HEADACHEMARYAM JAMILAH BINTI ABDUL HAMID
082013100002
IMS BANGALORE
LEARNING OUTCOME
Approach to the patients
Diurnal patterns of pain
Clinical approach
Tension type headache
Migraine
INTRODUCTION
Cardinal symptoms and very common complaint
Can be classified as primary or secondary
Commonest cause of headache is respiratory
infection
Diagnostic strategy model
1. Probability diagnosis
Acute: Respiratory infection
Chronic:
A. Tension-type headache
B. Combination headache
C. Migraine
D. Transformed migraine
2. Serious disorders not to be missed
Cardiovascular: SAH, intracranial haemorrhage,
carotid/vertebral artery dissection, temporal arteritis,
cerebral venous thrombosis
Neoplasia: cerebral tumour, pituitary tumor
Severe infections: meningitis, encephalitis, intracranial
abscess
Haematoma: extradural/subdural
Glaucoma
Benign intracranial HT
3. Pitfalls (often missed)
Cervical spondylosis/dysfunction
Dental disorders, refractive errors of eyes, sinusitis,
ophthalmic herpes zoster, exertion headache,
hypoglycemia, post-traumatic headache, post-
spinal procedure, sleep apnoea
rarities: Paget disease, post-sexual intercourse,
Cushing syndrome, Conn syndrome, Addison
disease, dysautonomic cephalgia
4. Masquerades checklist
Depression, diabetes, drugs, anaemia,
thyroid/endocrine disorder, spinal dysfunction
(cervicogenic), UTI
5. Psychogenic disorder
Timelines for causes of
headache/facial pain
Acute severe headache
SAH
Benign sex or exertional
headache
migraine/cluster headache
Subacute headache (recent
onset, increasing)
expanding intracranial lesion
temporal arteritis
Recurrent episodes
• Migraine/cluster headache
• benign sex or exertional headache
• neuralgia (trigeminal)
Chronic headache
• tension-type headache
• transformed migraine/rebound
headache
• cervivogenic/post-traumatic
• atypical facial pain
Diurnal patterns of pain
CLINAL APPROACH
Hx:
describe your headache (pain)
tempo, night/day, episodes
other symptoms during
headache; nausea/vomit
aura,light hurts your eyes,
blurred vision
watering or redness of one or
both eyes
• pain when combing hair
• stress
• cold during headache?
• tablets
• high temperature, sweats and
chill
• trouble with sinuses
• trauma
Examination
thermometer, sphygmomanometer, pen torch. diagnostic
set (ophthalmoscope & stethoscope)
inspect: head, temporal arteries & eyes
palpate: temporal arteries, facial, neck muscles, cervical
spine, sinuses teeth and TMJ
mental state examination- altered consciousness or
cognition, assessment of mood, anxiety-tension-
depression,any mental changes
neurological examination
Special signs
Upper cervical pain sign: palpate C2 & C3 (cervical spine
area, 2 finger breadths out from spinous process of C2)
Ewing sign for frontal sinusitis: press finger gently upwards
& inwards against orbital roof medial to the supra-orbital
nerve. Pain on pressure is a positive
Invisible pillow sign: Pt. lies with head on pillow.Examiner
support head with hands as the pillow is removed,ask pt.
relax the neck muscles & examiner remove the supporting
hands.Positive test indicate tension from contracting neck
muscles pt’s head does not readily to change position.
