headache is one of the most common symptoms in the world, many people suffer from it. there are 150 different types of headache. there are red flags in patients with headache.there is algorithm for emergency management. you must know some information about it.

1. Headache

2. Definition &Types of
Migraines

3. Definition
• A pain in the head with the pain being above the eyes or the ears,
behind the head (occipital), or in the back of the upper neck.
Headache, like chest pain or back ache, has many causes.
• All headaches are considered primary headaches or secondary
headaches.
• Primary headaches are not associated with other diseases. Examples
of primary headaches are migraine headaches, tension headaches,
and cluster headaches.
• Secondary headaches are caused by other diseases. The associated
disease may be minor or major.

4. There are 150 different types of headaches.
The most common ones are :
• Tension headaches: Also called stress headaches,
• chronic daily headaches, or chronic non-progressive headaches, they
are the most common type among adults and teens.
• They cause mild to moderate pain and come and go over time.

5. • Tension Headache Tension headaches are a pressure or tight
sensation, he pain is typically mild to moderate, but can become
severe.
• There is no associated throbbing or pulsing to the pain of a tension
headache. Furthermore, there is no exacerbation or increase in the
pain with exercise.
• Nausea and vomiting are not associated with tension headaches.
However, some patients do occasionally describe either light sensitivity
or noise sensitivity.

6. • Migraines: These headaches are often described as pounding,
throbbing pain.
• They can last from 4 hours to 3 days and usually happen one to four
times per month.
• Along with the pain, people have other symptoms, such as sensitivity
to light, noise, or smells; nausea or vomiting ; loss of appetite; and
gastric pain

7. • Cluster headaches: This type is intense and feels like a burning or
piercing pain behind the eyes, either throbbing or constant.
• Pain frequently develops during sleep and may last for several hours.
Attacks occur every day for weeks, or even months, then disappears
for up to a year.
• Eighty percent of cluster patients are male, most between the ages of
20 and 50. It’s the least common but the most severe type of
headache. The pain can be so bad that most people with cluster
headaches can’t sit still and will often pace during an attack.

8. • Sinus headaches: With these, you feel a deep and constant pain in
your cheekbones, forehead, or bridge of your nose.
• They happen when sinuses get inflamed. The pain usually comes
along with other sinus symptoms, such as a runny nose, feeling of
fullness in the ears, fever, and swelling in your face

9. • Mixed Tension Migraine This headache type has features of both
migraine headache and tension headache. Sufferers describe the pain
as dull and constant or throbbing
• the severity may be mild, moderate, or severe.
• Other symptoms of migraine, including light and sound sensitivity or
nausea and vomiting, may be present. There may be neck pain
or scalp muscle tension.

10. Clinical picture
Symptoms
History & Examination

12. Table 1. Red flags in patients with headache
New (recent onset or change in pattern)
Effort-induced or positional
Late life onset (middle age or later)
Meningismus, fever
AIDS, cancer, or other known systemic illness
Neurologic or psychological symptoms or signs

13. • symptoms such as a fever, weakness, vision loss or double vision, or
confusion are some of most concerning symptoms.
• If you have a new symptom and serious, life-threatening medical
problems such as liver, heart or kidney disease, are pregnant, or have
a disorder which affects your immune system such as HIV infection, an
ER visit may be more essential.

14. History-taking in acute headache
Mode of onset (fast vs. slow)
Exertion during onset or before
Location
Focal symptoms
Current medications and drugs
Family history
Medical illnesses

15. • mode of onset is very important, with a rapid evolution to severe pain
suggesting secondary causes.
• Exertion during or before onset is also worrisome, although it can be a
benign presentation.
• Severity is important, but most patients in the ED will probably endorse
a high level of pain intensity. Asking the patient if it is the worst
headache they have ever had is not particularly useful.

16. • Focal neurologic symptoms suggest neurologic disease, such as
arterial dissection, intracranial mass or vasculitis.
• Current medications (such as sedatives, stimulants, and
anticoagulants) and other substances must be known so potential
causes of headache as well as potential roadblocks to treatment can
be clarified.
• The presence of concurrent medical illnesses, such as diabetes, HIV
infection and neoplastic disease, must be understood for similar
reasons

17. Acute narrow-angle glaucoma
• An uncommon eye condition that results from blockage of the drainage
of fluid from the eye.
• Symptoms of acute glaucoma may include headache with a painful red
eye and misty vision or haloes, and in some cases nausea.
• Acute glaucoma may be differentiated from cluster headache by the
presence of a semi-dilated pupil compared with the presence of a
constricted pupil in cluster headache

18. Bout of cluster headache
The duration over which recurrent cluster headaches occur, usually lasting
weeks or months.
Headaches occur from 1 every other day to 8 times per day.
Giant cell arteritis
Also known as temporal arteritis, giant cell arteritis is characterised by the
inflammation of the walls of medium and large arteries. Branches of the carotid
artery and the ophthalmic artery are preferentially involved, giving rise to
symptoms of headache, visual disturbances and jaw claudication

19. • When going to the ER, be sure to mention:
• your symptoms, including any that are new or unusual for you
• Any medications you have taken, especially in the last few days; and
• if you have had good results from a particular medication regimen, that
can be helpful to the ER

20. Examination criteria in acute headache
Vital signs
Meningismus
Eye exam including pupillary light response and
funduscopy
Head and neck exam – sinuses,
temporomandibular region, submandibular
areas, carotid arteries, superficial nerves
Neurologic exam
Dix-Hallpike maneuver

