Dr.Shelley- A systematic approach to the patients with headaches: When and How to Investigate Patients with Headaches

1. HOW DO I DIAGNOSE HEADACHE?
A clinical approach
Prof. Dr.B.P.SHELLEY MBBS,MD ,,FRCP Edin
DEPARTMENT OF NEUROLOGY
YMC

2. Learning Objectives
At the conclusion of this CME, you should know:
• What are Primary and Secondary Headaches? (ICHD-HIS
classification) What Is and What Isn’t a Migraine?
• How to approach the headache patient ? (Systematic History,
Phenotypic symptoms profile & Examination)
• How to get an accurate diagnosis (Investigations) and
determine if headache is primary or secondary in origin?
• What are and How to look for the presence of Red flags?
(Secondary/Sinister headaches)
• What are the common primary headache disorders?
• Outline of management of Migraine

3. Personalities with Migraine
Carroll Lewis: Alice in Wonderland
Syndrome (AIWS)
Vincent Van Gogh-’Starry Nights’ painting;
St. Remy Asylum, France, 1889
Charles Darwin, Einstein, Julius Caesar, Napolean Bonaparte, Sigmund Freud,
Immanual Kant, Thomas Jefferson, JFK, Elvis Presley, Elizabeth Taylor

4. World Headache Awareness Month-September
American Headache Society
International Headache Society
European Headache Federation
World Headache Alliance
Journals: Headache; J Headache & Pain; Cephalalgia
IHS President: Prof Peter J Goadsby, Prof William Dodick

5. Introduction
• Headaches: ‘bread & butter’ of every physician and neurologist;
common, disabling problem; maybe intractable, medically refractory
• Over 300 different headache types and aetiologies - Headache
Specialist
• Primary Headaches (90%); Secondary Headaches (10%);
Differentiation is the most critical step
• Migraine and Tension-type headache (TTH) account for over 90% of
the primary headache disorders in clinical practice
• Dictum: Not to overlook a sinister cause for headache (Red Flags);
Red Flags: Aetiology; Diagnosis; Investigations
• Co morbidities of Migraine; Migraine Disability; Management Issues
• Systematic approach: History taking, Phenotypic symptoms, Red
flags, Headache diary, IHS-ICHD-2 criteria ‘cookbook’, Examination,
Investigations

6. ©International Headache Society 2003/4
ICHD-II. Cephalalgia 2004; 24 (Suppl 1)
INTERNATIONAL CLASSIFICATION
of
HEADACHE DISORDERS
2nd edition
(ICHD-II)
COMMON PRIMARY HEADACHE
DISORDERS
Migraine; Tension type headaches;
Mixed Migraine + TTH
Cluster Headaches (CH)
Chronic Daily Headache (CDH): MOH,
Chronic migraine
Trigeminal autonomic cephalgias (TAC):
SUNCT/SUNA, Paroxysmal hemicrania

7. General approach & Classification of headaches
Clinical Rules
• PRIMARY HEADACHES
• Idiopathic headaches
– THE HEADACHE IS ITSELF THE
DISEASE
– NO ORGANIC LESION IN THE
BACKGROUND (NO OTHER
CAUSATIVE DISORDER)
– TREAT THE HEADACHE!
– NO WARNING/SINISTER S/S
– NEUROIMAGING-NOT
REQUIRED
– Migraine, TTH, Mixed, CH;
MOH, CDH
• SECONDARY HEADACHES
• Symptomatic headaches
– THE HEADACHE IS ON LY A
SYMPTOM OF AN OTHER
UNDERLYING DISEASE (HEADACHE
OCCURING IN CLOSE TEMPORAL
RELATION TO ANOTHER DISORDER)
– HEENT, IIH-BIH, ICSOL, GCA-TA,
SDH, CVA,AVM,THS, Cervicogenic,
Posterior fossa lesions
– TREAT THE UNDERLYING DISEASE!
– RED FLAGS;
INVESTIGATIONS/NEUROIMAGING
REQUIRED
ICHD-2; Cephalalgia 2004 (IHS)

