1. Headache
Department of Family Medicine Case Discussion
A 22 years old female university student complained of headache for a week. The headache was
continuous, almost daily
She denied any other problem exept for the stress in her studies. Physical examination was not
remarkable.
Questions
1) What relevant history would you ask?
2) What are the differential diagnosis
3) What are the red flags of headache
4) What is the most probable cause of this patient’s headache
5) How will you treat this patient

2. Classification of the headache
Classification of headache according to American College of Emergency Physicians, “Clinical
“
Policy for the Initial Approach to Adolescents and Adults Presenting to the Emergency
Department With a Chief Complaint of Headache 1996
hief Headache”,
Headache Category Examples
I Critical secondary causes requiring Subarachnoid hemorrhage, meningitis, brain
emergent identification and treatment tumor with raised ICP
II Critical secondary causes not necessarily Brain tumor without raised ICP
requiring emergent identification or
treatment
III Generally benign and reversible secondary Sinusitis, hypertension, post–
–lumbar puncture
causes headache
IV Primary headache syndromes Migraine, tension type, or cluster

3. Pathophysiology of pain in headache
Notes: Brain cell do not have pain receptor. Therefore headache mainly arise due to
stimulation of pain receptor on vessel, meningeal irritation or by direct stimulation of
adjacent nerve.
Extracted from Clinical Policy: Critical Issues in the Evaluation and Management of Adult
Patients Presenting to the Emergency Department With Acute Headache, 2008
Headache can be caused by (1) distention, traction, or dilation of intracranial or extracranial
arteries; (2) traction or displacement of large intracranial veins or the dural envelope; (3)
compression, traction, or inflammation of cranial and spinal nerves; (4) head and neck muscle
spasm, inflammation, or trauma; (5) meningeal irritation; (6) raised intracranial pressure; and (7)
disturbance of intracerebral serotonergic projections
Maltifactorial triggers stimulating trigeminal nerve from the blood vessels of the pia mater and
dura mater
Onset of pain and releasing of neurogenic peptides from afferent C fibers innervating cephalic
blood vessels
These vasoactive substance stimulate endothelial cell, mast cells and platelets
Activate inflammatory cascade known as “neurogenic inflammation”
5-HT agonist (Triptans) or,
dihydroergotamine, prochlorperazine, and
metoclopramide, act at a variety of 5-HT and
other aminergic receptors
Vasodilatation with enhanced permeability of plasma proteins follows with a perivascular
inflammatory reaction
Eventhough neurogenic inflammation was proposed as pathogenic mechanism of pain,
however selective and potent inhibitors of neurogenic are proven ineffective in clinical trials.
Serotonin (5-HT) receptors are the main focus of pain management because they are known
to modulate neurogenic peptide release and vasoconstrict dilated dural vessels.

4. Further history to elicit in this patient
1) Elicit the life threatening cause of headache first
a) Is it the worst headache of life and characterized by thunder clap at occipital region-
subarachnoid hemorrhage
b) Any sign and symptoms of increase ICP (blurring of vision, projectile vomiting
especially in the morning, severe headache, altered mental status)
c) Fever, neck stiffness and vomiting to rule out meningitis.
d) Presence of neurological deficit to rule out stroke.
2) Once the life threatening causes has been rule out, then elicit history to exlude differential
diagnosis which is commonly primary headache.
a) Tension headache – diffuse and dull aching headache, tight band headache around
head, associated with stress, relieve on weekend
b) Migraine headache - pain in relationship to food like alcohol, chocolate and cheese,
relieve by sleep, family history of migraine, sensory aura
c) Cluster headache – Severe unilateral headache accompanied with tearing of the left
eye, left ptosis, rhinorrhea, left facial redness, pain on awakening from sleep,
recurrent attack with one episode lasting for 20-30 minutes.
3) If still no clue, then elicit the secondary causes of headache
a) Optic causes- any recent change of spectacle, blurring of vision, astigmatism
b) Ophthalmology pathology – acute closure glaucoma
c) Other secondary causes – VITAMIN CDE.
The Red Flag of Headache
Red flag means emergency and require further evaluation
including CT Scan.
1) Acute onset of first most severe headache ever in life.
2) Headache that is increase in frequency or intensity
3) New onset of headache after age of 50 years old
4) Present of mental state changes
5) Associated with fever, neck stiffness and vomiting
6) Presence of neurological deficit
7) Headache with evidence of increase ICP
Additional note: HIV-positive patients with a new type of headache
should be considered for an emergent neuroimaging study.

