Diagnosis of Common Primary Headache Disorders Dr.Mufeed Akram Taha Board Neurology (FIBMS) Kirkuk College of Medicine Kirkuk - IRAQ Quick Introduction…

Headache occurs in all age groups and is the seventh leading reason for medical office visits; Although most often a benign condition (especially when chronic and recurrent), headache of new onset may be the earliest or the principle manifestation of serious systemic or intracranial disease and therefore requires thorough and systematic evaluation.

APPROACH TO DIAGNOSIS Headache is caused by traction, displacement, inflammation, vascular spasm, or distention of the pain-sensitive structures in the head or neck. Isolated involvement of the bony skull, most of the dura, or most regions of brain parenchyma does not produce pain.

A. PAIN-SENSITIVE STRUCTURES WITHIN THE CRANIAL VAULT These include:- The venous sinuses (eg, sagittal sinus), The anterior and middle meningeal arteries The dura at the base of the skull. The trigeminal (V), glossopharyngeal (IX), and vagus (X) nerves. The proximal portions of the internal carotid artery and its branches near the Circle of Willis. The brainstem periaqueductal gray matter. The sensory nuclei of the thalamus.

B. EXTRACRANIAL PAIN-SENSITIVE STRUCTURES These include:- The periosteum of the skull. The skin. The subcutaneous tissues, muscles, and arteries; the neck muscles; the second and third cervical nerves. The eyes, ears, teeth, sinuses, and oropharynx; and the mucous membranes of the nasal cavity.

Neurology Ambassador Program Headache Disorders Headaches are extremely common Two main categories of headache Primary tension-type, migraine, cluster Secondary Secondary to another disease such as brain tumors, aneurysms, meningitis, etc… Patients seen in clinical practice frequently have had a headache. Headaches occur in the overwhelming majority of men and women each year. The two major categories of headache are primary and secondary. The International Headache Society classifications divide headaches into the major categories noted in this slide. Primary headaches are a entity unto themselves; secondary headaches are attributable to another disorder, including both serious and benign conditions (from brain tumors to subdural hematomas to hangovers). Neurology Ambassador Program

Common causes of Headache

Primary Headaches In ER This study investigated the diagnosis and clinical outcome of patients who went to the emergency department for treatment of headache. Fifty seven patients treated for acute primary headache in the emergency department completed a questionnaire. Overall, 95% of the 57 respondents met International Headache Society diagnostic criteria specifically for migraine. However, only 32% received an actual diagnosis of migraine. Fifty nine 59% were diagnosed as having "cephalgia" or "headache NOS" (not otherwise specified). All patients had taken nonprescription medications, 24% received opioids, and 7% received a migraine-specific medication; 65% percent received a "migraine cocktail" comprised of a variable mixture of a nonsteroidal anti-inflammatory agent, a dopamine antagonist, and/or an antihistamine. Forty nine 49% had never taken a triptan. All 57 patients reported that they had to rest or sleep after being discharged, and they were unable to return to normal function. Additionally, 60% of the patients reported either recurrent or persistent headache 24 hours after being discharge from the emergency department. Blumenthal HJ, Weisz MA, Kelly KM, Mayer RL, Blonsky J. Treatment of primary headache in the emergency department. Headache. 2003;43(10):1026-1031. N=57 Blumenthal et al., Headache 2003:43:1026-1031.

Migraine Migraine is generally an episodic headache often with sensitivity to light, sound or movement, and with nausea or vomiting accompanying the headache. Big ones…

Types of Migraine Migraine with aura(classical). Migraine without aura(common). Vertebrobasilar Migraine. Ophthalmoplegic Migraine. Migraine equivalents : Especially in the elderly, prodromal symptoms may occur without headache. Familial Hemiplegic Migraine. Abdominal Migraine.

