Approach the headache bin kakada

Neurology Department, KSFH
Approach the Headache
Bin kakada, Internal Medicine Residency
3/3/2020 Service Neurology, Bin Kakada, Internal Medicine Residency 1

Approach the Headache
 Introduction
● Headache is Headache is defined as diffuse pain in various parts of the head, with the
pain not confined to the area of distribution of a nerve.
● Headache is among the most common pain problems encountered in family practice.
Headache is among the most common reasons patients seek medical attention.
● It accounts for 4.4% of consultations in primary care and 30% of neurology outpatient
consultations
 Classification of the Headache
1. Primary headache
2. Secondary headache

Classification of
Headache
Primary headache
Benign, Recurrent, No organic
diseases
Secondary headache
Underlying organic diseases
1. Migraine
2. Tension-type headache
3. Cluster headache
1. Headache associate head trauma
2. Headache associated with vascular disorders
● SAH
● Acute ischemic cerebrovascular disorder
● Unruptured vascular malformation
● Arteritis (e.g. temporal arteritis)
● Arterial HTN
3. Headache associated with nonvascular
intracranial disorder
● Benign intracranial HTN (pseudotumor cerebri)
● Intracranial infection
● Low CSF pressure (e.g., headache subsequent
to LP)
4. Headache associated with substance use or
withdrawal

Classification of
Headache
(1)
Primary headache
Benign, Recurrent, No organic
diseases
Secondary headache
Underlying organic diseases
5. Headache associated with non cephalic infection
(viral infection, bacterial infection)
6. Headache associated with metabolic disorder
(hypoxia, hypercapnia, hypoglycemia, dialysis)
7. Headache or facial pain associated with disorder of
cranium, neck, eyes, ears, nose, sinuses, teeth or
mouth
8. Cranial neuralgias pain

History taking
 First or worst headache
● Primary headaches can occur at any age but most often begin during childhood or
between 20 and 50 years of age.
● Onset of headache after 50 years of age is a red flag for consideration of a secondary
headache disorder such as temporal arteritis or a mass lesion.
● If the patient routinely has headaches, it is important to determine whether the current
episode is typical. Is this headache like the ones you usually have?
 Symptoms
● Three questions should be verification and asking the patients
1. What the symptoms do you have before the headache start?
2. What the symptoms do you have during headache?
3. What the symptoms do have right now?

History taking (1)
 Symptoms (continue)
● Primary headache disorder such as cluster headache (ipsilateral lacrimation and/or
nasal congestion) or migraine with aura (e.g., scotomata, photophobia, phonophobia,
nausea)
● Secondary headache disorder (stiff neck, disorientation, rash, fever, eye pain,
diplopia, unilateral paresthesias, unilateral weakness, balance change).
● Onset (whether start gradually or suddenly)
● Headache of sudden and severe onset can be due to
- SAH
- Vascular malformations
- Acute ischemic CVA
- Posterior fossa mass lesions.

● Location and radiation of pain
- Cluster headaches are strictly unilateral
- Tension-type headaches are usually band-like and bilateral
- Migraines generally begin unilaterally but may progress to involve the entire head
- Pain along the distribution of the temporal artery may suggest temporal arteritis, and
pain along the distribution of the trigeminal nerve may be a sign of trigeminal neuralgia
- Eye pain may suggest acute glaucoma.
● Severity and quality of pain
1. Tension-type headache: Mild or moderate, pressing or tightening pain.
2. Cluster headache : Severe, stabbing pain
3. Migraine headache: Moderate or severe, pulsating, throbbing or dull aching pain.

● Current medical condition
1. Meningitis
2. CNS lymphoma
3. Toxoplasmosis
4. Metastases
5. Intracranial vascular disorder
6. Acute viral syndrome or acute bacterial infection
● Medication
- Prescription and over-the-counter medications (especially caffeine-containing
analgesics) have been implicated as triggers for drug-rebound and nonspecific headaches.
- Thus, it is important to review any medication that a patient is taking for its potential
to cause headache.

● Current trauma or procedure
1. Headache subsequent to trauma may signify a post concussive disorder, although ICH
should always be suspected.
2. Migraine and cluster headaches may be triggered by head
trauma.
3. Headache has also been associated with common medical procedures (e.g. LP,
rhinoscopy) and dental procedures (e.g., tooth extraction).

Diagnostic Criteria for Cluster Headache
A. At least five attacks fulfilling criteria B through D
B. Severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes
C. Headache associated with at least one of the following signs on the pain side:
1. Conjunctival injection
2. Lacrimation
3. Nasal congestion
4. Rhinorrhea
5. Forehead and facial sweating
6. Miosis
7. Ptosis
8. Eyelid edema
D. Frequency of attacks: one attack every other day to eight attacks per day

Diagnostic Criteria for Migraine
without aura
A. At least five attacks fulfilling criteria B through D
B. Headache lasting 4 to 72 hours
C. At least two of the following pain characteristics:
1. Unilateral location
2. Pulsating quality
3. Moderate or severe intensity
4. Aggravation by walking stairs or similar physical activity
D. During headache, at least one of the following:
1. Nausea and/or vomiting
2. Photophobia and phonophobia

Diagnostic Criteria for Episodic
Tension-Type Headache
A. At least 10 previous headache episodes fulfilling criteria B through D; number of days
with such headaches: less than 180 days per year
B. Headache lasting from 30 minutes to 7 days
C. At least two of the following pain characteristics:
1. Pressing or tightening quality
2. Mild or moderate intensity
3. Bilateral location
4. No aggravation by walking stairs or similar routine physical activity
D. Both of the following:
1. No nausea or vomiting
2. Photophobia and phonophobia are absent, or one but not the other is present.

Diagnostic Criteria for Migraine with
aura
A. At least two attacks fulfilling criterion B
B. At least three of the following characteristics:
1. One or more fully reversible aura symptoms indicating focal cerebral cortical and/or
brain-stem dysfunction
2. At least one aura symptom develops gradually over more than 4 minutes, or two or
more symptoms occur in succession.
3. No aura symptom lasts more than 60 minutes
4. Headache follows aura, with a free interval of less than 60 minutes.

Figure 1: Type of Primary Headache

Physical Examination
 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)
 Complete neurologic examination (focal neurologic signs)
 Neurological Examination
● Mental status
● Level of consciousness
● Cranial nerve testing

Physical Examination (1)
 Neurological Examination
● Motor strength testing
● Deep tendon reflexes
● Pathologic reflexes (e.g. Babinski’s sign)
● Sensation
● Cerebellar function
● Gait testing
● Signs of meningeal irritation (Kernig’s and Brudzinski’s signs).

Figure 2: Scale Pain assessment (EVA)

Figure 3: Scale Pain assessment (EVA)

Figure 4: Score DN4

Any Questions ?

Thank you to attention !

Approach the headache bin kakada

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