Headache
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  • 1. APPROACH TO HEADACHE Dr Surya Kumar
  • 2. Headaches in ChildrenHeadaches in Children ObjectiveObjective  Learn the Causes of Headaches inLearn the Causes of Headaches in Children.Children.  Learn common causes of chronicLearn common causes of chronic headache and common causes of severeheadache and common causes of severe headache.headache.  Learn to evaluate a patient withLearn to evaluate a patient with headache.headache.  Understand parental concerns.Understand parental concerns.
  • 3. INTRODUCTION  The term headache should encompass all aches and pains located in the head, but in practice its applications is restricted to discomfort in the region of the cranial volt.  Headache, or cephalalgia, is defined as diffuse pain in various parts of the head, with the pain not confined to the area of distribution of a nerve  Incidence of Chronic or recurrent headacheIncidence of Chronic or recurrent headache 40% by age 7 years.40% by age 7 years. 75% by age 15 years.75% by age 15 years.  Accounts for 10% referrals to NeurologistAccounts for 10% referrals to Neurologist..
  • 4. CLASSIFICATION (International headache society) 1. Migraine: •Migraine without aura. •Migraine with aura. •Ophthalmoplegic migraine. •Retinal migraine. 2.Tension type headache 3.Cluster headache
  • 5. 4.Miscellaneous headache not associated with structural lesion: Idiopathic stabbing headache. Cold stimulus headache . Benign cough headache . Headache associated with sexual activity . 5.Headache associated with head trauma. 6.Headache associated with vascular disorder. Acute ischaemic (CVD) Intracranial haematoma . SAH Arteritis- Giant cell arteritis. Venous thrombosis. Arterial hypertension. Classification contd..
  • 6. 7. Headache associated with non vascular intracranial disorder. 8. Headache associated with substances or their withdrawal. 9. Headache associated with non cephalic infection 10. Headache associated with metabolic disorder. 11.Headache or facial pain associated withdisorders of facial or cranial structures. 12.Cranial neuralgias ,nerve trunk pain 13.Headache not classified
  • 7. RECURRENT HEADACHE TENSION TYPE HEADACHE. CLUSTER HEADACHE. MIGRAINE.
  • 8. Case history 1Case history 1  7 year old boy with history of frequent7 year old boy with history of frequent headaches for the last 4 monthsheadaches for the last 4 months  Not responding to paracetamole andNot responding to paracetamole and Ibuprofen and CodeineIbuprofen and Codeine  Not associated with vomitingNot associated with vomiting  CNS , eye, ears, and systemic examinationCNS , eye, ears, and systemic examination were normalwere normal  Cranial CTCranial CT  More anxietyMore anxiety
  • 9. TENSION TYPE HEADACHE  The word "tension" implies that this typeThe word "tension" implies that this type of headache can be attributed entirely toof headache can be attributed entirely to tension or stress, which may maketension or stress, which may make people with this type of headachepeople with this type of headache reluctant to consult a physician.reluctant to consult a physician.
  • 10. .. International Headache SocietyInternational Headache Society diagnostic criteria for tension-typediagnostic criteria for tension-type headacheheadache  Primary diagnosisPrimary diagnosis 1.1. Headache hasHeadache has at leastat least two of the followingtwo of the following characteristicscharacteristics:: Bilateral painBilateral pain PressurePressure Mild to moderate painMild to moderate pain No increased pain with physical exertionNo increased pain with physical exertion 2.2. AndAnd no more than one of the following:no more than one of the following: Sensitivity to lightSensitivity to light Sensitivity to soundSensitivity to sound 3.3. AndAnd neither of the following*:neither of the following*: NauseaNausea VomitingVomiting 4.4. AndAnd duration of 30 minutes to 7 daysduration of 30 minutes to 7 days
  • 11. Subdivision diagnosisSubdivision diagnosis  1.1. Episodic (<15 days/mo)Episodic (<15 days/mo) oror chronic (chronic (>>1515 days/mo for >6 mo)days/mo for >6 mo) 2.2. Associated withAssociated with oror not associated withnot associated with coexisting pericranial muscle tenderness**coexisting pericranial muscle tenderness**  **Chronic tension-type headache may include oneChronic tension-type headache may include one of these symptoms.of these symptoms.  **Diagnosed by manual palpation or**Diagnosed by manual palpation or electromyographic studies.electromyographic studies.  Adapted from Headache Classification Committee of the InternationalAdapted from Headache Classification Committee of the International Headache Society (2).Headache Society (2).
