HEADACHE in Primary Care Aye Arzu Akaln MD Family Medicine
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In the end of this lecture the students will be able to;
Differentiate primary and secondary headache Distinguish life
threatening headaches from benign headaches. List the
characteristics of most common headache types in primary care
Explain the warning features in history and physical exam List the
common headache triggers 2
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Key facts - WHO Headache disorders are among the most common
disorders of the nervous system. Almost half of the adult
population have headache at least once within last year in general.
Headache disorders are associated with personal and societal
burdens of pain, disability, damaged quality of life and financial
cost. 3
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Key facts - WHO A minority of people with headache disorders
worldwide are diagnosed appropriately by a health-care provider.
Headache has been under-estimated, under- recognized and
under-treated throughout the world. 4
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Definition Headache is Headache is pain located above the
orbitomeatal line Facial pain is Facial pain is pain below the
orbitomeatal line, above the neck and anterior to the pinna* 5 IHS
- International Headache Society * part of ear that is on the
outside of head
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The International Classification of Headache Disorders I.
Primary headaches II. Secondary headaches III. Painful cranial
neuropathies, other facial pains and other headaches Headache
Classification Committee of the International Headache Society
(IHS) 2013
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Primary Headaches Definition are not associated with other
diseases a. No organic disease or b. No structural neurologic
abnormality Laboratory and imaging test results are generally
normal. The physical and neurologic examinations are also usually
normal During the headache attack, patients might have some
abnormal clinical findings 7 There is
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Secondary Headache Definition There is an underlying pathology
(eg., aneurysm, infection, inflammation, or neoplasm) Secondary
headaches are usually of recent onset and associated with
abnormalities found on clinical examination. Laboratory testing or
imaging studies confirm the diagnosis. 8
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Secondary Headache Recognizing headaches related to an
underlying condition or disease is critical: a. because treatment
of the underlying problem usually eliminates the headache b. the
condition causing the headache may be life-threatening. 9
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Intracranial structures & pain sensitivity 10 Pain
Insensitive Structures in Brain Pain Sensitive Structures in
Brain
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Causes of Headaches 1. Traction or dilatation of intracranial
or extracranial arteries. 2. Traction of large extracranial veins
3. Compression, traction or inflammation of pain sensitive
intracranial structures 4. Spasm and trauma to cranial and cervical
muscles. 5. Meningeal irritation and raised intracranial pressure
6. Eye, ear, nose and throat pathologies 11
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Terms Prevalence: Prevalence: The actual number of existing
cases of a disease that appear in a given population at a specific
time. Incidence: Incidence: The number of new cases of a disease
that appear in a given population, over a period of time. 12
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Epidemiology of Primary Headache Headache, in general, is
incredibly common The global lifetime prevalence of headache (all
types), is 66% (male 65%, female 69%) while the 1-year period
prevalence is approximately 47% (male 37%, female 52%) 13
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Headache Classification Committee of the International Headache
Society (IHS) 2013 14
B- Secondary Headaches (10%) 5. Headache attributed to head
and/or neck trauma, including: 5.2 Chronic post-traumatic headache
6. Headache attributed to cranial or cervical vascular disorder,
including: 6.2.2 Headache attributed to subarachnoid hemorrhage
6.4.1 Headache attributed to giant cell arteritis 7. Headache
attributed to non-vascular intracranial disorder, including: 7.1.1
Headache attributed to idiopathic intracranial hypertension 7.4
Headache attributed to intracranial neoplasm 17
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B- Secondary Headaches 8. Headache attributed to a substance or
its withdrawal, including: 8.1.3 Carbon monoxide-induced headache
8.1.4 Alcohol-induced headache 8.2 Medication-overuse headache
8.2.1 Ergotamine-overuse headache 8.2.2 Triptan-overuse headache
8.2.3 Analgesic-overuse headache 9. Headache attributed to
infection, including: 9.1 Headache attributed to intracranial
infection 18
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B- Secondary Headaches 10. Headache attributed to disorder of
homoeostasis 10.1. Headache attributed to hypoxia and/or
hypercapnia 10.2. Dialysis headache 10.3. Headache attributed to
arterial hypertension 10.4. Headache attributed to hypothyroidism
10.5. Headache attributed to fasting 10.6. Cardiac cephalalgia
10.7. Headache attributed to other disorder of homoeostasis 19
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B- Secondary Headaches 11. Headache or facial pain attributed
to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth,
mouth or other facial or cranial structures, including: 11.2.1
Cervicogenic headache 11.3.1 Headache attributed to acute glaucoma
12. Headache attributed to psychiatric disorder 20
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C- Cranial Neuralgias, Central and Primary Facial Pain and
Other Headaches 13. Trigeminal neuralgia 14. Other headache,
cranial neuralgia, central or primary facial pain 21
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Migraine Migraine is recurrent, often life-long, and
characterized by attacks. Prevalence in Turkey: 10% in men and 22%
in women. Most often begins at puberty and most affects those aged
between 35 and 45 years. Has a genetic basis It is caused by the
release of pain-producing inflammatory substances around the nerves
and blood vessels of the head. 22
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Migraine Attacks include features such as headache of moderate
or severe intensity; nausea (the most characteristic), vomiting;
photophobia and phonophobia; one-sided and/or pulsating quality;
aggravated by routine physical activity; 23
