My name is Dr Amanda Hope Askar, and I am the director of the primary stroke center at U H ST John Medical Center. Today, I will be talking to you about headache red flags. First, I will go through an overview of the warning signs of a headache, and then I will review some of the common vascular syndromes and the associated headache patterns. The red flags for a headache include the characteristic features agent onset, associate ID symptoms and focal neurologic deficits. Any headache that is sudden and maximal onset, also called a thunderclap headache, should raise concern for further investigation. Any new onset headaches after the age of 50 should raise concern and any signs of increased intracranial pressure, such as position changed to the headache where the headache worsens when a patient lies flat, improves with them sitting up or has associated PayPal oedema, which is swelling of the optic nerves and is a sign of increased intracranial pressure. Additionally, there is concern when a headache is associated with focal neurologic deficits. This includes a change in level of consciousness cranial nerve palsy such as cranial nerve three or six, which calls Diplo Pia, which is double vision or signs of brain compression or increased intracranial pressure. Difficulty speaking, unilateral weakness, numbness or a taxi. The most classic brain injury that causes a sudden, severe headache is a subarachnoid hemorrhage. Just to review a subarachnoid hemorrhage is the rupture of a secular aneurysm in the brain predicted on the right. This causes bleeding in the suburb retinoid space in the lining of the brain, and it's seen on the cat scan at the bottom, right as the starfish pattern. A subarachnoid hemorrhage is a neurologic emergency and is associated with the high morbidity and mortality and therefore needs to be recognized. Urgent. This classically presents as the patient's worst headache of life with a stabbing, occipital based headache that is rapid in its peak of intensity. It is associated with men in just Miss due to irritation of the blood on the meninges in the subarachnoid space, and this causes neck stiffness without fever. A suburb wreck. Annoyed hemorrhage accounts for 25% of all thunderclap headache presentations, but it is important to note that 50% have, um, or transient or mild headache with the sentinel bleed so high suspicion is needed when a new onset headache presents. There are also focal neurologic signs. Depending on the location of the aneurysm, he come. Aneurysms could be associated with cranial nerve. Three. Paul sees. Due to compression of the midbrain, a calm aneurysms cause bilateral leg weakness and Apulia due to frontal lobe involvement. M. C. A. Aneurysms are associated with Hemi, Paris's or neglect, and if there is any increased intracranial pressure in the posterior fossa, patients may have cranial nerve. Six policies. Nystagmus or ataxia. In contrast, a subdural hematoma is a Venus hemorrhage, which involves bleeding from the bridging veins in between the meninges. Therefore, it presents with a more insidious onset headache that progressively worsens over a few weeks. As the blood accumulates, it will cause brain compression and eventually midline shift. And once the patient develops brain compression, they may develop sudden onset focal neurologic deficits such as Beef Asia in a left sided subdural. If there is midline shift or herniation, then patients will present with altered mental status. A subdural hemorrhage is more common in elderly patients and is typically proceeded by trauma several weeks before presentation. But it can also occur spontaneously in the setting of a coagulate apathy. An arterial dissection is a rare cause of an acute ischemic stroke. This is, Um, or common presentation of stroke in young patients and is typically associated with headache and neck theme on the picture. To the right, there is a sagittal image of a right carotid artery dissection and then an axial CT angiogram below with bilateral carotid artery dissections indicated by the Red Arrows. Carotid artery dissection is commonly associated with a headache in about 60 to 95% of patients. Headache is typically ipsa lateral to the dissection and associated with face or neck pain. Patients may also develop an IPs lateral Horner syndrome duda sympathetic nerve injury as the sympathetic nervous system runs parallel to the carotid artery. Or they could develop a morose ISF you Jax due toa embolization from a thrombosis associated with the dissection. Vertebral artery dissections also have an associate ID headache in about 70% of patients. This headache is more occipital in location and is associated with Sarah Beller or brain stem signs such as lower cranial neuropathy. These Sarah Beller signs and visual field deficits and acute ischemic stroke can also present with a headache. We commonly teach that s key mix. Stroke does not cause a headache, as the pain fibers in the brain are in the meninges and not in the brain. Perrin Coma. However, many retrospective and prospective reviews have found a headache reported in 25 to 30% of acute ischemic strokes the characteristic features of the headache, or that it is a tension type headache in anterior circulation. In FARC's, it's more IPSA lateral or frontal in location and in poster, your circulation in FARC's. The headache is occipital. The associated factors include female sex, younger age Ah, prior history of migraine