This document summarizes different types of headaches including primary and secondary headaches. It describes tension-type headaches, migraines, cluster headaches, and other primary headache disorders. It also discusses various secondary headache causes such as infections, head injuries, tumors, and vascular disorders. Diagnostic criteria and management approaches are provided for several headache types.

1. Headache Review
Santosh K. Dhungana
JR Y1
Dept of GP& EM

2. scenario..
 28/ F from Siraha, presented to GOPD with-
◦ h/o repeated headaches, left sided
◦ 2-3 episodes/ month, lasting 30 mins to hrs
◦ Variable pattern
◦ Increased severity during menses
◦ Relieved by avoiding family members and
sleeping

3.  Gives h/o multiple treatments at various
centers
 All investigations- baseline, eye consult, CT,
EEG normal
 She was accompanied by her husband
 Has 3 children, lives in a joint family of 8
members
 Can’t speak Nepali

4. headaches..
 >10 mil doctor visits/ year, 2 mil ER visits in
US
 One of primary symptom perpetuated/
exaggerated for 1˚/2˚ gain
 Headache + backache-
◦ Leading cause of lost productivity and
absenteeism
◦ Loss of > $61 bil/ yr
 JAMA, Nov 12, 2003

5. why worry?
 a lot of people think headaches are
“normal”
 take OTC drugs-
◦ Suppress symptoms
◦ curtain on “danger signs”
 drug dependence
 ADRs esp NSAIDs and kidney

6. Classification
 Primary headaches-
 those in which headache and its associated
features are the disorder in itself
 secondary headaches-
 those caused by exogenous disorders
◦ the International Headache Society (IHS)

7. Primary vs Secondary
headaches
 Tension type 69%
 Migraine 16%
 Idiopathic stabbing
2%
 Exertional 1%
 Cluster
0.1% • Systemic infection
63%
• Head injury
4%
• Vascular disorders
1%
• SAH
<1%
OPD vs ER

8. anat and physio
 pain perception-
◦ a normal physiologic response mediated
by a healthy nervous system
 Pain occurs when
◦ peripheral pain receptors are stimulated in
response to tissue injury, visceral
distension or
◦ pain-producing pathways of the PNS/
CNS are damaged or activated
inappropriately

9. anat and physio
 few cranial structures are pain-
sensitive-
◦ the scalp
◦ middle meningeal artery
◦ dural sinuses
◦ falx cerebri
◦ proximal segments of the large arteries
 much of the brain parenchyma-no pain

10. clinical approach
 History
 A full description of the pain
 site /radiation/ quality/ severity/ frequency/
duration/ onset and offset
 precipitating factors
 aggravating and relieving factors
 associated symptoms

11.  physical examination
 Inspect
◦ Head/ temporal arteries/ eyes
 palpate
◦ temporal arteries/ the face and neck muscles
◦ the cervical spine/ sinuses
◦ teeth and TMJ
 signs of meningeal irritation and papilledema
 A mental state examination
◦ Mood/ anxiety /tension/ depression
 Eye examination
 Neurological examination
◦ sensation and motor power in the face and limbs and
reflexes

12. red flag
 "Worst" headache ever/ thunder clap
 First severe headache
 Abnormal neurologic examination
 Fever or unexplained systemic signs
 Vomiting that precedes headache
 Pain induced by bending, lifting, coughing
 Pain that disturbs sleep or presents immediately upon
awakening
 age > 55
 Headache with local tenderness- region of temporal
artery

13. secondary headache

14. some causes
 URTI/ sinusitis
 Meningitis, encephalitis, brain abscess
 Intracranial hemorrhage (SAH, epidural, subdural)
 Brain tumor (cerebral, pituitary)
 Temporal arteritis
 Glaucoma, refractive errors
 Ophthalmic herpes zoster
 Cervical spondylosis

15. infections
 URTI/ sinusitis
◦ Most common cause of headache
 Meningitis-
◦ Bacterial, TB, fungal
 Encephalitis-
◦ Viral
 brain abscess
◦ Immune status

16. infections
 Rule of thumb
◦ Acute, severe headache
with stiff neck + fever
 Kernig’s / brudzinki
 Meningococcal rashes
 Dx-
◦ Blood, CSF, x-ray, CT, MRI
 Tt-
◦ Urgent Abx
LP vs Abx- which first?

