2nd CME Psychosomatic disorders Headache Insomnia Pain Disorder

1. 2nd CME Psychosomatic disorders Headache Insomnia Pain Disorder Doct. Jean-louis Aillon 04-11-10

2. Psychosomatic disorders (Psychological factors affecting medical condition) A general medical condition (coded on Axis III) is present. B. Psychological factors adversely affect the general medical condition in one of the following ways: • the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from the general medical condition • the factors interfere with the treatment of the general medical condition • the factors constitute additional health risks for the individual • Stress-related physiological responses precipitate or exacerbate symptoms of the general medical condition

6. Our datas Association with Mental disorders Association with Depression Prevalence of sintoms Gastric pain/problems: 58 pz:19,3 % Headache: 40pz 13,3% Pain how long? 29,2 months

7. Headache

8. Clinical assesment • TIME: onset, frequency, patterns, duration • CHARACTER: site, intensity, nature of pain • CAUSES: predisposition, triggering, aggravating, releaving factors • RESPONSE: patient actions and limitations during an attack, medications used • INTERVALS: how does patient feel between attacks; concern, anxieties and fears about attacks

9. Chronic Headache • Migraine • Tension-type Headache

10. Migraine

11. Switzerland 13% Denmark 10% France 8%† USA 12% Japan 8% Italy 16% • 1-year prevalence rates • Population-based studies • IHS criteria (or modified) Chile 7% Rasmussen and Olesen (1994); Rasmussen (1995);Lipton et al (1994); Lavados and Tenhamm (1997); Sakai and Igarashi (1997) †Prevalence measured over a few years World prevalence of migraine:A disorder of First World

12. Recognizing Migraine • Pounding unilateral headache • Preceded by visual or other aura • Nausea, vomiting • Light and sound sensitivity

13. Migraine without aura (MO) What is migraine? Migraine with aura (MA) • At least five attacks fulfilling these criteria: • Headache lasting 4–72 h • (2–48 h in children) • At least two attacks fulfilling these criteria: • At least three of the following: • one or more fully reversibleaura symptoms • gradually developing orsequential aura symptoms • no one aura symptom lastslonger than 1 h • headache shortly follows or accompanies aura • With at least two of: • unilateral location • pulsating quality • moderate/severe intensity • aggravated by activity • Accompanied by at least one of: • nausea • vomiting • photophobia and/or phonophobia • No evidence of organic disease • No evidence of organic disease Headache Classification Committee of IHS (1988)

14. Aura • Transient hemianopic disturbances prior to headache, lastin 10-30 minutes (occasionally up to 1 hour) • A spreading scintillating scotoma (patiens may draw a jagged crescent) • Other reversibile focal neurological disturbances (e.g. unilateral paraesthesiae of hand, arm or face)

15. Diagnosis of migraine • Diagnosis depends on patient history • No specific tests or clinical markers • Positive diagnosis if attack history fulfils IHS criteria for migraine • Other pointers include: • family history of migraine • age of onset <45 • presence of aura • menstrual association • Organic disease must be excluded Stress Depression Anxiety Menopause Head or neck trauma Cady (1999); Warshaw et al (1998)

16. Trigger • Relaxation after stress • Change in habit: sleep, travel etc.. • Bright lights/ loud noise • Diet: alcohol, cheese, citrus fruits, possibly chocolate, missed or delayed meals • Strenuous unaccustomed exercise • Mestruation

17. WORRISOME HEADACHE RED FLAGS“SNOOP” Systemic symptoms (fever, weight loss) or Secondary risk factors (HIV, systemic cancer) Neurologic symptoms or abnormal signs (confusion, impaired alertness, or consciousness) subarachnoid hemorrhage (SAH) venous sinus thrombosis, arterial dissection, or raised intracranial pressure. Onset: sudden, abrupt, or split-second Older: new onset and progressive headache, especially in middle-age >50 (giant cell arteritis) Previous headache history: first headache or different (change in attack frequency, severity, or clinical features)

18. Females Males Prevalence of migraine by sex and age Migraine prevalence (%) 30 25 20 15 10 5 0 20 30 40 50 60 70 80 100 Age (years) The American Migraine Study (n=2479 migraine sufferers) Lipton and Stewart (1993)

19. Physiology • Vasospasm – Lance • Spreading Wave of Depression – Leao • Trigeminocentric • Allodynia

20. Trigeminal Theory • Serotonin again • Trigeminal Afferents: sensory function of face and meninges • Trigeminal efferents to vessels • Cause vessel spasm and sensitivity • This theory primarily explains action of Triptans: 5-HT 1b,d agonists

21. Vasospasm • I. Aura: Arteries Spasm • Visual and focal neurological symtoms • Pial and Occipital small artery branches • II. Headache: Compensatory Vasodilation • Pounding unilateral sick headache • III. Inflammation and muscle spasm: second pain phase

22. Treatment • Effective treatment of attack • Prevention • Address comorbidities

23. 1 step • Oral Analgesics ± Antiemetic Paracetamol Metoclopramide Aspirin Domperidone Ibuprofen Naproxen

24. 2 Step Parenteral Analgesics ± Antiemetic Diclofenac Metoclopramide Domperidone Also suppositories

25. Paracetamol 1 g Tid

26. 3 Step • Rizatriptan • Contraindication: Uncontrolled Hypertension Risk factors for CHD or CVD Children under 12 Diagnose ad-exiuvantibus

