Headache Review

Santosh K. Dhungana

JR Y1

Dept of GP& EM

scenario..

28/ F from Siraha, presented to GOPD with-

◦ h/o repeated headaches, left sided

◦ 2-3 episodes/ month, lasting 30 mins to hrs

◦ Variable pattern

◦ Increased severity during menses

◦ Relieved by avoiding family members and

sleeping

Gives h/o multiple treatments at various

centers

All investigations- baseline, eye consult, CT,

EEG normal

She was accompanied by her husband

Has 3 children, lives in a joint family of 8

members

Can’t speak Nepali

headaches..

>10 mil doctor visits/ year, 2 mil ER visits in

US

One of primary symptom perpetuated/

exaggerated for 1˚/2˚ gain

Headache + backache-

◦ Leading cause of lost productivity and

absenteeism

◦ Loss of > $61 bil/ yr

JAMA, Nov 12, 2003

why worry?

a lot of people think headaches are

“normal”

take OTC drugs-

◦ Suppress symptoms

◦ curtain on “danger signs”

drug dependence

ADRs esp NSAIDs and kidney

Classification

Primary headaches-

those in which headache and its associated

features are the disorder in itself

secondary headaches-

those caused by exogenous disorders

◦ the International Headache Society (IHS)

Primary vs Secondary

headaches Tension type 69%

Migraine 16%

Idiopathic stabbing

2%

Exertional 1%

Cluster

0.1% • Systemic infection

63%

• Head injury

4%

• Vascular disorders

1%

• SAH

<1%OPD vs ER

anat and physio

pain perception-

◦ a normal physiologic response mediated

by a healthy nervous system

Pain occurs when

◦ peripheral pain receptors are stimulated in

response to tissue injury, visceral

distension or

◦ pain-producing pathways of the PNS/

CNS are damaged or activated

inappropriately

anat and physio

few cranial structures are pain-

sensitive-

◦ the scalp

◦ middle meningeal artery

◦ dural sinuses

◦ falx cerebri

◦ proximal segments of the large arteries

much of the brain parenchyma-no pain

clinical approach

History

A full description of the pain

site /radiation/ quality/ severity/ frequency/

duration/ onset and offset

precipitating factors

aggravating and relieving factors

associated symptoms

physical examination Inspect ◦ Head/ temporal arteries/ eyes

palpate◦ temporal arteries/ the face and neck muscles

◦ the cervical spine/ sinuses

◦ teeth and TMJ

signs of meningeal irritation and papilledema

A mental state examination◦ Mood/ anxiety /tension/ depression

Eye examination

Neurological examination◦ sensation and motor power in the face and limbs and

reflexes

red flag

"Worst" headache ever/ thunder clap

First severe headache

Abnormal neurologic examination

Fever or unexplained systemic signs

Vomiting that precedes headache

Pain induced by bending, lifting, coughing

Pain that disturbs sleep or presents immediately upon

awakening

age > 55

Headache with local tenderness- region of temporal

artery

secondary headache

some causes

URTI/ sinusitis

Meningitis, encephalitis, brain abscess

Intracranial hemorrhage (SAH, epidural, subdural)

Brain tumor (cerebral, pituitary)

Temporal arteritis

Glaucoma, refractive errors

Ophthalmic herpes zoster

Cervical spondylosis

infections

URTI/ sinusitis◦ Most common cause of headache

Meningitis-◦ Bacterial, TB, fungal

Encephalitis-◦ Viral

brain abscess◦ Immune status

infections

Rule of thumb

◦ Acute, severe headache

with stiff neck + fever

Kernig’s / brudzinki

Meningococcal rashes

Dx-

◦ Blood, CSF, x-ray, CT, MRI

Tt-

◦ Urgent Abx

LP vs Abx- which first?

empirical therapy

Preterm infants to infants <1 month

◦ Ampicillin + cefotaxime

Infants 1–3 mo

◦ Ampicillin + cefotaxime or ceftriaxone

Immunocompetent children >3 mo and adults

<55

◦ Cefotaxime, ceftriaxone or cefepime + vancomycin

Adults >55 and adults of any age with

alcoholism or other debilitating illnesses

◦ Ampicillin + cefotaxime, ceftriaxone or cefepime +

vancomycin

head injury

Skull/ scalp

intracranial

◦ Concussion

◦ Contusion

◦ Hemorrhage- subdural, epidural

Dx-

◦ Local examination, neurological, x-ray, CSF, CT,

MRI

• Px- GCS, Hunt and Hess scale

Tt-

◦ General-ABCs, BP

◦ Urgent referral for ICU/ operative measures

SAH

Life threatening, 40% die before tt

Features-◦ Sudden onset

◦ Occipitalgeneralised

◦ Pain, neck stiffness

◦ vomitting LOC

◦ Kernig’s +

◦ “sentinel headache”

