- 1. Dr PradipMate(Masters In Pharmaceutical Medicine)
2. Introduction Headache disorders are among the most common
disorders of the nervous system. It has been estimated that 47% of
the adult population have headache at least oncewithin last year in
general. Headache disorders are associated with Personal and
societal burdens of pain, Disability, Damaged quality of life and
financial cost.Headache disorders Fact sheet N277. WHO.October
2012. http://www.who.int/mediacentre/factsheets/fs277/en/index.html
. 3. Epidemiology As many as 90 % of all benign headaches fall
under a few categories,including Migraine, Tension-type, Cluster
headache. A population-based study found that the one-year
prevalence of episodictension-type headache was 38 %, Most of these
people do not present to physicians for care. 4. Indian
perspectiveJ Headache Pain (2012) 13:543550 5. Classification : The
International Classification of HeadacheDisorders, 3rd edition
(beta version)Part 1: The primary headaches 1. Migraine 2.
Tension-type headache 3. Trigeminal autonomic cephalalgias 4. Other
primary headache disorders 6. ClassificationPart 2: The secondary
headaches 5. Headache attributed to trauma or injury to the
headand/or neck 6. Headache attributed to cranial or cervical
vascular disorder 7. Headache attributed to non-vascular
intracranial disorder 8. Headache attributed to a substance or its
withdrawal 9. Headache attributed to infection 10. Headache
attributed to disorder of homoeostasis 7. ClassificationPart 2: The
secondary headaches 11. Headache or facial pain attributed to
disorder of thecranium, neck, eyes, ears, nose, sinuses, teeth,
mouth orother facial or cervical structure 12. Headache attributed
to psychiatric disorder 8. ClassificationPart 3: Painful cranial
neuropathies, other facialpains and other headaches 13. Painful
cranial neuropathies and other facial pains 14. Other headache
disorders 9. Evaluation of headacheHistoryPhysical examination
Neurological examination General physical
examinationInvestigationsCriteria for diagnosis of headache 10.
HistoryLocation of painDiffusefocalConstantSpreadingNatural history
of pain waveFluctuation, constant peakSymptom free periodTime of
dayAssociated symptomsRadiation of painMigrationShiftingSecondary
pain 11. History Severity of pain Characters of pain Throbbing
Neuralgic Dull aching etc. Precipitating and aggravating factors
Relieving factors & response to medications Other neurological
& systemic symptoms 12. Physical Examination Systemic
Hypertension Fever Focal mass lesion Bleeding tendency HIV
Neurological examination Cranial nerves & eye ground Other
neurological examination Cranial bruit Paracranial structures eye,
ear, nose Correlation of headache & physical findings 13.
Characteristics of migraine, tension-type, and cluster
headacheSymptom Migraine Tension-type ClusterLocationUnilateral in
60 to 70%;bifrontal or global in 30%BilateralAlways unilateral,
usuallybegins around the eye ortempleCharacteristicsGradual in
onset, crescendopattern; pulsating; moderate orsevere intensity;
aggravated byroutine physical activityPressure or tightness
whichwaxes and wanesPain begins quickly, reaches acrescendo within
minutes; painis deep, continuous,excruciating, and explosive
inqualityPatient appearancePatient prefers to rest in a dark,quiet
roomPatient may remain active ormay need to restPatient remains
activeDuration 4 to 72 hours Variable 30 minutes to 3
hoursAssociated symptomsNausea, vomiting,photophobia,
phonophobia;may have aura (usually visual,but can involve other
senses orcause speech or motor deficits)None Ipsilateral
lacrimation andredness of the eye; stuffy nose;rhinorrhea; pallor;
sweating;Horner's syndrome; focalneurologic symptoms
rare;sensitivity to alcoholsyndromes 14. Headache
triggersDietAlcoholChocolateAged cheesesMonosodium
glutamateAspartameCaffeineNutsNitrites,
NitratesHormonesMensesOvulationHormone replacement
(progesterone)Sensory stimuliStrong lightFlickering
lightsOdorsSounds, noiseStressLet-down periodsTimes of intense
activityLoss or change (death, separation, divorce, job
change)MovingCrisisChanges of environment or habitsWeatherTravel
(crossing time zones)SeasonsAltitudeSchedule changesSleeping
patternsDietingSkipping mealsIrregular physical activity 15.
