APPROACH TO HEADACHE

1. Approach To Headache
A Presentation By:
Dr. SHIVAOM CHAURASIA
MD INTERNAL MEDICINE, KUSMS
FIRST YEAR RESIDENT

2. INTRODUCTION:
 Headache, or cephalalgia, is defined as diffuse pain in various parts of the
head, with the pain not confined to the area of distribution of a nerve.
 The term headache should encompass all aches and pains located in the head,
but in practice its applications is restricted to discomfort in the region of the
cranial vault.
 Headache is usually a benign symptom but occasionally it is the manifestation
of a serious illness.

3. Common causes of headache:
There are mainly two causes of headache:
1. Primary headache:
 Primary headache often results in considerable disability and a decrease in the
patient's quality of life. It can be:
 i. Benign
 ii. Recurrent
 iii. No organic disease as their cause

4. 2. Secondary Headache:
i. Underlying organic disease.
ii. Headache associated with head trauma.
iii. Headache associated with vascular disorders.
 Acute ischemic cerebrovascular disorder
 SAH
 Un-ruptured vascular malformation
 Arterial HTN
 Arteritis (e.g. temporal arteritis, sinusitis )
iv. Headache associated with nonvascular intracranial disorder:
 Benign intracranial HTN ( pseudotumor cerebri –presence with headache papilledma,
diplopia and elevated CSF pressure > 20 cm of H2O in relaxed lateral decupitus position).
 Low CSF pressure (e.g., headache subsequent to LP)
 Intracranial infection

6. Classification:
 Primary headache syndromes include migraines with (classic) or without
(common) aura, the hemicranias and indomethacin-responsive headaches,
tension headaches, chronic daily headaches, and cluster headaches.
 Secondary headaches have specific etiologies, and symptomatic features
vary depending on the underlying pathology (i.e., SAH, tumor, hypertension,
posterior reversible encephalopathy syndrome [PRES], analgesic overuse,
iatrogenic).
 Migraine without aura (common): At least five attacks that last 4 to 72
hours.Symptomsshouldincludeatleasttwoofthefollowing:unilaterallocation,puls
atingorthrobbing,moderatetosevereinintensity,aggravatedbyactivity,andatleas
tone of these associated features: nausea/vomiting, photophobia, and/or
phonophobia.
 Migraine with aura (classic): Same as the aforementioned, except at least
two attacks with an associated aura that lasts from 4 minutes to 1 hour
(longer than 60 minutes is a red flag). The aura should have a gradual onset,
be fully reversible, and can occur before, with, or after headache onset

7.  Cluster headache: Unilateral orbital or temporal pain with lacrimation,
conjunctival injection, nasal congestion, rhinorrhea, facial swelling, miosis,
ptosis, and eyelid edema.
 Rebound headache (analgesic overuse headache) occurs in the setting of
chronic use of analgesics or narcotics.
 Trigeminal neuralgia presents as episodic sharp stabbing pain that is
unilateral. Rule out multiple sclerosis.
 Temporal arteritis presents as a dull unilateral headache with a thick
tortuous artery over temporal region. The disease is almost exclusively
limited to individuals over 60 years of age with jaw claudication, low-grade
fever, and an elevated ESR and C-reactive protein (CRP).

13. PATHOPHYSIOLOGY OF HEADACHE:
 Pain sensitive structures in brain
 Intracranial:
1. Cranial venous sinuses with afferent veins
2. arteries at base of brain and arteries of dura including middle meningeal
artery
3. Dura around venous sinuses and vessels
4. Flax cerebri
 Extracranial:
1. Skin
2. Scalp appendages
3. Periosteum

14. 4. Muscles
5. Arteries
6. Mucosa
 Nerves:
1. Trigeminal nerve(fifth)
2. Facial nerve ( seventh)
3. Vagal nerve (tenth)
4. Glossopharyngeal nerve (ninth)
5. Second and third cranial nerve( optic and oculomotor)

15. HISTORY:
FIRST OR WORST HEADACHE:
1.Age, Sex, Occupation:
 Migraine headache – more frequent in teenagers & young adults, higher
occurrence in female.
 Cluster headache – almost exclusively in males.
 Cranial arteritis – more frequently in late middle age & in elderly.
2. Duration:
 Tension headache -often has long duration.
 Headache due to expanding of intracranial disease – usually short duration.
 Headache due to meningeal cause – acute in onset.
 Migraine headache – recur over a long period of time, with symptoms free
interval between attacks

16. 3. Location:
 As a general rule localized headache is of greater significance than diffuse
headache.
 Tension headache – typically generalized, band like or bi-occipital.
 Migraine with aura – often unilateral & frequently more prominent interiorly.
 Migraine without aura – frequently bilateral.
 Cluster headache – invariably limited to the same side of the head in any
given attacks & usually periorbital.
4. Prodromal symptoms:
 Migraine headache – commonly precede by systemic complaints as
euphoria, anorexia, nausea.
 Migraine headache – often precede by neurological symptoms as
scintillating scotoma, transient hemianopia, hemi-motor or hemi-sensory
disturbance & dysphasia.

