The document provides an overview of the classification and treatment of primary headaches according to the International Headache Society. It discusses the four main categories of primary headache - migraine, tension-type headache, trigeminal autonomic cephalalgias (TACs), and other headaches. For each category, it provides the diagnostic criteria and recommendations for treatment, including acute and preventive pharmacological management. The treatment sections cover over-the-counter and prescription medications such as NSAIDs, triptans, antidepressants, anticonvulsants, and other therapeutic options.

1. PRIMARY HEADACHE Overview of diagnosis , classification and treatment DR.SRIRAMA ANJANEYULU

2. INTERNATIONAL HEADACHE SOCIETY ICHD-1 IN 1998 BY IHS. ICHD-2 IN 2004. PRIMARY HA- 4 categories : migraine , TTH , TAC’S and other HA’S. Criteria is clinical and descriptive and exclusion of others but not on etiology. SECONDARY HA- 8 cat, based on etiology and attributed to other disorder.

3. CLASSIFICATION & DIAGNOSTIC CRITERIA

4. IHS CLASSIFICATION Part I: The Primary Headaches 1. Migraine 2. Tension-type headache 3. Cluster headache and other trigeminal autonomic cephalalgias 4. Other primary headaches Part II: The Secondary Headaches 5. Headache attributed to head and/or neck trauma 6. Headache attributed to cranial or cervical vascular disorder 7. Headache attributed to non-vascular intracranial disorder 8. Headache attributed to a substance or its withdrawal 9. Headache attributed to infection 10. Headache attributed to disorder of homoeostasis 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures 12. Headache attributed to psychiatric disorder Part III: Cranial Neuralgias Central and Primary Facial Pain and Other Headaches 13. Cranial neuralgias and central causes of facial pain 14. Other headache, cranial neuralgia, central or primary facial pain

5. OPERATIONAL RULES FOR ICHD-2 HIERARCHICAL CLASSIFICATION. EACH HA AND SUB TYPE IN LAST YEAR SHOULD BE GIVEN DIAGNOSIS. PROBABLE CATEGORIES. PRIMARY HA- DIAGNOSIS BY INCUSION AND EXCLUSION. SEC.HA-TEMPORAL RELATIONSHIP AND ATTRIBUTION TO ANOTHER DISORDER. DIAGNOSIS OF SEC.HA IN PRIMARY HA’S.

6. PRIMARY HEADACHE MIGRAINE. TENSION TYPE. TAC’S. OTHER HA’S.

7. MIGRAINE 1.0 1.1-MIGRAINE WITHOUT AURA. 1.2-MIGRAINE WITH AURA. 1.3-CHILDHOOD PERIODIC SYNDROMES . 1.4-RETINAL MIGRAINE. 1.5-COMPLICATIONS OF MIGRAINE. 1.6-PROBABLE MIGRAINE.

8. 1.1-MIGRAINE WITHOUT AURA

9. MIGRAINE WITH AURA -1.2 1.2.1-TYPICAL AURA WITH MIGRAINE. 1.2.2-TYPICAL AURA WITH NON MIGRAINE HEADACHE. 1.2.3-TYPICAL AURA WITHOUT HEADACHE. 1.2.4-FAMILIAL HEMIPLEGIC MIGRAINE. 1.2.5-SPORADIC HEMIPLEGIC MIGRAINE. 1.2.6-BASILAR TYPE MIGRAINE.

10. 1.2.1-TYPICAL AURA WITH MIGRAINE HEADACHE

11. TENSION TYPE HEADACHE

12. CTTH

13. DIAGNOSTIC CRITERIA FOR CLUSTER HEADACHE

14. DIAGNOSTIC CRITERIA FOR PAROXYSMAL HEMICRANIA

15. DIAG. CRITERIA FOR SUNCT(SHORT LASTING UNILATERAL NEURALGIFORM HEADACHE ATTACKS WITH CONJUNCTIVAL INJECTION AND TEARING)

16. CLINICAL FEATURES OF TAC’S

17. OTHER PRIMARY HEADACHES PRIMARY STABBING HA. PRIMARY COUGH HA. PRIMARY EXERTIONAL HA. PRIMARY HA ASSOCIATED WITH SEXUAL ACTIVITY. HYPNIC HA. PRIMARY THUNDER CLAP HA. HEMICRANIA CONTINUA. NDPH.