Dx-◦ CT

◦ LP if CT negative- frank blood vs xanthochromia

Mgmt- airway, BP ◦ Medical and surgical intervention

Grade Hunt-Hess Scale WFNS Scale

1 Mild headache, normal mental status,

no cranial nerve or motor findings

GCS score 15, no

motor deficits

2 Severe headache, normal mental

status, may have cranial nerve deficit

GCS score 13–14, no

motor deficits

3 Somnolent, confused, may have

cranial nerve or mild motor deficit

GCS score 13–14,

with motor deficits

4 Stupor, moderate to severe motor

deficit, may have intermittent reflex

posturing

GCS score 7–12, with

or without motor

deficits

5 Coma, reflex posturing or flaccid GCS score 3–6, with

or without motor

deficits

brain tumors

5-10 per 100,000

Age- 2 peaks

Children <10yrs

Medulloblastoma

Astrocytoma

Glioma- brain stem

Age- 35- 60

• Meningioma

• Pituitary adenoma

• Mets from lung

• Glioma- cerebral

Inv- CT, MRI

temporal arteritis

AKA GCA, cranial arteritis

◦ Persistent unilat throbbing headache

◦ Over temporal and scalp

◦ Localized cord like thickening

◦ w or w/o loss of pulsation of temporal artery

◦ blurring of vision- danger sign!

Patho-

◦ Type of collagen disease

◦ Causes inflammation of extra-cranial vessels

Dx-◦ unilateral intermittent headache in 50 yr+ F>M

◦ fever

◦ Lab- high ESR, anemia

◦ Biopsy of STA (focal involvement)

◦ MRI best

Tx-◦ steroids

◦ Important to prevent blindness

◦ Prednisolone 50mg bid for 2-4 weeks

◦ Dose adjustment guided by CRP and ESR level

◦ May need 1- 2 yrs to resolve

glaucoma

Chronic elevation of IOP-

◦ Optic neuropathy

◦ Painless vs acutely painful

Dx-

◦ IOP measurement

◦ Cupping

Tx-

◦ topical adrenergic agonists, cholinergic agonists,

beta blockers, PG analogues, Laser

cervical spondylosis

Pain over nape of neck (-itis)

Palpable tenderness

Dx-

◦ clinical, x-ray, CT

Tx-

◦ NSAIDs, physio

post spinal headache

Cause- low ICP d/t CSF leak

Severe with N/ V

Tx-

◦ Bed rest

◦ Caffeine

◦ Blood patch

AMDA experience

primary headaches

some causes

Tension type

Migraine

Idiopathic stabbing

Exertional

Cluster

tension type headache

Aka muscle contraction headache

Symmetrical

Last for hours and recur daily

“tight band”/ heavy wt on top of head sensation

“invisible pillow” sign

More common in females (75%)

Onset: after rising, gets worse during day

Aggravating factors: stress, overwork

Relieving factors: alcohol

IHS criteria

At least 10 episodes

Each episode lasting 30 mins to 7 days

2 of the following 4

◦ Non-pulsating

◦ mild- mod intensity

◦ b/l location

◦ not ˄ by routine activity

Both of-

◦ No N/ V

◦ No photo/ phonophobia

Lasting <15 days/ month (<180 days/ yr)

Dx of exclusion

mgmt

patient education

massage

stress reduction

◦ relaxation therapy

◦ yoga or meditation classes

Analgesics- paracetamol, aspirin

migraine

Greek word meaning ‘pain involving half the head’

Very common (1 in 10 person)

F>M

Peak age 20- 50 yrs

Many types-

◦ Common

◦ Classic

◦ Complicated

◦ Unusual subtypes-

Hemiplegic, basilar, retinal, migranous stupor,

ophthalmoplegic, status migrainosus

classical features

Radiation: retro-orbital and occipital

Quality: intense and throbbing

Frequency: 1 to 2 per month

Duration: 4 to 72 hours (average 6 - 8 hours)

Onset: paroxysmal, often wakes with it

Offset: spontaneous (often after sleep)

Precipitating factors: tension, stress (commonest)

common migraine- IHS

criteria The patient should have had at least five of

these headaches

The headaches last 4 - 72 hours

The headache must have at least two of these-◦ unilateral location

◦ pulsing quality

◦ moderate or severe intensity, inhibiting or prohibiting daily activities

◦ headache worsened by routine physical activity

The headache must have at least two of these-◦ nausea and/or vomiting

◦ photophobia and phonophobia

Secondary causes of headache are excluded

classic migraine- IHS criteria

At least two attacks,

including at least 3 of the following

◦ reversible brain symptoms (cortical or brain stem)

◦ gradual development over 4 minutes

◦ aura duration less than 60 minutes

visual 25% (scintillation, scotoma, hemianopia)

sensory (unilateral paraesthesia)

◦ headache follows aura in less than 1 hour

migraine- triggers

• Foodstuffs - chocolate, oranges, tomatoes, citrus fruits, cheeses, gluten sensitivity (possible)

• Alcohol - especially red wine

• Drugs - vasodilators, oestrogens, monosodium glutamate, nitrites (‘hot dog’ headache), indomethacin, OCP

