Approach to the patients Diurnal patterns of pain Clinical approach Tension type headache Migraine

1. HEADACHE
MARYAM JAMILAH BINTI ABDUL HAMID
082013100002
IMS BANGALORE

2. LEARNING OUTCOME
Approach to the patients
Diurnal patterns of pain
Clinical approach
Tension type headache
Migraine

3. INTRODUCTION
Cardinal symptoms and very common complaint
Can be classified as primary or secondary
Commonest cause of headache is respiratory
infection

6. Diagnostic strategy model
1. Probability diagnosis
Acute: Respiratory infection
Chronic:
A. Tension-type headache
B. Combination headache
C. Migraine
D. Transformed migraine

7. 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

8. 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

9. 4. Masquerades checklist
Depression, diabetes, drugs, anaemia,
thyroid/endocrine disorder, spinal dysfunction
(cervicogenic), UTI
5. Psychogenic disorder

10. 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

11. Diurnal patterns of pain

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. • 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

19. 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)

21. 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

22. 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

23. TENSION-TYPE
HEADACHE

25. 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

26. 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

27. 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

28. 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

29. 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

30. MIGRAINE

32. 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

33. 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)

34. 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

35. 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

36. 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

37. 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

38. IHS3 criteria for common migraine
A. The patient should have had at least 5 attacks fulfilling criteria Band 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

39. Management of Migraine
Counselling and advice
Treatment of acute attack
Treatment for severe attack
Prophylaxis

40. 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

41. 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

42. 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

43. 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)

44. Prophylaxis migraine
non-drug self-management
beta blockers- propranolol 40mg (o) BD or TID
(max 320 mg/day)
TCA-amitriptyline
sodium valproate
cyproheptadine (children)

45. 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

46. 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

47. 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

49. REFERENCES
Murtagh’s General practice, 6th edition
Davidson’s Medicine textbook
http://www.webmd.com/migraines-
headaches/guide/status-migrainosus-symptoms-
causes-treatment

50. THANK YOU !