This document discusses approaches to evaluating and diagnosing different types of headaches. It provides guidance on taking a thorough headache history, including questions about timing, characteristics, potential triggers and aggravating/relieving factors. Common headache types like migraine and tension headache are described. The document also outlines acute and preventive treatment strategies for migraine and tension headache, emphasizing the importance of empathy, shared decision making and monitoring response to treatment.

1. Headache
Fayza Rayes
MBBCh. Msc. MRCGP
Consultant Family Physician
Joint Program of Family & Community Medicine, Jeddah
www.fayzarayes.com

2. :Contents
1. Approach to patient with headache
2. Migraine
3. Tension headache

3. An Approach to the Headache History
1. How many different headache types
does the patient experience?
(Separate histories are necessary for each)

4. An Approach to the Headache History
2. Time questions
a) Why now?
b) How recent in onset?
c) How frequent
d) What pattern (temporal distribution)
d) How long lasting?
3. Character questions
a) Intensity of pain?
b) Nature and quality of pain?
c) Site and spread of pain?
d) Associated symptoms?

5. Temporal distribution of different
types of headache with time
Migraine
Tension headache
Migraine + Tension
(combination)
Cluster headache
Raised intracranial
pressure

6. .Headache DD

7. An Approach to the Headache History
4. Cause questions
a) Predisposing and/or trigger factors?
b) Aggravating and/or relieving factors?
c) Family history of similar headache?
5. Response to headache questions
a) What does the patient do during the headache?
b) Function limited or prevented?
c) Medication

8. An Approach to the Headache History
6. State of health between attacks
a) Completely well, or residual or persisting
symptoms?
b) Concerns, anxieties, fears about recurrent
attacks and/or their cause?
Source: Steiner TJ, MacGregor EA, Davies PTG. Guidelines for All Healthcare Professionals
in the Diagnosis and Management of Migraine, Tension-Type, Cluster
and Medication Overuse Headache (3rd edition, 2007). www.bash.org.uk

9. Headache History
1st Consultation

10. Diary Card …what for
 Confirm the diagnosis
 Assess frequency and duration of the
attacks
 Assess response to treatment
 Identify potential triggers
 Involve patient in the managment

12. App. Headache diary

13. Headache diary: episodic headaches
It shows
episodic
headache
with complete
freedom from
symptoms
between
attacks,
confirming the
diagnosis of
migraine with
and without
aura

14. Headache diary: daily headaches
Possible
medication
overuse)
with
migraine

15. Headache diary:
daily headaches (possible medication overuse) with migraine

16. Episodic Headache & Chronic Headache

17. The mnemonic “SNOOP” as a reminder of the red
flags that may point to the potential of a more
serious, secondary headache

18. Headache History
2nd Consultation

19. Headache Physical Examination
 The examination must be thorough but can be brief.
 Examine the head and neck for muscle tenderness ,
stiffness, limitation in range of movement and
crepitation.
 Funduscopic examination is mandatory at first
presentation with headache, and it is always worthwhile
to repeat it during follow-up.
 Blood pressure measurement
 A quick neurological examination may be needed

20. Indications for Neuroimaging in
Patients with Headache Symptoms
 Focal neurological finding
 Headache starting after exertion or Valsalva's
maneuver
 Acute onset of severe headache
 Headache awakens patient at night
 Change in well-established headache pattern
 New-onset headache in patient >35 years of age
 New-onset headache in patient who has HIV
infection or previously diagnosed cancer

21. CASE HISTORY 1
Salma is 37year-old lady. She presents with severe
headache associated with nausea. The headache is
typically present on waking and worsens over the course of
the morning. The pain starts in the temples, affecting the
right more than the left side and is temporarily eased by
pressure. From the temples, the pain gradually spreads to
settle in the back of the head. She always feels nauseous,
but only vomits occasionally during particularly severe
attacks. Eventually he has to stop what he is doing and lie
down in a darkened room. Occasionally, Salma gets a
warning before the attack starts, with a bright spot in his
vision, which slowly expands over about 20 minutes before
disappearing. It is followed by headache.

