Headache

Fayza RayesMBBCh. Msc. MRCGP

Consultant Family Physician

Joint Program of Family & Community Medicine, Jeddah

www.fayzarayes.com

Contents:

1. Approach to patient with headache

2. Migraine

3. Tension headache

An Approach to the Headache History An Approach to the Headache History

1. How many different headache types

does the patient experience?

(Separate histories are necessary for each)

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?

An Approach to the Headache History An Approach to the Headache History

Temporal distribution of different Temporal distribution of different types of headache with timetypes of headache with time

Migraine

Tension headache

Migraine + Tension (combination)

Cluster headache

Raised intracranial pressure

Headache DD.

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

An Approach to the Headache History 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, Clusterand Medication Overuse Headache (3rd edition, 2007). www.bash.org.uk

An Approach to the Headache History An Approach to the Headache History

Headache HistoryHeadache History11stst Consultation Consultation

Confirm the diagnosis Assess frequency and duration of the

attacks Assess response to treatment Identify potential triggers Involve patient in the managment

Diary Card …what forDiary Card …what for

App. Headache diaryApp. Headache diary

Headache diary: episodic headachesHeadache diary: episodic headaches

It shows episodic headache with complete freedom from symptoms between attacks, confirming the diagnosis of migraine with and without aura

Headache diary: daily headachesHeadache diary: daily headaches

Possible medication overuse) with migraine

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

Episodic Headache & Chronic Headache

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

Headache History2nd Consultation

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

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

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.

Explore the Diagnostic ImperativesExplore the Diagnostic Imperatives

What Conditions/Diagnoses are:

Most common?

Most important?

Distinguishing Migraine Aura from a Distinguishing Migraine Aura from a Transient Ischemic AttackTransient Ischemic Attack

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.

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

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

International Classification of Headache Disorders.Diagnostic criteria for migraine with aura

Cont.

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.

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

Migraine Treatment

Empathy

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.

Migraine

Migraine

+

Acute Treatment:

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..

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.

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.

Migraine

Source: Headaches-Diagnosis and management of headaches in young people and adults . NICE Guidelines, September 2012

Migraine

Prophylactic Treatment:

CASE HISTORY 2The woman with ‘daily’ headachesThe 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

Explore the Diagnostic ImperativesExplore the Diagnostic Imperatives

What Conditions/Diagnoses are:

Most common?

Most important?

Tension Headache

Prevalence rates of tension-type headaches vary among studies from 30 to 71%

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

Diagnostic Criteria

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

Tension-type headache

TENSION-TYPE HEADACHE

MANAGEMENT

EMPATHY

Tension HeadacheAcute 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

Tension Headache

+

Acute Treatment:

Prophylactic Treatment:

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

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

Rebound Headache

Non-pharmacological Treatment for Headache

Smoking cessation

Higher levels of nicotine are

correlated with trends toward

higher measures of anger,

anxiety, and depression

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)

Non-pharmacological Treatment for Headache: Traditional physical therapy for

headacheProper posture Home exercise programUsed ice packsMassage, and “passive mobilization” of the

cervical facets.

Both headache frequency and psychologic well-being improved significantly

(Evidence level B, uncontrolled study)

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

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

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

Cont.

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