Approach to a patient with headache

1. APPROACH TO A PATIENT WITH
HEADACHE
Presented By Moderator
Dr. Swdwamshree Boro Dr. Rebecca Marak
PGT 1st Year Assistant Professor
Dept. of General Medicine Dept. of General Medicine

2. INTRODUCTION
• Headache is among the most common reasons
patients seek medical attention
• It is responsible for more disability than any
other neurological problem.
• Diagnosis and management are based on a
careful clinical approach augmented by an
understanding of different aspects

3. Pain sensitive structures
• Scalp
• meningeal arteries
• Dural sinuses
• falx cerebri
• Proximal segments of
large pial arteries
Pain insensitive structures
• Ventricular ependyma
• Choroid plexus
• Pial veins
• Brain parenchyma

4. CLASSIFICATION & COMMON CAUSES

6. 1. Migraine
• Episodic (MC) or Chronic (≥ 15 days/ mth)
• Associated features present
• Normal Physical Examination
• Medication overuse headache
– frequency, impairs effect of medicine
& induce a state of refractory daily or
near-daily headache

7. PATHOGENESIS
• Release of CGRP at vascular terminals of
trigeminal nerve & its nucleus
• serotonin level
• Dopamine receptor hypersensitivity

8. Triggers
• Glare, bright lights, sounds
• Stress
• Fluctuating hormones during menses
• Lack or excess sleep
• Alcohol

9. Phases of Migraine
1. PREMONITORY
• Neck discomfort
• Higher centre
– Cognitive impairment ( brain fog)
– Mood change
– Fatigue

10. • Homeostatic
– Yawning/ sleepiness
– Food cravings
2. Aura- Scintillating
Scotoma
3. Headache Phase
• Pain
• Nausea/ vomiting
• Sensory sensitivity
– Photophobia
– Phonophobia
– Vertigo

11. 4. Postdrome
• Tiredness
• Concentration impairment

13. 2. TENSION TYPE HEADACHE
• Episodic or chronic
• B/L, tight, bandlike
• No accompanying features

14. 3. TRIGEMINAL AUTONOMIC
CEPHALGIAS (TACs)
• Short lasting attacks
• lateralised cranial autonomic symptoms
• Severe & may occur more than once a day,
stabbing/boring
• Includes cluster headache, paroxysmal hemicrania,
SUNCT/ SUNA & hemicrania continua
• Migrainous features +

15. CLUSTER HEADACHE PAROXYSMAL
HEMICRANIA
SUNCT/ SUNA
Sex M>F M=F M=F
Pain site Orbital Orbital Periorbital
Duration 15-180 min 2-30 min 5-240 s
Alcohol trigger + - -
Cutaneous triggers - - +
Abortive treatment • Sumatriptan (inj/ ns)
• Zolmitriptan (ns)
• O2
• Nonivasive vagal nerve
stimulation
Indomethacin • IV Lidocaine

16. SECONDARY HEADACHE
MC- Systemic Infections
Meningitis
• Acute, severe headache, altered sensorium
• Stiff neck & fever
• LP is mandatory

17. • Temporal (giant cell) arteritis
– inflammatory disorder of arteries that frequently
involves the extra cranial carotid circulation
– elderly; F>M.
– U/L or B/L, polymyalgia rheumatica, jaw
claudication, fever, and weight loss.
– infrequently throbbing
– Scalp tenderness
– worse at night, aggravated by exposure to cold

18. • SAH
– Thunderclap Headache
– Stiff neck without fever
– CT Brain, LP- xanthocromia
• Glaucoma
– The headache often starts with severe eye pain.
– Nausea & vomiting
– Eye- red with fixed, moderately dilated pupil
– Tonometry

20. Chronic Headache

21. APPROACH TO HEADACHE
• History & examination- gold standard
• Evaluation focuses on
– Determining whether a secondary cause is present
– Checking for symptoms that suggest a serious cause
(Red flags of Headache)
• If no cause or serious symptoms are identified, it
focuses on diagnosing primary headache disorders

22. RED FLAGS

24. Algorithm
Proper H/O & examination
• If abnormal examination OR red flags are present,
do neuroimaging +/- LP & other tests
– if negative then treat as primary headache disorder OR
observe
– If positive, treat appropriate secondary headache
disorder OR do possible additional tests

