Migrainous features in NDPH. New daily persistent headache. New Daily Persistent Headache (NDPH) ICHD-2 definition

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(1)24.10.2013. New daily persistent headache New Daily Persistent Headache (NDPH) Farooq Maniyar Consultant Neurologist The Royal London and Basildon Hospitals, UK. • What is it? Is it a diagnosis? • What is the ICHD-2 definition? How about. ICHD-3? • Primary and secondary forms • Discuss some secondary causes in detail. NDPH – The original description… • Vanast et al, Headache, 1986 • N = 45 • Daily headache from onset, ‘no prior hist. of ha’ • 80 % - male • 1/3rd – unilateral, 1/3rd – pounding, 1/2 – nausea, upto 1/2. – photo or phono • 2/3rd resolved in 2 years. Is this all one thing?. ICHD-2 definition . Migrainous features in NDPH. Diagnostic criteria:. • Headache that, within 3 days of onset, fulfils criteria B-D • Headache is present daily, and is unremitting, for >3 months • At least two of the following pain characteristics: – – – –. Rozen et al, Headache currents, 2010. bilateral location pressing/tightening (non-pulsating) quality mild or moderate intensity not aggravated by routine physical activity such as walking or climbing. • Both of the following: – no more than one of photophobia, phonophobia or mild nausea – neither moderate or severe nausea nor vomiting. • Not attributed to another disorder In other words, like tension-type headache but daily from start. 1.

(2) 24.10.2013. Epidemiology. Pathophysiology. • Prevalence rates in general population. studies • Castillo et al - n = 2252, 0.1% NDPH (4.7% - CDH) • Grande et al – n = 3500, 0.03 % NDPH (30-44 years only). Not known • Viral infection – EBV, Herpes simplex,. CMV. ? CSF raised TNF-alpha • Stressful life event • Head/Neck trauma • Connective tissue - ? Low CSF pressure,. ? Cervical origin of pain. • In selected CDH, 7-13% had NDPH. Prognosis • Self-limiting form (? Migrainous-subtype) • Refractory form (? Featureless-subtype) •. Relapsing-remitting form. Treatment  Takase et al, cephalalgia, 2004  N = 30 (out of 1760 CDH) over a 5 yr period  ICHD-2 defined NDPH  17 males  Mean age – 38, mean age of onset – 35 yrs 1.. Muscle relaxants 2. TCA 3. SSRI 4. AEDs. Treatment  Meineri et al, Neurol sci, 2004  N = 18, retrospective  Amitryptiline, flouxetine, valproic acid  None effective. . Thankfully…..ICHD-3.  Evans et al, Headache 2001. n=1. effective for. gabapentin, venlafaxine, topiramate, nortryptiline (modified critiria)…  Marmura et al, Headache 2008. n = 3. mexilitine effective. 2.

(3) 24.10.2013. ICHD-3 definition. NDPH - the big picture! NDPH.  A. Persistent headache fulfilling criteria B and C  B. Distinct and clearly remembered onset, with pain. PRIMARY. SECONDARY. becoming continuous and unremitting within 24 hours MIGRAINE.  C. Present for > 3 months  D. Not better accounted for by another ICHD-3. diagnosis. Spontaneous intracranial hypotension. Tensiontype. Hemicrania continua. Low CSF pressure. High CSF pressure. Usually, preceding history of episodic headaches. CVST, IIH. Others – vascular, trauma, meningitis. Dissection, temporal arteritis. Is it pressure or volume?.  Orthostatic headaches first described by Georg. Schaltenbrand in 1939 “aliquorrhea” – reduced CSF production  Incidence – 5/100,000 per year ……(Schievink WI. JAMA. 2006;295:2286–96).  Classical triad – orthostatic headache,. pachymeningeal enhancement on imaging and low CSF pressure. Headache patterns in SIH Recent onset headache Orthostatic headaches Exertional headaches without any orthostatic features Acute thunderclap–like onset of orthostatic headaches Paradoxical orthostatic headaches. Mokri B. Headache. 2013 Jul-Aug;53(7):1034-53. Connective tissue disorders and SIH. Chronic headache Orthostatic headaches evolving in months to chronic lingering headaches Non-orthostatic chronic daily headache Second half of the day headaches (often with some orthostatic features). Marfans, Ehlers Danlos -2, Autosomal dominant polycystic kidney, retinal detachment, unnamed. 3.

