Approach to headache Primary Headache Secondary Headache

1. APPROACH TO HEADACHE
Dr. Bibek Bhandari
PAHS
ED

4. Acute Secondary Headache Disorders
1. Headache associated with head trauma
2. Headache associated with vascular disorders
– SAH
– Acute ischemic cerebrovascular disorder
– Unruptured vascular malformation
– Arteritis (e.g. temporal arteritis)
3. Headache associated with nonvascular intracranial
disorder
– Benign intracranial HTN (pseudotumor cerebri)
– Intracranial infection
– Low CSF pressure (e.g., headache subsequent to LP)

5. 4. Drugs and toxins: Analgesics overuse, Caffeine
withdrawal, Carbon monoxide, Hormones (estrogen),
Proton pump inhibitors
5. Headache associated with noncephalic infection (viral
infection, bacterial infection)
6. Headache associated with metabolic disorder (hypoxia,
hypercapnia, hypoglycemia, dialysis)
7. Headache or facial pain associated with disorder of
cranium, neck, eyes, ears, nose, sinuses, teeth or mouth

6. History
FIRST OR WORST HEADACHE
• Primary headaches can occur at any age but most often begin
during childhood or between 20 and 50 years of age.
• Onset of headache after 50 years of age is a red flag for
consideration of a secondary headache disorder such as
temporal arteritis or a mass lesion.
• If the patient routinely has headaches, it is important to
determine whether the current episode is typical. Is this
headache like the ones you usually have?

7. History
SYMPTOMS
What symptoms do you have before the headache starts?
What symptoms do you have during the headache?
What symptoms do you have right now?
• Primary headache disorder such as cluster headache
(ipsilateral lacrimation and/or nasal congestion) or migraine
with aura (e.g., scotomata, photophobia, phonophobia,
nausea).
• Secondary headache disorder (stiff neck, disorientation,
rash, fever, eye pain, diplopia, unilateral paresthesias,
unilateral weakness, balance change).

8. History
ONSET
Gradual or sudden onset
Headache of sudden and severe onset can be due to:
• SAH
• Vascular malformations
• Acute ischemic CVA
• Posterior fossa mass lesions.

9. History
LOCATION AND RADIATION OF PAIN
• Cluster headaches are strictly unilateral.
• Tension-type headaches are usually band-like and bilateral.
• Migraines generally begin unilaterally but may progress to
involve the entire head.
• Pain along the distribution of the temporal artery may suggest
temporal arteritis, and pain along the distribution of the
trigeminal nerve may be a sign of trigeminal neuralgia
• Eye pain may suggest acute glaucoma.

10. History
CONCURRENT MEDICAL CONDITIONS
• Meningitis
• Hypertension
• CNS lymphoma
• Toxoplasmosis
• Metastases
• Intracranial vascular disorder
• Acute viral syndrome or acute bacterial infection

11. History
MEDICATIONS
• Prescription and over-the-counter medications
(especially caffeine-containing analgesics) have
been implicated as triggers for drug-rebound and
nonspecific headaches.
• Long term use of PPIs
• Thus, it is important to review any medication
that a patient is taking for its potential to cause
headache.

12. History
RECENT TRAUMA OR PROCEDURES
• Headache subsequent to trauma may signify a
postconcussive disorder, although ICH should always be
suspected.
• Migraine and cluster headaches may be triggered by head
trauma.
• Headache has also been associated with common medical
procedures (e.g. LP, rhinoscopy) and dental procedures
(e.g., tooth extraction); functional endoscopic surgery

13. MIGRAINE HEADACHES
• Combined findings useful for distinguishing
migraine
– pulsatile quality,
– duration of 4 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.

14. • Useful clinical criteria from the history and physical
examination for distinguishing migraine from tension-
type headache include nausea, photophobia (sensitivity
to light), and phonophobia (sensitivity to sound)
• Physical activity often exacerbates migraine headache.
• Aura may be present in some cases of migraine. Aura
consists of visual, sensory, or speech symptoms that
appear gradually, last no longer than 60 minutes, and
are completely reversible.

15. CLUSTER HEADACHES
• relatively rare
• characterized by brief (15 to 180 minutes) episodes of
severe head pain with associated autonomic
symptoms
• The age of onset of cluster headaches varies, with 70
percent of patients reporting onset before 30 years of
age.

17. • Patients with cluster headache most commonly
describe the pain as sharp, but some report that it can
also be pulsating and pressure-like.
• Pain most commonly occurs in the retro-orbital area,
followed by the temporal region, upper teeth, jaw,
cheek, lower teeth, and neck.
• Ipsilateral autonomic symptoms such as eyelid
edema, nasal congestion, lacrimation, or forehead
sweating usually accompany the pain.

18. • Only 25 percent of patients with cluster headaches are diagnosed
correctly within one year of symptom onset, and more than 40
percent report a delay in diagnosis of five years or longer.
• The most common incorrect diagnoses were migraine (34 percent),
sinusitis (21 percent), and allergies (6 percent).
• Family history appears to have a role in some cases.
• A number of comorbidities are associated with cluster headaches,
including depression (24 percent), sleep apnea (14 percent), and
asthma (9 percent).
• Depression is an important diagnosis, because many individuals who
have cluster headaches report suicidal thoughts, and 2 percent of
patients had attempted suicide. (Rozen TD, Fishman RS. Cluster
headache in the United States of America: demographics, clinical
characteristics, triggers, suicidality, and personal burden. Headache.
2012;52(1):99–113.)