17. empirical therapy
 Preterm infants to infants <1 month
◦ Ampicillin + cefotaxime
 Infants 1–3 mo
◦ Ampicillin + cefotaxime or ceftriaxone
 Immunocompetent children >3 mo and adults
<55
◦ Cefotaxime, ceftriaxone or cefepime + vancomycin
 Adults >55 and adults of any age with
alcoholism or other debilitating illnesses
◦ Ampicillin + cefotaxime, ceftriaxone or cefepime +
vancomycin

18. head injury
 Skull/ scalp
 intracranial
◦ Concussion
◦ Contusion
◦ Hemorrhage- subdural, epidural
 Dx-
◦ Local examination, neurological, x-ray, CSF, CT,
MRI
• Px- GCS, Hunt and Hess scale
 Tt-
◦ General-ABCs, BP
◦ Urgent referral for ICU/ operative measures

19. SAH
 Life threatening, 40% die before tt
 Features-
◦ Sudden onset
◦ Occipitalgeneralised
◦ Pain, neck stiffness
◦ vomitting LOC
◦ Kernig’s +
◦ “sentinel headache”
 Dx-
◦ CT
◦ LP if CT negative- frank blood vs xanthochromia
 Mgmt- airway, BP
◦ Medical and surgical intervention

20. Grade Hunt-Hess Scale WFNS Scale
1 Mild headache, normal mental status,
no cranial nerve or motor findings
GCS score 15, no
motor deficits
2 Severe headache, normal mental
status, may have cranial nerve deficit
GCS score 13–14, no
motor deficits
3 Somnolent, confused, may have
cranial nerve or mild motor deficit
GCS score 13–14,
with motor deficits
4 Stupor, moderate to severe motor
deficit, may have intermittent reflex
posturing
GCS score 7–12, with
or without motor
deficits
5 Coma, reflex posturing or flaccid GCS score 3–6, with
or without motor
deficits

21. brain tumors
 5-10 per 100,000
 Age- 2 peaks
Children <10yrs
 Medulloblastoma
 Astrocytoma
 Glioma- brain stem
Age- 35- 60
• Meningioma
• Pituitary adenoma
• Mets from lung
• Glioma- cerebral
Inv- CT, MRI

22. temporal arteritis
 AKA GCA, cranial arteritis
◦ Persistent unilat throbbing headache
◦ Over temporal and scalp
◦ Localized cord like thickening
◦ w or w/o loss of pulsation of temporal artery
◦ blurring of vision- danger sign!
 Patho-
◦ Type of collagen disease
◦ Causes inflammation of extra-cranial vessels

23.  Dx-
◦ unilateral intermittent headache in 50 yr+ F>M
◦ fever
◦ Lab- high ESR, anemia
◦ Biopsy of STA (focal involvement)
◦ MRI best
 Tx-
◦ steroids
◦ Important to prevent blindness
◦ Prednisolone 50mg bid for 2-4 weeks
◦ Dose adjustment guided by CRP and ESR level
◦ May need 1- 2 yrs to resolve

24. glaucoma
 Chronic elevation of IOP-
◦ Optic neuropathy
◦ Painless vs acutely painful
 Dx-
◦ IOP measurement
◦ Cupping
 Tx-
◦ topical adrenergic agonists, cholinergic agonists,
beta blockers, PG analogues, Laser

25. cervical spondylosis
 Pain over nape of neck (-itis)
 Palpable tenderness
 Dx-
◦ clinical, x-ray, CT
 Tx-
◦ NSAIDs, physio

26. post spinal headache
 Cause- low ICP d/t CSF leak
 Severe with N/ V
 Tx-
◦ Bed rest
◦ Caffeine
◦ Blood patch
 AMDA experience

