APPROACH TO HEADACHE

ByDoctor IJAZ HUSSAINMBBS, MRCGP, MCPS, Dip Avn Med

Registrar Family Medicine PSMMC

SEQUENCE OF PRESENTATION

INTRODUCTION

CLASSIFICATION OF HEADCHE

APPROACH TO A PATIENT WITH HEADACHE

MANAGEMENT OF VARIOUS TYPES OF HEADACHE

DISCUSSION

CONCLUSION

INTRODUCTION

• The term headache should encompass all aches and pains located in the head, but in practice its applications is restricted to discomfort in the region of the cranial volt.

• Headache, or cephalalgia, is defined as diffuse pain in various parts of the head, with the pain not confined to the area of distribution of a nerve

• Headache is usually a benign symptom but occasionally it is the manifestation of a serious illness.

PATHOPHYSIOLOGY

Pain sensitive cranial structures

Skin, subcutaneous tissue, muscle, extra cranial arteries and periosteum of

the skull (scalp).

Intra-cranial venous sinuses and their large tributaries.

Parts of the dura of base of brain and falx cerebri.

Arteries within dura and pia-arachniod particularly proximal parts of

anterior & middle Cerebral arteries & the intra-cranial segments of ICA.

Middle meningeal and superficial temporal arteries.

II, III, V, IX, X cranial nerves and 1st three cervical nerves.

Delicate structures of the eye, ear, nasal cavities and sinuses.

The bony skull, much of the pia-arachniod and dura over the convexity of

the brain ,

PATHOPHYSIOLOGY OF HEADACHE

Pain sensitive Cranial Structures

The Parenchyma of the Brain

The Ependyma

Choroids Plexus

PATHOPHYSIOLOGY

1. Distension, traction or dilatation of intra-cranial or extra-cranial arteries,

e.g: - Headache that follows seizure.

- After ingestion of alcohol. - After taking nitrates. - After eating mono sodium glutamate. - Fever and - Extreme rise of BP. 2.Traction or displacement of large intracranial veins or their dural envelope. 3. Compression, traction or inflammation cranial or spinal nerves. 4. Spasm, inflammation or trauma to cranial & cervical muscles & epiphyseal joints in the upper part of spine. 5. Meningeal irritation & raised ICP. 6. Infection or blockage of PNS.

7. Headache of ocular origin:

Sustained Contraction Of Extra Ocular Muscles, Acute

Glaucoma, And Iridocyclitis.

HEADACHE CAN OCCUR AS A RESULT OF

CLASSIFICATIONS

1. Migraine: Migraine with aura

Migraine without aura

Ophthalmoplegic Migraine

Retinal migraine

2. Tension type headache3. Cluster headache4.Miscellaneous headache Idiopathic stabbing headache. Cold stimulus headache . Benign cough headache . Headache associated with sexual activity .

CLASSIFICATION ( International Headache Society )

Classification contd..

5.Headache associated with head trauma.6.Headache associated with vascular disorder. Acute ischaemic (CVD) Intracranial haematoma . SAH Arteritis- Giant cell arteritis. Venous thrombosis. Arterial hypertension.7.Headache associated with non vascular intracranial disorder. Intracranial neoplasm . Sarcoidosis and other non-infectious inflammatory disease. Intracranial infection-Meningitis High CSF pressure. Low CSF pressure.8.Headache associated with substances or their withdrawal.

9.Headache associated with non cephalic infection.10. Headache associated with metabolic disorder. Hypoxia Hypercapnia Mixed hypoxia and hypercapnia Hypoglycemia Dialysis11.Headache or facial pain associated with disorders of facial or cranial structures. Eyes- Glaucoma Ears, Nose and PNS Cranial bones,Teeth,TMJ12.Cranial neuralgias ,nerve trunk pain: Trigeminal neuralgia. Glossopharyngeal neuralgia. Nervous intermedius neuralgia. Superior laryngeal neuralgia. Occipital neuralgia.13.Headache not classified.