19. Tension Type Headache

20. Tension Headaches
• frequent or continuous,
• Mild and bilateral,
• ban-like holocranial,
• occipital or frontal pain that spreads to
entire head, worse at the end of the day
• Patient usually has stressors.
• Tension-type headache is generally
described as steady feeling of tightness or
pressure.
• Affects women more than men

21. Approach to Headache
• PHYSICAL EXAMINTAION
• Usually identifies secondary causes of headache
• General physical examination:
- VS (BP, temperature)
- Funduscopic examination (papilledema)
- CV assessment (assess risk of CVA)
- sinus tenderness (R/O sinusitis)
• Complete neurologic examination (focal neurologic
signs)

22. • Mental status
• Level of consciousness
• Cranial nerve testing
• Motor strength testing
• Deep tendon reflexes
• Pathologic reflexes (e.g. Babinski’s sign)
• Cerebellar function
• Gait testing
• Signs of meningeal irritation (Kernig’s and
Brudzinski’s signs).

23. Red flags in Headache
Danger sign or symptoms Possible Dx TESTS
First or worst headache of the patient's
life
Central nervous system
infection, intracranial
hemorrhage
Neuroimaging
Focal neurologic signs (not typical aura) Arteriovenous malformation,
collagen vascular disease,
intracranial mass lesion
Blood tests,
neuroimaging
Headache triggered by cough or
exertion, or while engaged in sexual
intercourse
Mass lesion, subarachnoid
hemorrhage
Lumbar
puncture,
neuroimaging
Headache with change in personality,
mental status, level of consciousness
Central nervous system
infection, intracerebral bleed,
mass lesion
Blood tests,
lumbar
puncture,
neuroimaging

24. Neck stiffness or meningismus Meningitis Lumbar
puncture
New onset of severe headache in
pregnancy or postpartum
Cortical vein/cranial sinus
thrombosis, carotid artery
dissection, pituitary apoplexy
Neuroimaging
Older than 50 years Mass lesion, temporal
arteritis
Erythrocyte
sedimentation
rate,
neuroimaging
Papilledema Encephalitis, mass lesion,
meningitis, pseudotumor
Lumbar
puncture,
neuroimaging
Rapid onset with strenuous exercise Carotid artery dissection,
intracranial bleed
Neuroimaging

25. Sudden onset (maximal intensity occurs
within seconds to minutes, thunderclap
headache)
Bleeding into a
mass or
arteriovenous
malformation,
mass lesion
(especially
posterior fossa),
subarachnoid
hemorrhage
Lumbar puncture,
neuroimaging
Systemic illness with headache (fever,
rash)
Arteritis, collagen
vascular disease,
encephalitis,
meningitis
Blood tests, lumbar
puncture,
neuroimaging, skin
biopsy
Tenderness over temporal artery Polymyalgia
rheumatica,
temporal arteritis
Erythrocyte
sedimentation rate,
temporal artery
biopsy
Worsening pattern History of
medication
overuse, mass
lesion, subdural
hematoma
Neuroimaging

26. Investigations
Laboratory
• No random use of laboratory testing in the
evaluation of acute headache.
• CBC when systemic or intracranial infection is
suspected
• ESR when temporal arteritis is a possibility.
Neuroimaging
• Usually warranted in patients to identify cause of
secondary headaches .
• CT scan to identify acute hemorrhage.
• MRI scan to evaluate the posterior fossa.

27. Investigations
Lumbar Puncture
• CT scanning without contrast medium, followed by LP if the scan is
negative, is preferred to rule out SAH within the first 48 hours.
• LP is useful for assessing the CSF for blood, infection and cellular
abnormalities.
• Headaches are associated with low CSF pressure (e.g. post-traumatic
leakage of CSF) and elevated CSF pressure (e.g. idiopathic
intracranial HTN and CNS space-occupying lesions)

28. Treatment

29. Migraine Headaches
1. Abortive Therapy:
Moderate : NSAIDs, Sumitriptans, Dopamine Antagonists
Severe: Naratriptan, Sumitriptan (s.c./ n.s.)
Extreme: Opiods
• Intravenous Metoclopromide is recognized as effective therapy
for acute migraine
• I.V. Ketorolac an effective alternative in ED
2. Prophylaxis
High efficacy: Beta blockers, TCAs, Antiepileptics like Valproic
Low efficacy: Verapamil, Flunarizine

30. Cluster Headache
• Abortive agents
– Oxygen (8L/min for 10 mins or 100% by mask)
– Triptans ( sumitriptan)
• Prophylactic
– CCBs – MOST effective for CH prophylaxis. Most used
Verapamil others: Nimodipine and diltiazem
– Corticosteroids to terminate the CH cyle and in
preventing immediate recurrence
• High dose prednisolone is first prescribed and gradually
tapered
– Beta blockers are not used as it may precipitate
bradycardia occuring during CH

31. Tension Headache
• No specific treatment
• NSAIDs/ Acetylsalicyclic acids
• Hot or cold packs
• Stretching and relaxing techniques

32. Other Modalities
• Accupuncture
• Accupressure

33. • Treatment of Secondary Headaches includes
identifying the disease and treating it.

34. When to refer to a neurologist????
 Physician has inadequate level of comfort in diagnosing or
treating patient’s headache.
 Patient requests a referral.
 Patient does not respond to treatment.
 Patient’s condition or disability continues or worsens.
 Physician is unable to classify patient’s headache
according to diagnostic criteria for primary or secondary
headache disorders.
 Habituation or rebound headaches limit outpatient
management.
 Patient has intractable or daily headaches.

35. References
• Harrison's Principles of Internal Medicine, 19th
Edition Textbook
• http://www.aafp.org/afp/2006/0101/p72.html
• http://emedicine.medscape.com/article/79238
4-overview
• http://emedicine.medscape.com/article/79238
4-overview

36. • Thankyou