clinical practice in the classification of headaches

1. B Y
K H A L E D O S A M A M O H A M E D
U N D E R S U P E R V I S I O N
PROF. NAGEH FOLLY EL GAMAL
Headache in Clinical Practice

2. Intended Learning Objectives “ILOs”
By the end of presentation audience can increase
their awareness about:
1- Difference between 1ry and 2nd headaches.
2- Management of common types of headache.

3. Primary or Secondary Headache?
Primary
Secondary

4. Red Flags Headaches “NESPCO”
 Neurological signs: impaired consciousness or
focal neurologic signs other than typical aura
(mass lesion, AVM, stroke).
 Eye: Visual disturbance (optic neuritis, glaucoma),
papilledema (mass lesion, encephalitis,
pseudotumor)
 Systemic symptoms: fever, neck stiffness,
cutaneous rash: (meningitis, encephalitis, collagen
vascular disease)

5. Red Flags Headaches cont.
 Secondary headache risk factors: pregnancy
and postpartum (VST), head trauma in elderly
(SDH), systemic cancer (metastases), HIV
(opportunistic infection),
 Specific trigger: cough or straining (mass or
SAH), changes in position (spontaneous CSF
leak).
 Sudden-onset headache: SAH, bleed into a
mass or AVM, pituitary apoplexy.

6. Red Flags headaches cont.
 Persistently progressive headache: mass
lesion, subdural hematoma.
 Change in the frequency, severity, or clinical
features of headache
 Older: new onset headache > 50 years: mass
lesion, temporal arthritis

7. Primary Headaches
Primary

9. Differential Diagnosis of common primary
headaches
Tension headache Migraine Cluster Headache
Age of onset Teens to 30s Childhood to 20s 20s
Gender Female ≥ male Female 3 X male Male 6 X female
Quality Pressure or band-like Pulsating Boring
Location Bifrontal, holocranial Unilateral Unilateral, orbital
Intensity Mild to moderate Moderate to severe Very severe
Duration Constant 4–72 hours 15–120 minutes
Frequency Daily or near daily Intermittent 1–8/day
Associated
symptoms
None Nausea, vomiting,
Photophobia,
phonophobia, > with
physical activity
Partial Horner $,
Lacrimation
Rhinorrhea
Triggers Stress Hunger, Menses, sleep
deprivation, stress
Alcohol, nitrates

10. Tension-Type Headache (TTH)
(A) At least 10 episodes fulfilling the criteria B-D:
(B) Lasting 30 min - 7 days
(C) Has at least 2 of the following:
- Bilateral location
- Pressing/tightening (non-pulsating) quality
- Mild or moderate intensity
- Not aggravated by routine physical activity
(D) Both of the following:
- No nausea or vomiting (anorexia may occur)
- No > 1 episode of photophobia or phonophobia
(E) Not attributable to another disorder

11. Categories of Tension Headache
 Infrequent Episodic (IFETH): <1day a month
 Frequent Episodic (FETH): 1-15 days a month.
 Chronic (CTH): ≥15 days a month.
 Chronic daily headache: at least 6 days / week

12. Management of Tension Headache
Non pharmacological Pharmacological
Prevention -Information, reassurance &
trigger factors identification
-Psychological Treatments
(Relaxation Training,
Biofeedback, CBT)
-Physical Therapy
-Acupuncture & Nerve block
-Antidepressants
-Topiramate
Treatment -Massage or hot packs on
the muscles of head & neck
-Simple Analgesics
-Muscle relaxants

13. Migraine without aura
(A) At least 5 attacks fulfilling criteria B–D (<5=Probable M)
(B) Lasting 4-72 hours (1-72 in children).
(C) Has at least 2 of the following:
- Unilateral
- Pulsating
- Moderate or severe
- Aggravation by or causing avoidance of routine activity
(D) During headache at least 1 of the following:
- Nausea and/or vomiting.
- Photophobia and phonophobia.
(E) Not attributed to another disorder

14. Migraine with aura
(A) At least 2 attacks fulfilling criteria B–D
(B) Consisting of at least 1 of the following fully reversible
symptoms: visual or sensory or speech (but no weakness)
(C) At least 2 of the following:
- Homonymous visual and/or unilateral sensory symptoms.
- At least 1 symptom develops over ≥5 min and/or different
symptoms occur in succession over ≥5 min.
- Each symptom lasts 5-60 min
(prolonged aura: 60 min-7days)
(D)Headache fulfilling criteria B–D for Migraine without aura
begins during or follows the aura within 60 min.
(E) Not attributed to another disorder.