Principles of the headache evaluation History A systematic case
history is the single most important factor in establishing a
headache diagnosis and determining thefuture work-up and treatment
plan. A thorough history also helps focus the physical examination
and prevent unnecessary investigation and imagingstudies A
systematic case history should include the following: Age at onset
Presence or absence of aura and prodrome Frequency, intensity and
duration of attack Number of headache days per month Time and mode
of onset Quality, site, and radiation of pain Zahid H Bajw.
Evaluation of headache in adults. Up to Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
16. A systematic case history should include Associated symptoms
andabnormalities Family history of migraine Precipitating and
relievingfactors Effect of activity on pain Relationship with
food/alcohol Response to any previoustreatment Any recent change in
vision Association with recent trauma Any recent changes in
sleep,exercise, weight, or diet State of general health Change in
work or lifestyle(disability) Change in method of birthcontrol
(women) Possible association withenvironmental factors Effects of
menstrual cycle andexogenous hormones (women) 17. A systematic case
history should include A version adopted by the American Academy of
Neurology includes thefollowing four questions: How often do you
get severe headaches (ie, without treatment it is difficult to
function)? How often do you get other (milder) headaches? How often
do you take headache relievers or pain pills? Has there been any
recent change in your headaches?Zahid H Bajw. Evaluation of
headache in adults. Up to Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
18. Danger signs on history Paying attention to danger signs is
important since headaches may bethe presenting symptom of A
space-occupying mass or vascular lesion Infection Metabolic
disturbance A systemic problem.Zahid H Bajw. Evaluation of headache
in adults. Up to Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
19. Danger signs on history Sudden onset of headache, or severe
persistent headache that reaches maximal intensity withina few
seconds or minutes after the onset of pain, warrants aggressive
investigation. Cluster headache may sometimes be confused with a
serious headache, since the pain from acluster headache can reach
full intensity within minutes The absence of similar headaches in
the past is another finding that suggests a possible
seriousdisorder. The "first" or "worst" headache of my life is a
description that sometimes accompaniesan intracranial hemorrhage or
central nervous system (CNS) infectionZahid H Bajw. Evaluation of
headache in adults. Up to Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
20. Danger signs on history A worsening pattern of headache
suggests a mass lesion, subdural hematoma, ormedication overuse
headache Fever associated with headache may be caused by
intracranial, systemic, or localinfection, as well as other
etiologies Any change in mental status, personality, or fluctuation
in the level of consciousnesssuggests a potentially serious
abnormality. The rapid onset of headache with strenuous exercise,
especially when minor traumahas occurred, raises the possibility of
carotid artery dissection or intracranialhemorrhage.Zahid H Bajw.
Evaluation of headache in adults. Up to Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
21. Differential diagnosis of headache with feverIntracranial
infectionMeningitisBacterialFungalViralLymphocyticEncephalitisBrain
abscessSubdural empyemaSystemic infectionBacterial infectionViral
infectionHIV/AIDSOther systemic infectionOther causesFamilial
hemiplegic migrainePituitary apoplexyRhinosinusitisSubarachnoid
hemorrhageMalignancy of central nervous system 22. Danger signs on
history Head pain that spreads into the lower neck and between the
shoulders may indicate meningealirritation due to either infection
or subarachnoid blood; it is not typical of a benign process. New
headache in patients under the age of 5 or over the age of 50 may
suggest underlying pathology. New headache type in a patient with
cancer suggests metastasis. New headache type in a patient with
Lyme disease suggests meningoencephalitis. New headache type in a
patient with HIV suggests an opportunistic infection or tumor.