Classification contd..

AN APPROACH TO HEADACHE

HISTORY:1.Age, Sex, Occupation:

Migraine headache – more frequent in teenagers & young adults, higher occurrence in female. Cluster headache – almost exclusively in males. Cranial arteritis – more frequently in late middle age & in elderly.

2. Duration Tension headache -often has long duration. Headache due to expanding of intracranial disease – usually short

duration. Headache due to meningeal cause – acute in onset. Migraine headache – recur over a long period of time, with symptoms

free interval between attacks

3. Location As a general rule localized headache is of greater significance than

diffuse headache. Tension headache – typically generalized, band like or bi-occipital. Migraine with aura – often unilateral & frequently more prominent

interiorly. Migraine without aura – frequently bilateral. Cluster headache – invariably limited to the same side of the head in

any given attacks & usually periorbital.

DIAGNOSTIC APPROACH OF HEADACHE

HISTORY:4. Prodromal symptoms

Migraine headache – commonly precede by systemic complaints as euphoria, anorexia, nausea.

Migraine headache – often precede by neurological symptoms as scintillating scotoma, transient hemianopias, hemimotor or hemisensory disturbance & dysphasia.

5. Associated symptoms Tension headache – often associated with other psycho-physiologic

disturbances. Cluster headache – typically associated with ipsilateral lacrimation,

Conjunctival injection, Rhinorrhoea, & Facial Flushing.

6. Quality of pain Tension headache – Pressing, Squeezing, Tight or Heavy. Migraine headache – Throbbing or Pounding. Headache due to intracranial lesion – Relatively Mild. Acute SAH- Pain tends to be explosive & intense.

DIAGNOSTIC APPROACH OF HEADACHE

HISTORY:8. Frequency, duration & diurnal variation

Tension headache – often persist & may worsen as the day progress. Migraine headache – the frequency is variable & unpredictable. Although

usual variation is from 4 - 72 hrs, they may persist for days. Cluster headache – occur repetitively over a period of weeks or months.

Often there are 1 or 2 attacks daily. The headache typically nocturnal & of brief duration (30 min to a few hours).

9. Family History Migraine headache – strong family history. Cluster headache – are not familial.

10. Intracranial Mass Lesion – Associated symptoms are more prominent than headache. Some

intra-cerebral lesion may exhibit seizure or vomiting.

11. Cranial arteritis Systemic symptoms as fever, anorexia & rheumatic symptoms.

12.Tension headache & Vascular Headache Induced or aggravated by emotional factors. Intraventricular & posterior fossa tumour – may be accentuated by

change in the head position, coughing & Valsalva maneuver

DIAGNOSTIC APPROACH OF HEADACHE

PHYSICAL EXAMINATION

1. General physical examination: Flushed face, lacrimation, and unilateral rhinorrhoea – cluster headache. Systemic sign (fever, weight loss, anaemia) – infectious disease, specific infection of CNS, metastatic disease of brain &/or meninges.2. Neurological examination: No neurological abnormality – tension headache. Evidence of cerebral ischaemia – small percentage of migraine (permanent residual damage). Horner’s syndrome – sometimes during migraine headache(rarely permanent). Localizing sign – expanding ICSOL. Papilloedema - ICP due to ICSOL. Bruits over the eyes/cranium – vascular malformation. Sign of meningeal irritation – lesion affecting the meninges.

SITUATION DIFFERRENTIAL WORK UP

Age > 50 Yrs Temporal Artritis, SOL ESR, Imaging

Age < 20 Yrs

Sudden Onset SAH, Pitutary Apoplexy, Mass Lesion, Hemorrhage into a mass lesion, Aneurysm Rupture.

