this lecture note important for both medicine and psychiatric students

1. Headache

2. .
Headache affects 95% of people
in their lifetime.
Headache affects 75% of people
in any one year.
One in 10 people have migraine.
One in 30 people have headache
more often than not, for 6
months or more.

3. Classification of Headache
1. Primary headaches –Idiopathic
with no identifiable underlying cause
Migraine
Tension-type headache
Cluster headache

4. Classification of Headache cont’d
2. Secondary headaches –
Symptomatic (organic)
Underlying condition such as
trauma or a mass lesion.
Intracranial diseases
Cranial trauma
Extra cranial causes – eye, ear
problems
Toxic or systemic illnesses –
febrile illnesses

5. History taking
1. Characteristics
of the pain
stabbing
Burning
Cold sensation
 Crawling sensation
 Itching sensation
 Tightness
 Heaviness

6. History taking cont’d
2. Localization and radiation
Generalized
Unilateral
Bi temporal
Occipital
Fronta
Periorbital

7. History taking cont’d
3. Pattern and duration
Intermittent- periodic
Continuous
In clusters
4. Time predilection
Nocturnal
On awakening
Afternoons

8. History taking cont’d
5. Aura symptoms
Presence or absence of aura
Characteristics of aura
Visual
Paresthesia
Olfactory
6. Associated symptoms
Nausea and vomiting
Photophobia
Noise intolerance

9. History taking cont’d
7. Precipitating factors
Dietary – alcohol, chocolate,
Sleep deprivation
Particular odors
Psychological stress
Weather changes

10. History taking cont’d
8. Current medication
 prescription drugs -contribute/cause
headache (oral contraceptive,
dipyridamole, etc.)
 Using recreational drugs

11. MIGRAINE

12. General features - migraine
Familial in 80% of cases
Usually begins in childhood or
adolescence
Precipitating factors
Stress
Diets –cheese, wine,
Sleep deprivation
Menses
Specific odor etc.

13. Classification of migraine(IHS)
1. Migraine without aura
2. Migraine with aura
Typical aura with migraine headache
Typical aura with non-migraine headache
Typical aura without headache


14. Migraine without aura (common migraine) - IHS
1. Five attacks lasting from 4 to 72 hours are
required.
2. Two of the following 3 pain characteristics:
unilateral location
moderate to severe intensity
aggravation by routine physical activity
3. Associated symptoms
Nausea or vomiting
Photophobia

15. Migraine with aura (classic migraine)
 At least two attacks that are not
attributable to another disorder
 Fewer attacks are required to make a
diagnosis of migraine with aura
 May be less severe, of shorter duration, or
both
 Aura - Visual Auras , Sensory auras
usually lasts 20–30 minutes
typically precedes the headache
occasionally it occurs only during the
headache.

16. Migraine Phases cont’d
Aura
• Sensory auras
Paresthesias (pins and needles) that
typically begin in the hand, move up the
arm
Move into the face and tongue over a
period of 10 to 15 minutes
Often associated with a visual aura

17. Migraine Phases cont’d
3. The headache itself
Throbbing headache
Unilateral mainly - frontal, temporal, peri
orbital
Onset is usually gradual
Usually lasts 4 to 72 hours in adults (2-48
hors in children)
Is aggravated by head movement or
physical activity.
Associated features
Nausea, vomiting
 Photophobia

18. Migraine Phases cont’d
4. Postdrome or postictal phase
May feel tired, washed out, irritable and
listless
May have impaired concentration
Feel scalp tenderness
Some feel
Unusually refreshed or euphoric, OR
Have depression and malaise.

19. Status migrainosus
• Attacks that persist for more than 3
days are known as Status Migraine
• Attack

20. Course and outcome of
Migraine
• Commonly life long
• Frequency and
severity varies
• ½ will have less
frequent migraine
• 1/3 will have no
migraine
• 1/6 will have
unchanged course
• Temporary relief
during pregnancy
• Increased
susceptibility
during menses
• Improvement
during menopause
• Changing pattern
of the headache

21. Treatment of Migraine
1. Treating the acute migraine headache
 When migraine frequency is once per
week or less
 Analgesics – ASA, paracetamol,
ibuprofen
 Ergotamine - 1-2 mg during the aura
phase or at the onset of headache
 Antiemetics – promethazine 25 mg
stat
 For migraine status – corticosteroid

22. Treatment of Migraine cont’d
2. Prophylactic treatment
When migraine frequency is twice or
more per week
Drugs are given daily irrespective of
whether the headache occurs or not
Treatment duration: after 6 months of
stable state trial of drug withdrawal

23. 1- Anti-depressant drugs
Tricyclics/venlafaxine appear effective, but
SSRIs –not usefu
Amitryptyline – 10-50mg(150) mg /day
dothiepin 25 mg/day
2- Beta-blockers
Propranolol 40–240 mg/day, should be
avoided in asthma
Others (eg, metoprolol,atenolol, timolol,
nadolol) - probably as effective as
propranolol

24. Treatment of Migraine cont’d
3. Avoiding precipitating factors
Specific for each individual
Give awareness so that they
recognize the precipitant and avoid
it
Dietary
Specific odors
Emotional
Weather,. etc

25. Cluster Headache
(Previously called migrainous
neuralgia)
Cluster headache is a primary headache disorder of
unclear etiology. It is more common in males, and is
often precipitated by ingestion of alcohol. Not
infrequently, the patient awakes from sleep with the
onset of the headache.

26. Clinical features
Acute, non- throbbing, unilateral
heaadache
No aura
Periorbital localization
Radiates to forehead, temple and
cheek
Occurs in clusters
Tend to occur nightly
Lasts 1-2 hours

27. Clinical features cont’d
Associated symptoms
Blocked nostrils
Rhinorrhea
Conjunctivitis
Flush and edema of cheeks
In 20%, family history of similar
headache
Common precipitating factor - alcohol

28. .
Differential diagnosis
Migraine
Sinusitis
Brain tumor

29. .
Treatment - for the period of the attack
• Ergotamine 3 mg PO or 1mg IM
• Sumatriptan 6 mg subcutaneous.
• Start prednisolone (50-75mg/day) and
verapamil (up to 240 mg/day, sometimes
higher) at the beginning of a cluster, tailing
the steroids after 2–3 weeks, but continuing
verapamil until the cluster has resolved.
• NSAID :Indometacin (up to225 mg/day)
– Start at 25 mg three times daily for first
week, then 50 mg three times daily for
second week, and 75 mg three times daily
in third week

30. Nursing Management
When migraine or the other types of
headaches described above have been
diagnosed, the goals of nursing management
are to enhance pain relief. It is reasonable to
try nonpharmacologic interventions first, but
the use of pharmacologic agents should not
be delayed. The goal is to treat the acute
event of the headache and

31. to prevent recurrent episodes.
Prevention involves patient education
regarding precipitating factors,
possible lifestyle or habit changes that
may be helpful, and pharmacologic
measures.