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Headache (tension type headache, migraine)

Approach to the patients Diurnal patterns of pain Clinical approach Tension type headache Migraine

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HEADACHE
MARYAM JAMILAH BINTI ABDUL HAMID
082013100002
IMS BANGALORE
LEARNING OUTCOME
Approach to the patients
Diurnal patterns of pain
Clinical approach
Tension type headache
Migraine
INTRODUCTION
Cardinal symptoms and very common complaint
Can be classified as primary or secondary
Commonest cause of headache is respiratory
infection
Headache (tension type headache, migraine)
Headache (tension type headache, migraine)
Diagnostic strategy model
1. Probability diagnosis
Acute: Respiratory infection
Chronic:
A. Tension-type headache
B. Combination headache
C. Migraine
D. Transformed migraine

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Headache (tension type headache, migraine)

  • 1. HEADACHE MARYAM JAMILAH BINTI ABDUL HAMID 082013100002 IMS BANGALORE
  • 2. LEARNING OUTCOME Approach to the patients Diurnal patterns of pain Clinical approach Tension type headache Migraine
  • 3. INTRODUCTION Cardinal symptoms and very common complaint Can be classified as primary or secondary Commonest cause of headache is respiratory infection
  • 6. Diagnostic strategy model 1. Probability diagnosis Acute: Respiratory infection Chronic: A. Tension-type headache B. Combination headache C. Migraine D. Transformed migraine
  • 7. 2. Serious disorders not to be missed Cardiovascular: SAH, intracranial haemorrhage, carotid/vertebral artery dissection, temporal arteritis, cerebral venous thrombosis Neoplasia: cerebral tumour, pituitary tumor Severe infections: meningitis, encephalitis, intracranial abscess Haematoma: extradural/subdural Glaucoma Benign intracranial HT
  • 8. 3. Pitfalls (often missed) Cervical spondylosis/dysfunction Dental disorders, refractive errors of eyes, sinusitis, ophthalmic herpes zoster, exertion headache, hypoglycemia, post-traumatic headache, post- spinal procedure, sleep apnoea rarities: Paget disease, post-sexual intercourse, Cushing syndrome, Conn syndrome, Addison disease, dysautonomic cephalgia
  • 9. 4. Masquerades checklist Depression, diabetes, drugs, anaemia, thyroid/endocrine disorder, spinal dysfunction (cervicogenic), UTI 5. Psychogenic disorder
  • 10. Timelines for causes of headache/facial pain Acute severe headache SAH Benign sex or exertional headache migraine/cluster headache Subacute headache (recent onset, increasing) expanding intracranial lesion temporal arteritis Recurrent episodes • Migraine/cluster headache • benign sex or exertional headache • neuralgia (trigeminal) Chronic headache • tension-type headache • transformed migraine/rebound headache • cervivogenic/post-traumatic • atypical facial pain
  • 12. CLINAL APPROACH Hx: describe your headache (pain) tempo, night/day, episodes other symptoms during headache; nausea/vomit aura,light hurts your eyes, blurred vision watering or redness of one or both eyes • pain when combing hair • stress • cold during headache? • tablets • high temperature, sweats and chill • trouble with sinuses • trauma
  • 13. Examination thermometer, sphygmomanometer, pen torch. diagnostic set (ophthalmoscope & stethoscope) inspect: head, temporal arteries & eyes palpate: temporal arteries, facial, neck muscles, cervical spine, sinuses teeth and TMJ mental state examination- altered consciousness or cognition, assessment of mood, anxiety-tension- depression,any mental changes neurological examination
  • 14. Special signs Upper cervical pain sign: palpate C2 & C3 (cervical spine area, 2 finger breadths out from spinous process of C2) Ewing sign for frontal sinusitis: press finger gently upwards & inwards against orbital roof medial to the supra-orbital nerve. Pain on pressure is a positive Invisible pillow sign: Pt. lies with head on pillow.Examiner support head with hands as the pillow is removed,ask pt. relax the neck muscles & examiner remove the supporting hands.Positive test indicate tension from contracting neck muscles pt’s head does not readily to change position. uncommon
  • 15. RED FLAGS INDICATORS sudden onset esp. no previous hx severe & debilitating pain progressive fever vomiting disturbed consciousness/confusion, drowsiness personality changes worse with bending, coughing or sneezing maximum in morning wakes patient at night neurological & visual symptoms/signs seizure young obese female:? on medication ‘New’ in elderly post head injury
  • 16. RED FLAGS POINTERS From physical examination Altered consciousness or cognition meningism abnormal vital signs: BP, temperature, respiration focal neurological signs, including pupil, fundi, eye movement tender, poorly pulsatile temporal arteries