8. IHS Classification
Secondary Headaches
• Headache attributed to
– Head and/or neck trauma
– Vascular disorders (Stroke, AVM, SAH, CAD,CNS vasculitis)
– Non-vascular intracranial disorders (IIH-BIH, SIH, neoplasms, meningitis)
– Substance abuse or its withdrawal
– Infection (Non cephalic-Toxic headache)
– Metabolic disorders (Hypoxia, hypercarbia, hypoglycemia, sleep apnea-
OSA, hypothyroidism)
– Disorder of cranium neck, eyes, ears, nose, sinuses, teeth, TMJ, mouth or
other facial or cranial structures (Cervical spine, Glaucoma, TMJ, HEENT
disorders)
– Headache attributed to a psychiatric disorder (somatization, psychotic
disorders)
– Cranial neuralgias and central causes of pain
(Trigeminal/Glossopharyngeal/Occipital neuralgias)
– Headache unspecified/not classified

9. Clinical Approach to Headache

11. ‘RED FLAG’ headaches
WARNING SYMPTOMS
• Worst headache ever
• First severe headache (sudden onset
headache)
• Worsening over days / weeks
• Abnormal neurologic examination
• Associated with fever; New onset
headache with underlying medical
condition
• Vomiting precedes headache
• Induced by bending, lifting, or
coughing
• Disturbs sleep or present on
awakening
• Onset after age 55
• Pain associated with localized
tenderness
SNOOP T
• Systemic symptoms (fever, weight loss)
• Secondary risk factors (cancer,
HIV/immunocompromised)
• Neurologic symptoms or abnormal signs
• Onset (i.e. new-onset chronic headache)
• Older patient (i.e. new headaches at age
>50 yrs)
• Previous headache different (i.e.
significant change in headache frequency
or clinical features)
• Positional component (i.e. increases
when upright)
• Provocative factors (precipitated by
coughing, exercise, sex)
• Triggered headache-by Valsalva activity,
or sexual intercourse

13. History
The key to diagnosis
• History is all-important : No diagnostic tests for primary headache
• Headache description/Behaviour of Pain: Location, Intensity-Time
duration; onset (e.g., sudden, gradual), and quality (e.g., throbbing,
constant, intermittent, pressure-like); Frequency and VAS severity;
Worrisome Headache: SNOOP T; Prodrome, Aura, Headache, Post
headache phase; Headache diary; Drug history; Treatment response;
MOH; Lifestyle; Co-morbid psychopathology; Exacerbating and
remitting factors (e.g., head position, time of day, sleep, light, sounds,
physical activity, odors, chewing) are noted. Family history, MM,
MAM, HEENT, Systemic causes and secondary causes screening
(Alcohol-SDH/Cancer-Metastasis/LPs-spinal anesthesia/Endocrine-
obesity/drugs-IIH); Family & Social history

14. • Crescendo onset: Migraine
• Sudden; Thunderclap: SAH
• Occipitocervical headache: Posterior fossa lesion
• Frontotemporal headache: Supratentorial lesion
• Galactorrhea, amenorrhea, morbid obesity, visual field defects,
cranial nerve palsies: Pituitary/sellar tumors
• Obesity: BIH-IIH
• Cough headache, headache triggered by bending, sneezing, lifting,
Valsalva, occipitocervical-nuchal headache: Posterior fossa tumors;
ACM; raised ICP
• Orthostatic headache: post dural puncture headache (LP); SIH
(occipital, prominent neck pain, whooshing tinnitus)
• Painful, Red eye, Haloes around lights: Glaucoma
• Nasal purulent discharge; paranasal sinus tenderness: Sinusitis
related headache

