Approach to headache

Approach to Headache
and Migraine
Dr Sandhya Manorenj ,DNB Neurology
Neurophysician, ESIC Superspeciality centre,
ESIC Medical College Hyderabad
Sandhya Manorenj 11/2/17

Introduction
 It is estimated that nearly half of the
world’s adult population has an active
headache disorder (Robbins and
Lipton, 2010).
 The lifetime prevalence for any type of
headache as estimated from
population-based studies is more than
90% for men and 95% for women

 Affects virtually everyone at some time
in their life

How headache arrises ?
 Activation of pain-
sensitive intracranial
structures.
 Extracranial pain-
sensitive structures
external to the skull
cavity.
 Trauma inflammation,
traction, compression,
malignant infiltration, and
other disturbances of
pain-sensitive structures
lead to headache. Sandhya Manorenj 11/2/17

Intracranial pain sensitive
structures
 Arteries of the
circle of Willis and
the first few
centimeters of their
medium-sized
branches,
 meningeal (dural)
arteries,
 large veins and
dural venous
sinuses, and
portions of the dura
near blood vessels Sandhya Manorenj 11/2/17

Extracranial pain sensitive
structures
 External carotid artery
and its branches,
scalp and neck
muscles,
 skin and cutaneous
nerves, cervical
nerves and nerve
roots,
 mucosa of sinuses,
and teeth.
 Cranial nerves (CN)
V, VII, IX,and X in
addition to cervical
spine nerve/nerve
roots carry pain. Sandhya Manorenj 11/2/17

Headache Classification-IHS
2013
• Migraine
• Tension type headache
• Trigeminal autonomic cephalgia,
• Other primary headache
Primary headaches
• trauma to the head or neck cranial or
cervical vascular disorder, nonvascular
intracranial disorder, a substance or its
withdrawal, to infection. disorder of
homeostasis
• Headache or facial pain attributed to disorder
of the cranium neck, eyes, ears, nose,
sinuses, teeth, mouth, or other facial or
cervical structure
• psychiatric disorder
Secondary headaches
• Painful cranial neuropathies and
other facial pains
• Other headache disorders
Painful cranial
neuropathy, facial pain
and other headaches

Approach to Headache
History
ManagementExamination

History - SOCRATES
1Site
2Onset
3 Character
4 Radiation
5Association
6Timing
7 Exacerbating
&relieving
factors
8 Severity

Headache site

Onset of Headache

Character of headache
Throbbing
thunderclap
Throbbing sinus headache

Association of headache
Photophobia
Nausea/vomiting
Sensory/motor
symp
Autonomic
symptoms
Abdominal pain
Phonophobia Aura
Vertigo/giddiness
Loc/seizure

Timing and duration of
headache
Evening
Headache-
Migraine
Through out day
and more at
night-TTH
Short duration
headache- cluster
headache,
SUNCT
Long duration
headache- TTH,
Migraine
Night headache-
cluster headache,
hypnic headache
in elderly

Aggravating factors of
headache
Upright
position
Inclined
position
Torsion of neck
Cough

Relieving Factors of
headache
Rest Sleep
Avoidance of
light and noise
Local application
of pressure, cold
Massage
Recumbency

Family history of headache
Migraine, FHM
Tension type headache
Cluster headache

Medical and Drug history
Prior history of
treatment
Drug history
(Cardiac,
gastro
hormonal
drugs)
Medical
history

Migraine
 The World Health Organization has
declared migraine to be among the
most disabling medical conditions
experienced worldwide.
 Migraine may be episodic or chronic
 Chronic migraine is defined as
headache occurring on ≥ 15 days per
month for 3 ≥ months which has the
features of migraine headache on ≥ 8
days per month.

Clinical feature of migraine

Migraine Subtypes- IHS 2013

Migraine without aura

Examination of case of
headache
BP/Vitals
Any feature of
raised ICT
Fundus
Meningeal
signs
Skull/neck/PNS

Examination of case of
headache
Scalp,neck examination
Blood pressure

Examination -EYE

Examination

Special examination

Investigation- Neuroimaging
CT angiography
MRI brain
CT brain

Investigation
EEG
LP

CT scan Brain SAH

CT scan brain - Stroke
 Ischemic stroke
Hemorrhagic stroke

CT scan brain

Management of migraine
headache

Tryptans
subcutaneus/intranasal

Oral Serotonin(5HT) agonists

Migraine prophylaxis ?
 3 or more attacks /month
 Chronic migraine ,migraine with
severe aura
 Headache occur less often but are
very prolonged and debilitating.(>48
hrs)
 Target dosage is maintained for at
least 3 months.
 The medication is continued for at
least 6 to 12 months. Sandhya Manorenj 11/2/17

Botox therapy in chronic
migraine

Management of Tension type
headache
TTH
Simple
analgesic
Behavioural
approaches
Amitryptilline in
chronic TTH

Management of Cluster
headache
Acute treatment
Oxygen inhalation
(100%,10-12 l for
20 minutes
Tryptans
Sumatriptan
(S/C and nasal)
Zolmitriptan (nasal)

Prevention of cluster
headache
Short term prevention with steroids 1mg/kg tapered over 3
weeks
• For episodic cluster headache
Long term prevention with
verapamil,topiramate,gabapentine,methylsergide,lithium
• For episodic and chronic cluster headache

Take home message
 History –gold standard (SOCRATES)
 Do not miss signs of raised ICT.
 CT scan brain is the IOC
 CSF study and OP in certain cases
 Treat the underlying cause in case of
secondary headache

Approach to headache

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