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Migraine Attacks include features such as with duration of
hours to 2-3 days; attack frequency is anywhere between once a year
and once a week; and in children, attacks tend to be of shorter
duration and abdominal symptoms more prominent. 24
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Migraine with typical aura Migraine with aura affects one third
of people with migraine and accounts for 10% of migraine attacks
overall. Aura is a subjective sensation or motor phenomenon that
precedes and marks the onset of a neurological condition,
particularly an epileptic seizure or migraine 25
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Migraine with typical aura Characterized by aura preceding
headache, one or more neurological symptoms that develop gradually
over >5 minutes and resolve within 60 minutes: hemianoptic
visual disturbances, or a spreading scintillating scotoma (patients
may draw a jagged crescent if asked) and/or unilateral paresthesia
of hand, arm and/or face and/or (rarely) dysphasia. 26
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Examples of Migraine Aura 27
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Scintillating scotoma 30
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Tension-type headache (TTH) TTH is the most common primary
headache disorder. Episodic TTH is reported by more than 70% of
some populations; chronic TTH affects 1- 3% of adults. TTH often
begins during the teenage years, affecting three women to every two
men. Its mechanism may be stress-related or associated with
musculoskeletal problems in the neck. 31
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Tension-type headache (TTH) Episodic TTH attacks usually last a
few hours, but can persist for several days, are mild or moderate
in severity. Chronic TTH can be unremitting and is much more
disabling than episodic TTH. This headache is described as pressure
or tightness, like a band around the head, sometimes spreading into
or from the neck. 32
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Cluster Headache (CH) CH is relatively uncommon affecting fewer
than 1 in 1000 adults, affecting six men to each woman. Most people
developing CH are in their 20s or older. 33
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Cluster Headache (CH) It is characterized by frequent
recurring, brief but extremely severe headache associated with pain
around the eye with tearing and redness, the nose runs or is
blocked on the affected side and the eyelid may droop. CH has
episodic and chronic forms. 34
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Cluster headache manifests as strictly unilateral, excruciating
pain around the eye recurs frequently, typically once or more
daily, commonly at night is short-lasting, for 15-180 minutes (
typically 30-60 minutes ) causes marked agitation ( the patient,
unable to stay in bed, paces the room, even going outdoors )
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Medication-overuse headache (MOH) MOH is caused by chronic and
excessive use of medication to treat headache. MOH is the most
common secondary headache. It may affect up to 5% of some
populations, women more than men. MOH is oppressive, persistent and
often at its worst on awakening. All acute headache medications may
have this effect 36
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Acute Onset Headache Sudden onset headache is a red flag 38
Critical issues in the evaluation and management of patients
presenting to the emergency department with acute headache: Annals
of Emerg Med 2002 (1):39.
Life Threatening Causes of Acute Headaches contd Infections
Abscess Encephalitis Meningitis Intracranial masses Preeclampsia
Carbon monoxide poisoning 40
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Headache in Primary Care 41
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Taking a Diagnostic History The history is all-important in the
diagnosis of the primary headache disorders and of
medication-overuse headache There are no useful diagnostic tests.
The history should elicit any warning features of a serious
secondary headache disorder. 42
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Warning Features in History Any new headache in an individual
patient, or a significant change in headache characteristics,
should be treated with caution. "I have never had a headache like
this before" "This is the worst headache I have ever had" 43
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Specific Warning Features in History (1/5) Thunderclap headache
( intense headache with explosive or abrupt onset ) subarachnoid
hemorrhage) Estimated prevalence of subarachnoid hemorrhage in the
setting of thunderclap headache is 43% 44
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Specific Warning Features in History (2/5) Headache with
atypical aura ( duration >1 hour, or including motor weakness )
symptoms of transient ischemic attack (TIA) or stroke Aura without
headache in the absence of a prior history of migraine with aura
symptoms of TIA or stroke Aura occurring for the first time in a
patient during use of combined oral contraceptives risk of stroke
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Specific Warning Features in History (3/5) New headache; in a
patient older than 50 years symptom of temporal arteritis or
intracranial tumour, in a pre-pubertal child requires specialist
referral and diagnosis in a patient with a history of cancer, HIV
infection or immunodeficiency secondary headache 46
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Specific Warning Features in History (4/5) Progressive
headache, worsening over weeks or longer intracranial space-
occupying lesion Headache aggravated by postures or maneuvers that
raise intracranial pressure intracranial tumour, CNS infection
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Specific Warning Features in History (5/5) Headache first
occuring with exercise ruptured aneurysm Headache hours to weeks
after a history of trauma, especially in an older person subdural
hematoma Similar new onset of headaches in an acquaintance or
family member environment exposure such as carbon monoxide 48
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Questions to Ask in the History (1/7) How many different
headache types does the patient have? A separate history is needed
for each. Any change in character or intensity? Is this your first
or worst headache? Is this headache like the ones you usually have?
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Questions to Ask in the History (2/7) Time questions Why
consulting now? How recent in onset? When did this headache begin?
