Headache Fayza Rayes MBBCh. Msc. MRCGP Consultant Family PhysicianJoint Program of Family & Community Medicine, Jeddah www.fayzarayes.com
:Contents1. Approach to patient with headache2. Migraine3. Tension headache
An Approach to the Headache History1. How many different headache typesdoes the patient experience? (Separate histories are necessary for each)
An Approach to the Headache History2. Time questionsa) Why now?b) How recent in onset?c) How frequentd) What pattern (temporal distribution)d) How long lasting?3. Character questionsa) Intensity of pain?b) Nature and quality of pain?c) Site and spread of pain?d) Associated symptoms?
Temporal distribution of different types of headache with timeMigraineTension headacheMigraine + Tension(combination)Cluster headacheRaised intracranialpressure
An Approach to the Headache History4. Cause questionsa) Predisposing and/or trigger factors?b) Aggravating and/or relieving factors?c) Family history of similar headache?5. Response to headache questionsa) What does the patient do during the headache?b) Function limited or prevented?c) Medication
An Approach to the Headache History 6. State of health between attacks a) Completely well, or residual or persisting symptoms? b) Concerns, anxieties, fears about recurrent attacks and/or their cause?Source: Steiner TJ, MacGregor EA, Davies PTG. Guidelines for All Healthcare Professionalsin the Diagnosis and Management of Migraine, Tension-Type, Clusterand Medication Overuse Headache (3rd edition, 2007). www.bash.org.uk
Headache Physical Examination The examination must be thorough but can be brief. Examine the head and neck for muscle tenderness , stiffness, limitation in range of movement and crepitation. Funduscopic examination is mandatory at first presentation with headache, and it is always worthwhile to repeat it during follow-up. Blood pressure measurement A quick neurological examination may be needed
Indications for Neuroimaging inPatients with Headache Symptoms Focal neurological finding Headache starting after exertion or Valsalvas maneuver Acute onset of severe headache Headache awakens patient at night Change in well-established headache pattern New-onset headache in patient >35 years of age New-onset headache in patient who has HIV infection or previously diagnosed cancer
CASE HISTORY 1Salma is 37year-old lady. She presents with severeheadache associated with nausea. The headache istypically present on waking and worsens over the course ofthe morning. The pain starts in the temples, affecting theright more than the left side and is temporarily eased bypressure. From the temples, the pain gradually spreads tosettle in the back of the head. She always feels nauseous,but only vomits occasionally during particularly severeattacks. Eventually he has to stop what he is doing and liedown in a darkened room. Occasionally, Salma gets awarning before the attack starts, with a bright spot in hisvision, which slowly expands over about 20 minutes beforedisappearing. It is followed by headache.
Explore the Diagnostic Imperatives What Conditions/Diagnoses are: Most common? Most important?
Distinguishing Migraine Aura from a Transient Ischemic Attack
International Classification of Headache Disorders. Diagnostic criteria for migraine with aura A. At least five attacks fulfilling criteria B–D B. Headache attacks lasting 4–72 hours (untreated or unsuccessfully treated) C. Headache has at least two of the following characteristics: 1. unilateral location 2. pulsating quality 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs) D. During headache at least one of the following: 1. nausea and/or vomiting 2. photophobia and phonophobia E. Not attributed to another disorderSource: Headache Classifi cation Subcommittee of the International Headache Society (IHS). TheInternational Classification of Headache Disorders (2nd edition). Cephalalgia 2004; 24 (suppl 1): 1–160.
International Classification of Headache Disorders. Diagnostic criteria for migraine with auraTypical aura consisting of visual and/or sensory and/or speech symptoms. Gradual development, duration no longer than one hour, a mix of positive and negative features and complete reversibility characterize the aura which is associated with a headache fulfilling criteria for migraine without auraDiagnostic criteriaA. At least two attacks fulfilling criteria B–DB. Aura consisting of at least one of the following, but no motor weakness:1. fully reversible visual symptoms including positive features (e.g. flickering lights, spots or lines) and/or negative features (i.e. loss of vision)2. fully reversible sensory symptoms, including positive features (i.e. pins and needles) and/or negative features (i.e. numbness)3. fully reversible dysphasic speech disturbance
Cont. International Classification of Headache Disorders. Diagnostic criteria for migraine with auraC. At least two of the following:1. homonymous visual symptoms and/or unilateral sensory symptoms2. at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes3. each symptom lasts ≥5 and ≤60 minutesD. Headache fulfilling criteria B–D for migraine without aura (Box 2.1) begins during the aura or follows aura within 60 minutesE. Not attributed to another disorderSource: Headache Classifi cation Subcommittee of the International Headache Society (IHS). TheInternational Classification of Headache Disorders (2nd edition). Cephalalgia 2004; 24 (suppl 1): 1–160.
Estimates of migraine prevalence in studied using diagnostic criteria of the International Headache Society (IHS) .
