APPROACH TO HEADACHE

1. HEADACHE
Dr. Bimalesh Yadav
PRECEPTER: DR SUKDEV MANNA

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CONTENTS
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4
5
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Diagnosis
PREVENTION
&TREATMENT
INTRODUCTION
TYPES
PRIMARY
HEADACHE
SYNDROMES

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INTRODUCTION
Definition : Pain or discomfort in the head , scalp , or
neck.

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CLASSIFICATION
I. PRIMARY HEADACHE
 A headache that is not caused by another
underlying disease, trauma or medical condition.

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 Intrinsic dysfunction of the nervous system
 Most patients presenting with headache have primary
headache syndromes
 Episodic headache: more common
 Chronic headache: attacks occurring more frequently
than 15 days/month for more than 6 months
Cont.

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 PRIMARY HEADACHE SYNDROMES
 Tension type headache
 Migraine
 Trigeminal Neuralgia
 Cluster headache
 Others

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 <2% of headaches in primary care offices
 Caused by exogenous disorders:
o Head trauma
o Vascular disease
o Neoplasms
o Substance abuse or withdrawal
o Infection/Inflammation
o Metabolic disorders
o others
II. SECONDARY HEADCHE

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I- TENSION TYPE
 Most common-69%
 Episodic or chronic
 Primary disorder of CNS pain
modulation
 seen equally in both sexes

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 Precipitating factors
 Stress: usually occurs in the afternoon after long stressful work
hours or after an exam
 Sleep deprivation
 Uncomfortable stressful position and/or bad posture
 Irregular meal time (hunger)
 Eyestrain
 Caffeine withdrawal
 Dehydration

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SYMPTOMS & SIGNS
 Gradual onset , radiate forward from occiput
 Bilateral, dull, tight, band like pain
 Less in morning, pain increase as day goes on
 No accompanying N,V, throbbing, sensitivity to
light, sound or movement

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 Management
 Paracetamol,Aspirin,NSAIDs
 Behavioral approach-relaxation
 Chronic-amitriptyline

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II- MIGRAINE
 2nd most common-16%
 15% women and 6% men
 Severe, episodic, unilateral,throbbing pain
 Nausea,Vomiting
 Sensitivity to light ,sound, movement
 Genetic predisposition

18. THE STAGES OF A MIGRAINE ATTACK

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PATHOPHYSIOLOGY
 Different theories suggest different causes
I. Vascular theory :
 vasoconstriction followed by vasodilation with resulting in
changes in blood flow causes the throbbing pain .
II. Second theory :
 pain results from muscular tension
III. Biochemical changes:
 changes in serotonin level

20. TRIGGERS: CHANGES IN DAILY CYCLES

21. TRIGGERS: ENVIRONMENT OR DIET

22. MENTAL TRIGGERS

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CLASSICAL MIGRAINE OR MIGRAINE WITH AURA
 Symptom Triad
 Paroxysmal headache
 nausea &/or vomiting
 aura of focal neurological events(visual) 20-25%

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AURA
 Flashing lights, silvery zigzag lines moving across visual
field over a period of 20 minutes
 Sometimes leaving a trail of temporary visual field loss
 Sometimes-Auditory ,Olfactory, gustatory hallucinations
 Sensory aura-spreading front of tingling and numbness,
from one body part to another

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COMMON MIGRAINE /MIGRAINE WITHOUT AURA
 Paroxysmal headache
 Vomiting +/-
 NO AURA

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DIAGNOSIS
 Simplified Diagnostic Criteria for MIGRAINE
At least 2 of the following + At least 1 of the following:
o Unilateral pain o Nausea/vomitting
o Throbbing pain o Photophobia and phonophobia
o Aggravation by
movement
o Moderate or severe
intensity
Harrison's Principles of Internal Medicine, 21e

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MANAGEMENT
 Non drug treatment
 Preventive therapy
 Abortive therapy

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 Non drug treatment
 Avoid headache triggers: foods, drugs, activities
 Avoid frequent abortive treatment
 Stop smoking
 Normalize sleeping and eating
 Exercise
 Relaxation and biofeedback
 Psychotherapy

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 Preventive Treatment
 Tricyclic antidepressants (first-line)
o Amitriptyline
 Beta-blockers (first-line)
o Atenolol, nadolol
 Ca++ channel blockers – less effective
o Verapamil most commonly used

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 Preventive Treatment
 Anticonvulsants (second-line; valuable)
 Valproate and topiramate are quite effective
 Gabapentin
 Lamotrigine, levetiracetam
 Pregabalin

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 Preventive Treatment
 Ergots: Rarely used for prevention
o Side effects may be problematic
o Methysergide: fibrosis (use 6 months max)
 MAOIs: Can be very effective
o Tyramine-free diet a must
o Numerous drug interactions

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 Abortive Treatment
 Simple and combined analgesics e.g NSAIDs.
 Mixed analgesics (barbiturate plus simple analgesics)
 Ergot derivatives
 Triptans
 Opioids

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 OtherAgents
 Antiemetics/Neuroleptics:
o often combined with abortive agents
o Prochlorperazine, hydroxyzine, promethazine, metoclopramide

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III- Trigeminal Neuralgia
 Lancinating pain in 2nd and 3rd divisions of
trigeminal nerve
 >50yrs
 Severe, brief ,repetitive pain causing patient to flinch
 Precipitated by touching trigger zones: washing, shaving,
eating, cold wind

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Pathophysiology
 Compression of trigeminal Nerve by aberrant
loop of cerebellar arteries as nerve enters
brainstem
 Other benign compressive lesions
 Multiple sclerosis: occurs due to plaque of
demyelination in trigeminal root entry zone

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Management
 Carbamazepine
 Intolerant-Gabapentin/Pregabalin
 Injection of alcohol into peripheral branch of nerve
 Posterior craniotomy to relieve vascular compression of
trigeminal nerve

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IV- CLUSTER HEADACHE
 Headaches occur during a short time span.
 The cluster then recurs periodically.
 A typical cluster of headaches may last 4-
8weeks with 1-2 headaches/day during the
cluster.
 Patient may be free 6months to 1year before
another cluster of headache occurs.
 Male to Female ratio 5:1

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Symptoms & Signs
 Abrupt onset of headache originating in the eye and spreading
over the temporal area.
 Pain extremely severe and last 20-60minutes
 The headache associated with
 Nasal stuffiness
 Rhinorrhoea
 Redness of the Eye
 Flush and edema of the cheek

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Management
 Acute:
 Oxygen inhalation 100%
 Triptans/ergots
 Indomethacin

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Management
 Chronic/Preventive:
 Verapamil, lithium
 Valproate, topiramate
 Prednisone burst
 Melatonin
 Ergots

44. References:
• Harrison’s principles of internal medicine( 21st
edition)
• American Migraine Foundation
• Bhupendra et al. (European Journal of Biomedical and
Pharmaceuticals Sciences)
• Murtagh’s general practice, 5th edition
• Manadhar et al. (The Journal of Headache and
PainOfficial Journal of the "European Headache
Federation“)
• UpTodate

45. Thanks