  • 17. INVESTIGATIONS Hb White cell count ESR/CRP radiography: • CXR: lung mets to brain • cervical spine • skull X-ray; brain tumor, Paget disease, deposits in skull • sinus X-ray
  • 18. • CT scan: brain tumor (most effective), cerebrovascular accident (valuable), SAH • radioisotope scan (technetium-99m) localise specific tumors & hematoma • MRI: very effective for intracerebral pathology but expensive; better definition of intracerebral structures than CT scan but not sensitive for detecting bleeding; detect intracranial vasculitis in temporal arteries • LP: meningitis, suspected SAH (only if CT scan normal) *dangerous if raised intracranial pressure
  • 19. Headache in children Resp. infections & febrile illness are common causes isolated headache but chronic migraine-before adolescence; 1% aged 7 yrs to 5% aged 15 yrs. no aura, strong fam. hx, vertebrobasilar migraine (girls), hemiplegia (infants, children)-1st attack tension or muscle contraction headache-after adolescence progressive headaches->ICSOL, typically morning,vomit,dizziness, diplopia,ataxia,personality changes,deterioration of school performance neonates & children (aged 6-12months); greater risk for meningitis paracetamol 20mg/kg statim then 15 mg/kg 4-6 hrly up to 90 mg/kg/day ibuprofen 5-10 mg/kg statim up to 40 mg/kg/day (not for children <6 months)
  • 21. Headache in elderly must be treated with caution; could herald serious problem such as space occupying lesions (neoplasm,subdural hematoma), TA, trigeminal neuralgia or vertebrobasilar insufficiency difference between late onset migraine with TIA vomiting suggesting migraine
  • 22. Age-related causes of headache Age-related causes of headache children Intercurrent infections Psychogenic Migraine Meningitis Post-traumatic adults Migraine Cluster headache Tension Cervical dysfunction SAH Combination elderly Cervical dysfunction, Cerebral tumor, Temporal arteritis, Neuralgias, Paget disease, Glaucoma, Cervical spondylosis, SAH
  • 25. TENSION-TYPE HEADACHE tension or muscle contraction type headache typically symmetrical B/L tightness last or hours and recur each day ass. cervical dysfunction & stress or tension 75% females IHS criteria
  • 26. IHS criteria for tension-type headache International Headache Society (IHS3):- A. The patient should have had at least 10 of these headaches B. Headache last from 30 min to 7 days C. Headache must have at least 2 of the following 4:- • non-pulsating quality • mild/moderate intensity • B/L location • no aggravation with routine physical activity D. Headache must have both of the following:- • no nausea or vomiting • photophobia and phonophobia are absent, or one but not the other is present E. No attributable to another disorder
  • 27. Clinical features of tension headache Site: Frontal, over forehead & temples Radiation: occiput Quality: dull ache, like a ‘tight pressure feeling’, ‘heavy weight on top of head’, ‘tight band around head’; tightness or vice-like feeling rather than pain Frequency: almost daily Duration: almost daily Onset: after rising, gets worse during day
  • 28. Aggravating factors: stress, overwork with skipping meals Relieving factors: alcohol Associated features: lightheadedness, fatigue. neck ache or stiffness (occiput to shoulder), perfectionist personality, anxiety/depression Physical examination: muscle tension (frowning), scalp often tender to touch, ‘invisible pillow sign’ might be positive
  • 29. Management of tension-type headache Patient education: scalp muscles get tight like the calf muscles when climbing up stairs Counselling & relevant advice; CBT(Cognitive Behavioural Therapy) Stress reduction Medication
  • 32. Migraine ‘sick headache’, 1:10, F>M, peak 20-50 yrs old classic migraine & common migraine are best known most common trigger factor is stress
  • 33. Types of vascular headache Common migraine (aura is vague or absent) Classic migraine Complicated migraine Unusual forms of migraine: • hemiplegic, basilar, retinal, migrainous (vestibular) vertigo, migrainous stupor, ophthalmoplegic, migraine equivalents, status migrainosus Cluster headache Chronic paroxysmal hemicrania Menstrual migraine Lower half headache Benign exertional sex headache (beware SAH) Miscellaneous (icepick pains, ‘ice cream’ headache)
  • 34. Migrainous trigger factors Exogenous Foodstuffs-chocolate, oranges, tomatoes, citrus fruits, cheeses, gluten sensitivity alcohol- esp. red wine drugs- vasodilators, estrogens, MSG, nitrites(‘hot dog’ headache), indomethacin, OCP Glare or bright light (32%) Emotional stress (63%) head trauma allergen climate change excessive noise strong perfume
