Headache for Family medicine

1. Headache
Kishore S Rajan

2. TAKING HISTORY
• THE FOCUS HISTORY SHOULD INVOLVE THE
FOLLOWING :-
– SOCRATES
– FREQUENCY
– PH, FH, MENSTRUAL HISTORY
– RED FLAGS
– RESPONSE
– HEALTH BETWEEN ATTACKS
– ANXIETY AND CONCERNS

3. • Which one of the following is NOT a "red flag" sign for
headaches?
A. New onset headache and associated with a seizure
•
B. New onset headache in >50yo
•
C. New onset headache in someone who is taking an
anticoagulant
•
D. Headache in someone with stress
•
E. Headache associated with progressive worsening

4. RED FLAGS
1. Fever and worsening headache ± purpuric rash/meningism
2. Thunderclap headache (reaching peak intensity in <5min)
3. Progressive headache, worsening over weeks
4. Headache associated with postural change, sneezing, coughing, or exercise
5. Recent head injury (<3mo)
6. Papilloedema
7. Change in personality/new cognitive or neurological deficit
8. New onset in a patient with a history of HIV or cancer.
9. Headache with atypical aura (>1h ± motor weakness)
10. Aura for first time and using CHC
11. New onset age >50y or <10y

5. A. Headache coincidental with hemorrhage
B.Migraine
C.Tension headache
D.Cluster headache
E.Headache sentinel of aneurysm leak
F.Brain tumor
• A patient is experiencing a pulsating pain that
has gradually increased in intensity over the
last 3 hours. The pain has started on the left
forehead but is now present on both temples
and whole forehead. This is highly suggestive
of what?

6. MIGRAINE
• Useful clinical criteria from the history and physical
examination is useful for distinguishing migraine from
other types of headache.
• This includes nausea, photophobia (sensitivity to light),
and phonophobia (sensitivity to sound). Physical
activity often exacerbates migraine headache.
• Combined findings useful for distinguishing migraine
can be summarized by the POUND mnemonic
(pulsatile quality, duration of four to 72 hours,
unilateral location, nausea or vomiting, and disabling
intensity).
• Patients who meet at least four of these criteria are
most likely to have a migraine

7. Presentation (POUND)
• Pulsating or throbbing pain
• 4-72hrs in adults and 1-72hrs in children
• Unilateral
• Nausea, vomiting
• Disables activities
• ± AURA
Types
Episodic: occurs <15days/month
Chronic : occurs >15days/month over >3months

8. Aura
• Aura may be present in some cases of
migraine. Aura consists of visual, sensory, or
speech symptoms that appear gradually, lasts
more than 5min and no longer than 60
minutes, and are completely reversible.

11. Trigger factors
1. Psychological factors: Stress, anxiety and depression. Usually
migraine occurs after the period of stress.
2. Environmental factors: Loud noise, bright/flickering lights,
strong perfume, extreme temperatures, etc
3. Food: lack of food, food containing monosodium glutamate,
caffeine and tyramine, chocolate, cheese, red wine, citrus
fruits
4. Sleep: overtiredness, changing sleep patterns, long distance
travel
5. Hormonal factors: Hormonal changes (menstruation, CHC).
Assessing severity Assessment scales
e.g. Migraine Disability Assessment Score (MIDAS)
click on the link MIDAS

12. Management of Acute Migraine
Attack
Combination therapy with the following:
• Triptan (e.g. sumatriptan 50-100mg po)
– Not effective if taken before headache
– Consider nasal triptan if aged b/w 12-17y
• NSAID (naproxen 500mg bd) or Paracetamol (1g qds) ±
antiemitics (even if no N or V)
Management of Chronic
Migraine
Aims to control the symptoms and minimize the impact on the
patients life. Involves reducing the trigger factors, using
prophylaxis medications, etc

13. Prophylaxis
• Prophylaxis if more than 4 attacks per month
or severe attacks.
• 1st line: Propranolol S/R 80–160mg od/bd or
topiramate 25–50mg od/bd—start at low
dose and i dose every 2–4wk.
• 2nd line: Gabapentin (upto 1200mg/day)
(Anticonvulsants)
• 3rd line: Botulinum type A toxin. Useful for
pts. With chronic migraine

14. • A 26-year-old woman is evaluated in the office for a change in migraine
symptoms. She began having migraine attacks shortly after menarche at
age 13 years, experiencing an attack approximately every 2 months. For
the past 8 weeks, these attacks have been associated with visual aura. The
neurologic symptoms evolve over a period of 10 minutes, last less than 60
minutes, and are followed within 30 minutes by a severe, unilateral
throbbing headache associated with nausea. Sumatriptan relieves the
headache within 30 minutes. The patient also has asthma. Her mother
and sister have a history of migraine. Current medications are an oral
contraceptive pill started 9 weeks ago, sumatriptan as needed, a daily
inhaled corticosteroid, and an inhaled β-agonist as needed.
Results of physical examination, including neurologic examination, are
normal.
Complete blood count results, erythrocyte sedimentation rate, serum
chemistry study results, thyroid-stimulating hormone level, and
anticardiolipin and antinuclear antibody levels are normal.
An MRI of the brain shows no abnormalities.
Which of the following is the most appropriate next step in management?
A- Add propranolol
B- Add verapamil
C- Discontinue the oral
contraceptive pill
D- Discontinue the
sumatriptan
E- Measure serum
lactate and pyruvate
levels