21. • Examining the patient with acute headache must include
an assessment of meningismus as a clue to meningeal
inflammation due to infection or hemorrhage
• Head and neck evaluation should include palpation of the
paranasal sinuses, temporomandibular joint regions,
submandibular tissues, carotids, temporal arteries, and
supraorbital regions.
• A complete neurologic exam is essential. The Dix-Hallpike
maneuver may be helpful when vertigo is a key
accompaniment. Provocative maneuvers may help clarify
cervical spine disease, including the Spurling maneuver.
• Eye examination, including careful pupillary evaluation, is
very helpful to exclude ocular disease, such as acute
angle-closure glaucoma. Funduscopic evaluation is
essential as an indicator of intracranial pressure

22. • Routine laboratory testing in acute headache may be of low yield
• serum glucose, electrolytes, blood cell counts, and pregnancy testing are
generally recommended.
• Computed tomography (CT) is essential for patients who have had recent
head trauma or in whom a mass lesion or subarachnoid hemorrhage is
suspected. Computed tomography may be overused in evaluating acute
headache, as approximately 95% demonstrate no abnormality

23. Treatment

24. Migraine with or without aura
Acute treatment
• Offer combination therapy with an oral triptan and an NSAID, or an oral
triptan and paracetamol , for the acute treatment of migraine, 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 in whom oral preparations (or nasal preparations in young people
aged 12–17 years) for the acute treatment of migraine are ineffective or not
tolerated: offer a non-oral preparation of metoclopramide or prochlorperazine
andconsider adding a non-oral NSAID or triptan if these have not been tried.

25. • 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 of migraine comorbidities and risk of adverse events.
• When prescribing a triptan start with the one that has the lowest
acquisition cost; if this is consistently ineffective, try one or more
alternative triptans
• Consider an anti-emetic in addition to other acute treatment for
migraine even in the absence of nausea and vomiting

26. Prophylactic treatment
• Offer topiramate or propranolol for the prophylactic treatment of
migraine according to the person's preference, comorbidities and risk
of adverse events.
• 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 needed.

27. Tension-type headache
Acute treatment
Consider aspirin , paracetamol or an NSAID for the acute treatment of
tension-type headache,taking into account the person's preference,
comorbidities and risk of adverse events.
Do not offer opioids for the acute treatment of tension-type headache.
Prophylactic treatment
Consider a course of up to 10 sessions of acupuncture over 5–8 weeks
for the prophylactic treatment of chronic tension-type headache.

28. Cluster headache
Acute treatment
• Discuss the need for neuroimaging for people with a first bout of cluster
headache with a GP with a special interest in headache or a neurologist.
• Offer oxygen and/or a subcutaneous2 or nasal tripan3 for the acute
treatment of cluster headache.
When using oxygen for the acute treatment of cluster headache:
• use 100% oxygen at a flow rate of at least 12 litres per minute with a non-
rebreathing mask and a reservoir bag and arrange provision of home and
ambulatory oxygen. When using a subcutaneous or nasal triptan, ensure
the person is offered an adequate supply of triptans calculated according
to their history of cluster bouts, based on the manufacturer's maximum
daily dose.

29. Do not offer paracetamol, NSAIDs, opioids, ergots or oral triptans
for the acute treatment of cluster headache.
Prophylactic treatment
Consider verapamil1 for prophylactic treatment during a bout of cluster
headache. If unfamiliar with its use for cluster headache, seek specialist
advice before starting verapamil, including advice on electrocardiogram
monitoring.
Seek specialist advice for cluster headache that does not respond to
verapamil. Seek specialist advice if treatment for cluster headache is
needed during pregnancy

30. Interventional procedures
NICE has published guidance on the following procedures with special
arrangements for
clinical governance, consent and audit or research:
transcutaneous stimulation of the cervical branch of the vagus nerve for
cluster headache and migraine implantation of a sphenopalatine
ganglion stimulation device for chronic cluster headache deep brain
stimulation for intractable trigeminal autonomic cephalalgias.

31. Medication overuse headache
• Explain to people with medication overuse headache that it is treated
by withdrawing overused medication.
• Advise people to stop taking all overused acute headache medications
for at least 1 month and to stop abruptly rather than gradually.
• Advise people that headache symptoms are likely to get worse in the
short term before they improve and that there may be associated
withdrawal symptoms, and provide them with close follow-up and
support according to their needs.

32. • Consider prophylactic treatment for the underlying primary headache
disorder in addition to withdrawal of overused medication for people with
medication overuse headache.
• Consider specialist referral and/or inpatient withdrawal of overused
medication for people who are using strong opioids, or have relevant
comorbidities, or in whom previous repeated attempts at withdrawal of
overused medication have been unsuccessful.
• Review the diagnosis of medication overuse headache and further
management 4–8 weeks after the start of withdrawal of overused
medication.

33. Emergency
management

34. Algorithm

37. If no relief in step 3

38. Discharge patient

39. Admission criteria

40. Common Therapeutic Approach to Severe Migraine
• 1L bolus of NS
• Prochlorperazine 10 mg IV
• Diphenhydramine 25 mg IV
• Ketorolac 30 mg IV
• Dexamethasone 10 mg IV
• Other options include haloperidol, metoclopramide, ergotamine, sumatriptan, analgesics.