  • 12.  Synonym: Raeder’s syndrome, Histamine cephalalgia, Red migraine, paroxysmal nocturnal cephalagia.  Age – 20 to 50 yrs.  Sex – men are affected 7 to 8 times more than women.  The pain begins without warnings & reaches a crescendo within 5 minutes. Each attack last for 30 min to 2 hours. 1 – 3 short-lived attacks/day over a 4 – 8 weeks period, followed by a pain free interval that average one year. CLUSTER HEADACHE
  • 13. CLUSTER HEADACHE   Almost always the same orbit is involved during attacks.   The pain is excruciating in intensity & deep, non-fluctuating and explosive in quality.   Associated with - homolateral lacrimation, red eye, miosis, lid ptosis, nasal stuffiness & nausea.   Onset is nocturnal is about 50% of the cases & then pain usually awakens the patients within 2 hours of falling asleep.
  • 14. Diagnostic Criteria for ClusterDiagnostic Criteria for Cluster HeadacheHeadache A At least five attacks fulfilling criteria B through DA At least five attacks fulfilling criteria B through D B Severe unilateral orbital, supraorbital and/orB Severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes (untreated)temporal pain lasting 15 to 180 minutes (untreated) C .Headache associated with at least one of theC .Headache associated with at least one of the following signs on the pain side:following signs on the pain side: ConjunctivalConjunctival injectioninjection LacrimationLacrimation Nasal congestionNasal congestion RhinorrheaRhinorrhea Forehead and facialForehead and facial sweatingsweating MiosisMiosis PtosisPtosis Eyelid edemaEyelid edema D. Frequency of attacks: one attack every otherD. Frequency of attacks: one attack every other day to eight attacksday to eight attacks
  • 15. Contd..  Treatment: • Inhalation of 100% O2 for 10 – 15 minutes. • Intranasal lidocaine/sumatriptane. Prophylaxis Ergotamine Prednisolone Verapamil Lithium – Methysergide.  CLUSTER HEADACHE
  • 16. Case history 2Case history 2  A 10 year old boy with history of headache for 4A 10 year old boy with history of headache for 4 weeksweeks  Started as funny feeling inside his abdomenStarted as funny feeling inside his abdomen  Pain round the right eyePain round the right eye  Pain spread all over his headPain spread all over his head  VomitVomit  PhotophobiaPhotophobia  Fatigue, lethargic and want to sleepFatigue, lethargic and want to sleep
  • 17. MIGRAINE Periodic, commonly unilateral, often pulsatile headache, begins in childhood, adolescence, or early adult life & recur with diminishing frequency during advancing years. Associated with nausea, vomiting and/or other symptoms of neurological dysfunction of varying admixture.  The attacks cease during pregnancy in 75-80% of women.
  • 18. Migraine: contd. Some patients link their attacks to certain dietary items – chocolate, cheese, fatty foods, orange, tomatoes, onions.  In others headache are consistently induced by – exposure to glare or other strong sensory stimuli – worry. Sudden jarring of the head. Rapid change in barometric pressure. Lack of sleep.
  • 19. Migraine with aura:  Premonitory symptoms: Changes in mood (surge of energy & feeling of well being), appetite (hunger or anorexia).  Aura: Visual disturbance – Unformed flashes of white or multicoloured light (Photopsia), An enlarging blind spot with a shimmering edge (scintillating scotoma), formation of dazzling zigzag lines-, (fortification spectra), blurred or cloudy vision. Sensory disturbance – Numbness & tingling of the lips face & hand. Motor disturbance – Weakness of an arm or leg, mild aphasia or dysarthria.
  • 20. Migraine Variants:  Ophtlamoplegic migraine : Recurrent unilateral associated with weakness of the extra ocular muscle – A transient 3rd or 6th nerve palsy. More common in children.  Retinal migraine: Headache associated with monocular blindness due to retinal or ant. optic nerve ischaemia.  Basilar migraine: The patient first develop total blindness which is accompanied by admixture of – vertigo, ataxia, dysarthria, tinnitus, & distal or perioral paresthesia. The neurological symptoms are followed by throbbing occipital headache.