27. primary headaches

28. some causes
 Tension type
 Migraine
 Idiopathic stabbing
 Exertional
 Cluster

29. tension type headache
 Aka muscle contraction headache
 Symmetrical
 Last for hours and recur daily
 “tight band”/ heavy wt on top of head sensation
 “invisible pillow” sign
 More common in females (75%)
 Onset: after rising, gets worse during day
 Aggravating factors: stress, overwork
 Relieving factors: alcohol

30. IHS criteria
 At least 10 episodes
 Each episode lasting 30 mins to 7 days
 2 of the following 4
◦ Non-pulsating
◦ mild- mod intensity
◦ b/l location
◦ not ˄ by routine activity
 Both of-
◦ No N/ V
◦ No photo/ phonophobia
 Lasting <15 days/ month (<180 days/ yr)
 Dx of exclusion

31. mgmt
 patient education
 massage
 stress reduction
◦ relaxation therapy
◦ yoga or meditation classes
 Analgesics- paracetamol, aspirin

32. migraine
 Greek word meaning ‘pain involving half the head’
 Very common (1 in 10 person)
 F>M
 Peak age 20- 50 yrs
 Many types-
◦ Common
◦ Classic
◦ Complicated
◦ Unusual subtypes-
 Hemiplegic, basilar, retinal, migranous stupor,
ophthalmoplegic, status migrainosus

33. classical features
 Radiation: retro-orbital and occipital
 Quality: intense and throbbing
 Frequency: 1 to 2 per month
 Duration: 4 to 72 hours (average 6 - 8 hours)
 Onset: paroxysmal, often wakes with it
 Offset: spontaneous (often after sleep)
 Precipitating factors: tension, stress (commonest)

34. common migraine- IHS
criteria
 The patient should have had at least five of
these headaches
 The headaches last 4 - 72 hours
 The headache must have at least two of
these-
◦ unilateral location
◦ pulsing quality
◦ moderate or severe intensity, inhibiting or
prohibiting daily activities
◦ headache worsened by routine physical activity
 The headache must have at least two of
these-
◦ nausea and/or vomiting
◦ photophobia and phonophobia

35. classic migraine- IHS criteria
At least two attacks,
including at least 3 of the following
◦ reversible brain symptoms (cortical or brain stem)
◦ gradual development over 4 minutes
◦ aura duration less than 60 minutes
 visual 25% (scintillation, scotoma, hemianopia)
 sensory (unilateral paraesthesia)
◦ headache follows aura in less than 1 hour

36. migraine- triggers
• Foodstuffs - chocolate, oranges, tomatoes, citrus fruits, cheeses, gluten sensitivity (possible)
• Alcohol - especially red wine
• Drugs - vasodilators, oestrogens, monosodium glutamate, nitrites (‘hot dog’ headache), indomethacin, OCP
• Glare or bright light
• Emotional stress
• Head trauma (often minor), e.g. jarring - ‘footballer's migraine’
• Allergen
• Climatic change
• Excessive noise
• Strong perfume
Endogenous
• Tiredness, physical exhaustion, oversleeping
• Stress, relaxation after stress - ‘weekend migraine’
• Exercise
• Hormonal changes - puberty - menstruation
- climacteric
- pregnancy
• Hunger
• Familial tendency
• ? Personality factors
Practically any thing can trigger a migraine
headache!

37. the Migraine Disability assessment test

38. management- acute attack
 Start as soon as you suspect
 Complete rest in dark room
 Cold-pack
 Avoid triggering factors

39. medical management
• First line
 paracetamol or Dispirin 600-900 mg + metoclopramide
10mg
 Paracetamol (in children)
 NSAIDs
• Alternative -Ergotamine (helps about 80% of
patients)
◦ oral
 Ergotamine 1 mg + caffeine 100 mg –Migril/ Cafergot
 2 tabs stat
 Repeat after 1 hr if necessary (max. 6 per day)
◦ Inhaler- 1 puff stat, repeat in 5 mins (max 6 puffs/
day)
◦ P/R-ergot 2mg + caffeine 100mg
◦ i/m- Dihydroergotamine 0.5-1.0 mg (give perinom

