHS 2012

S.D. Silberstein, et al. Neurology 2012;78;1337

Treatment disturbing aura in


migraine with Lamotrigine

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU

Pascual J, Caminero AB et al. Headache 2004;44:1024-1028

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU
Case seminar-2
An 65 years old man with dull aching,
diffuse
headache triggered by stress
for 1 month. He has been diagnosed as
TTH and treated with simple analgesic ,
but no improvement
He noted that chaining position to
upright also trigger headache
PE: normal

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU
Just a TTH?
TTH mimicker

In context of bilateral,
mild to moderate
diffuse/temporal
headache without
significant other features

Tension-type headache

TTH with co-morbidities

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU
Tension-type like headache

Chronic transform migraine

Headache attributed to
disorder of homeostasis

Medication overused
headache

Hypoxia/hypercapnia,
aeroplane travel, sleep
apnea headache, arterial
hypertension,
hypothyroidism, fasting

Headache attributed to
cervical dystonia

Headache attributed to
psychiatric disorder

Headache attributed to a
substance or its withdrawal

Mild intracranial
hypertension/intracranial
hypotension

Diffuse incracranial
disorder

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU

What should we ask when we see TTH like


headache without localising neuro-signs?

The history of chronic migraine (to identify


transform migraine)

Trigger factor (to identify CSF disorder, diffuse


intracranial lesion, posterior fossa lesion, dystonia)

Systemic symptoms (to identify systemic illness)

Time (to identify OSA)

Blood pressure (to identify systemic hypertension)

HT and Headache
The Northern Neuroscience Centre
Chiang Mai University

NNC CMU

76 HT patients with ambulatory BP monitoring


between headache vs non-headache patients

Miguel Gus, Flavio Danni et al. Arch Intern Med 2001;161:252-255

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU
Headache and HT

Mild (140-159/90-99 mgHg) to moderate (160-179/100-109 mmHg)


chronic arterial HT does not appear to cause headache

Abrupt elevation of arterial BP is responsible for headache rather


than absolute value

Major causes of HT attributed headache

Pheochromocytoma

HT crisis with/without encephalopathy

Pre-eclampsia and eclampsia

Acute pressure response to an exogenous agent


Cephalalgia 2014 ICHD-III beta
Assarzadegan F, Asodollahi M et al. Ir J neurol 2013; 12(3): 106-110

The Northern Neuroscience Centre


Chiang Mai University

NNC CMU
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