(4) 24.10.2013. Non-headache symptoms in SIH. Diagnostic criteria – ICHD-3.  Spinal pain. A. Any headache fulfilling criteria C.  Cochleo-vestibular changes. B. Low CSF pressure (<60 mm CSF) and/or evidence of CSF leakage. on imaging.  Diplopia  Nausea. C. Headache has developed in temporal relationship to the low CSF. pressure or CSF leakage, or has led to its discovery.  Upper limb paraesthesiae  Personality change, memory. D. Not better accounted for by another ICHD-3 diagnosis. Diagnostic tests 1.. Spontaneous intracranial hypotension (SIH) • MRI Brain with contrast. Confirm the clinical suspicion of CSF leak. 2. If needed, demonstrate the site of leak. 20 % do not show meningeal enhancement…Mokri B.Mayo Clin Proc 1999;74:1113-23.. Spine MRI abnormalities in SIH. Spine MRI abnormalities in SIH. extradural extravasation of CSF. T2 vs STIR (short T1 inversion recovery) sequences. T2. STIR. Slide courtesy Alok Tyagi, Glasgow. 4.

(5) 24.10.2013. Spine MRI abnormalities in SIH extra-arachnoid extravasation of CSF. CSF findings in SIH  CSF pressures are less than 6 cm of water and can be. unmeasurable.  The CSF pressure can be normal in 40 %  CSF cell count can be high (upto 100 cells)  CSF protein can be high (upto 1 gm)  CSF glucose is never abnormal Schievink WI. Cephalalgia. 2008 Dec;28(12):1345-56 Slide courtesy Alok Tyagi, Glasgow. Demonstration of spinal CSF leak. Demonstration of CSF spinal leak. CT Myelogram.  CT myelogram.  Intrathecal contrast.  Radionuclide cisternography.  Early and delayed CT scans.  Spinal MRI myelography (with Gd).  May miss ‘fast flow’ leaks – Dynamic CT maybe useful.  Heavily T2 weighted spinal MR myelography.  ‘Slow flow’ leaks may take several hours  Majority of the leaks are at the cervico-thoracic. junction or in the thoracic spine  Multiple leaks are common  Considered the most reliable test to demonstrate site. of leak. Demonstration of spinal CSF leak CT Myelogram. Mokri B. Neurol Clin. 2004 Feb;22(1):55-74. Demonstration of spinal CSF leak Radionuclide cisternography  Intrathecal contrast, mostly Indium based. Seghal et al, Indian J Nucl Med. 2013 Jan;28(1):42-4. 5.

(6) 24.10.2013. Demonstration of spinal CSF leak Heavily T2-weighted MR myelography  Contrast not necessary. Management - conservative  Most CSF leaks resolve spontaneously and the majority. of patients may not require any treatment.  Treatments often tried :. Wang YF et al. Neurology. 2009 Dec 1;73(22):1892-8, Tomoda Y, Korogi Y, Aoki T, et al. Acta Radiol 2008;49:197–203. Yoo HM, Kim SJ, Choi CG, et al. Am J Neuroradiol 2008;29:649–6. Management – Epidural Blood Patch (EBP)  Should be considered if conservative means fail  Blind EBP at lumbar level with autologous blood –. effective in 36 - 57%. Bed rest (with head rest lowered) Hydration Abdominal binder Caffeine (oral or iv) Steroids Theophylline Intrathecal saline Vitamin A. Complications in SIH  Epidural blood patch related  Cerebral venous sinus thrombosis Savoiardo M. J Neurol. 2006 Sep;253(9):1197-202.  Subdural haematomas requiring intervention de Noronha RJ. J Neurol Neurosurg Psychiatry. 2003 Jun;74(6):752-5.  Rebound intracranial hypertension.  If the CSF leak is localised a targeted blood patch. Mokri B. Headache. 2013 Jul-Aug;53(7):1034-53. should be given. 87 % patients given a targeted blood patch showed clinical improvement when compared to 52 % of those given a ‘blind’ blood patch (p<0.05) Cho et al; Neurology; 2011 Mar 29;76(13):1139-44. Work-up algorithm  Thank you for your kind attention!  Open for questions!. Slide courtesy Alok Tyagi, Glasgow. 6.

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