17. 5. Associated symptoms:
 Tension headache – often associated with other psycho-physiologic
disturbances.
 Cluster headache – typically associated with ipsilateral lacrimation,
Conjunctival injection, Rhinorrhea, & Facial Flushing.
6. Quality of pain:
 Tension headache – Pressing, Squeezing, Tight or Heavy.
 Migraine headache – Throbbing or Pounding.
 Headache due to intracranial lesion – Relatively Mild.
 Acute SAH- Pain tends to be explosive & intense.

18. 8. Frequency, duration & diurnal variation:
 Tension headache– often persist & may worsen as the day progress.
 Migraine headache – the frequency is variable & unpredictable. Although usual
variation is from 4 - 72 hrs, they may persist for days.
 Cluster headache – occur repetitively over a period of weeks or months. Often
there are 1 or 2 attacks daily. The headache typically nocturnal & of brief
duration (30 min to a few hours).
9. Family History:
 Migraine headache – strong family history.
 Cluster headache – are not familial.
10. Intracranial Mass Lesion:
 Associated symptoms are more prominent than headache.
 Some intra-cerebral lesion may exhibit seizure or vomiting.

19. 11. Cranial arteritis:
 Systemic symptoms as fever, anorexia & rheumatic symptoms.
12.Tension headache & Vascular Headache:
 Induced or aggravated by emotional factors.
 Intraventricular & posterior fossa tumor – may be accentuated by change in
the head position, coughing & Valsalva maneuver

21. Approach to Headache
1. PHYSICAL EXAMINTAION:
 The primary purpose of the physical examination is to identify causes of
secondary headaches.
 General physical examination:
 VS (BP, temperature)
 Fundoscopic examination (papilledema)
 CV assessment (assess risk of CVA)
 Palpation of the head and face (R/O sinusitis).
 Systemic sign (fever, weight loss, anemia) – infectious disease, specific
infection of CNS, metastatic disease of brain &/or meninges

22. Complete Neurologic Examination:
 focal neurologic signs
 Mental status
 Level of consciousness
 Cranial nerve testing
 Motor strength testing
 Deep tendon reflexes
 Pathologic reflexes (e.g. Babinski’s sign)
 Cerebellar function
 Gait testing
 Signs of meningeal irritation ( Kernig’s and Brudzinski’s signs).

23. 2. Neurological examination:
 No neurological abnormality – tension headache.
 Evidence of cerebral ischemia – small percentage of migraine (permanent residual
damage).
 Horner’s syndrome – sometimes during migraine headache(rarely permanent).
Localizing sign – expanding ICSOL.
 Papilledema - ICP due to ICSOL.
 Bruits over the eyes/cranium – vascular malformation.
 Sign of meningeal irritation – lesion affecting the meninges.

25. INVESTIGATION:
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.

26. Neuroimaging:
 Neuroimaging is not usually warranted in patients with primary headaches.
 CT scanning is recommended to identify acute hemorrhage.
 MRI studies are recommended to evaluate the posterior fossa.

27. Lumbar Puncture:
 CT scanning without contrast medium, followed by LP if the scan is negative,
is preferred to rule out SAH within the first 48 hours.
 LP is useful for assessing the CSF for blood, infection and cellular
abnormalities.
 Headaches are associated with low CSF pressure (e.g. posttraumatic leakage
of CSF) and elevated CSF pressure (e.g. idiopathic intracranial HTN and CNS
space-occupying lesions)

28. Indication For Scan:
 First or worst headache, particularly if of sudden onset.
 Headache of increasing frequency or severity.
 Increased frequency of vomiting and headache on waking.
 Headache triggered by coughing, straining or postural changes.
 Persistent physical symptoms or signs after attack (neurological or endocrine)

29. When to refer 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.

30. Preventive Management Of Headache:
 Prophylactic medications should be considered if a patient
at least three disabling migraine per month. It is important
to review patient use of all medication and comorbidities.
 Lifestyle modification:
 Patient should keep a headache calendar to identify
possible triggers.
 Patient should reduce alcohol, caffeine and other triggers
that might increase the risk of migraine.

31. 1. Migraine Headache:
1. 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 in ED
 2. Prophylaxis:
 High efficacy: Beta blockers, TCAs, Antiepileptics like
Valproic
 Low efficacy: Verapamil, Flunarizine

32. 2. Tension-Type Headache:
 The pain of TTH can generally be managed with simple analgesics such as
acetaminophen, aspirin, or NSAIDs.
 Behavioral approaches including relaxation can also be effective.
 TRIPTANS in pure TTH are NOT HELPFUL, although triptans are effective in TTH when
the patient also has migraine.
 For chronic TTH , AMITRIPTYLINE is the only proven treatment Other TCA, SSRI and the
benzodiazepines have not been shown to be effective.

33. 3. 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

34. Secondary Headache:
 Treatment of Secondary Headaches includes identifying the disease and
treating it

35. References:
 Harrison’s_Principles_of_Internal_Medicine,_Twentieth_Edition_(Vol.1_&_Vol.
2
 Davidson’s Principles and Practice of the Medicine- 23rd Edition.
 The Washington Manual Of Medical Therapeutics- 34th Edition

36. THANK YOU!!!