15. • Vomiting: Migraine, increased intracranial pressure
• Fever: Infection (eg, encephalitis, meningitis, sinusitis)
• Red eye, visual symptoms (halos, blurring): Acute narrow-angle
glaucoma
• Visual field deficits, diplopia, or blurring vision: Ocular migraine, brain
mass lesion, idiopathic intracranial hypertension
• Lacrimation and facial flushing: Cluster headache
• Rhinorrhea: Sinusitis
• Pulsatile tinnitus: Idiopathic intracranial hypertension
• Preceding aura: Migraine
• Focal neurologic deficit: Encephalitis, meningitis, intracerebral
hemorrhage, subdural hematoma, tumor or other mass lesion
• Seizures: Encephalitis, tumor or other mass lesion
• Syncope at headache onset: Subarachnoid hemorrhage
• Myalgias, vision changes (people > 55 yr): Giant cell arteritis

16. Questions to Ask in Obtaining a Headache History
• Is this your first or worst headache? How bad is your pain on a scale of 1 to
10 (1 means not too bad, and 10 means very bad)? Do you have headaches
on a regular basis? Is this headache like the ones you usually have?
• What symptoms do you have before the headache starts? What symptoms
do you have during the headache? What symptoms do you have right now?
• When did this headache begin? How did it start (gradually, suddenly, other)?
• Where is your pain? Does the pain seem to spread to any other area? If so,
where?
• What kind of pain do you have (throbbing, stabbing, dull, other)?
• Do you have other medical problems? If so, what?
• Do you take any medicines? If so, what?
• Have you recently hurt your head or had a medical or dental procedure?

17. • M - Migraine
• M - Meningitis
• I - Increased Intracranial Pressure
• T - Tension Headache + Temporal Arteritis
• A - AV Malformations
• C - Cluster Headache
• H - Hypertension
• E - Eye Disorders (Refractory Errors + Glaucoma-red eye; haloes
around lights)
• S - Sinusitis + Sub-Arachnoid Hemorrhage + most Systemic illnesses

18. Is it
Migraine?

19. IHS Guidelines
This is migraine
‘Phenotypic knowledge of symptoms’
Age; sex/gender
Location, Quality, Intensity, Duration
(>4 hours), Mode of onset- Time-
intensity curve; Crescendo, Typical
phases, Pattern of headache; Avoid
physical activities
Episodic/Chronic
Aura, GI symptoms
Photo-Phono-Osmophobia
Trigger, provocative factors
Alleviating factors
Family history (50%)
No neurological signs/No Red flags

20. Duration:
• 4 - 72 hours
This is migraine
IHS Guidelines

21. This is migraine
At least two of:
• Unilateral
IHS Guidelines

22. This is migraine
At least two of:
• Unilateral
• Pulsating
IHS Guidelines

23. This is migraine
At least two of:
• Unilateral
• Pulsating
• Moderate/severe
intensity
IHS Guidelines

24. This is migraine
At least two of:
• Unilateral
• Pulsating
• Moderate/severe
intensity
• Aggravated by
movement
IHS Guidelines

25. This is migraine
Accompanied by:
• Photophobia
IHS Guidelines

26. This is migraine
Accompanied by:
• Photophobia
• Phonophobia
IHS Guidelines

27. This is migraine
Accompanied by:
• Photophobia
• Phonophobia
• Nausea
IHS Guidelines

28. This is migraine
Accompanied by:
• Photophobia
• Phonophobia
• Nausea
• Vomiting
IHS Guidelines

29. This is migraine
• Patients are
completely
symptom-free
between attacks
IHS Guidelines

30. A migraine attack: graphical profile
Aura
Vomiting
Time
(hrs)
Impact
Prodrome
Resolution
Postdrome
Headache
0 72
Vomiting precedes headache; non crescendo
Induced by bending, lifting, or coughing
Disturbs sleep or present on awakening
Prolonged aura > 60 min

