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 !