and Sarah Beller or right hemispheric location. It's important to note that migraine with aura can also mimic a stroke, which I will review in the next slides. However, migraine aura typically starts more gradually and progresses over several minutes to an hour, which is in contrast to esque e mia or hemorrhage that is more abrupt. Non set the associated features of a migraine aura are positive phenomenon, such as bright lights or tingling instead of negative phenomenon that occurs in ischemia, or hemorrhage, which would be loss of vision or numbness. The picture on this slide is of a scintillating Scott Oma, which is a classic visual aura of migrant. The International Headaches Society has a classification system for headaches called the International Classifications of Headache Disorders, and it is on its third iteration. This includes diagnostic criteria for migraine with aura. The aura must involve the following types visual, sensory speech or language, motor, brain stem or retinal and the migraine with aura must have three of the following six characteristics. At least one or a spreads gradually over greater than five minutes two or more or a symptoms in succession each or a last 5 to 60 minutes. One aura is unilateral one or a symptom is positive, and the aura is accompanied or followed within 60 minutes by a headache. In addition, there's also a separate diagnosis for migraine with brain stem aura. This is similar to the migraine with aura criteria, but the aura must involve two of the following with no motor or retinal symptoms. These two of the following symptoms include this are three a vertigo tinnitus type excuses by propia ataxia not attributable to a sensory deficit or decreased level of consciousness. Moving on to cerebral venous Sinus thrombosis. cerebral venous thrombosis is a Venus thrombosis embolism or a clot in the draining veins of the brain, either in the cortical veins or the Venus Sinuses. This classically presents with a headache in 75 to 90% of patients, but the headache is often non specific. The headache can be sudden in onset, in pregnant or postpartum patients, or more insidious than onset when not associated with pregnancy. As the backup of blood occurs, the pressure in the brain increases, and there could be insufficient oxygen. Deliver t from the arterial system and therefore Venus infarction. Hemorrhage occur. This can cause the associated features, such as signs of increased intracranial pressure with change in mental status or PayPal, oedema and focal neurologic deficits or seizures. Risk factors for cerebral venous Sinus thrombosis include female sex hyper coagulate ble states such as pregnancy or post pardon or use of estrogen containing Orel contraceptives. A newer headache that has been described is from reversible cerebral vessel constriction syndrome, or R C. V. S. This condition is described well by its name, where there is reversible vessel constriction in the intracranial arteries, as depicted in the images to the right patients will often present with a recurrent thunderclap headache. This is a headache that it's sudden and rapidly reaching its maximum severity. The headache will last for a few hours, but Rikers over days to weeks Image ing is typically normal at the initial presentation, but 2 to 3 weeks later may show segmental vessel constriction of the intracranial arteries. This condition is triggered by use of sympathy, UM, a medic. Medications such as marijuana, immuno suppressants, Tack Role, Emma's and Cyclophosphamide or Sarah. 10 ergic medications such as Suda, Fed S s rise. And lastly, from carcinoid tumor or the postpartum period. Treatment involves stopping any medications or associative drugs and sometimes calcium channel blockers. Air used but the headache and the blood vessel constriction usually resolves in about three months. Arterial hypertension can also cause a headache. This headache, classically associates with changes in the blood pressure so occurs with blood pressure's greater than 1 80/1 20 is usually bilateral diffuse, pulsating and aggravated by physical activity, the headache worsens with increase in blood pressure and resolves with blood pressure control. The associated features include lethargy, confusion, visual disturbances or seizures, and typically is classified is hypertensive emergency at that point to review. Headaches are common in many stroke syndromes and should be evaluated for any headache red flags that would prompt further evaluation. Headache Red flags include any headache that it's sudden and severe in onset, or any change to a pattern of headache that is more continuous or progressive. Any signs of increased intracranial pressure or other focal neurologic deficits. It's important to note that migraine with aura can mimic a stroke but is more graduate, gradual and onset, progressing over minutes to hours and disassociated with positive phenomenon such as tingling or a scintillating Scott oMa, or positive visual phenomenon, which is compared to an ischemic stroke that is more rapid onset and associated with negative phenomenon. This concludes my talk and headache. Red flags. Additional information regarding vascular headaches can be found in the American Academy of Neurology Continuum Review on Headache published in 2018, and I specifically referenced the sections on secondary headache syndromes and the migraine with aura. Okay, hi, everyone. That says Dr David Vincent. I am