all about headaches

1. D R R A V I R A J A N I
D R A R P A N S I N G H C H O U H A N
APPROACH TO A PATIENT WITH
HEADACHE

2. OBJECTIVES
 TO LEARN ABOUT THE GENERAL APPROACH TO
MAJOR TYPES OF HEADACHES
 TO UNDERSTAND THE DIFFERENCE BETWEEN
PRIMARY AND SECONDARY HEADACHES
 BE FAMILIAR WITH THE “RED FLAGS”
 TO UNDERSTAND WHEN AND HOW TO
INVESTIGATE HEADACHE

3. ORIGINS OF PAIN IN THE HEAD
 EXTRA-CRANIAL PAIN SENSITIVE
STRUCTURES
1. Sinuses
2. Eyes/orbits
3. Ears
4. Tooth
5. TMJ
 INTRA-CRANIAL PAIN SENSITIVE
STRUCTURES
1. Arteries
2. Veins
3. Meninges
4. Dura

4. HEADACHE
 HEADACHE IS THE PAIN LOCATED ABOVE THE
ORBITAL-MEATAL LINE.
 IT IS A LINE THAT CONNECTS THE OUTER
CANTHUS OF THE EYE TO THE CENTER OF THE
EXTERNAL AUDITORY CANAL.
 BELOW THIS LINE HEAD PAIN IS USUALLY
CALLED FACIAL PAIN.

5.  Sensory stimuli from head are conveyed to CNS via
Trigeminal nerves- for structures above the
tentorium in the anterior and middle fossae of the
skull and surface structures of most of the head.
C1, C2, C3 – for structures in the posterior fossa and
neck structures

6. CLASSIFICATION OF HEADACHES
 PRIMARY HEADACHES
(benign, recurrent, no organic disease):
 Migraine
 Tension-type headache
 Cluster headache
 Other primary headaches:
a)Primary stabbing headache
b)Primary cough headache

7. c)Primary exertional headache
d)Primary headache associated with sexual activity
e)Hypnic headache
f)Primary thunderclap headache
g)Hemicrania continua
h)New daily persistant headache

8.  SECONDARY HEADACHES
 Usually it occurs due to underlying organic disease
1.Headache associated with head trauma
2. Headache associated with vascular disorders
a) SAH
b) Acute ischemic cerebrovascular disorder
c) Unruptured vascular malformation
d) Arteritis (e.g. temporal arteritis)
e) Arterial HTN

9. 3. Headache associated with nonvascular intracranial disorder
a) Benign intracranial HTN (pseudotumor cerebri)
b) Intracranial infection
c) Low CSF pressure (e.g., headache subsequent to LP)
4. Headache associated with substance use or withdrawal
5. Headache associated with noncephalic infection (viral
infection, bacterial infection)
6. Headache associated with metabolic disorder (hypoxia,
hypercapnia, hypoglycemia, dialysis)

10. CLINICAL PRESENTATION OF PRIMARY
HEADACHES
MIGRAINE TENSION CLUSTER
Pain
Description
Throbbing,
Moderate to
severe, Worse
with exersion
Pressure,
Tightness,
Waxes and
wanes
Abrupt onset,
deep,
continuous,
excruciating,
explosive.
Associated
Symptoms
Photo/phono
phobia,
Nausea/vomiti
ng, Aura
NONE Tearing,
congestion,
rhinorrhea,
pallor,
sweating

11. MIGRANE TENSION CLUSTER
Location 60-70%
unilateral
Bilateral Unilateral
Duration 4-72 hours Variable 30 mins to 3
hours
Many per day
Patient
appearance
Resting in
quite room
Young female
Remains
active or
prefers to rest
Usually male,
smoker,
prefers hot
showers

12. CLINICAL APPROACH
1) PATIENT FACTORS
 THE MOST IMPORTANT PATIENT FACTORS IS AGE AND SEX.
 Migrane is equally common in boys and girl upto puberty,
then becomes more comon in women than in men.
 Cluster headache is mainly a disorder of men.
 Tension type headache is equal in both men and women.
 Chronic daily headache is more common in women.
 Temporal arteritis is not a diagnostic consideration in
patients below 50 years of age

13. 2) DESCRIPTION
 THE DESCRIPTION OF THE HEADCHE SOMETIMES CAN BE
MISLEADING
 Patients with migrane obviusly have throbbing headache. However, a
pressure or band headache around the head is common which is a
description of tension type headache.
 Patients with cluster headache describe severe orbital pain but
sometimes migrane patients also gives such description.