Headache during pregnancy or postpartum suggests possible cortical
vein or venous sinusthrombosis, carotid dissection, and pituitary
apoplexyZahid H Bajw. Evaluation of headache in adults. Up to
Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
23. Physical examination If a complete and careful history does not
point to an organic etiology,further examination is warranted in
the following areas: Obtain blood pressure and pulse Listen for
bruit at neck, eyes, and head for clinical signs of
arteriovenousmalformation Palpate the head, neck, and shoulder
regions Check temporal and neck arteries Examine the spine and neck
musclesZahid H Bajw. Evaluation of headache in adults. Up to
Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
24. Physical examinationA functional neurologic examination
including Getting up from a seated position without any support,
Walking on tiptoes and heels, Cranial nerve examination Funduscopy
and otoscopy Tandem gait and romberg test Symmetry on motor,
sensory, reflex and cerebellar(coordination) testsZahid H Bajw.
Evaluation of headache in adults. Up to Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
25. Danger signs on examination Neck stiffness and especially
meningismus suggests meningitis. Papilledema suggests the presence
of an intracranial mass lesion,benign intracranial hypertension
(pseudotumor cerebri), encephalitis,or meningitis. Focal neurologic
signs suggest an intracranial mass lesion,arteriovenous
malformation, or collagen vascular diseaseZahid H Bajw. Evaluation
of headache in adults. Up to Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
26. Indications for imaging studies Neuroimaging should be
considered in patients with nonacuteheadache and an unexplained
abnormal finding on neurologicexamination. Evidence is insufficient
to make specific recommendations in thepresence or absence of
neurologic symptoms (eg, headache worsenedby Valsalva, causing
awakening from sleep, new headache in olderpopulation, or
progressively worsening headache).Zahid H Bajw. Evaluation of
headache in adults. Up to Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
27. Indications for imaging studies Neuroimaging is usually not
warranted for patients with migraine and anormal neurologic
examination, Data were insufficient to make a specific
recommendation for patientswith tension-type headache. Data were
insufficient to make a specific recommendation regarding
therelative sensitivity of MRI compared with CT in patients who
have animaging study performed. 28. Indications for imaging studies
Given the lack of definitive data, one approach is to
considerneuroimaging in the following situations : Recent
significant change in the pattern, frequency or severity
ofheadaches Progressive worsening of headache despite appropriate
therapy Focal neurologic signs or symptoms Onset of headache with
exertion, cough, or sexual activity Orbital bruit Onset of headache
after age 40 yearsZahid H Bajw. Evaluation of headache in adults.
Up to Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
29. Indications for lumbar puncture Urgently indicated in patients
with headache when there is clinicalsuspicion of subarachnoid
hemorrhage in the setting of a negative ornormal head CT scan. In
addition, LP is indicated when there is clinical suspicion of
aninfectious or inflammatory etiology of headache.Zahid H Bajw.