22. Explore the Diagnostic Imperatives
What Conditions/Diagnoses are:
Most common?
Most important?

23. Distinguishing Migraine Aura from a
Transient Ischemic Attack

25. International Classification of Headache Disorders.
Diagnostic criteria for migraine with aura
A. At least five attacks fulfilling criteria B–D
B. Headache attacks lasting 4–72 hours (untreated or unsuccessfully
treated)
C. Headache has at least two of the following characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (e.g.
walking or climbing stairs)
D. During headache at least one of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia
E. Not attributed to another disorder
Source: Headache Classifi cation Subcommittee of the International Headache Society (IHS). The
International Classification of Headache Disorders (2nd edition). Cephalalgia 2004; 24 (suppl 1): 1–160.

26. International Classification of Headache Disorders.
Diagnostic criteria for migraine with aura
Typical aura consisting of visual and/or sensory and/or speech
symptoms. Gradual development, duration no longer than one hour,
a mix of positive and negative features and complete reversibility
characterize the aura which is associated with a headache fulfilling
criteria for migraine without aura
Diagnostic criteria
A. At least two attacks fulfilling criteria B–D
B. Aura consisting of at least one of the following, but no motor
weakness:
1. fully reversible visual symptoms including positive features (e.g.
flickering lights, spots or lines) and/or negative features (i.e. loss of
vision)
2. fully reversible sensory symptoms, including positive features (i.e.
pins and needles) and/or negative features (i.e. numbness)
3. fully reversible dysphasic speech disturbance

27. Cont.
International Classification of Headache Disorders.
Diagnostic criteria for migraine with aura
C. At least two of the following:
1. homonymous visual symptoms and/or unilateral sensory symptoms
2. at least one aura symptom develops gradually over ≥5 minutes
and/or different aura symptoms occur in succession over ≥5 minutes
3. each symptom lasts ≥5 and ≤60 minutes
D. Headache fulfilling criteria B–D for migraine without aura (Box 2.1)
begins during the aura or follows aura within 60 minutes
E. Not attributed to another disorder
Source: Headache Classifi cation Subcommittee of the International Headache Society (IHS). The
International Classification of Headache Disorders (2nd edition). Cephalalgia 2004; 24 (suppl 1): 1–160.

28. Estimates of migraine prevalence in studied using diagnostic criteria of the
International Headache Society (IHS) .

29. Migraine Treatment
Empathy

30. Migraine
Acute Treatment:
 Combination therapy with an oral triptan +NSAID, or
an oral triptan + paracetamol, for the acute treatment
of migraine, taking into account the person's preference,
comorbidities and risk of adverse events.
 For young people aged 12–17 years consider a nasal
triptan in preference to an oral triptan
 For people who prefer to take only one drug, consider
monotherapy with an oral triptan , NSAID, aspirin
(900 mg) or paracetamol for the acute treatment ,
taking into account the person's preference,
comorbidities and risk of adverse events.
 Consider an anti-emetic in addition to other acute
treatment for migraine even in the absence of nausea
and vomiting.

31. Migraine
Acute Treatment:
+

32. Migraine
Prophylactic Treatment:
 Discuss the benefits and risks of prophylactic
treatment for migraine with the person, taking into
account the person's preference, comorbidities, risk
of adverse events and the impact of the headache
on their quality of life.
 Offer topiramatec (anti epilepsy) or propranolol
for the prophylactic treatment of migraine according
to the person's preference, comorbidities and risk of
adverse events..

33. Migraine
 Advise women and girls of childbearing potential that
topiramate is associated with a risk of fetal
malformations and can impair the effectiveness of
hormonal contraceptives. Ensure they are offered
suitable contraception.
 If both topiramate and propranolol are unsuitable or
ineffective, consider a course of up to 10 sessions of
acupuncture over 5–8 weeks or gabapentin (up to
1200 mg per day) according to the person's
preference, comorbidities and risk of adverse events.

