Other Types of Headache

00:01 Our topic now brings us to chronic daily headache.

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

00:07 Almost universally associated with analgesic abuse.

00:12 Pain is generally reported as severe.

00:14 Our patients can carry out daily activities, but they’re not very happy.

00:18 First, the treatment is cessation of analgesic.

00:21 Tricyclics for underlying migraine or tension type headache.

00:26 Topic here brings us to an important trigeminal neuralgia issue.

00:31 It comes under your subacute or chronic headache.

00:34 Pain usually described as being electric, shooting.

00:39 Neuralgia of your fifth cranial nerve, trigeminal.

00:42 Most often, the mandibular or maxillary division.

00:45 Think about where you are, please.

00:46 Mandibular or maxillary, okay? Seen in middle age and later life.

00:54 How’s it triggered possibly? Non-noxious sensory stimuli to affected face, ipsilateral mucosa, or even teeth.

01:03 Exacerbating, remitting course over years.

01:06 Now, it keeps coming, keeps coming back.

01:09 Multiple attacks occur during any, any exacerbation.

01:13 Spontaneous remission occurs at any time.

01:16 This is a nerve, but then the remission could actually last for months or even years.

01:21 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.

01:32 Suicide risk is high during exacerbation.

01:36 Remember, we talked about cluster headache in which that patient is -- that male's running around screaming for medication.

01:42 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.

01:52 May be seen early in multiple sclerosis, possibly.

01:56 It kind of behaves exactly like this, doesn’t it? Remitting, remission, remitting, remission.

02:01 Divisions you’re paying attention to: mandibular, maxillary, most commonly.

02:08 Management: Carbamazepine.

02:10 In other words, the antiepileptic.

02:12 First line therapy, 70% to 80% response rate, actually.

02:17 Carbamazepine, antiepileptic.

02:19 Baclofen can be combined with carbamazepine.

02:23 Baclofen, carbamazepine.

02:26 They both have the C and B letters in them.

02:28 Surgical intervention could be a possibility.

02:31 Decompression of the trigeminal nerve or perhaps, what’s known as glycerol injection.

02:36 Your focus should be on carbamazepine, please, and maybe perhaps, baclofen.

02:40 In addition to carbamazepine, oxcarbazepine can also be used, which has better tolerability and decreased risk of drug interactions.

02:48 For patients who are intolerant of or have contraindications to these medications, the management of trigeminal neuralgia may include other anticonvulsants such as lamotrigine, gabapentin, or topiramate.

02:59 Other alternatives are the muscle relaxants baclofen or tizanidine.

03:03 Injections with botulinum toxin A may also be effective.

03:06 Subcutaneous sumatriptan, IV lidocaine or phenytoin may provide analgesia while other medications are being titrated.

03:14 Topical lidocaine may also be of benefit to patient.