25. Contd..
• If H/O S/O suspected primary headache &
neurologic examination is normal, treat the
appropriate primary headache disorder

26. HISTORY
• Age & Sex
• Site-
– U/L or B/L
– Frontal/temporal/occipital/periorbital/ generalised
• Mode of onset- sudden or gradual
• Frequency, periodicity
• Quality of pain & severity

27. • Diurnal pattern-
– Upon awakening or later in the day/
nocturnal/continuous
• Triggering or Relieving factors
• Associated features
• Past History- Recurrent headaches
• Personal H/O, habits & occupation- Alcohol, caffeine
consumption; sleep pattern
• Family H/O –Migraine has strong family H/O

28. PHYSICAL EXAMINATION
Primary purpose of examination is to identify causes of
secondary headaches
General examination
• Vitals- HTN, Fever
• Fundoscopic examination - papilledema, retinal pulsations
• Palpation of I/L temporal artery for tenderness
• Palpation of head/ face- sinusitis
• Eye & periorbital area- lacrimation, conjunctival injection,
flushing (glaucoma)

29. Neurologic examination
• Mental status
• Cranial nerves
• Motor
• Sensory ( esp trigeminal nerve sensation)
• DTR
• Coordination & gait
• Signs of meningeal irritation- Kernig’s & Brudzinski

30. INVESTIGATIONS
• CBC- for infection
• ESR/ CRP- temporal arteritis (respond to steroids)
• Refractive error testing, tonometry for glaucoma,
fundoscopy for papilledema
• Urine analysis – cardiovascular & renal status
• LP- for meningitis or SAH

31. • Neuroimaging
– CT Brain- intracranial bleed
– MRI
– Xray
INDICATIONS
– First or worst headache, particularly if sudden onset
– increasing frequency or severity
– Increased frequency of vomiting
– Headache triggered by coughing ,straining or postural
changes
– Persistent physical symptoms or signs after attack

32. MANAGEMENT
• Prophylactic medications should be considered if a
patient has at least 3 disabling migraine per month
• 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

33. 1. Migraine
Abortive treatments
• Mild- Simple analgesics, NSAIDs
• moderate—NSAIDs, sumatriptans, dopamine receptor
antagonists (adjunctive therapy)
• severe—sumatriptan (s/c )
• extreme—opioids
• Chronic Migraine- Monoclonal antibodies to calcitonin
gene related peptide (CGRP) or its receptor

34. 1. Migraine
Acute Attack
Drug Side effects
NSAIDs Naproxen, Ibuprofen GI irritation, dyspepsia
5 HT1B/1D receptor
agonists
Triptans Rizatriptan,
Eletriptan,Zolmitriptan (n/s),
Sumatriptan (n/s, iv, im,sc)
• CI in ischemic cardiac
& cerebrovascular d/o
• Headache recurrance
5 HT1F receptor
agonists
Ditans Lasmiditan Dizziness, somnolence
CGRP receptor
antagonists
Gepants Rimegepant, Ubrogepant
Dopamine receptor
antagonists
Metoclopromide, Domperidone,
Prochlorperazine,
Chlorpromazine

35. Prophylaxis
• High efficacy- beta blockers, TCAs, AED like
Valproate
• Low efficacy- verapamil, flunarizine

36. 2. Tension type Headache
• Simple analgesics- acetaminophen, aspirin, or NSAIDs
• Chronic- Amitriptyline is the only proven treatment
• Triptans are ineffective
3. Cluster Headache
• Acute attack
– O2 inhalation- 100% O2 at 10-12L/ min for 15-20 min
– Triptans (Sumatriptan)

37. • Preventive treatment

38. TAKE HOME MESSAGE
• History is the most important diagnostic tool in
evaluation of headache
• Early recognition of Red Flags in a case of
headache is invaluable
• Not all cases of headache require neuroimaging,
judicious use of investigations must be done
weighing their benefits and harms

39. REFERENCES
• Harrison’s Internal Medicine 21st edition
• Bradley Neurology 8th edition

40. Thank You