15. DO NOT OFFER CHC TO
WOMEN WITH
MIGRAINE , ESPECIALLY
IF AURA

16. Menstrual Migraine
• If migraine occurs from 2 days before to 3
days after start of menstruation on at least 2
out of 3 consecutive months.
Management
– NSAIDs – started from the onset of menstruation
to the last day of bleeding
– Triptans – started 2 days before expected onset of
migraine (5mg on day 1 & 2.5mg from days 2-6)

17. A 36 yr old woman, harshila, has bilateral
headache occurring at around 10 times per
month and is worse especially when her two
children near their exam dates. Both her kids
are doing average in school. What is the most
likely diagnosis for her headache?
a- migraine
b- cluster headache
c- tension headache
d- trigeminal
neuralgia

18. TENSION TYPE HEADACHE
Associated with stress and anxiety and/or functional or
structural abnormalities of the head or neck.
• Episodic: as headache lasting 30min–7d and occurring
<180d/y (<15d/mo)
• Chronic: Headaches on ≥15d/mo (≥180d/y) for ≥3mo.
Presentation:
 Is bilateral, pressing, and/or tightening in quality.
 Of mild/moderate intensity.
 Does not prohibit activities
 Is not associated with vomiting Is not aggravated by
physical activity.

19. Non-drug management
• Reassure no serious underlying pathology. Try
measures to alleviate stress—relaxation; massage;
yoga; exercise. Treat the musculoskeletal symptoms
with physiotherapy.
Drug therapy
• Analgesics are of limited value and might make matters
worse
• Acute management Simple analgesia, e.g. paracetamol,
ibuprofen.
• Avoid codeine-containing preparations and other
opioids.
• Prophylaxis is Acupuncture—up to 10 sessions over 5–
8wk

20. • Mr. A is a chronic smoker, who has been
presenting with episodes of severe painful
headaches (8/10) that is focused on his right
eye. His headaches are predictable after
consumption of alcohol. He was diagnosed
with lung cancer since a year. He is on
prophylactic medication(80mg tds) for his
h’ache. What is the most probable
Prophylactic medication he's on?

21. CLUSTER HEADACHES
• Extremely painful headaches focused around 1
eye.
• M>F (7:1), More common in smokers
• Pain lasts 15–180min and occurs from 1x every
2d to 8x/day. Recurrences affect the same side.
Symptoms:
• Autonomic symptoms on that side (drooping
eyelid, constricted pupil, red watery eye, runny or
blocked nose, forehead sweating).
• Onset is often predictable (1–2h after falling
asleep; after alcohol).
• TWO PATTERNS
– Episodic Remissions of >1mo
– Chronic Remissions of <1mo in a 12mo period

22. Management
• Refer for specialist advice/neuroimaging for first
attack of cluster headache.
Acute attack :
• 100% oxygen (>12L/min) for 10–20min;
• 5HT1 agonists, e.g. sumatriptan (6mg sc or 20mg
nasal)—stops 75% in <15min.
Prophylaxis:
• Consider verapamil 80mg tds/qds if attacks are
frequent (needs ECG monitoring—seek specialist
advice if unfamiliar with use).

23. • A 64 year old lady complains of severe
unilateral headache on the right side and
blindness for 2 days. She also have tenderness
on combing her hair On examination there is a
thick cord like structure on the lateral side of
the head. CBC was done and was normal. The
ESR test showed 80 mm/hr in the first hour.
What is the most likely diagnosis?
a- temporal arteritis
b- migraine
c- cluster headache
d- sinusitis

24. TEMPORAL ARTERITIS (Giant Cell
arteritis)
• Temporal arteritis or GCA is commonly
seen in elders. (>50y)
Symptoms: H’ache, temporal artery and
scalp tenderness, jaw claudication,
amaurosis fugax, sudden blindness in
one eye.
EC symptoms may include; Dyspnea,
morning stiffness, unequal or weak
pulses
• Diagnosis is clinical.
• Check ESR/CRP on presentation.
• Temporal biopsy can also be done

25. Management
• If you suspect TA (GCA), do ESR and start the
patient on Prednisolone 60mg/d po
IMMEDIATELY
• Corticosteroids prevent vascular
complications, particularly blindness and
relieve symptoms rapidly.

26. TRIGEMINAL NEURALGIA
 Paroxysms of intense stabbing, burning, or ‘electric shock’
type pain.
 Lasting seconds to minutes in the trigeminal (V) nerve
distribution.
 Frequency: 100/d to remissions lasting years
 96% unilateral.
 Mandibular/maxillary > ophthalmic division.
 Between attacks there are no symptoms.
 Pain may be provoked by movement of the face (talking,
eating, laughing) or touching the skin(shaving, washing).
 Can occur at any age but more common >50y
 Unknown cause but associated with MS

27. Management
• Carbamazepine – start at low dose (100mg
od/bd
• Pregabalin – start with 75mg bd
• Amitriptyline –Start at a dose of 25mg at 5–7
p.m.
• 10mg if elderly. ↑ dose by 10–25mg every 5–7d to a
maximum of 75mg in a single dose as needed. Consider
combining with pregabalin if ineffective alone.

