History and Examination Headache Date of clerking: 11/1/2013
History of Presenting Illness• Mr Y is a 40 years old Malay man with complains of sudden onset of headache since this morning when he woke up from sleep. He do not have any known co- morbid.• The pain was throbbing on his right side of the head• The pain was constant. The severity of the pain was 4/10.• The pain was associated with visual disturbance. Patient experience blurry vision .• Bright light would trigger his headache to become worse.• No aura. No previous history of migraine.
History of Presenting Illness• However , the pain did not associate with any nausea , vomiting , weakness or sensory disturbance.• Mr. Y did not had any fever or neck stiffness, but he do have neck tenderness.• He do had sleep deprivation(sleep for 2 hours) last night because he being took care of his 3 month baby.• He did not on regular painkillers.
Physical examination• General examination: – Pt conscious and alert. – Vital signs: • Capillary refill time <2 seconds. • Pulse rate: 78 bpm with regular rhythm and good volume. • Temperature: 37 • Blood pressure: 130/80 mmHg • Respiratory rate about 16 breath per minute. – Lung and airway are clear – CVS: dual rhythm no murmur
General Principles• There are lots of pain sensitive structures in the head and neck• The key to proper management is to make an accurate diagnosis.• Recognize the features of “dangerous” headaches, and know how to “rule out”.
HISTORY• Headache Characteristics: – Temporal profile: acute vs chronic, frequency – Location and radiation – Quality – Alleviating and exacerbating factors – Associated symptoms• Constitutional symptoms• PMH: HTN, DM, hyperlipidemia, smoking
Physical Exam• Blood pressure• Fundoscopy• Auscultation for bruits in H/N• Temporal artery inspection and palpation• Meningismus• Neurologic exam: motor, sensory, coordination and gait
Primary Headache1. Migraine without aura2. Migraine with aura3. Tension headache4. Combination headache5. Cluster headache
Primary Headache1. Migraine without aura; > 5 attacks with: A- duration 4-72 hours B- > 2 of: i. unilateral ii. pulsating iii. interferes with daily activity iv. aggravated by routine activity C- > 1 of: i. nausea and/or vomiting and/or ii. photophobia and/or phonophobia D- No secondary cause
Primary Headache2- Migraine with aura; > 2 attacks of: A- Any 3 or more of: 1-one or more reversible aura symptoms 2-At least one aura symptom develops over > 4 min., or two or more symptoms in succession 3-No single symptom lasts > 60 min. 4-Headache follows aura with free interval < 60 min, or begins before or with aura. B- No evidence of secondary cause.
Primary Headache3. Tension-type headache: At least 10 attacks of: A- Duration 30 min – 7 days. B- > 2 of the following characteristics: i. Pressing/ tightening (non-pulsating) ii. Mild/Moderate intensity. “Inhibits but doesn’t prohibit activity”. iii. Bilateral iv. Not aggravated by routine activity C- Both of: i. absence of nausea and vomiting (anorexia may occur) ii. absence of photophobia or phonophobia N.B. > 15 days/ month = Chronic Tension Headache.
Primary Headache4. Combination Headache Tension-type headache + migraine. The tension headache may precipitate a migraine.
Primary Headache5. Cluster headache• Age of onset 25-50 y.o., M>F• Features: – Attacks clustered in time (>5) – Severe unilateral, orbital or temporal pain – Lasting 15 min – 3 h – Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead/facial swelling, miosis, ptosis
Secondary Headache: Pain-sensitive structures in the head and neckExtra-cranial Intracranial • Periosteum• Scalp • Cranial nerves• Scalp muscles • Meninges• Skull • Meningeal arteries and dural• Carotid and vertebral arteries sinuses• Paranasal sinuses • Proximal intracranial arteries• Eyes and orbits • Sphenoid sinus• Mouth, teeth, and pharynx • Thalamic nuclei• Ears • Brainstem pain-modulating• Cervical spine and ligaments centers• Cervical muscles
“Red Flags”• New headache especially in over 50 y.o.• Abrupt onset, unusually severe• Change in usual headache pattern• Associated with focal neurologic findings• Change in LOC, personality, lethargy• Fever, neck stiffness• Systemic signs/symptoms• Temporal artery tenderness
The Headache DiaryPurpose:• To aid diagnosis• To identify triggers• To provide a self-monitoring tool for patients
The Headache Diary• Frequency of pain• Quality of pain• Duration of pain:• Intensity of pain: Use a rating scale 1-5• Accompanying symptoms: Neurologic e.g. visual disturbance, hemiparesis, hemianopsia, etc., and Autonomic e.g. nausea, vomiting, diarrhea• Mental, cognitive and mood disturbance• Triggers: hormonal, environmental, food, drug
Therapy of Primary HeadachesPrinciples of Therapy:Stratified approach rather than a stepped care approach i.e. treat according to severityDetermine level of intensity and frequency of headache to decide on appropriate acute treatment.Determine whether to use a combination of pharmacologic and non- pharmocologic therapies.Determine whether prophylactic therapy is indicated.
TherapyMigraine – Acute Attacks• set limits on treatments, i.e. no more than 2 days/week• if oral agents not tolerated, use nasal sprays, suppositories, or injectables• for GI dysmotility/ nausea/ vomiting, use metoclopromide 10mg.• Can use”MIDAS” Scale to guide therapy
Tension-type headaches • For moderate attacks NSAIDS useful • For severe attacks triptan drugs effective • Non-pharmacologic Therapy
Cluster headache:• Rare but debilitating • Carry high risk of suicide • Agent must have rapid onset of action • Acute treatment: • Oxygen 100% (evidence?)• Injectable sumatriptan (6mg.)
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