the medical director and chiropractic massage therapy, University Hospitals, Connor Integrative Health Network. I want to thank uh, their neurological institute and uh, obviously case, uh, Western Reserve University and all the folks that help put the neuroscience nursing supposing together. I know how much work it ISS. So we appreciate, uh and we're grateful to be part of this presentation today. My injections, they're pretty straightforward. I wanted to find integrative health and medicine. I want to review the different integrative health modalities and their role in the treatment of pain. And I want to provide an overview of the current research of our various integrative treatment modalities that pertains to patients with headache. I'll note that I will focus on Migraine Assn. We move forward into that piece. What is integrative health? Integrative health, uh, is sort of the current nomenclature, a Z Any of you have been around health care for any length of time. Know that it used to be called alternative health. And then it was complementary house. Uh, and then integrative health seems to be the current terminology. Sometimes it's called integrative and complementary health. Um, all all the same stuff. It's just sort of changed with attitudes within medicine, integrative health. That terminology came or out of the academic side of medicine, and I think for the most part integrative, collaborative, complimentary. All good terminology. Uh, it's important to know that integrative health isn't functional medicine, so functional medicine is part of integrative health. I know there's some confusion around that sometimes, but that's just another one of the modalities that are providers use, uh, to help patients, uh, find their way through through their health journey. Integrative health and medicine reaffirms relationship. We focus on the whole person way put a strong emphasis on preventative care. Importantly, we informed by evidence is a big part of who we are and what we dio, Uh, and we make use of the appropriate therapeutic and lifestyle approaches for the patient, right? So if what we're doing isn't the right choice for the patient, we make sure that they're aware of that. We work to integrate care among specialties. We want to always improve communication. We want to be partnered and be part of the total U H team. As Dr Adan often says, we way want to be part of the fabric of University hospital and be part of the treatment teams here. The National Center for Complimentary and Integrative Health is really who we model uh, you age, Connor. Integrative Health Network By we We're all about providing evidence based care that safe and effective, which is an alignment with the and the pain consortium. Uh, you may be aware there's a growing evidence base that showing that these complementary approaches, like acupuncture and hypnosis, massage, mindfulness, spinal manipulation and yoga are all part of, ah, strong evidence that be effective for managing chronic pain and other painful conditions. I have highlighted the areas that we, uh, provide care. Prevalence of counter chronic pain we know is high 20% of the population, 8% of those being highly disabled by chronic pain. Note that headache makes up 15% which includes head pain, facial pain, migraine. Ah, here it, Connor and I know my team particularly. We see all of these types of chronic pain. It's a big part of the patient population we serve at Connor. We have just want to go over there doing a quick overview of what we offer. Acupuncture massage mind body therapies such as therapeutic yoga and mindfulness therapeutic yoga and mindfulness are both being offered online. Currently not live, but almost everything else you see here we have been part of the the team at U H. Right to the current crisis, and and we'll continue today. So, uh, we I will add one person to the physician services We recently added, Dr Miller, who is, uh, integrative pediatrician is part of the rainbow, uh, facility, uh, currently. And he's been here about 90 days, and and he's doing just a really great job. Inpatient services include music therapy, art therapy. We doing massage rainbow up in the haimang towards acupuncture at the Simon Cancer Center, and acupuncture at Hoosier is part of, ah, a program that is looking at acupuncture defectives for post knee replacement, uh, pain control, uh, in in in that orthopedic department, acupuncture is been around forever. This ancient, ancient, ancient, ancient, commonly used treatment, uh, uses a find needles to illicit responses in the body. You know, we knew forever that acupuncture worked. I mean, it was you know, there are volumes and volumes of information from the Master is talking about acupuncture and the effects and mapping out points and doing all that, but we didn't know well, what how it works. But current science is able to show us through brain mapping and MGs and blood testing that we can improve blood flow and immune response control inflammation. Obviously, through trigger point care, we can we can relax, uh, tight and sore muscles. Relief pain Regulate the parasympathetic nervous system, the the effects of dramatic. And we're seeing more and more research coming out about acupuncture. Chiropractic has also been around a long time. It came. It had its beginnings around the same time. It's off the opera, the in the United States. Um, the chiropractic adjustment or chiropractic manipulation