5. Provisional diagnosis
In this patient, the most likely diagnosis is TENSION HEADACHE because of few parameters
1) Young female
2) university student with stressful study life.
3) onset start within one week and continuous almost daily
4) unremarkable physical examination
Management for this patient
a) Pharmacological
Analgesic; paracetamol (1g PRN or QID) , Aspirin, NSAIDS (Tab Mefenamic acid 500
mg or sodium diclofenac 50 mg)
+ anti emetic like tab. Metaclopromide (maxalon) 10 mg stat.
b) Non pharmacology
1. Ice pack
2. Relaxation technique
c) Other management
1. Caunselling on stress management.

6. Evidence Based Medicine
Level A recommendations. Generally accepted principles for patient management that reflect a
high degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming
evidence from strength of evidence Class II studies that directly address all of the issues).
Level B recommendations. Recommendations for patient management that may identify a
particular strategy or range of management strategies that reflect moderate clinical certainty
(ie, based on strength of evidence Class II studies that directly address the issue, decision
analysis that directly addresses the issue, or strong consensus of strength of evidence Class III
studies).
Level C recommendations. Other strategies for patient management that are based on
preliminary, inconclusive, or conflicting evidence, or in the absence of any published literature,
based on panel consensus.
Extracted from Clinical Policy: Critical Issues in the Evaluation and Management of Adult
Patients Presenting to the Emergency Department With Acute Headache, 2008
1) Response to therapy for prediction of acute headache aetiology
Level C recommendations. Pain response to therapy should not be used as the sole diagnostic
indicator of the underlying etiology of an acute headache.
Serotonin (5-HT) receptors are the main focus of pain management because they are known to
modulate neurogenic peptide release and vasoconstrict dilated dural vessels. Despite many
adverse effects, 5-HT is a potent vasoconstrictor, a property that may be a factor in its ability to
treat migraines
Some agents, such as the triptans, are specific agonists at the 5-HT1 receptor, whereas other
medications, such as dihydroergotamine, prochlorperazine, and metoclopramide, act at a variety
of 5-HT and other aminergic receptors
Numerous artile describes that most secondary headache show clinical improvement to many
different analgesic but not limited to the following. intracerebral hemorrhage/subarachnoid
hemorrhage (ibuprofen, ketorolac, prochlorperazine), viral meningitis/meningeal carcinomatosis
(dihydroergotamine and metoclopramide) carbon monoxide–induced headache (sumatriptan),
cerebral venous thrombosis (sumatriptan and various common analgesics),carotid artery

7. dissection (sumatriptan), subarachnoid hemorrhage (sumatriptan), and cysts of the cavum septi
pellucidi (indomethacin).
2) Which patient should be evaluated with CT Scan
Level B recommendations.
a. Patients presenting to the ED with headache and new abnormal findings in a neurologic
examination (eg, focal deficit, altered mental status, altered cognitive function)-
noncontrast head CT.
b. Patients presenting with new sudden-onset severe headache - head CT.
c. HIV-positive patients with a new type of headache - neuroimaging study.
Level C recommendations
a. Patients who are older than 50 years and presenting with new type of headache but with a
normal neurologic examination
3) Role of Lumbar puncture in ED patient who being worked up for non traumatic SAH
but with normal non contrast CT Scan
Level B recommendations. In patients presenting to the ED with sudden-onset, severe headache
and a negative noncontrast head CT scan result, lumbar puncture should be performed torule out
subarachnoid hemorrhage.
4) Lumbar puncture in patient complaint of lumbar puncture but no prior neuroimaging
study
Level C recommendations.
a. Adult patients with headache and exhibiting signs of increased intracranial pressure (eg,
papilledema, absent venous pulsations on funduscopic examination, altered mental status,
focal neurologic deficits, signs of meningeal irritation) should undergo a neuroimaging
study before having a lumbar puncture.
b. In the absence of clinical findings suggestive of increased intracranial pressure, a lumbar
puncture can be performed without obtaining a neuroimaging study. (Note: A lumbar
puncture does not assess for all causes of a sudden severe headache.)
5) Role of Emergent angiography in patient presented with sudden-onset, severe headache
who has negative findings in both CT and lumbar puncture
Level B recommendations.