uncommon
RED FLAGS INDICATORS
sudden onset esp. no previous hx
severe & debilitating pain
progressive
fever
vomiting
disturbed consciousness/confusion,
drowsiness
personality changes
worse with bending, coughing or
sneezing
maximum in morning
wakes patient at night
neurological & visual
symptoms/signs
seizure
young obese female:? on
medication
‘New’ in elderly
post head injury
RED FLAGS POINTERS
From physical examination
Altered consciousness or cognition
meningism
abnormal vital signs: BP, temperature, respiration
focal neurological signs, including pupil, fundi, eye
movement
tender, poorly pulsatile temporal arteries
INVESTIGATIONS
Hb
White cell count
ESR/CRP
radiography:
• CXR: lung mets to brain
• cervical spine
• skull X-ray; brain tumor, Paget disease, deposits in skull
• sinus X-ray
• CT scan: brain tumor (most effective),
cerebrovascular accident (valuable), SAH
• radioisotope scan (technetium-99m) localise
specific tumors & hematoma
• MRI: very effective for intracerebral pathology
but expensive; better definition of intracerebral
structures than CT scan but not sensitive for
detecting bleeding; detect intracranial vasculitis
in temporal arteries
• LP: meningitis, suspected SAH (only if CT scan
normal) *dangerous if raised intracranial
pressure
Headache in children
Resp. infections & febrile illness are common causes
isolated headache but chronic
migraine-before adolescence; 1% aged 7 yrs to 5% aged 15 yrs. no aura, strong
fam. hx, vertebrobasilar migraine (girls), hemiplegia (infants, children)-1st attack
tension or muscle contraction headache-after adolescence
progressive headaches->ICSOL, typically morning,vomit,dizziness,
diplopia,ataxia,personality changes,deterioration of school performance
neonates & children (aged 6-12months); greater risk for meningitis
paracetamol 20mg/kg statim then 15 mg/kg 4-6 hrly up to 90 mg/kg/day
ibuprofen 5-10 mg/kg statim up to 40 mg/kg/day (not for children <6 months)
Headache in elderly
must be treated with caution; could herald serious
problem such as space occupying lesions
(neoplasm,subdural hematoma), TA, trigeminal
neuralgia or vertebrobasilar insufficiency
difference between late onset migraine with TIA
vomiting suggesting migraine
Age-related causes of headache
Age-related causes of headache
children
Intercurrent infections
Psychogenic
Migraine
Meningitis
Post-traumatic
adults
Migraine
Cluster headache
Tension
Cervical dysfunction
SAH
Combination
elderly
Cervical dysfunction, Cerebral tumor,
Temporal arteritis, Neuralgias, Paget
disease, Glaucoma, Cervical
spondylosis, SAH
TENSION-TYPE
HEADACHE
TENSION-TYPE HEADACHE
tension or muscle contraction type headache
typically symmetrical B/L tightness
last or hours and recur each day
ass. cervical dysfunction & stress or tension
75% females
IHS criteria
IHS criteria for tension-type headache
International Headache Society (IHS3):-
A. The patient should have had at least 10 of these headaches
B. Headache last from 30 min to 7 days
C. Headache must have at least 2 of the following 4:-
• non-pulsating quality
• mild/moderate intensity
• B/L location
• no aggravation with routine physical activity
D. Headache must have both of the following:-
• no nausea or vomiting
• photophobia and phonophobia are absent, or one but not the other is
present
E. No attributable to another disorder
Clinical features of tension headache
Site: Frontal, over forehead & temples
Radiation: occiput
Quality: dull ache, like a ‘tight pressure feeling’, ‘heavy weight on
top of head’, ‘tight band around head’; tightness or vice-like
feeling rather than pain
Frequency: almost daily
Duration: almost daily
Onset: after rising, gets worse during day
Aggravating factors: stress, overwork with skipping
meals
Relieving factors: alcohol
Associated features: lightheadedness, fatigue.
neck ache or stiffness (occiput to shoulder),
perfectionist personality, anxiety/depression
Physical examination: muscle tension (frowning),
scalp often tender to touch, ‘invisible pillow sign’
might be positive
Management of tension-type
headache
Patient education: scalp muscles get tight like the
calf muscles when climbing up stairs
Counselling & relevant advice; CBT(Cognitive
Behavioural Therapy)
Stress reduction
Medication
MIGRAINE
Migraine
‘sick headache’, 1:10, F>M, peak 20-50 yrs old
classic migraine & common migraine are best
known
most common trigger factor is stress
Types of vascular headache
Common migraine (aura is
vague or absent)
Classic migraine
Complicated migraine
Unusual forms of migraine:
• hemiplegic, basilar, retinal,
migrainous (vestibular)
vertigo, migrainous stupor,
ophthalmoplegic, migraine
equivalents, status
migrainosus
Cluster headache
Chronic paroxysmal
hemicrania
Menstrual migraine
Lower half headache
Benign exertional sex
headache (beware SAH)
Miscellaneous (icepick
pains, ‘ice cream’ headache)
Migrainous trigger factors
Exogenous
Foodstuffs-chocolate,
oranges, tomatoes, citrus