Neuroimaging, L.P

Increasing in Frequency & Severity

Subdural Hematoma, SOL, Med Over Use Neuroimaging, Med Screening

New Onset Headache in a Pt with Risk Factors ie HIV, Cancer

Meningitis, Brain Abscess, Metastases“”

Headache with Sign of Systemic Illness Fever, Neck Rigidity

Meningitis, Encephalitis, Lyme Disease, Collagen Vascular Disease, Systemic Infection

Neuroimaging, L.P Serology

Focal Neurological Signs SOL, Stroke, Infarction, Collagen Vascular Disease

Neuroimaging, Collagenvascular evaluation Incl Antiphospholipid antibodies.

Papilledema SOL, BIH, Meningitis Neuroimaging, L.P

Subsequent to Trauma IC Hemorrhage, Sub/Epi dural Hematoma,Post Trauma Headache

Neuroimaging of Skull, Brain & C Spine

RED FLAGS

DIAGNOSIS

•Accurate history taking is fundamental

•Need for further investigation is determined by red flag symptoms

•Or symptoms that do not corresponding to a recognized primary headache pattern

INVESTIGATIONS

INVESTIGATIONS

• FBC & ESR.

• X-Ray Skull, Paranasal Sinuses, Cervical Spine.

• CT Scan of the head.

• MRI of the Brain.

• Eye & ENT Evaluation.

• Cardiologic & Renal Evaluation.

INDICATIONS FOR SCAN

• First or worst headache, particularly if of sudden onset.

• Headache of increasing frequency or severity.

• Increased frequency of vomiting and headache on waking.

• Headache triggered by coughing, straining or postural changes.

• Persistent physical symptoms or signs after attack (neurological

or endocrine)

• Meningism, Confusion, Impairment of Consciousness or Seizures.

M A N A G E M E N T

NONPHARMACOLOGIC APPROACHES TO TREATMENT OF TENSION-TYPE HEADACHE

• Regulation of lifestyle Maintain regular sleep scheduleEat regular meals, Avoid known dietary triggersGet regular aerobic exercise

• Minimization of emotional stressorsPlan ahead and avoid stressful situationsConsider individual or family psychotherapy

• Avoidance of environmental precipitantsWear sunglassesAvoid smoke, strong odors, and noisy areasMaintain proper posture; limit sustained positions

• Physical therapy techniquesHeat, ice, ultrasound, TENS

• Massage or cervical tractionStretching and strengthening exercises for cervical musculatureTrigger point stretching, compression,

Abortive therapySimple analgesics without caffeineSimple analgesic combinations with caffeineNonsteroidal anti-inflammatory drugsMuscle relaxants with or without an analgesic combinationNarcotic analgesics Prophylactic therapyNonsteroidal anti-inflammatory drugsTricyclic antidepressants Selective serotonin reuptake inhibitors Monoamine oxidase inhibitors

Pharmacologic treatment of tension-type headache

Contd.. Treatment: Inhalation of 100% O2 for 10 – 15 minutes. Intranasal lidocaine/sumatriptane. Prophylaxis – Ergotamine – before anticipatory attacks.Prednisolone – 75 mg/day for 3 days then reducing the at 3 days interval.Verapamil – upto 480 mg/day.Lithium – 600 to 900 mg/day.Methysergide.

CLUSTER HEADACHE

Temporal arteritis/giant cell arteritis:

Age – older patients (>50 yrs). Site – uni/bilateral & is located temporally in 50% patients.·Character – dull & boring with superimposed lancinating Appears gradually over a few hours before peak intensity Worse at night & is often aggravated by exposure to cold.Associated with polymyalgia rheumatica, jaw claudication, fever & weight loss. ·Scalp tenderness . Temporal artery & less commonly occipital artery may be tender. ESR - . Temporal artery biopsy – diagnostic. Treatment – prednisolone 80 mg daily for 4-6 wks.

POTENTIAL TRIGGERS OF TENSION-TYPE HEADACHE

• Stress (eg, everyday hassles, family crises, heavy workloads, unpleasant work or social situations)

• Change in sleep regimen (eg, shift work, oversleeping)

• Skipping meals

• Certain foods (eg, caffeine, alcohol, cheese, chocolate)

• Physical exertion

END