  • 21.  Hemiplegic migraine:  Childhood periodic syndrome: Instead of complaining of headache, the child appears limp & pale & complains of abdominal pain. Vomiting is more common than in the adult..  Complicated migraine: Migraine with dramatic transient focal neurologic features. Or, migraine attack that leaves a persisting residual neurologic deficit.  Status migrainosus: Migraine patient who lapses into a condition of daily or virtually continuous migraine.
  • 22. Modified Diagnostic Criteria for Migraine Episodic attacks of headache lasting 4-72hr With two of the following symptoms: •Unilateral pains •Throbbing/pulsating •Aggravation on movement. •Pain of moderate or severe intensity. And one of the following symptoms: •Nausea or vomiting. •Photophobia or Phonophobia.
  • 23.  Diagnostic Criteria for MigraineDiagnostic Criteria for Migraine Migraine without auraMigraine without aura  At least five attacks fulfilling criteria B through DAt least five attacks fulfilling criteria B through D  Headache lasting 4 to 72 hours (untreated or unsuccessfully treated)Headache lasting 4 to 72 hours (untreated or unsuccessfully treated)  At least two of the following pain characteristics:At least two of the following pain characteristics:  Unilateral locationUnilateral location  Pulsating qualityPulsating quality  Moderate or severe intensityModerate or severe intensity  Aggravation by walking stairs or similar physical activityAggravation by walking stairs or similar physical activity  During headache, at least one of the following:During headache, at least one of the following:  Nausea and/or vomitingNausea and/or vomiting  Photophobia and phonophobiaPhotophobia and phonophobia  Migraine with auraMigraine with aura  At least two attacks fulfilling criterion BAt least two attacks fulfilling criterion B  At least three of the following characteristics:At least three of the following characteristics:  One or more fully reversible aura symptoms indicating focal cerebral corticalOne or more fully reversible aura symptoms indicating focal cerebral cortical and/or brain-stem dysfunctionand/or brain-stem dysfunction  At least one aura symptom develops gradually over more than 4 minutes, or twoAt least one aura symptom develops gradually over more than 4 minutes, or two or more symptoms occur in succession.or more symptoms occur in succession.  No aura symptom lasts more than 60 minutes; if more than one aura symptom isNo aura symptom lasts more than 60 minutes; if more than one aura symptom is present, accepted duration is proportionally increased.present, accepted duration is proportionally increased.  Headache follows aura, with a free interval of less than 60 minutes (headacheHeadache follows aura, with a free interval of less than 60 minutes (headache may also begin before or simultaneously with aura).may also begin before or simultaneously with aura).
  • 24. B. Pharmacologic therapy: Staged approach to migraine pharmacotherapy: StageStage DiagnosisDiagnosis TherapiesTherapies MildMild • Occasional throbbingOccasional throbbing headache (less than oneheadache (less than one attack per month)attack per month) • No major impairment ofNo major impairment of functioningfunctioning.. • Control of migraineControl of migraine attacks –attacks – ModerateModerate • Some impairment of function.Some impairment of function. • Moderate or severeModerate or severe headache (1-3 attacks perheadache (1-3 attacks per month)month) • Nausea commonNausea common • Control of migraineControl of migraine attacks –attacks – SevereSevere • Severe headache (>3 attacksSevere headache (>3 attacks per month)per month) • Marked nausea and/orMarked nausea and/or vomiting.vomiting. • Significant functionalSignificant functional impairment.impairment. • Control of migraineControl of migraine attacksattacks • ProphylacticProphylactic medicationmedication
  • 25. Control of acute migraine attacks: The drugs should be taken as soon as the headache component of the attack is recognized. Drugs used in the control of migraine attacks are  Analgesics  Combination analgesics 5HT agonist (Oral, Nasal, SC, IM, or IV) Dopamine antagonists (Oral, IM or IV).
  • 26. The vast majority of migraine attacks can be treated solely with mild analgesics such as – •Acetaminophen – •Aspirin - • Other NSAIDs – Ibuprofen – Naproxen. Indomethacin -. Combination analgesics: •The combination of Acetaminophen, Aspirin & Caffeine has been approved for use by the FDA for the treatment of mild to moderate migraine. •The combination of Acetaminophen, Dichloral phenazone & Isometheptene has been classified by the FDA as “possibly” effective in the treatment of migraine.