How did it start (gradually, suddenly, other)? How frequent, and
what temporal pattern (episodic or daily and/or unremitting)? Do
you have headaches on a regular basis? How long lasting? 50
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Questions to Ask in the History (3/7) Character questions
Intensity of pain? How bad is your pain on a scale of 1 to 10?
Nature and quality of pain? What kind of pain do you have
(throbbing, stubbing, dull, other)? Site and spread of pain? Where
is your pain? Does the pain seem to spread to any other area? If
so, where? 51
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Questions to Ask in the History (4/7) Character questions
Associated symptoms? What symptoms do you have before the headache
starts? What symptoms do you have during the headache? What
symptoms do you have right now? 52
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Questions to Ask in the History (5/7) Cause questions
Predisposing and/or trigger factors? Aggravating and/or relieving
factors? Family history of similar headache? 53
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Common Headache Triggers Alcohol Caffeine Food additives (MSG,
aspartame, tyramine (found in aged cheeses, some red wines, smoked
fish, etc.), sodium nitrite (found in processed meats). 54
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Common Headache Triggers Foods (Chocolate, fruits, dairy,
onions, beans, nuts) Environmental changes (Light, odors (perfume,
paint, etc.), travel, abrupt changes in weather or altitude)
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Common Headache Triggers Lifestyle factors (Insufficient,
excessive, disrupted, or irregular sleep; tobacco or alcohol use;
fasting; physical activity; head injury; schedule changes; stress
or release from stress; anger; or exhilaration) Hormone changes, or
addition of estrogen- containing medication (Timing of headache
with menses or change/ addition of hormones) 56
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Questions to Ask in the History (6/7) Response questions What
does the patient do during the headache? How much is activity
(function) limited or prevented? What medication has been and is
used, in what manner and with what effect? Do you take any
medicines? If so, what? 57
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Questions to Ask in the History (7/7) State of health
Completely well, or residual or persisting between attacks
symptoms? Concerns, anxieties, fears of recurrent attacks and/or
their cause? Do you have other medical problems? If so, what? Have
you recently hurt your head or had a medical or dental procedure?
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Diagnostic Diary Once serious causes have been ruled out, a
headache diary kept over a few weeks clarifies the pattern of
headaches and associated symptoms as well as medication use or
overuse. 59
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Physical Examination Physical examination is mandatory when the
history is suggestive of secondary headache. General appearance,
Does s/he look unwell? Vital signs, Measure BP Head and neck exam
including palpation Neurological exam including fundoscopy ENT
exam, Ophtalmologic exam (astigmatism, glocoma) 60
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Warning Features on Examination Pyrexia Blood Pressure ( sist
>200 mmHg / diast >120 mm Hg) hypertensive encephalopathy, A
palpable tender temporal artery Temporal arteritis Papilledema
increased intracranial pressure 61
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Warning Features on Examination Focal neurological signs Stiff
neck, rush, fever, photophobia, vomiting and other systemic signs
meningitis, encephalitis Headache aggravated by postures or
maneuvers raising intracranial pressure intracranial tumour,
subdural hematoma, epidural bleeding 62
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Investigations Investigations, including neuroimaging, are
indicated when the history or examination suggest headache may be
secondary to another condition. 63
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Case A 26-year-old woman presents to the emergency room with a
severe left-sided throbbing headache associated with nausea,
vomiting, and photophobia. She has tried taking ibuprofen without
relief. On further questioning, she relates that she has been
having similar headaches three to four times per month for the past
year. Her mother had a similar problem. Her exam is normal. 64
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Case This patient has common migraine. 65
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Case A 35-year-old man complains of severe throbbing pain
waking him from sleep at night and persisting into the day. This
pain is usually centered about his left eye and appears on a nearly
daily basis for several weeks or months each year. 66
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Case contd It occurs most prominently at night within a few
hours of falling asleep and is associated with a striking
personality change in which the man becomes combative and agitated.
He never vomits or develops focal weakness. 67
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Case Cluster headache 68
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Case A 30-year-old man presents with a headache that started
yesterday. As he was shoveling snow yesterday, he felt a sudden
pain in the front of his head. The pain does not throb and has been
relatively constant since. He says that now his neck also has
become a little stiff. He carries a diagnosis of migraine
headaches, but says that this is different than his usual
headaches. He is afebrile and has a normal exam except for slight
photophobia and mild discomfort with neck flexion. 69
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Case SUBARACHNOID HEMORRHAGE 70
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References Headache disorders Fact sheet N277 October 2012
World Health Organization
http://www.who.int/mediacentre/factsheets/fs277/en/# Aids for
management of common headache disorders in primary care, World
Health Organization, European Headache Federation J Headache Pain
(2007) 8:S1-47 Aminoff MJ, Kerchner GA. Nervous System Disorders,
Headache in Current Medical Diagnosis & Treatment edts:
Papadakis M, McPhee SJ. 2013;24,962-966 Gamboa S. Headache in
Essentials of Family Medicine edts: Sloane PD, Slatt LM, Ebell MH,
Smith MA, Power D, Viera AJ. 2011;45,533- 541 72