18. DIAGNOSTIC CRITERIA FOR PRIMARY STABBING HA

19. DIAGNOSTIC CRITERIA FOR PRIMARY COUGH HA

20. DIAGNOSTIC CRITERIA FOR PRIMARY EXERTIONAL HA

21. DIAGNOSTIC CRITERIA FOR PRIMARY HA ASSO. WITH SEXUAL ACTIVITY

22. DIAGNOSTIC CRITERIA FOR HYPNIC HA

23. DIAGNOSTIC CRITERIA FOR THUNDER CLAP HA

24. DIAGNOSTIC CRITERIA FOR HEMICRANIA CONTINUA

25. DIAGNOSTIC CRITERIA FOR NEW DAILY PERSISTENT HEADACHE

26. DIAGNOSTIC CRITERIA FOR NUMMULAR HEADACHE

27. DIAGNOSIS

28. RED FLAGS IN DIAGNOSIS OF HA

29. ALGORITHM FOR HA DIAGNOSIS

30. ALGORITHM FOR PRIMARY HEADACHE DIAGNOSIS

31. TREATMENT

32. TREATMENT OF MIGRAINE -AVOIDING TRIGGERS

33. STAGED APPROACH

34. NSAIDS TYPES

35. ANALGESICS

36. U.S HEADACHE CONSORTIUM CONCLUSIONS AND RECOMMENDATIONS ASPRIN, NAPROXEN , IBUPROFEN, DICLONAC-K SHOULD BE USED FOR THE ACUTE TREATMENT OF NON -DISABLING MIGRAINE (LEVEL -A). KETORLAC IV OR IM SHOULD BE CONSIDERED FOR ACUTE TREATMENT OF MIGRAINE FOR PATIENTS REQUIRING PARENTERAL THERAPY (LEV-B). ACETAMINOPHEN SHOULD BE CONSIDERED FOR THE ACUTE TREATMENT OF NON DISABLING MIGRAINE (LEV-B). AAC SHOULD BE USED FOR THE ACUTE TRATMENT OF MIGRAINE (LEV-A).

37. REC. FOR BARBITURATE HYPNOTICS BUTALBITAL CONTAINING ANALGESICS ARE NOT RECOMMENDED AS FIRST LINE THERAPY FOR THE ACUTE TREATMENT OF MIGRINE (LEV-U). LIMIT AND CAREFULLY MONITOR PATIENT’S USE OF BUTALBITAL CONTAINING ANALGESICS BECAUSE OF RISK OF DEPENDENCY, MEDICATION OVER USE HEADACHE AND WITHDRAWAL CONCERNS (LEV-U).

38. DOSES OF DOPAMINE ANTAGONISTS

39. RECOMMENDATIONS FOR DOPAMINE ANTAGONISTS ORAL METACLOPRAMIDE AS MONOTHERAPY SHOULD NOT BE USED FOR THE ACUTE TREATMENT OF MIGRAINE( LEV-A). HOWEVER ,ORAL METACLOPRAMIDE PROBABLY SHOULD BE CONSIDERED AS ADJUNCT THERAPY TO NSAIDS OR TRIPTANS FOR ACUTE TEATMENT (LEV-B). MET.IM SHOULD PROBABLY NOT BE USED AS MONOTHERAPY FOR ACUTE TEATMENT FOR PATIENTS REQUIRING PARENTERAL THERAPY (LEV-B). MET.IV SHOULD BE CONSIDERED FOR THE ACUTE TREATMENT OF MIGRAINE FOR PATIENTS REQUIRING PARENTERAL THERAPY (LEV-B). CHLORPROMAZINE IV AND PROCHLORPERAZINE IV SHOULD BE USED FOR ACUTE TREATMENT OF MIGRAINE FOR PATIENTS REQUIRING PARENTERAL THERAPY (LEV-A). ONDASETRAON AND GRANISETRAN SHOULD NOT BE CONSIDERED FOR ACUTE TREATMENT OF MIGRAINE (LEV-B).

40. 5-HT 1 AGONISTS

41. RECOMMENDATIONS FOR DHE DHE NS SHOULD BE USED FOR THE ACUTE TREATMENT OF MIGRAINE IN ADULTS (LEV-A). DHE IM, SC, IV MAY BE USED IN THE TREATMENT OF MIGRAINE (LEV-B).

42. HEADACHE RESPONSE FOR TRIPTANS

43. RECOMMENDATIONS FOR TRIPTANS ALL 7 TRIPTANS IN ALL FORMULATIONS ( ORAL TABLETS, ORAL DISINTEGRATING TABLETS, NS’S& INJECTABLES) SHOULD BE USED FOR THE ACUTE TREATMENT OF MILD, MODERATE OR SEVERE MIGRAINE (LEV-A). FOR PATIENTS WHO EXPERIENCE MIGRAINE RELATED DISABILITY, TRIPTANS SHOULD BE USED BY ADULTS FOR THE ACUTE TREATMENT OF MIGRAINE UNLESS CONTRAINDICATED (LEV-A). COMBINATIONS OF TRIPTANS AND NAPROXEN SHOULD BE USED IN THE ACUTE TREARMENT OF MIGRIAINE AND OFFERS IMPROVED CLINICAL RESPONSE OVER EITHER TREATMENT GIVEN AS MONOTHERAPY (LEV-A) .