34. Migraine
 For people who are already having treatment with
another form of prophylaxis such as amitriptyline ,
and whose migraine is well controlled, continue the
current treatment as required.
 Review the need for continuing migraine prophylaxis
6 months after the start of prophylactic treatment.
 Advise people with migraine that riboflavin (400
mg once a day) may be effective in reducing
migraine frequency and intensity for some people.
Source: Headaches-Diagnosis and management of headaches in
young people and adults . NICE Guidelines, September 2012

35. Migraine
Prophylactic Treatment:

36. CASE HISTORY 2
The woman with ‘daily’ headaches
Salem is a 30-year-old policeman and does
shift work. He presents with troublesome
headaches, which he gets most days. The
headache can come on at any time of the
day. Sometimes the pain is on the left side
of his head, but more often it is like a band
across the back of his head. There are no
associated symptoms. The headaches do
not stop him working, but they affect his
ability to concentrate

37. Explore the Diagnostic Imperatives
What Conditions/Diagnoses are:
Most common?
Most important?

38. Tension Headache
Prevalence rates of tension-type
headaches vary among studies
from 30 to 71%

39. Diagnostic Criteria
Tension-type headache
 Headaches lasting from 30 minutes to 7 days
 At least two of the following pain characteristics:
 Pressing or tightening (non-pulsating) quality
 Mild to moderate intensity
 Bilateral location
 No aggravation from walking stairs or similar routine
activities
 Both of the following:
 No nausea or vomiting
 Photophobia and phonophobia absent, or only one is
present

40. Tension-type headache
 Diary cards can aid diagnosis and assessment
of response to Treatment
 Referral is indicated if the diagnosis is unclear or
there is no response to standard treatment
strategies

41. TENSION-TYPE HEADACHE
MANAGEMENT
EMPATHY

42. Tension Headache
Acute Treatment:
 Aspirin , paracetamol or an NSAID, taking
into account the person's preference,
comorbidities and risk of adverse events.
Prophylactic Treatment:
 A course of up to 10 sessions of acupuncture
over 5–8 weeks for the prophylactic treatment of
chronic tension-type headache.
Source: Headaches-Diagnosis and management of headaches in
young people and adults . NICE Guidelines, September 2012

43. Tension Headache
Acute Treatment:
+
Prophylactic Treatment:

44. Rebound Headache
Patients with chronic tension-type
headache should limit their use of
analgesics to two times weekly to
prevent the development of
Chronic daily headache . Or
Rebound headache

45. Rebound Headache
1. Daily analgesic medication can be
withdrawn
2. Withdrawal symptom frequently reduce
after 2 weeks
3. Pt. often show migraine headache
4. Give migraine specific treatment

46. Non-pharmacological Treatment
for Headache
 Smoking cessation
 Higher levels of nicotine are correlated
with trends toward higher measures of
anger, anxiety, and depression

47. Non-pharmacological Treatment
for Headache
 biofeedback, relaxation training (No strong
evidence)
 cognitive psychotherapy alone and in
combination with other behavioral treatment for
chronic tension-type headache (No strong
evidence)
 acupuncture treatment (Evidence level A,
systematic review of RCTs)

48. Non-pharmacological Treatment
for Headache:
 Traditional physical therapy for headache
 Proper posture
 Home exercise program
 Used ice packs
 Massage, and “passive mobilization” of the
cervical facets.
Both headache frequency and psychologic
well-being improved significantly
(Evidence level B, uncontrolled study)

49. Acute Secondary Headache
 Headache associated with head trauma
 Acute post-traumatic headache
 Headache associated with vascular disorders
 Subarachnoid hemorrhage
 Acute ischemic cerebrovascular disorder
 Unruptured vascular malformation
 Arteritis (e.g., temporal arteritis)
 Venous thrombosis
 Arterial hypertension
 Headache associated with nonvascular
intracranial disorder

50. Cont.
Acute Secondary Headache
 Headache associated with metabolic disorder
 Hypoxia
 Dialysis
 Other metabolic abnormality
 Headache or facial pain associated with disorder
of cranium, neck, eyes, ears, nose, sinuses,
teeth, mouth, or other facial or cranial structures
 Cranial neuralgias and nerve trunk pain

51. Cont.
Acute Secondary Headache
 Benign intracranial hypertension
 Low cerebrospinal fluid pressure (e.g. headache
subsequent to lumbar puncture).
 Headache associated with substance use or
withdrawal
 Acute use or exposure
 Chronic use or exposure
 Headache associated with noncephalic infection
 Viral infection
 Bacterial infection

52. Final message and
conclusion:
When dealing with patient suffering from headache
1. You need to make accurate diagnosis
2. You need to determine the severity
3. Show your empathy and give appropriate
treatment
4. Do not deprive the patient from preventive
medications