• Glare or bright light

• Emotional stress

• Head trauma (often minor), e.g. jarring - ‘footballer's migraine’

• Allergen

• Climatic change

• Excessive noise

• Strong perfume

Endogenous

• Tiredness, physical exhaustion, oversleeping

• Stress, relaxation after stress - ‘weekend migraine’

• Exercise

• Hormonal changes - puberty - menstruation

- climacteric

- pregnancy

• Hunger

• Familial tendency

• ? Personality factors

Practically any thing can trigger a migraine

headache!

the Migraine Disability assessment test

management- acute attack

Start as soon as you suspect

Complete rest in dark room

Cold-pack

Avoid triggering factors

medical management

• First line paracetamol or Dispirin 600-900 mg + metoclopramide

10mg

Paracetamol (in children)

NSAIDs

• Alternative -Ergotamine (helps about 80% of patients)

◦ oral Ergotamine 1 mg + caffeine 100 mg –Migril/ Cafergot

2 tabs stat

Repeat after 1 hr if necessary (max. 6 per day)

◦ Inhaler- 1 puff stat, repeat in 5 mins (max 6 puffs/ day)

◦ P/R-ergot 2mg + caffeine 100mg

◦ i/m- Dihydroergotamine 0.5-1.0 mg (give perinomfirst)

◦ Sumatriptan (a serotonin receptor agonist)-Migratan

Oral

50 - 100 mg at the time of prodrome

repeat in 2 hours if necessary

max 300 mg/24 hours

Nasal spray

10-20 mg per nostril (max 40mg/ day)

Subcutaneous

6mg stat

Repeat 1 hrly (max 12 mg/ day)

Severe attack – red flag

Review for other causes – SAH, CVA, drug abuse

Meds-

◦ Dihydroergotamine 0.5-1.0 mg +perinom 10 mg i/m

◦ Or sumatriptan 6mg s/c

◦ Or dihydroergotimine 0.5 mg + perinom 10 mg i/v

No ergot if triptan used within 6 hrs!

No triptan if ergot used within 24 hrs!

prophylaxis

When?

◦ 2 or more attacks/ month

◦ Disturbing daily activity

What?

◦ Propanolol 40mg bid/ tds (max 320 mg)

◦ TCA- amitriptylin 10mg hs (50-75 mg maintainance)

◦ Pizotifen 0.5- 2.0 mg hs

◦ Cyproheptadin

◦ Nifedipine

◦ Naproxen

◦ Gapapentin

◦ Sod. valproate

How long?

◦ Try single drug for at least 2 months

◦ No set time frame for termination of treatment

Add TCA (amitriptyline) to others

Alternatives medicines-

◦ herbal, homeopathy, chiropratice, naturopathy,

relaxation, massage

choice of initial drug

if low or normal weight - pizotifen

if hypertensive - a beta-blocker

if depressed or anxious - amitriptyline

if tension - a beta-blocker

if cervical spondylosis - naproxen

food-sensitive migraine - pizotifen

menstrual migraine - naproxen or ibuprofen

transformed migraine

progressive increase in frequency of migraine

attacks until the headache recurs daily.

The typical migraine features become modified-

resembles that of tension headache but with the

unilateral situation of migraine

Analgesic abuse can transform episodic migraine

into chronic daily headache

cluster headache

AKA migrainous neuralgia

Paroxysmal cluster of unilateral headache during

nights

Rhinorrhea/ lacrimation/ red eye/

Hallmark- predictable cyclical nature- “alarm clock

headache”

Male: female = 6:1

No visual problem

No nausea

mgmt

Acute◦ 100% oxygen inhalation

◦ Sumatriptan 6mg s/c or 20 mg intranasal

◦ Ergot inhalation

◦ Perinom 10 mg + dihydroergotamine 0.5 mg i/v

◦ Greater occipital nerve block

Prophylaxis◦ Ergotamine

◦ Prednisolone 50 mg x 10 days then lower

◦ Lithium 250mg bd

◦ Verapamil

other causes of headache

Mixed headache

Drug rebound headache

Hypertension headache

Pseudotumor cerebri

Cough and extertional

Gravitational

Coming back to the case

Female

Unilateral headache (but prolonged duration)

Isolation and sleep helps

Examination and inv- Normal

?

Stopped all meds

Started on TRIAD

Followed up for 3 consecutive OPD days..

Lost to follow up

Medication alone not enough

Non-pharmacological tt, pt education

Language/ education barrier

the children and elderly

Children

• Intercurrent infections

• Psychogenic

• Migraine

• Post-traumatic

Elderly

• Cervical dysfunction

• Cerebral tumour

• Temporal arteritis

• Subdural haemorrhage

references

John Murtagh's General Practice, 4th Edition

Harrison's Principles of Internal Medicine, 18th Ed

An introduction to clinical emergency medicine- Mahadevan

uptodate 19.3

Diagnosis and management of headache in adults: summary

of SIGN guideline

BMJ 2008; 337

thank you