8. Patients with a sudden-onset, severe headache who have negative findings on a head CT,
onset, who
normal opening pressure, and negative findings in CSF analysis do not need emergent
angiography and can be discharged from the ED with follow up recommended.
follow-up
6) Indication for imaging for children with headache in ED
Ref: Faiqa Qureshi &Donald Lewis
7) Acute Migraine Treatment (update in medicine) based on study by Kostic MA, Gutierrez
FJ, Rieg TS, Moore TS, Gendron RT. Emerg Med. 2009 Dec 31, “A Prospective,
Randomized Trial of Intravenous Prochlorperazine versus Subcutaneous Sumatriptan in
Acute Migraine Therapy in the Emergency Department", and summarized by Associate
Professor Rashidi Ahmad (Emergency specialist HUSM) in his blog,
http://drcd2009.wordpress.com/2010/01/07/579/
ress.com/2010/01/07/579/
1) Single dose aspirin 1000 mg + 10 mg Metoclopramide
- Effective in more than half of the patient.
- Aspirin reduced associated symptoms of nausea, vomiting, photophobia, and phonophobia
- More superior to sumatriptan 50 mg for 2 hours pain relief and pain free.
2) Sumatriptan 100 mg
- Superior to aspirin plus Metoclopramide for 2 h pain free.
Ref: Emma Hitt, " Single Dose of Aspirin Effective in Relieving Migraine Pain",
http://cme.medscape.com/viewarticle/720439?src=cmenew
http://cme.medscape.com/viewarticle/720439?src=cmenews&uac=113567PT
3) 500mL NS + IV stemetil 10 mg + IV promethazine 12.5 mg
- IV prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the
treatment of migraine.

9. 8) Common Causes of headache in pediatric population
Study Burton et al Kan et al Lewis DW &Qureshi F
Sample 288 patients ranging in 130 children with the prospectively investigated
age from 2 to 18 years chief complaint of causes of abrupt headache
who presented with the headache onset in 150 consecutive
chief complaint of children presenting to the
headache ED
Result The most frequent majority were due to Upper respiratory tract
etiologies were viral concurrent viral infections with fever (viral
illness, sinusitis, and /respiratory illness or URI, sinusitis, and strep
migraine. minor head trauma pharyngitis) were
diagnosed in 57% of
19 (6.6%) patients had Significant neurological cases, and 18% of the
serious neurologic abnormality was found in children had migraines
conditions - 15 had only 9 (6.9%) of these
viral meningitis, and children and included 15% of patients had
there was 1 case each 1 subdural hematoma, serious underlying
of shunt malfunction, 1 epidural hematoma, etiologies for the
hydrocephalus, 2 ventriculoperitoneal headache, including viral
metastatic lymphoma, (VP) shunt malfunctions, meningitis (9%), tumor
and punctuate 1 brain abscess, (2.6%),VP shunt
hemorrhage following 1 pseudotumor cerebri, malfunction (2%), and
head trauma. and intracranial hemorrhage
3 patients with (1.3%)
meningitis
Conclusion: most headaches in children and adolescents were due to upper respiratory infections
or migraines. Children with serious underlying conditions had demonstrable objective finding on
neurological examination
Reference: Faiqa Qureshi &Donald Lewis, "Managing Headache in the Pediatric Emergency
Department", Clin Ped Emerg Med 4:159-170. © 2003 Elsevier Inc

10. 9) Post headache recurrence after ED discharge
Regardless of type of primary headache disorder, ED headache patients frequently experience
pain and functional impairment during the hours and months after discharge. [Ann Emerg Med.
2008;52:696-704.]
10) Treating headache recurrence within 48 hours post ED discharge
In this trial, nearly three quarters of patients reported headache recurrence within 48 hours of ED
discharge. Naproxen 500 mg and sumatriptan 100 mg taken orally relieve post-ED recurrent
primary headache and migraine comparably. Clinicians should be guided by medication costs,
contraindications, and a patient’s previous experience with the medication. [Ann Emerg Med.
2010;56:7-17.]
Take home message
Extra notes
1) Most of the headache are primary headache
2) Patient with Subarachnoid hemorrhage may explain the headache as acute onset, most
severe headache in their life, thunder clap around occipital area.
3) Primary headache can be safely manage with NSAIDs
4) Brain cell do not have pain receptor. Headache usually cause by stretching of pain
receptor in blood vessel either due to direct insult or increase ICP.
5) Although first line of treatment for migraine is 5HT3 antagonist or triptans group, patient
can be managed with IV NSAIDs + IV Maxalon.
6) Hypertension rarely cause headache unless the diastolic blood pressure more than 120
mmHg.