is what we're most well known for, Which is that applied force to joints. Uh, and it improves to improve altered biomechanics and restore normal motion. Are reduced tension from long term postural stress. Uh, the researcher at the in the UK The evidence report there showed that there was strong to moderate evidence for chiropractic manipulation for, uh, neck pain headaches, including migraine, upper and lower extremities, joint conditions, web slash associate disorders. And we're finding more and more information. Andi studies coming out for ridiculous pain Siderurgica on other syndromes related to the neuro muscular scholar system real quick. Oh, is want to talk about chiropractic care, chiropractic manipulation is in chiropractic chiropractic. Physicians were trained to use, Ah, a lot of different therapeutic and rehabilitative exercises. They provide physio therapies In many ways. There's crossover at this point with our physical therapists, Uh, and with our nutritional consultants, Um, and it's not uncommon for chiropractic positions to be deported, certified, and multi, especially is like acupuncture or sports medicine. Occupational health, clinical nutrition, I for one and board certified and acupuncture long ago became bored, sort of forward in sports medicine. And again, this is not uncommon massage therapy and something we offer pretty widely at University Hospital, we are involved with massage area throughout the system. Um, we, uh, provide a massage therapy on an outpatient basis, uh, to two degrees, anxiety and stress. We use it to, uh, to lessen muscle pain and strain, uh, and relieve pain. But I think that biggie is that we can we know that we can reduce those cortisol a stress stress hormones and give people a better sense of well being mindfulness out of the practice of of cabins in, uh, this is really the mainstay of or the beginning point for integrative health as we know it today. Body mind medicine is a field that focuses on the interaction of the brain and the mind and the body. Some of those mind somatic interactions that air so common and chronic pain patients. Um, and again, mindfulness meditation is the most prominent effect on physiological aspect on living with chronic pain, improving associative depression and quality of life. Powerful, powerful tool music therapy also uses many of these tools here atyou age where music therapy is, uh, throughout the health system as well that Z provided an inpatient basis. We're closely with with pain management. Uh, and, uh, it can be very, very effective. We are. We are using, uh, doing a lot of studies currently on the effect of music therapy and reducing pain in palliative care patients. Powerful tool. Ah, just as a side note. Music therapy department at U. H. Is one of the largest in the nation. Um, they are training ground for new music therapist. This is, uh, they are really the envy of most academic centers. Medical centers in the United, evaluating patients and pain is not always easy. It takes a team and the team it does. Where Connor were actively involved with Pain Management Institute. Um and we help create algorithms for a variety of different pain syndromes, chronic pain syndromes, for example. We just finished one for lower back pain. Uh, and we're working thio currently. What? The pain management It's to to create comprehensive pain center model that we're gonna pilot soon at the Parliament Medical Center. Let's do a little bit of lit review. Uh, acupuncture. Uh, we'll start with them, and I just brought up some of the studies I could find. Ah, on that shows the effectiveness of acupuncture and the other modalities we used on migraine patients. And you could see and I've outlined underlined the important areas. In the first day. We found that that suggests the acupuncture is at least similarly effective as a treatment with prophylactic drugs. The second study found that acupuncture resulted in significant greater reduction in migraine days and reduction in migraine attack. It is one of the things I tell patients when they come in with migraine is that listen may not be able to get ready of migraines, but I am quite positive that I can reduce the impact of those migraines, and I'm quite certain in most cases that I can reduce the number of migraines that you have over a year, and that, in my practice has been pretty consistent. Moved on to chiropractic Emmanuel therapies, um, that the current research shows that massage therapy, physiotherapy, relaxation, chiropractic, it's and chiropractic spinal manipulation therapy. It might be equally, uh, efficient as propranolol and trope in it and a proper like mountain of migraine, all important pieces, that sort of that non farmer approach or an additional approach. Thio Pharma To help reduce that my migraine impact another study with with a chiropractic manipulation study eso statistically significant improvement in migraine frequency. And again, that's what I see mostly in my practice is, well, we may not be able to get rid of the migraine in that patient, but we can reduce the impact of that migraine on the patient again. Another study for chiropractic shows 90% reduction of migraines as a consequence of two months of of manipulation, and again, more than 50% of participants reported significant improvement in morbidity of each episode. And again, that's in alignment. What I see in practice every day, Onda again, um, with manipulation, migraines, days