28. • 64 y old male, with mild headache since 2
months with DM and high myopia. Since then,
he has progressive loss of vision in sausage
shaped blind spot and eye ache. What is the
most probable diagnosis?

29. GLAUCOMA
• Raised intraocular pressure that leads to damage of the
optic nerve
• Presentation:
– Mild headache
– Eye ache
– Loss of vision
– Hazy cornea
• Management:
– Pilocarpine
– Acetazolamide
– Refer to opthalmology

30. MEDICATION OVERUSE HEADACHE
• Persistant headache
• H’ache develops or worsens with analgesic
medication for over 3mo
• Implicated drugs include: Triptans, Paracetamol,
aspirin or NSAIDs
MANAGEMENT
Advise to stop the overused drug for 1mo
Follow up and support
Warn that symptoms may worsen for initial 3-7days

31. • A 64 years old lady has the worst headache of
her life. She was brought to the hospital with
photophobia and vomiting as well. On
examination she had neck stiffness and
bilateral extension on plantar reflex. Lumbar
puncture showed blood, thoroughly mixed
with CSF. She had a contrast MRI which
showed blood in the subarachnoid space and
in the ventricles. She had an emergency
neurosurgical treatment and she survived.
What was the most probable diagnosis?
A.Glioblastoma of parietal
lobe
B.Medulloblastoma
C.Ruptured berry aneurysm
D.Meningitis

32. ↑ INTRACRANIAL PRESSURE
Clinical features of increased Intracranial pressure:
• Drowsiness
• Reduced conscious level
• Irritability
• VI nerve palsy
• Papilloedema
• Dropping pulse
• Rising BP
• Focal neurological signs
• Pupil changes

33. Causes of raised ICP:
• Benign intracranial hypertension
• SOL
– Brain abscess
– Intracranial tumors
• Hydrocephalus
• Subarachnoid hemorrhage
• Subdural hemorrhage
• Extradural hemorrhage

34. SOL
• BRAIN ABSCESS
– Single/multiple
– Infection via blood stream, direct implantation or local
extension from adjacent sites (SINUSITIS)
– Presentation:
• Raised ICP
• Focal neurological signs
• Systemic effects of infection and/or local effects due to cause
– If suspected admit as an emergency
– Treatment is with IV antibiotics +/- surgical drainage

35. • INTRACRANIAL TUMORS
– Can be primary (70%) or secondary (30%, breast, lung or
melanoma)
– <1% of patients with a headache have a tumor
– Presentation:
• Raised ICP
• Seizures
• Evolving focal neurology
• Subtle personality change (frontal lobe)
• Local effects

36. Subarachnoid hemorrhage (SAH)
• Spontaneous bleeding into the subarachnoid space
• F>M and peak age of 35-65ys
• Causes:
– Rupture of a congenital berry aneurysm (75%)
– AV malformation (15%)
– No cause (15%)
– Bleeding disorder
– Mycotic aneurysm secondary to endocarditis (RARE)

37. Risk factors: Smoking, Alcohol, High BP Lack of estrogen,
Berry aneurysms may run in families and are associated
with PKD, coarctation of the aorta & Ehlers-Danlos
syndrome
Presentation:
• Sudden devastating h’ache- THUNDERCLAP
headache- Often Occipital
• Rarely can be preceded by a Sentinal H’ache,
representing a small leak prior to a larger bleed
• Vomiting and collapse with LOC ± fits ± focal
neuro follows

38. Examination: {May find nothing initially}
Later stages
• Neck stiffness (take 6 hrs to develop)
• Papilloedema
• Retinal or other intraocular hemorrhages
• Focal neurology
• Reduced level of consciousness
If suspected, admit immediately as a medical
emergency

39. ACUTE SINUSITS
Infection of 1 or more paranasal sinus (maxillary,
frontal, ethmoid or sphenoid).
Causes:
• Usually follows URI.
• Can also be due to tooth infection.
Presentation:
• Presents with frontal headache/facial pain.
• Typically worse on movement/bending with or
without purulent nasal discharge.
• Can be accompanied by fever.

40. Management
• Most resolve spontaneously within 7-10 days
• Analgesia (paracetamol/ibuprofen)
• Fluids
• Other treatment options:
– Decongestants (saline drops) or Xylomethazoline sprays
– Steroid nasal sprays (Beclomethasone)
– Antibiotics (Amoxycillin) OR amoxiclav (aftr 2 and half
weeks or in those who are immunocomp!)

41. Summary
• Acute new headache (sinusitis)
• Acute recurrent headache( migraine ,cluster
headache, trigeminal neuralagia ,glaucoma)
• Subacute headache (temporal arteritis)
• Chronic headache (tension type headache ,
medication over-use headache, increased
intracranial pressure)

42. THANK YOU