44. Oral CGRP Receptor Antagonist Multicentre, randomised, placebo-controlled clinical trial in adult patients with acute migraine. A total of 1,703 patients were randomised into the study and 1,294 administered study treatment. Telcagepant (MK-0974)at doses of either 300 mg (n=371), 150 mg (n=381), 50 mg (n=177) or placebo (n=365). Analysing five primary endpoints at two hours post-dose: pain freedom (reduction to no pain), pain relief (reduction to mild or no pain), absence of photophobia (sensitivity to light), absence of phonophobia (sensitivity to sound), and absence of nausea. Telcagepant was significantly greater than placebo for all five primary endpoints in the study (p<0.001 for both doses on all endpoints . Most common side effects were fatigue (6.8 %), dizziness (5.4 %), dry mouth (5.1 %), nausea (5.1 %), upper abdominal pain (3.2 %) and somnolence (2.7 %) European Headache and Migraine Trust International Congress 2008 in London.

45. PROPHYLAXIS - INDICATIONS RECURRING MIGRAINE ATTACKS THAT IN THE PATIENTS OPINION, SIGNIFICANTLY INTERFERE WITH HIS OR HER DAILY ROUTINES, DESPITE APPROPRIATE TREATMENT. FREQUENT HEADACHES, >4/MONTH. CONTRAINDICATION TO, FAILURE WITH, OVERUSE OF, OR INTOLERENCE TO ACUTE THERAPIES. PATIENT PREFERENCE. PRESENCE OF UNCOMMON MIGRAINE CONDITIONS, INCLUDING HEMIPLEGIC MIGRAINE, BASILAR MIGRAINE, MIGRAINE WITH PROLONGED AURA, OR MIGRAINOUS INFARCTION. (Silberstein on behalf of the quality standards improvement committee,2007,revised US EBM guidelines)

46. ANTIDEPRESSENTS IN PROPHYLAXIS

47. PRINCIPLES OF ANTIDEPRESSENTS USE TCA’S DOSE IS WIDE AND MUST BE INDIVIDULISED. TCA’S CAUSE SEDATION EXCEPT PROTRIPTYLINE. START WITH LOW DOSE AT BED TIME . IF TOO SEDATING SWITCH FROM TERTIARY TCA’S (AMITRIPTYLINE, DOXEPIN) TO SECONDARY TCA’S( NORTRIPTYLINE, PROTRIPTYLINE). IF INSOMNIA OR NIGHTMARES DEVELOP GIVE TCA IN MORNING. SSRI ‘S CAN BE USED OD MORNING OR EVENING, LESS SEDATING THAN TCA’S, MAY NEED HYPNOTIC FOR SLEEP INDUCTION. BIPOLAR PATIENTS IN A DEPRESSED STATE CAN BECOME MANIC ON ANTIDEPRESSANTS.

48. AED’S FOR MIGRAINE PROPHYLAXIS

49. ß- BLOCKERS FOR PROPHYLAXIS

50. Ca CHANNEL BLOCK ERS FOR PROPHYLAXIS

51. MISCELLANEOUS MEDICINES

53. TREATMENT OF STATUS MIGRAINOUS

54. TREATMENT OF TTH

55. Treatment of TTH

56. ABORTIVE MANAGEMENT OF CLUSTER HA

57. PREVENTIVE MANAGEMENT OF CLUSTER HA

58. TREATMENT OF PAROXYSMAL HEMICRANIA PREVENTIVE. INDOMETHACIN. TYPICAL DOSE=25-100 mgs. DOSAGE RANGE=12.5-300. SKIPPING OR DELAYING DOSES- PROMPT REOCCURENCE OF HA. DRUG WITHDRAWAL ADVISED AT LEAST ONCE IN EVERY 6 MONTHS. GI SIDE EFFECTS.

59. TREATMENT OF SUNCT PREVENTIVE. LAMOTRIGINE - TREATMENT OF CHOICE, 1 ST LINE. TOPIRAMATE, GABAPENTINE- 2ND LINE DRUGS. CARBAMAZEPINE –IF BOTH FAIL. IF ACUTE INTERVENTIONS ARE NEEDED- IV LIDOCAINE.