  • 27. 5HT agonist (Oral, Nasal, SC, IM, or IV): Ergot derivatives – Ergotamine & Dihydro ergotamine (DHE) Ergot preparation can be taken – Orally, Sublingually, Rectally, IM, IV, Inhalers.
  • 28. Indications for migraine prophylaxis  Attacks occur >2-4 times per month  Disability occurs > 3 days per month  Duration of attack > 48 h  Medications for acute attack are ineffective, C.I or  overused  Attacks produce prolonged aura or true migrainous  infarction  Patient preference
  • 29. Duration of prophylactic therapy The optimum duration of prophylactic therapy is uncertain   The approach is to treat for 6-12 months and then taper  over the course of several weeks.  Data are limited on the effectiveness of preventive agents  in children 
  • 30. DRUGS USED FOR PROPHYLAXIS OF MIGRAINEDRUGS USED FOR PROPHYLAXIS OF MIGRAINE  Propranolol.Propranolol.  Timolol.Timolol.  Sodium valproateSodium valproate  Methyserzide.Methyserzide. These drugs are approved by FDA, USA.These drugs are approved by FDA, USA. Others:Others:  Amitryptyline, Nortryptilline.Amitryptyline, Nortryptilline.  Phenelzine, Cyproheptadine.Phenelzine, Cyproheptadine. Under research:Under research:  GabapentineGabapentine  TopiramateTopiramate
  • 31. •Accurate history taking is fundamental •Need for further investigation is determined by red flag symptoms •Or symptoms that do not corresponding to a recognised primary headache pattern DIAGNOSIS
  • 32. HISTORY TAKING: 1.Age, sex, occupation:  Migraine headache – more frequent in teenagers & young adults, higher occurrence in female. Cluster headache – almost exclusively in males. Cranial arteritis – more frequently in late middle age & in elderly. 2. Duration:  Tension headache -often has long duration.  Headache due to expanding of intracranial disease – usually short duration.  Headache due to meningeal cause – acute in onset.  Migraine headache – recur over a long period of time, with symptoms free interval between attacks
  • 33. DIAGNOSTIC APPROACH: Contd.. 3. Location of headache:  As a general rule localized headache is of greater significance than diffuse headache. Tension headache – typically generalized, band like or bioccipital. Migraine with aura – often unilateral & frequently more prominent interiorly.  Migraine without aura – frequently bilateral.  Cluster headache – invariably limited to the same side of the head in any given attacks & usually periorbital.
  • 34. APPROACH: Contd 8. Frequency, duration & diurnal variation:  Tension headache – often persist & may worsen as the day progress.  Migraine headache – the frequency is variable & unpredictable. Although usual variation is from 4 - 72 hrs, they may persist for days.  Cluster headache – occur repetitively over a period of weeks or months. Often there are 1 or 2 attacks daily. The headache typically nocturnal & of brief duration (30 min to a few hours). 9. Family history:  Migraine headache – strong family history.  Cluster headache – are not familial.
  • 35. Red flag for secondary headache - Silberstein SD et al Flag Descriptios/example Systemic symptoms or secondary risk factors Fever,W. Loss,or known cancer,HIV, immunosupression or thrombotic risks Nerological symptoms or abnormal signs Confusion,impaired alertness/drowsy, persistent focal signs> 1 H onset First and worst headache,sudden abrupt from sleep, or progressively worsening older New onset and progressive-Giant cell arteritis Previous headache history Significant change in features, freq. or severity Triggered headache By valsalva, exertion, sexual intercourse
  • 36. When to scan a patient withWhen to scan a patient with headacheheadache  First or worst headache, particularly if of suddenFirst or worst headache, particularly if of sudden onset.onset.  Headache of increasing frequency or severity.Headache of increasing frequency or severity.  Increased frequency of vomiting and headache onIncreased frequency of vomiting and headache on waking.waking.  Headache triggered by coughing, straining orHeadache triggered by coughing, straining or postural changes.postural changes.  Persistent physical symptoms or signs after attackPersistent physical symptoms or signs after attack (neurological or endocrine)(neurological or endocrine)  Meningism, confusion,impairment ofMeningism, confusion,impairment of consciousness or seizures.consciousness or seizures.
  • 37. ThanksThanks