Approach to Headache

Dr. Faisal Al Hadad

Consultant of Family Medicine & Occupational Health

PSMMC

Introduction

Headache is defined as diffuse pain in various parts of the head, with the pain not confined to the area of distribution of a nerve.

Headache is among the most common pain problems encountered in family practice.

Classification

1. Primary headaches (benign, recurrent, no organic disease):

Migraine Tension-type headache and Cluster headache

2. Secondary headaches are caused by underlying organic diseases.

Acute Secondary Headache Disorders

1. Headache associated with head trauma

2. Headache associated with vascular disorders SAH Acute ischemic cerebrovascular disorder Unruptured vascular malformation Arteritis (e.g. temporal arteritis) Arterial HTN

3. Headache associated with nonvascular intracranial disorder Benign intracranial HTN (pseudotumor cerebri) Intracranial infection Low CSF pressure (e.g., headache subsequent to LP)

Contd;

4. Headache associated with substance use or withdrawal

5. Headache associated with noncephalic infection (viral infection,bacterial infection)

6. Headache associated with metabolic disorder (hypoxia, hypercapnia, hypoglycemia, dialysis)

7. Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose, sinuses, teeth or mouth

8. Cranial neuralgias pain

History

FIRST OR WORST HEADACHE

Primary headaches can occur at any age but most often begin during childhood or between 20 and 50 years of age.

Onset of headache after 50 years of age is a red flag for consideration of a secondary headache disorder such as temporal arteritis or a mass lesion.

If the patient routinely has headaches, it is important to determine whether the current episode is typical. Is this headache like the ones you usually have?

History

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?

Primary headache disorder such as cluster headache (ipsilateral lacrimation and/or nasal congestion) or migraine with aura (e.g., scotomata, photophobia, phonophobia, nausea).

Secondary headache disorder (stiff neck, disorientation, rash, fever, eye pain, diplopia, unilateral paresthesias, unilateral weakness, balance change).

History

ONSET

Whether start gradually or suddenly?

Headache of sudden and severe onset can be due to : SAH Vascular malformations Acute ischemic CVA Posterior fossa mass lesions.

History

LOCATION AND RADIATION OF PAIN

Cluster headaches are strictly unilateral.

Tension-type headaches are usually band-like and bilateral.

Migraines generally begin unilaterally but may progress to involve the entire head.

Pain along the distribution of the temporal artery may suggest temporal arteritis, and pain along the distribution of the trigeminal nerve may be a sign of trigeminal neuralgia

Eye pain may suggest acute glaucoma.

History

SEVERITY AND QUALITY OF PAIN

Tension-type headache: Mild or moderate, pressing or tightening pain.

Cluster headache : Severe, stabbing pain

Migraine headache: Moderate or severe, pulsating, throbbing or dull aching pain.

History

CONCURRENT MEDICAL CONDITIONS

Meningitis CNS lymphoma Toxoplasmosis Metastases Intracranial vascular disorder Acute viral syndrome or acute bacterial infection

History

MEDICATIONS

Prescription and over-the-counter medications (especially caffeine-containing analgesics) have been implicated as triggers for drug-rebound and nonspecific headaches.

Thus, it is important to review any medication that a patient is taking for its potential to cause headache.

History

RECENT TRAUMA OR PROCEDURES

Headache subsequent to trauma may signify a postconcussive disorder, although ICH should always be suspected.

Migraine and cluster headaches may be triggered by head trauma.

Headache has also been associated with common medical procedures (e.g. LP, rhinoscopy) and dental procedures (e.g., tooth extraction).

Diagnostic Criteria for Cluster Headache

A. At least five attacks fulfilling criteria B through D

B. Severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes

C. Headache associated with at least one of the following signs on the pain side:1. Conjunctival injection2. Lacrimation3. Nasal congestion4. Rhinorrhea5. Forehead and facial sweating6. Miosis7. Ptosis8. Eyelid edema

D. Frequency of attacks: one attack every other day to eight attacks per day

Diagnostic Criteria for Episodic Tension-Type Headache

A. At least 10 previous headache episodes fulfilling criteria B through D; number of days with such headaches: less than 180 days per year

B. Headache lasting from 30 minutes to 7 days

C. At least two of the following pain characteristics:1. Pressing or tightening quality2. Mild or moderate intensity3. Bilateral location4. No aggravation by walking stairs or similar routine physical activity

D. Both of the following:1. No nausea or vomiting 2. Photophobia and phonophobia are absent, or one but not the other is

present.

