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Chronic Daily Headache and Imaging

by Carlo Raj, MD
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    00:01 Our topic now brings us to chronic daily headache.

    00:04 Most often evolve out of tension type though.

    00:08 Almost universally associated with analgesic abuse.

    00:11 As I said, you’re using the analgesics so that you can take care of the tension headache.

    00:16 But then at the same time, because you’re so addicted to these analgesics, you end up developing headache because of the analgesics Pain is generally reported as severe.

    00:26 Our patients can carry out daily activities, but they’re not very happy.

    00:31 First, the treatment is cessation of analgesic.

    00:33 That’s where you begin.

    00:35 These drugs, it’s one of those situations where it’s like the catch-22.

    00:39 What do you do? I mean, the patient is in pain, you’ve got to take something.

    00:43 But then you take something and you start abusing it, and you don’t even realize it’s happening.

    00:47 Then this itself can cause a secondary issue.

    00:50 Welcome to chronic daily headache.

    00:52 Tricyclics for underlying migraine or tension type headache.

    00:59 Topic here brings us to an important trigeminal neuralgia issue.

    01:04 It comes under your subacute or chronic headache.

    01:07 Pain usually described as being electric, shooting.

    01:12 You’ve heard of sciatica.

    01:14 And what do you know about that pain? It’s shooting, it’s trigeminal, a nerve.

    01:20 So, you have sciatica or trigeminal nerves, and when you have nerves that are being affected, then the pain here is “shooting.” Or lancinating, lasting seconds.

    01:31 So, very quick.

    01:32 Boom, literally, a shooting pain up and down that particular nerve of concern.

    01:39 Milder itching or burning may also be present between the attacks.

    01:42 That’s important.

    01:43 Pay attention to that.

    01:45 “Doc, I feel itchy. I have the shooting pain and then I feel itchy.” But this, you need to make sure that you ask.

    01:51 The patient doesn’t even know to offer such information.

    01:57 Neuralgia of your fifth cranial nerve, trigeminal.

    02:01 Most often, the mandibular or maxillary division.

    02:03 Think about where you are, please.

    02:05 Mandibular or maxillary, okay? Seen in middle age and later life.

    02:12 How’s it triggered possibly? Non-noxious sensory stimuli to affected face, ipsilateral mucosa, or even teeth.

    02:21 Exacerbating, remitting course over years.

    02:25 Now, it keeps coming, keeps coming back.

    02:27 Multiple attacks occur during any, any exacerbation.

    02:32 Spontaneous remission occurs at any time.

    02:35 This is a nerve, but then the remission could actually last for months or even years.

    02:40 The patient feels as though that the drug, actually -- the drug if they were taking anything, they might feel as though that the drug was effective, but in all reality, what happened? They went into remission.

    02:51 Suicide risk is high during exacerbation.

    02:54 Remember, we talked about cluster headache in which that patient is -- that male's running around screaming for medication.

    03:01 And when there’s such pain that’s taking place during such exacerbation, you need to make sure that you rule out or you properly manage this patient for suicidal ideation.

    03:10 May be seen early in multiple sclerosis, possibly.

    03:14 It kind of behaves exactly like this, doesn’t it? Remitting, remission, remitting, remission.

    03:19 Divisions you’re paying attention to: mandibular, maxillary, most commonly.

    03:26 Management: Carbamazepine.

    03:29 In other words, the antiepileptic.

    03:30 First line therapy, 70% to 80% response rate, actually.

    03:35 Carbamazepine, antiepileptic.

    03:38 Baclofen can be combined with carbamazepine.

    03:42 Baclofen, carbamazepine.

    03:44 They both have the C and B letters in them.

    03:47 Surgical intervention could be a possibility.

    03:50 Decompression of the trigeminal nerve or perhaps, what’s known as glycerol injection.

    03:54 Your focus should be on carbamazepine, please, and maybe perhaps, baclofen.

    04:01 Imaging: So, under the guidelines: new onset headache in patients less than 40, headache with abnormal neurologic exam, and to reassure an anxious patient.

    04:13 The CT of the head: useful in the ER situation, sensitive to blood if subarachnoid hemorrhage is suspected, and can rule out mass effect prior to lumbar puncture.

    04:26 Remember, please, that before you do any type of lumbar puncture, you need to make sure that increased intracranial pressure, if it exists, is properly managed.

    04:34 In fact, whenever there is increased pressure anywhere in the body, you need to make sure that it’s addressed properly.

    04:42 MRI brain without contrast.

    04:45 Study of choice if imaging is indicated to rule out tumors or masses.

    04:50 But definitely, not as sensitive to blood as the CT is, because once again, if you’re worried about or suspecting subarachnoid hemorrhage, there, the imaging study that would be preferred will be CT.


    About the Lecture

    The lecture Chronic Daily Headache and Imaging by Carlo Raj, MD is from the course Headache. It contains the following chapters:

    • Chronic Daily Headache
    • Imaging

    Included Quiz Questions

    1. A headache due to Trigeminal neuralgia
    2. A headache due to Temporal arteritis
    3. Cluster headache
    4. Tension headache
    5. Migraine headache
    1. Multiple sclerosis
    2. Guillain-Barre syndrome
    3. Picks disease
    4. Schizophrenia
    5. Multiple myeloma
    1. Carbamazepine
    2. Tricyclic antidepressants
    3. Over the counter analgesics
    4. Sumatriptan
    5. Ergotamine
    1. CT without contrast
    2. CT with contrast
    3. MRI
    4. X-ray
    5. Ultrasound

    Author of lecture Chronic Daily Headache and Imaging

     Carlo Raj, MD

    Carlo Raj, MD


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