On Tuesday evening, June 14, the Navigating the Medical System Lecture Series shared an informative virtual lecture on headaches in adult and elderly population with Dr. Dev Mehta, DO, and Assistant Professor of Neurology at Weil Cornell. The virtual lecture was hosted by Congregation Etz Chaim.

Dr. Mel Breite, Director and Founder of the Navigating the Medical System Lecture Series, welcomed everyone to the last lecture of this season.

Dr. Mehta shared there are three types of headaches: primary headaches, secondary headaches, and red flags. Primary headaches include migraine headaches, tension-type headaches, and trigeminal autonomic cephalalgia.

He first discussed the characteristics of migraine headaches, which last from four to 72 hours. They occur on one side and are pulsating, and they can be moderate to severe. They are worsened by routine activity and may include nausea or vomiting and sensitivity to light or sound. There can be a visual aura and sensory or language aura. Treatment includes preventive treatments such as triptans, which come in oral pill, nasal spray, and subcutaneous injection. These treatments cause constriction of blood vessels, so they are not recommended for use in a patient with heart or brain vascular disease. Ergot alkaloids are used as fourth or fifth line of treatment and also are not recommended for use in a patient with heart or brain vascular disease. Gepants are a new treatment with no risk to the former type of patient. Ditans are also another treatment that is okay for these patients. Barbiturates and opioids are not recommended because they are addictive. Tylenol and NSAIDs can be used to treat the pain, as well.

A preventive option reduces frequency, severity, and length of time the headache lasts. First line are oral beta blockers, which are antihypertensives, or calcium blockers. Antiepileptics and also antidepressants can help. In the last few years breakthrough in headache technology and second line medications, which are used every three months, are injection of botulinum or GRP antibodies.

He also mentioned taking riboflavin, magnesium, and feverfew combined. He recommends MigreLief, a nutritional supplement for migraine headache sufferers.

The most common type of headache is a tension-type headache, which occurs on both side of the head, band-like. There is no nausea, and it can be episodic or chronic. There can be light sensitivity or sound sensitivity. Tylenol and NSAIDs are the treatment. Caffeine should not be used in excess because it can cause rebound headaches. He shared treatments like antidepressants or EMG biofeedback, acupuncture, physical therapy, relaxation training, and yoga.

Trigeminal autoimmune cephalgia are cluster headaches that are rare but very painful. It occurs on one side and is behind the eye and is very severe. It lasts 15-180 minutes. There is redness or tearing of the eye, swollen eyelid, sweating, and possibly drooping eyelid, and the patient has trouble sitting still because of the pain. Treatment includes inhaled oxygen delivered from home oxygen, triptans subcutaneous intranasal, and steroids. There are other treatments including lithium, melatonin, and optical nerve blocks.

He then spoke about several other types of headaches. In the elderly population he shared that hypnic headache or alarm clock headache happens during sleep, between 2 a.m. and 4 a.m. It lasts anywhere from 15 minutes to four hours, and if there are ten attacks within three months, this would lead to a diagnosis. It occurs on both sides of the head and there are no migraine features. Treatment includes nocturnal caffeine, lithium, or melatonin.

Another type of headache common in the elderly population is primary cough headache, which is participated by a cough or Valsalva, and it lasts from one second up until two hours. It stops after a few months of treatment. It is treated with indomethacin.

He then spoke about secondary headaches due to vascular disease. These can occur from medication overuse. Over the age of 50, giant cell arteritis which is inflammation in arteries around the scalp. It causes scalp tenderness, jaw fatigue, or double-blurred vision. Diagnosis is done with elevated ESR and biopsy of the temporal artery. The treatment is steroids.

He noted that 27% of patients experience a headache at the onset of a stroke, while 34%-58% have a headache with intracerebral hemorrhage. Subarachnoid hemorrhage is sudden and severe.

Intracranial hypotension is a leak and it’s a low-pressure headache. The classic sign is that it goes away when one is lying flat, and it returns when one is sitting or standing. It can cause tinnitus, blurred vision, limb numbness, tingling, stiffness, and neck pain. Treatment includes caffeine, hydration, bed rest, epidural blood patch, and surgical options like Teflon placed over the leak. In 64% of cases of intracranial tumors, there are seizures. In this case, opiates are used for pain control. Neurosurgery, radiotherapy, and chemotherapy are the treatments.

Dr. Metha concluded with a list of red flags: It’s the first or worst headache of your life. There is a sudden onset or thunderclap headache or new onset of headache above the age of 50, or a change in typical headache pattern or frequency, or neurologic symptoms longer than one hour, or headache triggered by Valsalva or exertion, seizure, or alteration of consciousness, or a new headache in an immunocompromised state.

This comprehensive lecture detailed so many types of headaches and headache treatments that everyone left feeling very well-informed and hopefully headache-free.

 By Susie Garber

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