31. Migraine ; Phenotypic symptoms
• Hemicrania (50%); Holocranial/Holocephalic
• Pulsatile; throbbing; Movement aggravation of headache
• Typical phases: Prodrome, Aura, Headache, Defervescence, Postdrome
• Nausea; vomiting; photo-phono-osmophobia
• Predictable headaches during menstrual cycles (MM/MAM), characteristic
premonitory symptoms such as tiredness, stiff neck, craving for sweets, and
yawning, characteristic triggers, abatement with sleep, positive family history
• Typical triggers: Hunger; lack of sleep; change in sleep patterns; mental or
physical overtiredness; unaccustomed exertion/exercise; travel; psychological
stressors, food-MSG (Chinese restaurant syndrome), beer, cheese, red wine,
chocolates, nuts, bananas, citrus fruits, fried food, meat preserved with
nitrites (sausage); environmental triggers-loud noise, bright/flickering lights,
strong perfume; weather changes; stuffy atmosphere, visual display units,
strong winds or extreme heat or cold
• Alleviating factors: sleep; vomiting; desire to lie down in a dark, quiet place

32. Headache Diary

33. Tension-type headache
(TTH)
• Featureless headache; non throbbing, pressing, tightening in quality, ‘
squeezing pressure’; generalised headache
• Bilateral, Often tight band around head / fronto-occipital, Occipito-nuchal
location; Muscular tightness or stiffness in neck, occipital, and frontal regions
• Absence of symptoms- no photophonophobia, gastrointestinal symptoms
(anorexia, stress, anxiety, depression may be present); attacks not
worsened/aggravated by activity such as walking or climbing stairs
• No more than one of photophobia, phonophobia, or mild nausea (no
moderate or severe nausea nor vomiting)
• Mild to moderate intensity; not as disabling as migraine; lasts hours, less
frequently days
• Worse at the end of the day; Difficulty concentrating
• No prodrome; No aura
• Treatment: ASA/Paracetamol / TCA (Amitryptline 25-150mg/day)

36. 1. Nausea and vomiting if present, rules out the diagnosis of
tension type headache
2. 2Photophobia or phonophobia may be present while
presence of both symptoms is not allowed.

37. Pericranial myofascial mechanisms –pathophysiology in episodic TTH, whereas
sensitization of pain pathways in the central nervous system resulting from
prolonged nociceptive stimuli from pericranial myofascial tissues seems to be
responsible for the conversion of episodic to chronic TTH
Local Trigger Points (multiple pericranial) BTX-A injection (%U per site;
TD-25/75U) : efficacious in CTTH patients, Severe refractory Chronic
Migraine with MPS

38. Episodic TTH Chronic TTH

40. CHRONIC
DAILY
HEADACHE
(CDH)
Medication
Overuse
Headache
(MOH)
Chronic/
Transformed
Migraine
Chronic TTH
New Daily
Persistent
Headache
(NDPH)
Hemicrania
Continua
(HC)
CDH: headache on more than 15 days per month for three
months or more

41. Trigeminal
Autonomic
Cephalgia (TAC)
Cluster
Headache
SUNCT
SUNA
Paroxysmal
Hemicrania
HC
Hypnic
Headache
Short duration headaches
(< 4 hours), Frequent,
Unilateral
Ipsilateral Conjunctival
injection +/or lacrimation
• Nasal congestion +/or
rhinorrhoea
• Eyelid oedema
• Forehead and facial
sweating
• Miosis +/or ptosis

44. Cluster headache
• Males; Suicide headache; periodicity (cluster bouts); nocturnal (alarm clock
headache); multiple bouts per day
• Shorter attack duration (<4 hours), typically 45 minutes to one hour
(definitely less than four hours)
• Daily nature of headaches often with multiple attacks daily (compared with
migraine with attacks occurring episodically but lasting days)
• Agitated behaviour of sufferers (running, pacing, sitting, body rocking) during
the attack (in contrast to a migraineur’s preference to avoid movement)
• Prominence of ipsilateral cranial autonomic symptoms with CH (which can
occur with migraine, but more rarely)
• Treatment: 100% oxygen (7-12L/min); 6mg Sumatriptan sc; Prednisolone
60mg X 5 days and taper/ Verapamil (240-969mg/day)