  • 35. Endogenous tiredness, physical exhaustion, oversleeping lack of sleep stress,relaxation after stress- ‘weekend migraine’ exercise/physical stress hormonal changes: puberty, menses, climacteric, pregnancy hunger fam. tendency ?personality factors
  • 36. Clinical features of Classic Migraine Site: temporofrontal region (unilateral), can be bilateral Radiation: retro-orbital & occipital Quality: intense & throbbing Frequency: 1-2 per month Duration: 4-72 hours (average 6-8 hours) Onset: paroxysmal,often wakes with it Offset: spontaneous (often after sleep) Precipitating factors: tension & stress Aggravating factors: tension, activity Relieving factors: sleep, vomiting Associated factors: nausea, vomiting (90%), irritability, aura Other pointers: abd. pain in childhood, fam hx migraine, asthma, eczema
  • 37. IHS3 criteria for migraine with typical aura (classic) A. At least 2 attacks fulfilling criteria B and C B. One or more of the following fully reversible aura symptoms: visual, sensory, speech and/or language, motor, brainstem, retinal C. At least two of: • at least one aura symptoms spreads gradually over at least 5 minutes • each aura symptoms lasts 5-60 minutes • at least one symptom is unilateral • headache follows aura within 60 minutes D. not attributable to another disorder including TIA
  • 38. IHS3 criteria for common migraine A. The patient should have had at least 5 attacks fulfilling criteria Band D B. Headaches last 4-72 hours C. Headache must have at least 2 of the following:- • unilateral location • pulsating quality • moderate or severe intensity, inhibiting or prohibiting daily activities • headache worsened by routine physical activity D. Headache must be at least 2 of the following:- • nausea and/or vomiting • photophobia and phonophobia E. Not attributable to another disorder
  • 39. Management of Migraine Counselling and advice Treatment of acute attack Treatment for severe attack Prophylaxis
  • 40. Treatment of acute attack commence treatment at earliest impending sign mild headaches; 2 aspirins/PCM, lie down in a dark quiet, cool room cold packs on forehead or neck avoid coffee, tea or orange juice avoid moving around too much don’t read or watch tv patient who relieve by sleeping off an attack, consider prescribe temazepam 10 mg or diazepam 10 mg moderate attack oral ergotamine or sumatriptan avoid opioids
  • 41. Medication (if necessary) 1st line acute migraine: aspirin/PCM + anti-emetic; aspirin 600-900 mg (o) & metoclopramide 10 mg (o) PCM/ibuprofen (children) triptans; sumatriptan 50-100 mg (o) at prodrome, repeat in 2 hrs if necessary, max 300mg/day. or nasal spray 10-20 mg/nostril (upto 40mg/24hr) or 6mg SC repat 1hr or more to max dose 12 mg/24hr zolmitriptan 2.5-5 mg (o), rpeat in 2 hr if nec. (max 10 mg/24 hr) naratriptan 2.5 mg (o), repeat in 4 hr (max 5mg/24 hr) rizatriptan 10mg of wafer, repeat in >2 hr (max 30mg/24 hr) eletriptan 40-80 mg (o) up to 160 mg/24 hr
  • 42. Treatment of severe attack at home: sumatriptan 6 mg (SC) in surgery or emergency room: • metoclopramide 10 mg IV slowly over 2 mins + oral analgesics or • metoclopramide 10 mg IV + dihydroergotamine 0.5 mg IV slowly or • simatriptan 6mg SC or • chlorpromazine 0.1 mg/kg IV infusion over 30 mins *do not use ergotamine if sumatriptan used in previous 6 hrs and do not use sumatriptan if ergotamine is used in previous 24 hrs practice tips: IV metoclopramide + 1 L NS IV in 30 mins + oral aspirin/PCM + continue high fluid intake
  • 43. STATUS MIGRAINOSUS Persistent migraine; lasts >72 hours IV dihydroergotamine 0.25-1 mg over 2 minutes (may have to be given 8hrly over 3-7 days in hospital) or chlorpromazine 0.1 mg/kg IV, repeat every 15 mins for up to 3 doses (if necessary) consider corticosteroids (dexamethasone 10-20 mg IV statim & taper)
  • 44. Prophylaxis migraine non-drug self-management beta blockers- propranolol 40mg (o) BD or TID (max 320 mg/day) TCA-amitriptyline sodium valproate cyproheptadine (children)
  • 45. Menstrual migraine Naproxen 550 mg (o) BD, 48 hrs before expected attack for 4-10 days or estradiol gel 1.5mg transdermally, once daily for 7 days
  • 46. Guidelines if low or N weight-pizotifen if HT-beta blocker if depressed or anxious-amitriptyline if tension-beta blocker if cervical spondylosis-naproxen food-sensitive migraine-pizotifen menstrual migraine-naproxen or mefenamic acid or ibuprofen or estradiol transdermal gel
  • 47. Take home points diagnose headache causes tension headache -reassurance and lifestyle changes migraine -should know to differentiate common and classical, treatment during attack and prophylaxis
  • 49. REFERENCES Murtagh’s General practice, 6th edition Davidson’s Medicine textbook http://www.webmd.com/migraines- headaches/guide/status-migrainosus-symptoms- causes-treatment