were significantly reduced with all three groups from baseline Post treatment. My going derision and headache index was reduced significantly. Mawr than the control group. Adverse for effects were a few mild and transient massage and dry needling. Uh, I thought that I thought this study was, uh, really, uh, pretty interesting with the lymphatic drainage technique, uh, and that there was a significant increase in amount of ah, an energetic and intake compared to the other groups and resulted in a in a reduction of migraine attack frequency dry needling many of the, uh, same outcomes. And that's usually a trigger point therapy. Uh, and it's a line with the other studies were finding with with manual therapies, I typically include dry needling as, ah, as a manual therapy technique. We use it, uh, commonly in chiropractic practice, mindfulness and meditation. Um, we find that I actually really love the final statement. Uh, that distraction is not enough, but medic meditation takes time. Uh, 30 minutes of daily practice for 20 days appeared necessary to reach efficacy. Forwarded for the reduction of migraine enhanced mindfulness based stress reduction. Episodic migraine showed superior treatment effects compared with active control with significant reduction A headache, frequency again, Frequency magnitude. This is what we tend to find with all of these integrative, uh, complimentary modal yoga and cognitive therapy. It's a nice study with yoga Yoga's, uh, as an add on therapy. And migraine is superior to a medical therapy alone. So yoga, in combination with standard medical care with migraines, is a safe and cost effective Ah, tool for helping management helping the management of migrants. Ah, and, ah, last study I have here, uh, from the journal of Head and Face Pain. I thought that mindfulness based cognitive therapy, which is actually what we dio at Connor, had showed, uh, as promising in an emerging treatment for addressing migraine related disability not to go over, uh, this case study I found real quickly. I I thought it was a great one because it kind of covers some ah lot of areas and, uh, certainly an area that comes up commonly within a chiropractic profession. Um, and that's the idea of vertebral artery dissection. Ah, I mean and chiropractic care. And this is a case that I have found a, uh, a vertebral artery dissection in process during during a chiropractic examination. We found through that this is in alignment with a big medicine. E that was done through the Canadian health system that found that stroke occurs equally is commonly in the primary care office as it does in a chiropractic office. And it's felt that many of those cases were probably in process when the when the patient came into the office. They're experiencing extreme neck pain, something that we commonly treat. So this is a case where a 30 year old woman presented to emergency department with sudden nonsense of transient loss of left professor excuse me peripheral vision going to a history of migraine headaches. He was released with a diagnosis of ocular migraine to to Two days later, she sought out chiropractic care for chief symptom of severe neck pain. The chiropractor suspected, possibly vertebral artery dissection. No manipulation reform. Instead, uh, memory Nick of the neck was obtained, which revealed a cute left F a D with early thrombosis formation. The patient was placed on ESPN therapy in the hospital. A repeat emery of the neck three months later revealed resolution and promise without progression of stroke. Again, this case illustrates the importance for all health care briars who see patients with back pain and headache to be attentive to symptomatic presentation of possible V, A. T and progress. We offer free, online and guided audio meditations, and it's growing. So you know, Please take note of this scan this slide. I know that you all have their hand out. We're gonna have thousands of these meditations available to our patients soon. We have reached an agreement with one of the meditation providers that we use to create this. And they have. They're going to allow us to take in their whole catalog. This is gonna be available to patients at U H for free eso stay tuned. With that, it will be linked at the same website. Scheduling. Referring is pretty straightforward. If your out patient all you have to do is a m R type Connor, or you can type chiropractic or you can type, uh, acupuncture. You will come. Uh, it'll automatically lead you towards those fields. I know that chiropractic medicine, uh, is, uh is used commonly here atyou H and acupuncture as well. If you don't know who to refer to and you have a patient this in chronic pain can always start with an integrated medical consultation with one of our physicians or nurse practitioners. Um, currently, my chiropractic team is taking the load of some of those consoles because we're down a couple of nurse practitioners, but, um, again, they're there to do that whole console to make sure that people in the appropriate place, we do our own scheduling at Connor. So the staff there can answer patient questions directly, or they filled them to one of the providers. If you have questions for me, please email me. I'm always available and and willing to ask your questions. So I think we're gonna lead into a question answer sessions. So I'm gonna leave you there. Don't be afraid to contact me if you have any questions at all. Thank you.