15. Retinal migraine
(A) At least 2 attacks fulfilling B-C.
(B) Fully reversible monocular positive and/or
negative visual phenomena.
(C) Headache fulfilling criteria B-D for migraine
without aura begins during the visual symptoms
or follows them within 60 min.
(D) Normal ophthalmological examination outside of
attack.
(E) Not attributed to another disorder.

16. Basilar-type migraine
 As migraine with aura except aura consisting of ≥2
of the following fully reversible symptoms:
 Tinnitus, Hypacusia, Vertigo,
 Ataxia, Dysarthria, Diplopia,
 Visual symptoms simultaneously in both
temporal and nasal fields of both eyes,
 Simultaneously bilateral paraesthesias or
 Decreased level of consciousness.
but no motor weakness.

17. Familial hemiplegic migraine (FHM)
(A) At least 2 attacks fulfilling criteria B and C
(B) Aura consisting of fully reversible motor weakness & ≥1
of fully reversible symptoms: visual or sensory or
speech.
(C) At least 2 of the following:
- At least 1 symptom develops over ≥5 min. and/or
different aura symptoms occur over ≥5 min.
- Each aura symptom lasts 5 min-24 h.
- Headache fulfilling criteria B-D for Migraine without aura
begins during or follows onset of aura within 60 min.
(D) At least 11st- or 2nd-degree relative fulfils these criteria
(E) Not attributed to another disorder

18. Cyclical vomiting
(A) At least 5 attacks fulfilling criteria B and C.
(B) Episodic attacks of vomiting and intense nausea,
stereotypical in the individual patient, of intense
nausea and vomiting lasting from 1 h to 5 ds.
(C) Vomiting during attacks occurs at least 4
times/hour for at least 1 hour.
(D) Symptom free between attacks.
(E) Not attributed to another disorder.

19. Abdominal migraine
(A) At least 5 attacks fulfilling criteria B-D
(B) Attacks of abdominal pain lasting 1-72 h
(C) Abdominal pain has all of the following:
- Midline, periumbilical or poorly localized.
- Dull or “just sore” quality.
- Moderate or severe intensity.
(D) During abdominal pain ≥2 of the following:
- Anorexia; Nausea; Vomiting; Pallor.
(E) Not attributed to another disorder

20. Benign paroxysmal vertigo of childhood
(A) At least 5 attacks fulfilling criterion B.
(B) Multiple episodes of severe vertigo, occurring
without warning and resolving spontaneously after
min to hs.
(C) Normal neurological examination; normal
audiometric and vestibular functions between
attacks.
(D) Normal EEG.

21. Complications of migraine
 Chronic migraine: migraine ≥ 15 days/m for >3 m
in the absence of medication overuse.
 Status migrainosus: Debilitating migraine attack
lasts >72 hs and refractory to standard therapy.
 Migraine-triggered seizures or Migralepsy:
seizure of any kind occurring in continuation of
migraine aura or within 1 hour from the resolution of
symptoms

22. Complications of migraine cont.
 Persistent aura without infarction: It is >7 days
of aura symptoms, without evidence of infarction.
 Migrainous infarction: cerebral infarction
occurring during the course of typical migraine with
aura and in appropriate territory demonstrated by
neuroimaging.

23. Management of Migraine
Non pharmacological Pharmacological
Prevention -Headache diary
-Regular & sufficient sleep,
exercise and meals, but not
excessive
-Relaxation, biofeedback &
cognitive behavioral
therapies
-Beta-blockers
-Anti-depressants
-Anti-serotonin
-Anti-epileptic
-Ca channel blockers
Treatment -Rest in quiet, darkened
room
-Sleep
-Application of ice
-Rehydration
-Simple Analgesics
-Caffeine Containing
Analgesics
-Ergotamines
-Triptans