Diagnostic Criteria for Migraine without aura

A. At least five attacks fulfilling criteria B through D

B. Headache lasting 4 to 72 hours

C. At least two of the following pain characteristics:1. Unilateral location2. Pulsating quality3. Moderate or severe intensity4. Aggravation by walking stairs or similar physical activity

D. During headache, at least one of the following:1. Nausea and/or vomiting2. Photophobia and phonophobia

Diagnostic Criteria for Migraine with aura

A. At least two attacks fulfilling criterion B

B. At least three of the following characteristics:

1. One or more fully reversible aura symptoms indicating focal cerebral cortical and/or brain-stem dysfunction

2. At least one aura symptom develops gradually over more than 4 minutes, or two or more symptoms occur in succession.

3. No aura symptom lasts more than 60 minutes

4. Headache follows aura, with a free interval of less than 60 minutes.

Physical Examination

The primary purpose of the physical examination is to identify causes of secondary headaches.

General physical examination: - VS (BP, temperature) - Funduscopic examination (papilledema) - CV assessment (assess risk of CVA) - Palpation of the head and face (R/O sinusitis)

Complete neurologic examination (focal neurologic signs)

Neurological examination

Mental status Level of consciousness Cranial nerve testing Motor strength testing Deep tendon reflexes Pathologic reflexes (e.g. Babinski’s sign) Sensation Cerebellar function Gait testing Signs of meningeal irritation (Kernig’s and Brudzinski’s signs).

Red Flags

Headache beginning after 50 years of age (temporal arteritis, mass lesion)

Sudden onset of headache (SAH, hemorrhage into a mass lesion or vascular malformation, mass lesion especially posterior fossa mass)

Headaches increasing in frequency and severity (mass lesion, subdural hematoma, medication overuse)

New-onset headache in patient with risk factors for HIV infection or cancer (brain abscess, meningitis, metastasis)

Red Flags

Headache with signs of systemic illness (e.g. fever, stiff neck, rash indicating meningitis)

Focal neurologic signs (mass lesion, vascular malformation, stroke, collagen vascular disease evaluation)

Papilledema (mass lesion, pseudotumor cerebri, meningitis)

Headache subsequent head trauma (ICH, subdural hematoma, epidural hematoma, post traumatic headache)

Investigations

Laboratory Random use of laboratory testing in the evaluation of acute

headache is not warranted. CBC when systemic or intracranial infection is suspected ESR when temporal arteritis is a possibility.

Neuroimaging Neuroimaging is not usually warranted in patients with primary

headaches . CT scanning is recommended to identify acute hemorrhage. MRI studies are recommended to evaluate the posterior fossa.

Investigations

Lumbar Puncture CT scanning without contrast medium, followed by LP if the

scan is negative, is preferred to rule out SAH within the first 48 hours.

LP is useful for assessing the CSF for blood, infection and cellular abnormalities.

Headaches are associated with low CSF pressure (e.g. post-traumatic leakage of CSF) and elevated CSF pressure (e.g. idiopathic intracranial HTN and CNS space-occupying lesions)

Indications of referral to Neurologist

Physician has inadequate level of comfort in diagnosing or treating patient’s headache.

Patient requests a referral. Patient does not respond to treatment. Patient’s condition or disability continues or worsens. Physician is unable to classify patient’s headache according to

diagnostic criteria for primary or secondary headache disorders.

Habituation or rebound headaches limit outpatient management.

Patient has intractable or daily headaches.

Thank you

Level of consciousness

Eye opening Spontaneous To speech To pain None

Verbal response Oriented Confused Words Sounds None

Level of consciousness

Motor response Obey commands Localising pain Flexing to pain Extending to pain None

Higher cerebral function

Congnitive skills Dysphasia (expressive/receptive/nominal) Dyslexia Dysgraphia Dyscalculia Agnosia

Memory test Immediate Recent Remote Verbal Visual

Higher cerebral function

Reasoning and problem solving Two-step calculation Reverse 3/4 random numbers Explain proverb

Emotional state Anxiety Depression Personality disorder

Cranial nerves examination

1. Olfactory (I)

2. Optic nerve (II) Visual acuity Visual fields Optic fundus Pupils (equality, RX to light, RX to accomodation

and convergence)

Cranial nerves examination

Oculomotor (III) Ptosis Pupil Ocular movement

Trochlear (IV) and Abducens (VI) LR6 SO4

Cranial nerves examination

Trigeminal (V) Sensation Corneal reflex Motor examination

Facial (VII) Asymmetry Frontalis Orbicularis oculi Buccinator Orbicularis oris Taste

Cranial nerves examination

Auditory (VIII) Weber’s test Rinne’s test

Glossopharyngeal (IX) Swallowing Uvula Gag reflex

Cranial nerves examination

Accessory (XI) Sternomastoid Trapezius

Hypoglossal (XII) Tongue atrophy Tongue fibrillation Tongue deviation

Motor, Sensation and Reflexes

Motor Muscle wasting Tone Power

Sensation Pain Touch Temperature Joint position Vibration

Reflexes (deep tendon, pathologic)

Cerebellar function and meningeal irritation signs

Cerebellar function Finger-nose testing Supination and pronation of the forearms Romberg’s test Gait

Signs of meningeal irritation Kernig’s sign Brudzinski’s sign

Thank you