Evaluation of headache in adults. Up to Date.Available from URL:
http://www.uptodate.com/contents/evaluation-of-headache-in-adults
30. Etiologic classification of headache in
childrenAcuteLocalizedAssociated with URI (sinusitis, otitis media)
or viral infection (influenza)Post-traumaticRelated to oral cavity
(dental abscess, TMJ dysfunction)Brain abscessFirst
migraineGeneralizedFeverSystemic infection (influenza)Central
nervous system infection (meningitis, viral
encephalitis)Hypertension, hypertensive encephalopathyIntracranial
hemorrhageExertionalFirst migraine headacheTraumaToxins (eg, carbon
monoxide), medications (eg, amphetamines, oralcontraceptives), or
illicit substancesAcute and recurrentMigraine headacheCluster
headacheChronic and non-progressiveTension-type headachePsychiatric
(depression, school phobia)Post-traumatic, postconcussiveMedication
overuseChronic and progressiveIdiopathic intracranial
hypertensionSpace-occupying lesion (tumor, abscess,
hemorrhage,hydrocephalus, vascular malformation)Post-traumatic,
postconcussive 31. Important aspects of the examination of a
childwith headacheExamination feature Possible significanceGeneral
appearanceAltered mental status may indicate meningitis,
encephalitis, intracranial hemorrhage, elevatedintracranial
pressure, hypertensive encephalopathy.Vital signs Hypertension may
cause headache or be a response to increased intracranial pressure
Fever suggests infection (most commonly upper respiratory
infection) but may occur withintracranial hemorrhage or central
nervous system malignancyHead circumference Macrocephaly may
indicate slowly progressive increases in intracranial
pressure.Height and weight trajectories Abnormal or altered
trajectories may indicate intracranial pathology.Auscultation of
the neck, eyes, and headBruit may indicate arteriovenous
malformation.for bruitPalpation of the head and neck Localized
scalp tenderness may occur in migraine and tension-type headaches
Scalp swelling may indicate head trauma Sinus tenderness may
indicate sinusitis Temporomandibular joint (TMJ) and/or masseter
tenderness suggests TMJ dysfunction Nuchal rigidity may indicate
meningitis Posterior neck pain may indicate an anatomic abnormality
(eg, Chiari malformation) Thyromegaly may indicate thyroid
dysfunction 32. Important aspects of the examination of a childwith
headacheVisual fieldsVisual field abnormalities may indicate
increased intracranial pressure and/or a
space-occupyinglesion.Funduscopy Papilledema may indicate increased
intracranial pressure Retinal hemorrhages may indicate increased
intracranial pressure or head traumaOtoscopy May demonstrate otitis
media; hemotympanum may indicate trauma.Oropharynx Signs of
pharyngitis? Dental decay or abscess?Neurologic examination (see
text fordetails)Abnormal neurologic examination (particularly
mental status, eye movements, papilledema,asymmetry, coordination
disturbance, abnormal deep tendon reflexes) may indicate
intracranialpathology but also may occur with migraine
headache.Skin examinationSigns of neurocutaneous disorders (eg,
neurofibromatosis, tuberous sclerosis complex, which areassociated
with intracranial neoplasms) or trauma (bruises, abrasions,
etc).SpineSigns of occult spinal dysraphism (eg, midline vascular
of pigment changes), which may beassociated with structural
abnormalities (eg, Chiari malformation). 33. Clinical features that
may indicate intracranialpathology in children with
headacheHeadache characteristicsHeadache awakens the child or
occurs upon wakingSudden severe headache ("thunderclap" headache,
"worst headache of my life")Associated neurologic signs and
symptoms (eg, persistent nausea/vomiting, altered mental status,
ataxia, etc)Headache worsened in recumbent position or by cough,
micturition, or defecationAbsence of auraChronic progressive
headache patternChange in quality, severity, frequency, or pattern
of headacheOccipital headacheRecurrent localized headacheLack of
response to medical therapyHeadache duration of less than six
months 34. Clinical features that may indicate
intracranialpathology in children with headacheExamination
findingsAbnormal neurologic examination (eg, ataxia, weakness,
diplopia, abnormal eye movements)Papilledema or retinal
hemorrhagesGrowth abnormalities (increased head circumference,
short stature or deceleration of linear growth, abnormal pubertal
progression, obesity)Nuchal rigiditySigns of traumaCranial
bruitsSkin lesions that suggest a neurocutaneous syndrome
(neurofibromatosis, tuberous sclerosis complex)Patient historyRisk
factor for intracranial pathology (eg, sickle cell disease, immune
deficiency, malignancy or history of malignancy, coagulopathy,
cardiac disease withright-to-left intracardiac shunt, head trauma,
neurofibromatosis type 1, tuberous sclerosis complex)Age
