, 25 tweets, 14 min read Read on Twitter
Happy Saturday! Ready for some #headache management tips from #AIHS19 / @aihsHeadache ?

1/
First, from @123Migraine: Medication overuse headache.
5% of the population has a chronic daily headache - HALF of these are due to MOH; 8 million people!

Criteria:
15+ days per month of a headache medication if over-the-counter, 10+ if Rx or combo
>3 months of regular use

2/
Medication overuse #headache:

Treatment is removing the overused drug!

Sometimes this requires inpatient treatment and tweaking of the current regimen. Butalbital/#fiorcet withdrawal can be dangerous. Sometimes it gets worse before it gets better. Help with coping skills!

3/
Next up: cervicogenic (head pain arising from a neck cause) #headache from @NarouzeMD:

Diagnosis:
HA always related to neck pain
HA improves when neck pain improves
HA worse with certain neck movements
HA improves after a diagnostic cervical injection

4/
If the pain is related to

Cervical facets --> facetogenic
Myofascial pain --> episodic tension headache
Nerve roots --> cervical radiculopathy

These may not fit the criteria of cerivcogenic headache.

@narouzemd

5/
Occipital #headache is a symptom, not a diagnosis. Figure out the cause!

"Splitting"? Consider vascular cause
Tension/myofascial? --> TPI/Botox
Cervicogenic? See above
Occipital neuralgia (like trigeminal neuralgia of the occiput)? Nerve block/stimulation

@NarouzeMD

6/
Occipital nerve blocks with ultrasound at C2:

Trapezius
-------------------------
Splenius
-------------------------
Semispinalis capitis
--GREATER OCCIPITAL N--
Inferior Oblique muscle
-------------------------
C-spine!

@NarouzeMD

7/
Atlanto-occipital joint (pain with nodding "yes") HIGH risk injection!
Atlanto-axial (pain nodding "no"): also higher risk due to overlying large C2 dorsal root ganglion (yellow) and vertebral artery (red).

@NarouzeMD

8/
@NarouzeMD Next, #migraine by @123Migraine :

Migraine costs $12 billion per year in the US.

CGRP is related to migraine - infusing #CGRP into people with a history of migraines can trigger a migraine! New treatments target this pathway.

9/
To diagnose #migraine, the symptoms need to fulfill specific criteria. Aura is only present in 30% of patients, and not necessary for diagnosis. Common phases:

Prodrome <72h (fatigue/insomnia) -->
Aura <60m -->
Headache 4-72h -->
Postdrome <24h (fatigue/difficulty to focus)

10/
#StatusMigranosus:

Migraine lasting 72+ hours + symptoms are debilitating.

11/
Migraines often start early - girls during puberty, boys often earlier!

Cluster headaches can start early in life or start later in life (bimodal)

Exertional headache - consider a vascular cause

12/
#migraine
Abortives: ergotamine, triptans, diclofenac

Prophylaxis: propranolol, topamax, valproic acid, longer-acting triptans

Chronic migraine: onabotulinium toxin or new CGRP antagonists

13/
Now @DmitriSouza on #clusterheadache:
Common symptoms:
*lasts 15-180m
*one-sided
*eye tearing or irritation
*nasal congestion/runny nose
*eyelid swelling
*forehead/facial swelling
* " " flushing
*ear fullness sensation
*eyelid droop/small pupil
**a sense of restlessness**

14/
#ClusterHeadache

3x more common in men
Prevalence 1 in 1,000
Provoked by alcohol, histamine, or nitroglycerin, but not usually facial stimulation (e.g. brushing teeth)

@DmitriSouza
15/
#ClusterHeadache is different from other TACs (trigeminal autonomic cephalalgias)

Ddx:
-Paroxysmal hemicrania
-Hemicrania continua
-Short-lasting unilateral neuralgiform HA
-SUNCT-conjunctival injection/tearing
-SUNA-autonomic

May, et al. 2005. Lancet

@DmitriSouza

16/
@DmitriSouza Next up: @123Migraine on #TensionHeadache

Diagnostic considerations:

10 episodes, <12 days per *year*
Mild-moderate
Bilateral
Pressing/tightening
Prefer increased physical activity
No nausea/vomiting
Rare photophobia or phonophobia
No other more likely #headache diagnosis

17/
#TensionHeadache

Tenderness over the head is common.
If there is allodynia (more pain than one would expect with touch), consider the role of central sensitization.

Common triggers: stress, dehydration, hunger, lack of sleep.

@123Migraine

18/
Treatments for tension #headache

Acute:
Acetaminophen, NSAIDs, Caffeine

Prophylaxis:
Amitriptyline, Mirtazepine(!), Venlafaxine

Most importantly:
Trigger avoidance!
EMG-guided biofeedback
Acupuncture
Cognitive-behavioral therapy

@EUneurology guidelines 2010
@123Migraine

19/
Now @diana_banoub on #TrigeminalNeuralgia:

R side more common
More common w diabetes & hypertension
Rule out other common causes (TACs, TMJ pain, migraine, giant cell arteritis, glaucoma, more)

20/
*Bilateral TN - consider multiple sclerosis*

In ~4% of multiple sclerosis cases, the first symptom is #TrigeminalNeuralgia

21/
V2-3 most common distribution of #TrigeminalNeuralgia.

The only interventional approach is via the foramen ovale, which is where V3 lies. One would advance the needle further to approach the gasserian ganglion.

@diana_banoub

21/
Carbamazepine & oxcarbazepine are classic treatments for #TrigeminalNeuralgia.

Lab tests:
CBC
CMP (especially sodium)
LFT

HLA-B1502 is associated with risk of Stevens Johnson Syndrome, especially in those w/Asian descent

@diana_banoub

22/
Other #TrigeminalNeuralgia treatments:

Lamotrigine adjunct
Phenytoin
Baclofen

Microvascular decompression (w/neuromonitoring)
Percutaneous balloon microcompression (V1 especially)
Gamma knife radiation
Gasserian ganglion RFA

@diana_banoub

23/
That’s all on #headache and #migraines today from @aihsHeadache !

Thanks to awesome presenters
@123Migraine @DmitriSouza @NarouzeMD @diana_banoub!

Sign up to join us at the next meeting:
interventionalheadache.net
Missing some Tweet in this thread?
You can try to force a refresh.

Like this thread? Get email updates or save it to PDF!

Subscribe to Amy Pearson, MD
Profile picture

Get real-time email alerts when new unrolls are available from this author!

This content may be removed anytime!

Twitter may remove this content at anytime, convert it as a PDF, save and print for later use!

Try unrolling a thread yourself!

how to unroll video

1) Follow Thread Reader App on Twitter so you can easily mention us!

2) Go to a Twitter thread (series of Tweets by the same owner) and mention us with a keyword "unroll" @threadreaderapp unroll

You can practice here first or read more on our help page!

Follow Us on Twitter!

Did Thread Reader help you today?

Support us! We are indie developers!


This site is made by just three indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3.00/month or $30.00/year) and get exclusive features!

Become Premium

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!