14. 3)LOCALIZATION OF PAIN
 In headache disorders pain is where it is expected to be if local
structures are involved such as scalp or bone.
 It may not be localized if it involves arterial or venous blood vessels and
meninges.
 In some primary headaches such as migranes and tension type
headaches the pain is localized and is diffused
 In cluster and similar disorders the pain is usually in periorbital.

16. 4)AGGRAVATING FACTORS
MIGRANES CLUSTER TESION TYPE
AGGRVATING
FACTORS
• SOUND,
• LIGHT,
• HIGH
ALTITUDE
• CHOCOLAT
• NITRATES
• SUGAR
• SMOKED
MEATS
• RED WINE
• WORSENS
WHEN THE
PATIENT LIES
DOWN,
• COUGHING
• SOMETIMEAG
GRAVTEDURI
NG NIGHT
• CAN
AGGREVATAN
YTIME
• DURING
STRESS
• PANIC
ATTACK
• CRYING

17. 5) RELIEVING FACTORS
 RELIEVING FACTORS SIMILAR TO AGGRAVATING FACTORS ARE
RELEVANT IN PRIMARY AND SECONDARY HEADACHES.
 Migrane headache usually is relieved by rest and sleep
 Lying down helps releiving tension type headache.
 Avoidance of aggravating factors helps some headaches.
 Ice applied at the time of the pain on patients head may relieve migrane
 Pressure on a pulsating temporal artery helps relieving tension
headache.

18. 6) OTHER FACTORS
 The other factors to consider in the evaluation of the headache of
patient are symptoms like nausea and vomiting as they are common in
patients with migrane.
 Patient with tension type head will have anorexia.
 Patient with cluster will lack nausea.

19.  Visual symptoms are also important to evaluate as there are wide
vairety of visual disturbances In migrane headache from blurring or
classical zig-zag which is suggestive of migrane with aura.
 In cluster headache there is associated autnomic symptoms in cluding
nasal discharge, horners syndrome consisting of droopy eyelid and
small pupil.

20. 7) CONCURRENT MEDICAL CONDITIONS
 Meningitis
 CNS lymphoma
 Toxoplasmosis
 Metastases
 Intracranial vascular disorder
 Acute viral syndrome or acute bacterial infection

21. 8)PAST HISTORY
 THE PAST HISTORY IS RELEVANT IN HEADACHE PATIENT.
 Migrane headache can begin in childhood and in all primary headaches
there frequently is a long history of similar complaints.
 A previous head injury sometimes is overlooked or forgotten in patients
with chronic subdural hematoma who now have chronic headache.
 Patients with neoplasms can have personality change or memory
problems along with headaches.

22. 9)SOCIAL HISTORY
 The social history should include whether the patient smokes or not
and for how log as well as alcohol consumption.
 Alcohol is an important trigger factor for migrane and cluster
headaches and may relieve a tension type headache in some patients.
 Medication usage is a vital part of the headache evaluation and it is
important to mention all the medications the patient is taking for
headaches or took in past for other medical conditions.

23.  All non prescription medications and agents should be listed.
 The patient should be asked whether or not the medication worked and
for how long the patient took the mediation and in what dosage.
 The clinician should ask if there were any adverse effects and to
determine if these were true side effects or allergic reactions.
 The clinician should ask if any specific medication or class of
medications worked in past for the headache as it helps in formulating
the management plan.

24.  DRUGS THAT CAN CAUSE HEADACHES
 CCBs
 Antiarrhythmics
 α1 adrenergic antagonists
 α2 adrenergic agonists
 β adrenergic antagonists
 ACE inhibitors
 Angiotensin II inhibitors
 Nitrates
 Diuretics
 Antimicrobials

25.  Gastrointestinal- H2 blockers/ PPI
 Endocrinological- Gonadotropin inhibitors
 Psychiatric-
Antidepressants/antipsychotics/Sedative/hypnotics
 Misc- Antiobesity,Statins,Prostaglandins

26. 10)PHYSICAL EXAMINATION
 Vital sign along with body temperature
 General appearance- whether restless or calm in a dark room (cluster
vs migraine)
 Palpation of ipsilateral temporal artery for tenderness, tm joint for
crepitance while pt closes or opens jaw
 Area over infected sinus may be tender
 Pseudotumor cerebri- often seen in young obese females
 Eye and periorbital area- lacrimation, conjuctival injection, flushing
(TACs vs glaucoma)

27.  Pupillary size and light responses, extra ocular muscles, visual acuity
 Fundus- papilledema and retinal pulsations
 Neck for rigidity, kernig, brudzinski signs
 Cervical spine palpated for tenderness