47. Medication Overuse Headache
Clinical features
Chronic daily headache> 15 days/mth
Regular intake for >3mths
Chronification of headache from intermittent, episodic pattern to near daily,
daily persistent headache; co morbidities of anxiety and depression
May differ depending on drug being overused:
Triptans- daily migrainous headache
Develops on using triptans for >/= 10days/mth
Analgesics- diffuse featureless headache
On using opiate or combination analgesics for > /= 10 days/month
On using simple analgesics for >/= 15 days /month
Treatment: Gradual withdrawal /Weaning and Avoid NSAIDs, triptans / Setting
strict limits on the use of NSAIDs/OTC/triptans/opoids/ Start
Preventive/Prophylactic treatment & Non drug treatments- Relaxation &
Biofeedback therapies, CBT

48. MOH CRITERIA
MORE ANALGESICS IS LESS
USEFUL: CLINICAL PARADOX
& DILEMMA OF ACUTE
TREATMENT
• ASA/Dolo > 5/week (15/mth)
• Triptans > 5/week
• Opiates >2 / week (> 1tablet
/day)
• Combination analgesics
(Ibugesic) >3/ day
(> 3 days/week)

49. Migraine & co-morbidities
• Migraine & CVS: Atrial septal defect; PFO; PFO with ASA; MVP;
Pulmonary AVM; increased stroke-platelet hyperaggregability ; Long QT
syndrome (channelopathies); Migraine and syncope; autonomic
dysfunction and POTS & Vasovagal syncope
• Migraine & CVA: PFO; Cervical artery dissection; Endotheliopathy
(polymorphisms from NOS3, EDN, and EDNRB); CADASIL; MELAS; APLA
syndrome; HHcy; Thrombophilia; Silent Brain Infarction; WMHIs;
Cerebellar infarcts (CAMERA study); Migraine specific drugs: Triptans &
Ergot Overuse
• Metabolic syndrome: Obesity-Migraine Link

50. Migraine & co-morbidities
• Epilepsy: Migralepsy; Neuronal Channelopathies-NMDA related)
Migralepsy; MELAS;BOE, BRE, APLA, CADASIL; Familial
occipitotemporal epilepsy; 6% migraine have associated epilepsy and
8-15% of epilepsy have co morbid migraine; FHM; Benign familial TLE,
Familial Adult Myoclonic Epilepsy; Familial Idiopathic Epilepsy
• Migraine related Vestibulopathy: Migrainous vertigo; BPPV; Meniere
‘s Disease
• Migraine & Psychiatry
• Multiple sclerosis; Tourette’s Syndrome

52. Migraine & psychopathology
(Psychiatric screening)
• Anxiety; GAD & Depression (higher MMPI scores); Bipolar Disease
• Borderline personality
• Panic/Phobic disorders (Agoraphobia, Social phobia)
• Migraine personality (Wolff): anger, hypercontrol, high harm
avoidance, high persistence, low self-directedness, rigidity, reserve,
obsessivity, Cluster C avoidant personality)
• High neuroticism score (MMPI/BDI)
• Hypochondriasis
• Increased stress susceptibility, post-traumatic stress disorders
• Hysterical traits (MMPI)
• Temperament Character Inventory/State-trait anxiety Inventory
• Associated MVP,PFO, ASD, Atrial septal aneurysm (ASA), PFO plus
ASA, Congenital heart disease, Pulmonary AV malformations
• Fibromyalgia Syndrome/ Functional Somatic Pain Syndromes (Other
Pain Syndromes)

53. • Psychiatrists and other mental health specialists should
familiarise themselves with the revised diagnostic criteria
for the various migraine subtypes. In common with people
with other neuropsychiatric disorders, patients with
migraine benefit most from treatment within the context
of a multidisciplinary team that includes neurologists,
psychiatrists and psychologists. Such a model facilitates
both improved diagnostic accuracy and a more
coordinated approach to treatment

