HEADACHE

Dr Ahmad Shahir bin MawardiSpecialist Registrar,

Neurology DepartmentHospital Kuala Lumpur

31st March 2015

Myth about Headache

Headache = Migraine

Headache = CT scan

Outlines

1.Introduction

2.Classification of headache

3.Diagnosis of headache• History, Examination, Ix

1.Red flag for headche

2.Common causes of headache• Migraine, TTH, CH,MOH

1.Management of headache

Introduction

• Headache affects nearly everyone at least occasionally.

• Most frequent causes of consultation in GP and neurological clinics.

• Migraine occurs in 15% of the UK adult population– women more than men in a ratio of 3:1

• >100,000 people are absent from work or school because of migraine every working day.

The International Classification of Headache Disorders, 2nd Edition

HEADACHEHEADACHE

Primary SecondaryNeuralgias &

other headaches

Diagnosis of headache

1)History

2)Physical examination

3)Investigations

1) History of headache

• The history is all-important

• Headache diary- pattern of headache

• Excludes sinister causes of headcahe– Intracranial tumor– Meningitis– Sudarachoid Haemorrhages– Giant Cell Arteritis– Primary angle-glaucoma– Idiopathic Intracranial Hypertension– Carbon Monoxide posioning

1) History of headache

Differential diagnoses

• Posterior headache- functional or structural derangement of the neck (cervicogenic headache)

• Acute exacerbation of chronic sinusitis

• Refraction Errors - mild, frontal, absent on waking & confined to eyes only

• Diseases of ears, temporomandibular joints or teeth

Red Flag of Headache (I)

1. Headache that is new or unexpected in an individual patient

2. Thunderclap headache (intense headache with abrupt or “explosive” onset)

3. Headache with atypical aura (duration >1 hour, or including motor weakness)

4. Aura occurring for the first time in a patient during use of combined oral contraceptives

5. New onset headache in a patient older than 50 years

Red Flag of Headache (II)

6. New onset headache in a patient younger than 10 years

7. Persistent morning headache with nausea

8. Progressive headache, worsening over weeks or longer

9. Headache associated with postural change

10. New onset headache in a patient with a history of cancer

11. New onset headache

2) Examination of headache

• Normal most of time

• BP

• Fundoscopy- papiloedema

• Head and neck - muscle tenderness, stiffness, limitation in range of movement and crepitation

3) Investigations

• Neuroimaging (CT/MRI brain)– not required for diagnosis of migraine or tension-type headache.– history or examination suggest secondary headache – therapeutic value of convincing a patient

• Cervical spine x-rays

• Eye tests

Common types of headache

• Migraine

• Tension-type headache (TTH)

• Cluster headache (CH)

• Medication overuse headache (MOH)

Migraine

• Typical history– recurrent episodic moderate or severe headaches– unilateral and/or pulsating– duration: 4-72 hours– a/w GI symptoms, during– limit activity – prefer dark and quiet– symptoms free between attacks

Migraine with aura

• 1/3 of migraine sufferers• Aura

– Visual blurring and “spots” – progressive, last 5-60 minutes prior to headache– transient hemianopic disturbance/ scintillating scotoma – sometimes can occur together with other reversible focal

neurological disturbances • unilateral paraesthesia,of hand, arm or face • dysphasia• functional cortical manifestations • disturbance of one cerebral hemisphere

– may occur without migraine– aura persisting after resolution of the headache, and aura

involving motor weakness-> further Ix– familial : familial hemiplegic migraine

Scintillating scotoma

Migraine without aura

Tension type Headache (TTH)

• episodic, very low frequency and short-lasting (< several hours)

• Often generalised but can be unilateral

• Nature of pain: – pressure or tightness,/tight band around the head– spreads into or arises from the neck– can be disabling for a few hours– lacks of specific features and associated symptom

• May be stress-related or a/w functional or structural cervical or cranial musculoskeletal abnormality

• Chronic tension-type headache: >15 days a month, and may be daily

Cluster headache (CH)

• CH affects mostly men – (male to female ratio 6:1)

• Age 20s or older and very often smokers.

• Typically headaches occur in bouts for 6-12 weeks, once a year or two years, often at the same time each year.

Cluster headache (CH)

• Nature of pain:– intense, unilateral– focused in one or other eye, --> spread over

• Occurs daily, at a similar time each day, always at night, 1-2 hours after falling asleep.

• Duration: 30-60 minutes

• Associated features:– ipsilateral conjunctival injection and lacrimation, – rhinorrhoea or nasal blockage– ptosis/ Horner’s syndrome

Medication overuse headache (MOH)

• Headache caused by overuse of medication – phenacetin, ergotamine, triptan– analgesics containing barbiturates, caffeine, and codeine– aspirin and paracetamol

• Mechanisms not yet clear– probably as a results in down-regulation of 5-HT1B/1D

receptors– addictive properties– changes in neural pain pathways

• may take weeks to months for the headache to resolve after withdrawal.

Medication overuse headache (MOH)

• Small amounts are sufficient to induce MOH– >15 days a month or of codeine-containing analgesics,– >10 or more days a month of ergot or triptans on

• Frequency is important: – low doses daily carry greater risk than larger doses weekly.

• Nature of pain– worst on awakening in the morning– increases after physical exertion– In the end-stage, headache persists all day, fluctuating with

medication use repeated every few hours.

Medication overuse headache (MOH)

• Prophylactic medication aggravate the condition

• Headache diary

• The (presumptive) diagnosis made based on symptoms and drug used.

• Confirmed when symptoms improve after medication is withdrawn.

Management

• a positive diagnosis, including an explanation of the diagnosis and reassurance that other pathology has been excluded

• recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers.

• Give the person written and oral information about headache disorders, including information about support organisations.

• Explain the risk of medication overuse headache to people who are using acute treatments for their headache disorder

TENSION-TYPE HEADACHE

• Acute treatment

– aspirin, paracetamol or an NSAID

– consider person's preference, comorbidities and risk of adverse events.

– Do not offer opioids

• Prophylactic treatment

– Consider a course of up to 10 sessions of acupuncture over 5–8 weeks for the prophylactic treatment of chronic tension-type headache.

MIGRAINE WITH OR WITHOUT AURA• Acute treatment

Combination: Oral triptan + an NSAID, or an oral triptan + paracetamol.

Monotherapy: oral triptan, NSAID, aspirin(900 mg) or paracetamol

Consider an anti-emetic even in the absence of nausea and vomiting.

Do not offer ergots or opioids

If oral preparations are ineffective or not tolerated:

non-oral preparation of metoclopramide or prochlorperazine

consider adding a non-oral NSAID or triptan

• Prophylactic treatment

topiramate or propranolol

Amitriptyline is widely used, off-label, to treat chronic painful disorders, including migraine. Inadequate evidence was found

Pizotifen is a popular treatment for migraine prevention, been in use since the 1970s and appears to be well tolerated. Inadequate evidence.

Review the meds after 6 months.

MIGRAINE WITH OR WITHOUT AURA

CLUSTER HEADACHE

• Acute treatment

Offer oxygen and/or a subcutaneous or nasal triptan.

use 100% oxygen at a flow rate of at least 12 litres per minute with a non- rebreathing mask and a reservoir bag

Do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans

Prophylactic treatment

Verapamil

Reference

Thank you