Headache
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This document provides an overview of pediatric and adult headaches. It begins by classifying headaches as acute, subacute, or chronic. For pediatric headaches, it outlines the important aspects of history taking and danger signs that warrant further evaluation. It describes migraine headaches in children in detail. For adult headaches, it discusses mechanisms, classification, precipitating factors, and characteristics. It provides guidance on evaluation, management, and when to refer or admit patients with headaches.
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Headache
- 1. HEADACHE DEPARTMENT OF FAMILY MEDICINE POST GRADUATE INTERNS 2016: PROCIANOS, GELEEN ANNE RODRIGUEZ, JISA GEMORA, KATRINA
- 2. OBJECTIVES: • To classify headache according to: – Acute – Subacute – Chronic • To identify the precipitating factors, prodomal symptoms, and its location and characteristics • To identify pediatric and adult headache and their managements
- 3. Reference: - Clinical Neurology 6th edition , Greenberg, David et al. - Nelson Textbook of Pediatrics 19th Edition, Kliegman, Robert et al.
- 5. History Taking in Children: • Location • Character • Triggering factors • Relieving factors • Time and duration • Nausea, vomiting • Aura, prodromal period Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 6. Danger Signals in Children: • Progressive headache • Sudden onset of severe headache, unrelieved by rest or analgesics • Headache precipitated or aggravated by exertion, coughing or straining • Presence of fever, seizures or neurologic deficits Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 7. Danger Signals in Children: • Occur in early morning then quickly improve • Exacerbated by Valsalva maneuver • Presence of signs of ICP • Any change in gait, behavior, personality Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 8. Indications for Neuroimaging Studies: • History is not compatible with a known headache disorder • Points in the history are consistent with a serious pathology • Any focal finding in the history or neurologic exam • Any abnormality in the neuro exam Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 9. MIGRAINE • Episodic headache • Intensity: moderate or severe • Location: focal • Quality: throbbing • Associated with: nausea, vomiting, light sensitivity, sound sensitivity and aura (typical or atypical) Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 10. CLASSIFICATION AND CLINICAL MANIFESTATIONS: MIGRAINE W/O AURA Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 11. CLASSIFICATION AND CLINICAL MANIFESTATIONS: MIGRAINE W/ AURA Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 12. Stages in Migraine with Aura I. Aura: lasts for 15 to 30 minutes II. Headache Phase: nausea, vomiting, photophobia, phonophobia III.Post Headache: area on the side of the attack remains tender patient may feel exhausted Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 13. Migraine Variants • Cyclic Vomiting - recurrent monthly bouts of vomiting • Acute Confusional State - confusion,hyperactivity, disorientation, unresponsiveness, memory disturbances, vomiting and lethargy • Benign Paroxysmal Vertigo Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 14. Complicated Migraine • Basilar Artery Migraine – vertigo, tinnitus, diplopia, blurred vision, ataxia and an occipital headache – alterations in consciousness and generalized seizures may result • Ophthalmoplegic Migraine – a third nerve palsy ipsilateral to the headache Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 15. Complicated Migraine • AmaurosisFugax – transient monocular blindness • Hemiplegic Migraine – unilateral sensory or motor signs during the headache Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 16. Management of Migraine Non-pharmacologic • - Reassurance • - Elimination of trigger factors • - Modification of stress • - Regular diet • - Sufficient sleep Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 17. Management of Migraine Pharmacologic - Analgesics - Antiemetics (prophylactic) - Beta blockers - Calcium channel blockers - Tricyclicantidrepressants Reference: Nelson’s Textbook of Pediatrics, 19th edition
- 18. HEADACHE: ADULT
- 19. Mechanism of Headache • Traction • Inflammation • Vascular Spasm • Distention
- 20. Classification • Primary – Migraine, Cluster, Tension; 90% of headaches • Secondary – associated with underlying organic lesion or systemic illnesses; 10%