54. Predisposing factors & triggers
(Migraine Lifestyle)
• Psychological factors : Stress or relief of stress; anxiety and depression and
extreme emotions such as anger or grief
• Food factors : Lack of food or infrequent meals; foods containing
monosodium glutamate, caffeine and tyramine; specific c foods such as
chocolate, citrus fruits and cheese and alcohol, especially red wine
• Sleep : Overtiredness (physical or mental); changes in sleep patterns such as
late nights, weekend lie-in, shift work or holidays or long-distance travel.
• Environmental factors : Loud noise, bright or flickering lights, strong perfume,
stuffy atmosphere, visual display units, strong winds or extreme heat or cold
• Health factors : Hormonal changes such as monthly periods, the combined
oral contraceptive pill, hormone replacement therapy or the menopause;
increased blood pressure; toothache or pain in the eyes, sinuses or neck or
unaccustomed physical activity.

56. Examination
Neurological
• Behavioural & personality changes;
frontal lobe signs; Release reflexes
(MMSE-unexplained cognitive
deficits)
• Cranial nerves-II, III, IV, VI/Pupils/
EOM, Fundoscopy, Visual fields
• Focal deficits: Motor, Sensory or
Posterior fossa signs, Plantar
response, Gait & Tandem test
• Meningeal signs
• Carotids- pulsations, bruits
• STA-Palpation, corkscrew-cord like,
tender
• Skull bruits, Orbital bruits
Non neurological
• HEENT examination
• Head, Cervical spine & muscles;
Myofascial Triggers points; tender
spots; dental, eyes/orbits/IOP; ear,
nose, throat, PNS, Stylalgia, TMJ
• Systemic signs-underlying medical
disorders (malignancy, vasculitides,
collagen vascular disorders;
metabolic disorders; Purpuric skin
rash)
• BP (malignant/Accelerated
hypertension, Hyperadrenalism)

57. Management of Migraine
• Pharmacological: Acute, abortive & Prophylactic/Preventive therapies
• Non Pharmacological: Lifestyle modification; Avoid trigger factors; relaxation
techniques and stress management (Biofeedback/CBT; TENS, Infrared laser
therapy; Acupuncture; I nvasive & Noninasive Neurostimulation-
Transcutaneous Supraorbital, supratrochlear, tVNS, Occipital nerve, TMS,
DBS-Thalamus, hypothalamus)
• Ask the patient to keep a diary to identify possible trigger factors, assess
headache frequency, severity and response to treatment
• Consider prophylaxis if the patient has frequent or very severe attacks
• Consider prophylaxis if the patient has four or more migraine attacks every
month or very severe attacks. Prophylactic treatment reduces attacks by
roughly 50%. Patients should try a drug for 2 months before deciding it is
ineffective. If a prophylactic drug is effective, the patient should continue
taking it for 4 – 6 months, then decrease the dose slowly before stopping
• 1st line: Beta blockers, TCA
• 2nd line: TPM, VP, SSRI, SNRI
• 3rd line: GBP, Methysergide

58. Migraine- preventive therapies
When to use?
• Frequent headaches >3-4/month
• Migraine significantly interferes with patient’s daily life
despite abortive treatment
• Acute/abortive therapies contra-indicated, ineffective, not
tolerated or OVERUSED

59. Pharmacological therapy
• Headache with MVP/HT/Anxiety/Panic attacks-beta blockers
• Headache with HT-Clonidine, Metoprolol
• Headache with GAD/Panic-Beta blockers
• Headache with depression/Social phobia/Myofascial pain
syndrome/FMS-SSRI, SNRI, TCA (Sleep patterns)
• Headache-Obesity (IIH/BIH)-TPM (Oesity)-Leptin-MetS-Migraine Link
• Headache; Gracile habitus; Decreased appetite; severe headache;
CDH-VP
• Headache with Epilepsy: AEDs- VP, TPM; GBP, Pregabalin, LEV
• Rx: Lifestyle Modification-Behavioural therapy/CBT/Biofeedback
therapy (Stress management; Relaxation); EMG biofeedback for TTH;
Botox
• Refractory Pr Headaches (Chronic Migraine & Cluster Headaches):
Neurostimulation-Occipital nerve & Supraorbital nerve stimulation;
Hypothalamic DBS