27. Trigeminal nerve INHIBITION 5-HT1D 5-HT1F triptan CGRP NK SP CONSTRICTION 5-HT1B CGRP calcitonin gene related peptide NK neurokinin A SP substance P Blood vessel Adapted from Goadsby (1997) Mechanisms for treatment

28. Emergency • Diclofenac IM Or • Clorpromazine IM

29. Prophilaxys Atenolol Even combined in serious cases Depression, another chronic pain, Disturbed Sleep, TTH

30. Tension-type headache (TTH) • Episodic • Chronic • Bilateral • Also every day • No nausea or photophobia • No pulsation

31. Treatment 1) infrequent episodic TTH (-2 days/week) Paracetamol, aspirine, ibuprofen or Codeine 2) Chronic TTH Sintomatic treatment only for short time Consider a course of Naproxen Prophilaxis with Amitriptiline (10-75 mg nocte)

32. Non drug intervention for Migraine and TTH • Improving physical fitness • Physiotherapy • Acupunture • Psychological therapy • Relaxation • Stress reduction • Coping Strategies • Biofeedback

33. Phisiotherapy and CBT

34. Relaxation exercise (once or twice a day) Sit down on a comfortable armchair in a quiet room. Let the mandible drop in a position of maximum relaxation for about 10-15 minutes. Apply warm pads on cheeks and shoulders. Posture exercises 8-10 times every 2-3 hours 1) Keep an erect position with the tallons, the hips and the nape against the wall. While the rest of the body does not move bring the shoulders into contact with the wall and release, rhythmically 2) While body and head are kept against the wall, make horizontal movements of the head, forwards and backwards 3) After having cupped the hands behind the neck, performs stretching movements of the head backward, with forward counterpressure from the hands. Relax after 2-3 seconds. Visual feedback Place colored labels in strategic sites to remind to keep muscle contraction at a normal level.

36. An Insomnia Typology • Difficulty falling asleep • Difficulty staying asleep • Waking too early • Non-restorative poor quality sleep anxiety Depression, PTSD

37. Insomnia Mechanisms • Disorders of circadian rhythms • Disordered homeostatic drive for sleep • Disordered sleep mechanisms • Dyssomnias & Parasomnias • Disordered arousal mechanisms • Medical & psychiatric disorders • Substance/medication-induced disorders

38. Sleep Disorder Classification • Dyssomnias are disorders of initiating & maintaining sleep, with Excessive Daytme Somnolence (EDS) – 3 types: intrinsic, extrinsic, and circadian • Parasomnias - characterized by abnormal behavior or physiological events at specific stages or sleep-wake transitions, involving inappropriate activation of autonomic & motor systems – usually with both normal restful sleep & REM Latency, and without EDS

39. Dyssomnias - Intrinsic • Primary Insomnia – Psychophysiologic and Idiopathic • Narcolepsy • Sleep Apnea • Periodic Limb Movements • Restless Legs Syndrome

40. Dyssomnias - Extrinsic • Inadequate sleep hygiene • Environmental sleep disorder • Secondary to toxins & substance dependence

41. Dyssomnias - Circadian • Time zone changes (jet lag) • Shift work • Changes in sleep phase – advanced & delayed

42. Parasomnias • Sleep Terrors • Somnambulism • Nightmares • REM Sleep Behavior Disorder • Jactatio Capitis Nocturna • Bruxism • Enuresis

43. Medical & Psychiatric Causes of Sleep Disorders • Hyperthyroidism • Arthritis or any other painful condition • Chronic lung or kidney disease • Cardiovascular disease (heart failure, CAD) • Heartburn (GERD) • Neurological disorders (epilepsy, Alzheimer’s, headaches, stroke, tumors, Parkinson’s Disease) • Diabetes • Menopause • Major Depression • Bipolar Disorder • Seasonal Affective Disorder • PTSD, anxiety Pain Syndromes Cluster Headaches

44. Alcohol Caffeine/chocolate Nicotine/nicotine patch Beta blockers Calcium channel blockers Bronchodilators Corticosteroids Decongestants Antidepressants Thyroid hormones Anticonvulsants High blood pressure medications Common drugs that can cause insomnia

45. Therapy of insomnia

46. 1) Non-drug treatments • Cognitive-behavioral therapy (CBT) • Stimulus control • Cognitive therapy • Sleep restriction • Relaxation training • Sleep hygiene

47. How to keep track of your sleep • Daily sleep diary or sleep log • Bedtime • Falling asleep time • Nighttime awakenings • Time to get back to sleep • Waking up time • Getting out of bed time • Naps

48. Cognitive Therapy • Identify beliefs about sleep that are incorrect • Challenge their truthfulness • Substitute realistic thoughts

49. False beliefs about insomnia • Misconceptions about causes of insomnia • “Insomnia is a normal part of aging.” • Unrealistic expectations re: sleep needs • “I must have 8 hours of sleep each night.” • Faulty beliefs about insomnia consequences • “Insomnia can make me sick or cause a mental breakdown.” • Misattributions of daytime impairments • “I’ve had a bad day because of my insomnia.” • I can’t have a normal day after a sleepless night.”

50. More common myths about insomnia • Misconceptions about control and predictability of sleep • “I can’t predict when I’ll sleep well or badly.” • Myths about what behaviors lead to good sleep • “When I have trouble getting to sleep, I should stay in bed and try harder.”