24. Cluster headache
(A) At least 5 attacks fulfilling criteria B–D
(B) Severe or very severe unilateral orbital, supra-
orbital and/or temporal pain lasting 15-180 min.
(C) Accompanied by at least 1 of:
1. Ipsilat. conjunctival injection and/or lacrimation
2. Ipsilat. nasal congestion and/or rhinorrhoea
3. Ipsilat. eyelid oedema
4. Ipsilat. miosis and/or ptosis
5. Ipsilat. forehead & facial sweating
6. Sense of restlessness or agitation
(D) Frequency:1/2d - 8/d
(E) Not attributed to another disorder

25. Management of Cluster headache
Abortive
Treatment
-Oxygen: 100% at 10-12 L/min for 15 min
-Triptans: SC or IN. oral has no role
-Dihydroergotamine: IM. IN is less effective
-Lidocaine: nasal drops ?
Prophylactic
Treatment
Short Term Long Term
-Corticosteroids
-Ergotamine
-Verapamil
-Greater occipital n. Injec.
-Surgical: DBS & occipital n.
stim.
-Verapamil
-Lithium
-Topiramate ?
-Gabapentin ?
-Melatonin ?

26. Primary Thunderclap Headache
(A) Severe head pain fulfilling criteria B and C
(B) Both of the following:
- Sudden onset, reaching max in <1 min
- Lasting 1 h - 10 d
(C) Doesn’t recur regularly over subsequent weeks
or months
(D) Not attributed to another disorder
DD: SAH

27. Primary Stabbing Headache
(A) Head pain occurring as a single stab or a series
of stabs and fulfilling criteria B–D
(B) Exclusively or predominantly felt in the
distribution of the first division of the trigeminal
nerve (orbit, temple and parietal area)
(C) Stabs last up to a few sec and recur with
irregular frequency ranging from 1 to many/day
(D) No accompanying symptoms
(E) Not attributed to another disorder

28. Primary cough headache
(A) Headache fulfilling criteria B and C
(B) Sudden onset, lasting from 1 sec to 30 min
(C) Brought on by and occurring only in association
with coughing, straining and/or Valsalva
manoeuvre
(D) Not attributed to another disorder

29. Primary Exertional Headache
(A) Pulsating headache fulfilling criteria B and C
(B) Lasting from 5 min to 48 hr
(C) Brought on by and occurring only during or after
physical exertion
(D) Not attributed to another disorder

30. Hypnic Headache
(A) Dull headache fulfilling criteria B-D
(B) Develops only during sleep, and awakens patient
(C) At least two of the following characteristics:
- Occurs >15 times/mo
- Lasts ≥15 min after waking
- First occurs after age of 50 y
(D) No autonomic symptoms and no >1 of: nausea,
photophobia or phonophobia
(E) Not attributed to another disorder

31. Management of Hypnic Headache
Using on of the following at bed time
 Lithium
 Verapamil
 Methysegide
 Caffeine

32. Primary headache associated with sexual
activity
Preorgasmic headache
(A) Dull ache in the head and neck associated with
awareness of neck and/or jaw muscle contraction
and fulfilling criterion B
(B) Occurs during sexual activity and increases with
sexual excitement
(C) Not attributed to another disorder
Orgasmic headache
(A) Sudden severe (“explosive”) headache fulfilling
criterion B
(B) Occurs at orgasm
(C) Not attributed to another disorder

33. New daily-persistent headache
(A) Headache for >3 mo fulfilling criteria B-D
(B) Daily & unremitting from onset or from <3 d from onset
(C) At least 2 of the following:
- Bilateral location
- Pressing/tightening (non-pulsating) quality
- Mild or moderate intensity
- Not aggravated by routine physical activity
(D) Both of the following:
- Not >1 of photophobia, phonophobia or mild nausea
- Neither moderate or severe nausea nor vomiting
(E) Not attributed to another disorder

34. Hemicrania continua
(A) Headache for >3 mo fulfilling criteria B-D
(B) All of the following:
- Unilateral pain without side-shift
- Daily & continuous, without pain-free periods
- Moderate intensity, with severe exacerbations
(C) At least 1 of the following autonomic features
occurs during exacerbations, ipsilateral to the pain:
- Conjunctival injection and/or lacrimation
- Nasal congestion and/or rhinorrhoea
- Ptosis and/or miosis
(D) Complete response to indomethacin
(E) Not attributed to another disorder