60. DRUGS PREGNANCY LACTATION
1st 2nd 3rd
Paracetamol, Aspirin,
NSAIDs
Y Y N Y [Premature closure of PDA;
Oligohydramnious, Decreased
platelet function/PPH, neonatal
bleeding]
Antiemetics (Stemetil,
Diligan, Domstal, Maxeron)
Y Y Y Maxeron, Domstal increased
lactation; Stemetil, Diligan -Y
Ergot N N N N [Decreased lactation; increased
uterine hypertonicity & increased
risk of miscarriage]
Triptans N N N N
Beta blockers N N N N [IUGR, fetal bradycardia,
decreased uterine contraction;
infant bradycardia, hypoglycemia]
TCA N N N Y
AEDs N N N Y [Valproate]; GBP safe in
pregnancy
Calcium Channel Blockers N N N Y [3rd trimester- tocolytic effects]

62. DIAGNOSTIC TESTING
DICTUMS
 High burden of headache- rational & cost effective
 Majority of headaches- no need for diagnostic testing
 No valid confirmatory laboratory diagnostic tests for primary headaches
 Primary headaches- 90% Secondary headaches- 10%
 Investigations- follow evidence based guidelines
 Critical diagnostic tool- systematic headache history, physical &
neurological examination, working classification-IHS diagnostic criteria

63. Associated neurological findings
Presence of Red Flag symptoms
Atypical headache history; featureless headaches; headaches made worse
by head movement, jarring, coughing, sneezing, straining,positional
Reassurance - explain to patient WHY the scan is being done

64. When Don’t You Need to Get a Scan?
• Patient with established history of episodic headache
• Current headache is consistent with previous headaches or is consistent
with different manifestation of a primary headache
• Normal neurological exam
• No Red Flags

65. DIAGNOSTICS- INDICATIONS
 Should be evidence based

66. NEUROIMAGING- FRISHBERG STUDY (1994)
Abnormal CT/MRI in migraine
Total scans 897(100%)
Tumour 3 (0.3%)
AVM 1 (0.1%)
Abnormal CT/MRI in unspecified
headache
Total scans 1825(100%)
Tumour 21 (1%)
AVM 6 (0.3%)
H’cephalus 8 (0.4%)
Aneurysm 3 (0.2%)
SDH 5 (0.3%)

67. NEUROIMAGING
AAN PRACTICE GUIDELINES (1994)
“ In adult patients with recurrent headaches that have been defined as
migraine-including those with visual aura, with no recent change in
pattern, no history of seizures and no focal neurologic signs or
symptoms, the routine use of neuroimaging is not warranted. In
patients with atypical headache patterns, and/or a history of seizures,
or physical examination findings of focal neurologic signs or symptoms,
CT or MRI may be indicated ”

68. GOOD PRACTICE POINTS
o Neuroimaging is required for secondary headaches ( Gr C,level IV)
o Neuroimaging is generally not indicated for primary headaches ( Gr
B,level III)
o EEG is not a recommended test in the evaluation of headaches ( Gr
B,level III)
o Skull X-rays is not a recommended test in the evaluation of
headaches ( Gr B,level III)
o CSF test should be performed only for specific indications
( Gr C,level IV)
o Secondary headaches- should be referred to a specialist

69. NEUROIMAGING IN MIGRAINE
• HEADACHE associated with
Focal neurologic signs
Papilloedema, cognitive impairment, personality change
Seizures, systemic symptoms & abnormal physical findings
Meningeal signs
• Increases the likelihood of finding significant intracranial pathology by
neuroimaging studies
• Headaches precipitated by coughing, sneezing, bending forwards, early
morning or nocturnal, sub occipital headaches
• RED FLAGS

70. CT Vs MRI
o SAH
o ICH
o Posterior fossa tumour
o Cerebral venous thrombosis
o SDH, EDH
o Meningeal disease
o Cerebritis/abscesses
o Pituitary pathology