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

29. HEADACHE WARNING FLAGS

30.  RED FLAGS
RED FLAGS CONSIDERATIONS
Head or neck injury • Hemorrhage -Epidural ,Subdural,
Subarachnoid,Intraparenchymal
• Dissection-Carotid arteries and
Vertebral arteries
New onset or new type or worsening
pattern of existing headache
• Mass lesion
• Subdural hematoma
• Medication overuse
• Meningoencephalitis
New level of pain (e.g. “worst ever”) • Subarachnoid hemorrhage

31. RED FLAGS CONSIDERATIONS
Abrupt or split-second onset • Intraparenchymal hemorrhage
• Bleed into a mass
• Dissection
• Cerebral venous thrombosis
• Spontaneous intracranial
hypotension
• Reversible cerebral vasoconstriction
syndrome
• Acute hypertensive crisis
Triggered by Valsalva manouver or
cough
• Chiari malformation
• Mass lesion
Triggered by exertion • Subarachnoid hemorrhage
• Dissection
• Angina equivalent
• Pheochromocytoma

32. RED FLAGS CONSIDERATIONS
Triggered by sexual activity
( Preorgasmic,orgasmic)
• Subarachnoid hemorrhage
• Dissection
Headache during pregnancy or
puerperium
• Cortical venous/cranial sinus
thrombosis
• Pituitary apoplex
Age more than 50 years • Brain tumour(primary, metastatic)
• Cerebrovascular diseases.
Neurological Symptoms • Mass lesion
• AVM
• Benign intracranial hypertension
• Meningoencephalitis

33. RED FLAGS CONSIDERATIONS
Systemic illness
 Fever
 Nuchal rigidity
• Meningoencephalitis
• Meningeal carcinomatosis
• Lyme disease
• Collagen vascular disease
Weight loss • Malignancy
Scalp artery tendernes • Giant cell arteritis
Recent Travel • Meningioencephalitis

34.  YELLOW FLAGS
YELLOW FLAGS CONSIDERATIONS
Wakes Patient From Sleep At Night • Sleep related disorders(e.g.
Obstructive sleep apnea)
• Rebound withdrawal headaches
• Poorly controlled hypertension
New onset Side locked headaches • Head trauma
• Dissection
• Intracranial aneurysm
• Lung carcinoma
Postural Headaches • Spontaneous intracranial hypotension
• Post lumbar puncture headach

35. THUNDERCLAP HEADACHE
 Defined as severe headache reaching maximal
intensity within seconds to a minute
 Thunderclap headache is a NEUROLOGICAL
EMERGENCY
 Numerous etiologies ranging from benign to life-
threatening have been reported most notable being
aneurysmal subarachnoid hemorrhage

36. DISORDERS ASSOCIATED WITH THUNDERCLAP
HEADACHE
1. Subarachnoid hemorrhage
2. Unruptured intracranial aneurysm(“Sentinal
Headache”)
3. Cervical artery dissection
4. Stroke( H’ragic>Ischemic)
5. Cerebral venous sinus thrombosis
6. Intraparenchymal hemorrhage
7. Spontaneous intracranial hypotension
8. Reversible cerebral vasoconstrictn synd.
9. Reversible post. Leukoencephalopathy
10. Infections- intracranial,sinusitis

37. DIAGNOSTIC CRITERIA FOR MIGRANE
HEADACHES

38. TREATMENT OF MIGRANE HEADACHES
 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.
 Prophylaxis
 High efficacy: Beta blockers, Antiepileptics like Valproic Acid
 Low efficacy: Verapamil, Flunarizine

39. DIAGNOSTIC CRITERIA FOR TENSION TPE
HEADACHE

40. TREATMENT OF TENSION TYPE HEADACHE
 No specific treatment
 NSAIDs/ Acetylsalicyclic acids
 Hot or cold packs
 Stretching and relaxing techniques

41. DIAGNOSTIC CRITERIA FOR CLUSTER
HEADACHE

42. TREATMENT OF 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

43. APPROACH IN A PATIENT WITH HEADACHE

44. INVESTIGATIONS
 Laboratory
Random use of laboratory testing in the evaluation of
acute headache is not warranted.
CBC when systemic or intracranial infection is
suspected
ESR when temporal arteritis is a possibility.
 Neuroimaging
Neuroimaging is not usually warranted in patients
with primary headaches .

45.  CT and MRI should be done in pts with the following
findings:
Thunderclap headache
Altered mental status
Meningismus
Palliledema
Signs of sepsis
Acute focal neurological deficit
Severe hypertenstion (SBP>220, DBP>120)

46.  If meningitis, SAH, or encephalitis is being
considered- CSF study if not contraindicated
 For acute angle closure glaucoma: tonometry, slit
lamp shows shallow ant. Chamber, h/0- nausea,
visual hallows

47. WHEN TO REFER THE PATIENT 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.