40. ◦ Sumatriptan (a serotonin receptor agonist)-Migratan
 Oral
 50 - 100 mg at the time of prodrome
 repeat in 2 hours if necessary
 max 300 mg/24 hours
 Nasal spray
 10-20 mg per nostril (max 40mg/ day)
 Subcutaneous
 6mg stat
 Repeat 1 hrly (max 12 mg/ day)

41.  Severe attack – red flag
 Review for other causes – SAH, CVA, drug abuse
 Meds-
◦ Dihydroergotamine 0.5-1.0 mg +perinom 10 mg i/m
◦ Or sumatriptan 6mg s/c
◦ Or dihydroergotimine 0.5 mg + perinom 10 mg i/v
 No ergot if triptan used within 6 hrs!
 No triptan if ergot used within 24 hrs!

42. prophylaxis
 When?
◦ 2 or more attacks/ month
◦ Disturbing daily activity
 What?
◦ Propanolol 40mg bid/ tds (max 320 mg)
◦ TCA- amitriptylin 10mg hs (50-75 mg
maintainance)
◦ Pizotifen 0.5- 2.0 mg hs
◦ Cyproheptadin
◦ Nifedipine
◦ Naproxen
◦ Gapapentin
◦ Sod. valproate

43.  How long?
◦ Try single drug for at least 2 months
◦ No set time frame for termination of treatment
 Add TCA (amitriptyline) to others
 Alternatives medicines-
◦ herbal, homeopathy, chiropratice, naturopathy,
relaxation, massage

44. choice of initial drug
 if low or normal weight - pizotifen
 if hypertensive - a beta-blocker
 if depressed or anxious - amitriptyline
 if tension - a beta-blocker
 if cervical spondylosis - naproxen
 food-sensitive migraine - pizotifen
 menstrual migraine - naproxen or ibuprofen

45. transformed migraine
 progressive increase in frequency of migraine
attacks until the headache recurs daily.
 The typical migraine features become modified-
resembles that of tension headache but with the
unilateral situation of migraine
 Analgesic abuse can transform episodic migraine
into chronic daily headache

46. cluster headache
 AKA migrainous neuralgia
 Paroxysmal cluster of unilateral headache during
nights
 Rhinorrhea/ lacrimation/ red eye/
 Hallmark- predictable cyclical nature- “alarm clock
headache”
 Male: female = 6:1
 No visual problem
 No nausea

47. mgmt
 Acute
◦ 100% oxygen inhalation
◦ Sumatriptan 6mg s/c or 20 mg intranasal
◦ Ergot inhalation
◦ Perinom 10 mg + dihydroergotamine 0.5 mg i/v
◦ Greater occipital nerve block
 Prophylaxis
◦ Ergotamine
◦ Prednisolone 50 mg x 10 days then lower
◦ Lithium 250mg bd
◦ Verapamil

48. other causes of headache
 Mixed headache
 Drug rebound headache
 Hypertension headache
 Pseudotumor cerebri
 Cough and extertional
 Gravitational

49. Coming back to the case
 Female
 Unilateral headache (but prolonged duration)
 Isolation and sleep helps
 Examination and inv- Normal
?

50.  Stopped all meds
 Started on TRIAD
 Followed up for 3 consecutive OPD days..
 Lost to follow up

51.  Medication alone not enough
 Non-pharmacological tt, pt education
 Language/ education barrier

52. the children and elderly
 Children
• Intercurrent infections
• Psychogenic
• Migraine
• Post-traumatic
 Elderly
• Cervical dysfunction
• Cerebral tumour
• Temporal arteritis
• Subdural haemorrhage

53. references
 John Murtagh's General Practice, 4th Edition
 Harrison's Principles of Internal Medicine, 18th Ed
 An introduction to clinical emergency medicine- Mahadevan
 uptodate 19.3
 Diagnosis and management of headache in adults: summary
of SIGN guideline
BMJ 2008; 337

54. thank you