71. PSEUDOMIGRAINE- MIGRAINE MIMICS
• AVM / aneurysm- CT (Contrast), MRI, MRA, CT angiogram
• Post stroke/ CVA/ ICH- CT/MRI
• Tolosa-Hunt syndrome- MRI
• Spontaneous carotid/ vertebral artery dissection-
MRI,angiogram,duplex studies
• MELAS/MERRF- MRI,lactic acid,Mt DNA mutations

72. PSEUDOMIGRAINE (II)
• ICSOL, III Ventricular colloid cyst, suprasellar cysts, ependymoma,
ACM - CT/ MRI
• Pituitary tumour, pituitary bleed - MRI
• Giant cell arteritis – ESR,anemia,↑ ESR,CRP,α-2 globulin, ALP,AST
• CADASIL- MRI,Notch 3 gene (Chr 19p12)
• APLA syndrome- platelets,coagulation studies, APLA, aCL, VDRL
• Low/ High CSF pressure- IIH- LP Opening pressure

73. CLUSTER LIKE MIMICS
• Pituitary tumours- MRI
• AVMs- CT(Contrast), MRI, MRA, Angiogram
CPH LIKE MIMICS
• Gangliocytoma of the sella turcica (Vijayan 1992)
• Collagen vascular disease (Medina 1992)
• Cerebrovascular disease –AVM (Newman 1992)
• Pancoast tumour (Delreux 1989)
• Frontal lobe tumour ( Medina 1992)
• Cavernous sinus meningioma (Sjaastad 1995)
• Intracranial hypertension ,↑ CSF pressure ( Hannerz 1993)

74. LUMBAR PUNCTURE

75. BLOOD TESTS

77. ICH

78. SAH

79. ANEURYSM

80. SAH-ANEURYSM-CTA

81. AVM

82. AVM
MRI,MRA,DSA

83. CAROTID DISSECTION

84. Copyright restrictions may apply.
Wityk, R. J. JAMA 2001;285:2757-2762.
Anatomy of Carotid Artery Dissection
Subintimal dissection
-stenosis
Mickey mouse ears:
expansion by hyperintense
hematoma of the outer
lumen of the artery

85. 37 year old after a motorcycle accident Sara Mazzucco, MD; and Nicolo`

86. INTRACAVERNOUS ICA ANEURYSM

87. Key points
• Headache is a common and challenging presentation in primary care
• Clinical Rule: Knowledge of phenotypic symptoms of primary
headaches and ‘Red flag’ headaches- SNOOP T, detailed history and
thorough examination
• Migraine Mimics: Structural lesions, such as vascular malformations,
can produce similar symptoms to migraine with aura: paraclinical
investigations are necessary in most patients with headache and focal
neurological symptoms.
• It is critical to distinguish serious, life threatening causes from more
benign, idiopathic or primary headache disorders
• Careful & comprehensive History is the key to making the accurate
diagnosis; Emphasis on Headache Diary; OTC analgesics-MOH
• Confirm or refute the suspected diagnosis with careful examination
• Specific treatments depend on the cause of the headache; Correct
headache diagnosis is the start of the headache treatment pathway

89. MIGRAINE
‘THE SEROTONIN STORY’
NEUROBIOLOGY

94. Triggers
Brain excitability
Cascade of
neurochemical
events NO
glutamate
5-HT
Lumen
Trigeminovascular
activation
Afferent firing via
trigeminal nerve
Pain / headache
Cascade of events underlying migraine

95. Distension
Inflammation
Trigeminal
nucleus
Cerebral
cortex
PAIN
Trigger
Pain impulses
Trigeminal nerve
Associated symptoms
(e.g. nausea and
visual disturbances)
5HTs
5HTs
Blood
brain
barrier
1
2
3
5HTs: sites of action

96. Overall Approach to Headache
Wolff HG, et al., 2001
Any secondary
Headache disorder
can mimic a
primary headache
disorder