- 21. Classification ACUTE New in onset Subarachnoid Hemorrhage -Bleeding into the subarachnoid space is usually due to a ruptured saccular aneurysm or AVM -75 % due to anuerysm , 15 % AVM -Aneurysm : females 50-60y.0 -AVM : males , 20-40 y.o Pathology : Aneurysm •Congenital weakness of the vessel wall at sites of branching •20% multiple •May be associated with other congenital anomalies
- 22. Pathology : AV Malformation •Cause SAH in 10% •Abnormal vessels bypass the capillary system •More often result in IC hematoma than SAH
- 23. OTHER CAUSE OF ACUTE HEADACHE -> SEIZURES as Post Ictal Phenomenon -> Lumbar Puncture – increased in upright position and relieved with recumbency ; due to persistent CSF leak --- Use small gauge needle and get only limited amount of CSF ---- Lying flat after LP Hypertensive Encephalopathy Ocular Disorders - Angle Closure Glaucoma
- 24. Sexual Headaches sexual excitement Orgasmic Post – orgasmic Benign but SAH sometimes be excluded, self limiting Males > Females Long foreplay or Abstinence may prevent
- 25. Classification SUBACUTE Weeks or months Giant Cell Arteritis • - temporal arteritis • - Subacute granulomatous inflammation (lymphs, neutrophils and giant cells ) • - 2x women } MEN • - 50 Years and above • - scalp tenderness, jaw claudication (pain / stiffness on chewing) • - blindness in 50 % due to involvement of opthalmic artery • - diagnosis – biopsy of thickened , dilated STA Intracranial Lesions • Brain Abscess – foci of infection, fever may or may not be present •Subdural Hematoma – elderly, alcoholic, ; Hx of trauma ; waxing and waning S/S • Brain tumors •Diagnosis – CT scan and MRI •LT - is contraindicated in most cases and not very helpful Neuralgia •Trigeminal Neuralgia – V2, V3 •Glossopharyngeal Neuralgia – swalllowing, may be associated with syncopal attacks •Post Herpetic Neuralgia – V1, vesicular lesions or scar in distribution of nerve •Diagnosis : Clinical; CT to R/O SOL
- 26. Classification Migraine with Aura Migraine without Aura Cluster headache Tension Type Headache Cervical Spine Disease Sinusitis Dental Disease
- 30. Location of Pain
- 31. Other features of headache
- 32. P.E : scalp , face, head Vital signs Temperature, Pulse , cardiac rate, BP Weight loss, Malignancy Skin Cutaneous lesions in meningococcemia, herpes zoster, AVM Scalp Tenderness, nodularity, erythema, signs of trauma, tongue lacerations, bruits, conjunctival injenction, Horners
- 33. NEUROLOGIC EXAMINATION • MSE – confusion in SAH • Focal deficits, in cranial nerve , motor and sensory examination
- 34. Management • Treatment should be directed at the cause of acute headache
- 35. Treatment • NSAIDs • 5 Hydroxytriptamine Agonists • High Flow Oxygen
- 36. Treatment • Analgesic Withdrawal Headache – Oral Triptans or Parenteral Dihydroergotamine if needed • Cluster Headache – manage acute pain and prevent subsequent ones with Sumatriptan or Dihydroergotamine • Tension-type Headache – may be managed using same agents used for migraine; may respond to aspirin, acetaminophen, NSAIDs, or dihydroergotamine
- 37. Prophylactic Treatment 1. Beta Blockers Ex: Propranolol 1. Tricyclic Antidepressants Ex: Amitriptyline 1. Anticonvulsants Ex: Valproic Acid 1. Calcium Channel Blockers – efficacious in the prophylactic treatment of migraine Ex: Verapamil, Nicardipine 1. Ergot Alkaloids Ex: Methergine
- 38. Prophylactic Treatment • Indicated for patients who – have frequent headaches – acute attacks that are difficult to manage – those for whom symptomatic therapy is poorly tolerated
- 39. When to Refer • Frequent migraines not responsive to standard therapy • Migraines with atypical features • Chronic daily headache due to medication overuse
- 40. When to Refer • Acute onset of “worst headache in my life” • History of trauma, hypertension, fever, visual changes • Presence of neurologic siggns or of scalp tenderness
- 41. When to Admit • Need for repeated doses of parenteral pain meds • To facilitate an expedited work-up requiring a sequence of neuroimaging and procedures • Monitoring for progression of symptoms and neurologic consultation when the initial emergency department work-up is inconclusive
- 42. When to Admit • Pain severe enough to impair ADLs or limit participation in follow-up appointments or consultation • Suspected subarachnoid hemorrhage or structural intracranial lesions
- 43. THANK YOU
Editor's Notes
- Chronic Headache