fruits, cheeses, gluten
sensitivity
alcohol- esp. red wine
drugs- vasodilators,
estrogens, MSG,
nitrites(‘hot dog’ headache),
indomethacin, OCP
Glare or bright light (32%)
Emotional stress (63%)
head trauma
allergen
climate change
excessive noise
strong perfume
Endogenous
tiredness, physical exhaustion, oversleeping
lack of sleep
stress,relaxation after stress- ‘weekend migraine’
exercise/physical stress
hormonal changes: puberty, menses, climacteric, pregnancy
hunger
fam. tendency
?personality factors
Clinical features of Classic Migraine
Site: temporofrontal region
(unilateral), can be bilateral
Radiation: retro-orbital & occipital
Quality: intense & throbbing
Frequency: 1-2 per month
Duration: 4-72 hours (average 6-8
hours)
Onset: paroxysmal,often wakes
with it
Offset: spontaneous (often after
sleep)
Precipitating factors: tension &
stress
Aggravating factors: tension,
activity
Relieving factors: sleep,
vomiting
Associated factors: nausea,
vomiting (90%), irritability, aura
Other pointers: abd. pain in
childhood, fam hx migraine,
asthma, eczema
IHS3 criteria for migraine with typical
aura (classic)
A. At least 2 attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura symptoms: visual, sensory, speech and/or language, motor, brainstem, retinal
C. At least two of:
• at least one aura symptoms spreads gradually over at least 5 minutes
• each aura symptoms lasts 5-60 minutes
• at least one symptom is unilateral
• headache follows aura within 60 minutes
D. not attributable to another disorder including TIA
IHS3 criteria for common migraine
A. The patient should have had at least 5 attacks fulfilling criteria B and D
B. Headaches last 4-72 hours
C. Headache must have at least 2 of the following:-
• unilateral location
• pulsating quality
• moderate or severe intensity, inhibiting or prohibiting daily activities
• headache worsened by routine physical activity
D. Headache must be at least 2 of the following:-
• nausea and/or vomiting
• photophobia and phonophobia
E. Not attributable to another disorder
Management of Migraine
Counselling and advice
Treatment of acute attack
Treatment for severe attack
Prophylaxis
Treatment of acute attack
commence treatment at earliest impending sign
mild headaches; 2 aspirins/PCM, lie down in a dark quiet, cool room
cold packs on forehead or neck
avoid coffee, tea or orange juice
avoid moving around too much
don’t read or watch tv
patient who relieve by sleeping off an attack, consider prescribe temazepam
10 mg or diazepam 10 mg
moderate attack oral ergotamine or sumatriptan
avoid opioids
Medication (if necessary)
1st line acute migraine:
aspirin/PCM + anti-emetic; aspirin 600-900 mg (o) & metoclopramide 10 mg (o)
PCM/ibuprofen (children)
triptans; sumatriptan 50-100 mg (o) at prodrome, repeat in 2 hrs if necessary, max 300mg/day. or nasal spray 10-20 mg/nostril (upto 40mg/24hr) or 6mg SC repat 1hr or more to max dose 12 mg/24hr
zolmitriptan 2.5-5 mg (o), rpeat in 2 hr if nec. (max 10 mg/24 hr)
naratriptan 2.5 mg (o), repeat in 4 hr (max 5mg/24 hr)
rizatriptan 10mg of wafer, repeat in >2 hr (max 30mg/24 hr)
eletriptan 40-80 mg (o) up to 160 mg/24 hr
Treatment of severe attack
at home: sumatriptan 6 mg (SC)
in surgery or emergency room:
• metoclopramide 10 mg IV slowly over 2 mins + oral analgesics or
• metoclopramide 10 mg IV + dihydroergotamine 0.5 mg IV slowly or
• simatriptan 6mg SC or
• chlorpromazine 0.1 mg/kg IV infusion over 30 mins
*do not use ergotamine if sumatriptan used in previous 6 hrs and do not use sumatriptan if ergotamine is used in previous 24 hrs
practice tips: IV metoclopramide + 1 L NS IV in 30 mins + oral aspirin/PCM + continue high fluid intake
STATUS MIGRAINOSUS
Persistent migraine; lasts >72 hours
IV dihydroergotamine 0.25-1 mg over 2 minutes
(may have to be given 8hrly over 3-7 days in
hospital) or
chlorpromazine 0.1 mg/kg IV, repeat every 15
mins for up to 3 doses (if necessary)
consider corticosteroids (dexamethasone 10-20
mg IV statim & taper)
Prophylaxis migraine
non-drug self-management
beta blockers- propranolol 40mg (o) BD or TID
(max 320 mg/day)
TCA-amitriptyline
sodium valproate
cyproheptadine (children)
Menstrual migraine
Naproxen 550 mg (o) BD, 48 hrs before expected
attack for 4-10 days or
estradiol gel 1.5mg transdermally, once daily for 7
days
Guidelines
if low or N weight-pizotifen
if HT-beta blocker
if depressed or anxious-amitriptyline
if tension-beta blocker
if cervical spondylosis-naproxen
food-sensitive migraine-pizotifen
menstrual migraine-naproxen or mefenamic acid or ibuprofen or
estradiol transdermal gel
Take home points
diagnose headache causes
tension headache -reassurance and lifestyle
changes
migraine -should know to differentiate common
and classical, treatment during attack and
prophylaxis
REFERENCES
Murtagh’s General practice, 6th edition
Davidson’s Medicine textbook
http://www.webmd.com/migraines-
headaches/guide/status-migrainosus-symptoms-
causes-treatment
THANK YOU !