MigraineAcute Treatment: Combination therapy with an oral triptan +NSAID, or an oral triptan + paracetamol, for the acute treatment of migraine, taking into account the persons preference, comorbidities and risk of adverse events. For young people aged 12–17 years consider a nasal triptan in preference to an oral triptan For people who prefer to take only one drug, consider monotherapy with an oral triptan , NSAID, aspirin (900 mg) or paracetamol for the acute treatment , taking into account the persons preference, comorbidities and risk of adverse events. Consider an anti-emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting.
MigraineProphylactic Treatment: Discuss the benefits and risks of prophylactic treatment for migraine with the person, taking into account the persons preference, comorbidities, risk of adverse events and the impact of the headache on their quality of life. Offer topiramatec (anti epilepsy) or propranolol for the prophylactic treatment of migraine according to the persons preference, comorbidities and risk of adverse events..
Migraine Advise women and girls of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception. If both topiramate and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5–8 weeks or gabapentin (up to 1200 mg per day) according to the persons preference, comorbidities and risk of adverse events.
Migraine For people who are already having treatment with another form of prophylaxis such as amitriptyline , and whose migraine is well controlled, continue the current treatment as required. Review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment. Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people.Source: Headaches-Diagnosis and management of headaches inyoung people and adults . NICE Guidelines, September 2012
CASE HISTORY 2The woman with ‘daily’ headachesSalem is a 30-year-old policeman and doesshift work. He presents with troublesomeheadaches, which he gets most days. Theheadache can come on at any time of theday. Sometimes the pain is on the left sideof his head, but more often it is like a bandacross the back of his head. There are noassociated symptoms. The headaches donot stop him working, but they affect hisability to concentrate
Explore the Diagnostic Imperatives What Conditions/Diagnoses are: Most common? Most important?
Tension HeadachePrevalence rates of tension-typeheadaches vary among studiesfrom 30 to 71%
Diagnostic CriteriaTension-type headache Headaches lasting from 30 minutes to 7 days At least two of the following pain characteristics: Pressing or tightening (non-pulsating) quality Mild to moderate intensity Bilateral location No aggravation from walking stairs or similar routine activities Both of the following: No nausea or vomiting Photophobia and phonophobia absent, or only one is present
Tension-type headache Diary cards can aid diagnosis and assessment of response to Treatment Referral is indicated if the diagnosis is unclear or there is no response to standard treatment strategies
Tension HeadacheAcute Treatment: Aspirin , paracetamol or an NSAID, taking into account the persons preference, comorbidities and risk of adverse events.Prophylactic Treatment: A course of up to 10 sessions of acupuncture over 5–8 weeks for the prophylactic treatment of chronic tension-type headache.Source: Headaches-Diagnosis and management of headaches inyoung people and adults . NICE Guidelines, September 2012
Rebound HeadachePatients with chronic tension-typeheadache should limit their use ofanalgesics to two times weekly toprevent the development ofChronic daily headache . OrRebound headache
Rebound Headache1. Daily analgesic medication can be withdrawn2. Withdrawal symptom frequently reduce after 2 weeks3. Pt. often show migraine headache4. Give migraine specific treatment
Non-pharmacological Treatmentfor Headache Smoking cessation Higher levels of nicotine are correlated with trends toward higher measures of anger, anxiety, and depression
Non-pharmacological Treatmentfor Headache biofeedback, relaxation training (No strong evidence) cognitive psychotherapy alone and in combination with other behavioral treatment for chronic tension-type headache (No strong evidence) acupuncture treatment (Evidence level A, systematic review of RCTs)
Non-pharmacological Treatmentfor Headache: Traditional physical therapy for headache Proper posture Home exercise program Used ice packs Massage, and “passive mobilization” of the cervical facets. Both headache frequency and psychologic well-being improved significantly (Evidence level B, uncontrolled study)
Acute Secondary Headache Headache associated with head trauma Acute post-traumatic headache Headache associated with vascular disorders Subarachnoid hemorrhage Acute ischemic cerebrovascular disorder Unruptured vascular malformation Arteritis (e.g., temporal arteritis) Venous thrombosis Arterial hypertension Headache associated with nonvascular intracranial disorder
Cont.Acute Secondary Headache Headache associated with metabolic disorder Hypoxia Dialysis Other metabolic abnormality Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures Cranial neuralgias and nerve trunk pain
Cont.Acute Secondary Headache Benign intracranial hypertension Low cerebrospinal fluid pressure (e.g. headache subsequent to lumbar puncture). Headache associated with substance use or withdrawal Acute use or exposure Chronic use or exposure Headache associated with noncephalic infection Viral infection Bacterial infection
Final message andconclusion:When dealing with patient suffering from headache1. You need to make accurate diagnosis2. You need to determine the severity3. Show your empathy and give appropriate treatment4. Do not deprive the patient from preventive medications