Neurology Ambassador Program Features of Aura About 15% of patients with migraine experience aura Aura symptoms can be: Visual (most common by far) Sensory Speech disturbances Aura mimics include: Stroke/TIA Seizure disorders Tumors Venous thrombosis AVM Carotid artery dissection Aura has certain distinctive characteristics. Only about 15% of migraine patients experience aura, and many of those individuals do not have aura with each of their headaches. Visual symptoms are most common. Some patients may have aura characterized by weakness or speech disturbance. Because other medical conditions can mimic aura, the clinician should be alert for other possible causes, which can pose greater risks to the patient. These other conditions include stroke, transient ischemic attack, seizure disorders, tumors, and arterial venous malformation, among others. The clinician also should try to distinguish between the focal neurologic symptoms of aura and prodromal symptoms (e.g., fatigue, yawning, changes in mood or appetite). Neurology Ambassador Program

Diagnostic criteria for Migraine

Headache Precipitating Factors in Migraine Environment alters the patterns of: Sleep too little or too much; Eating skipping meals, or alcohol in particular; Stress excess stress or in the relaxation phase; Physical activity such as exertion; Weather stormy or barometric pressure change; Hormonal environment such as the menstrual cycle; Afferent stimulation such as bright lights or loud sounds.

MIGRAINE ADDITIONAL FEATURES Predictable timing around menstruation (or ovulation?) . Stereotyped prodromal symptoms Characteristic triggers Abatement with sleep Positive family history Childhood precursors (motion sickness, episodic vomiting, episodic vertigo) As experienced clinicians who care for patients know, pattern recognition is an invaluable diagnostic technique in clinical practice, particularly for heterogeneous disorders such as migraine. Therefore, although not included in the IHS criteria, there are a number of additional and characteristic features of the migraine syndrome that are considered to be strongly supportive of the diagnosis. These features, when present, may substantially increase diagnostic accuracy, particularly in patients who do not fully satisfy IHS criteria. Osmophobia, in addition to photo and phonophobia, has been shown to be a highly sensitive and specific feature of migraine. Pryse-Phillips WEM, Dodick DW, Edmeads JG, Gawel MJ, Nelson RF, Purdy RA, Robinson G, Stirling D, Worthington I. Guidelines for the diagnosis and management of migraine in clinical practice. Can Med Assoc J. 1997;156(9):1273-1287.

Things to Know !!! Migraine is an inherited tendency to headache; it is a congenital disorder and therefore it cannot be cured

Migraine Management A-Non-pharmacological management B- Pharmacological management include:- Acute attack treatment.(non specific, specific) Prophylactic treatment. (>4 attacks/mon.) Too wordy

Acute Attack Treatment

Prphylactic Treatment

Botulinium Toxin !!!

Tension-type Headache Be careful about diagnosing this one in practice…probably something else Migraine is more likely cause Maybe TTH, but if migraine history…. CNS tumors can present as TTH More history and more history…. The lost headache….

Tension-type headache Description: Frequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There is no nausea but photophobia or phonophobia may be present. Chronic TTH is 15 days/month for >3 month… Too wordy

Think of this as the most interesting… Cluster Headache Think of this as the most interesting… Headache with special clinical features Mainly male…. Autonomic features and orbital severe pain Triggered by Alchohol. Careful if short duration, female or signs… TAC (Trigeminal Autonomic Cephalagia) Secondary causes… Neat

Cluster Headache Description: Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15-180 minutes and occurring from once every other day to 8 times a day. The attacks are associated with one or more of the following, all of which are ipsilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis, eyelid oedema. Most patients are restless or agitated during an attack. Complicated

Prominent attack-related cranial autonomic (parasympathetic) features Severe, short-lasting, exclusively unilateral, trigeminal (orbital - temporal pain) pain Prominent attack-related cranial autonomic (parasympathetic) features “Cluster and other trigeminal autonomic cephalgias” refers to a group of disorders characterized by pain in the somatic distribution of the trigeminal nerve associated with cranial autonomic features during the painful episodes.

Clinical features of the trigeminal autonomic cephalalgias

Hypnic headache Affect pateints aged 67–84 years. Moderately severe nature that typically came on a few hours after going to sleep. These headaches last 15–30 minutes. Typically generalized, although may be unilateral, and can be throbbing. Patients may report falling back to sleep only to be awoken by a further attack a few hours later with up to three repetitions of this pattern over the night. HT shoud be excluded !!! Treated by:- 1- One to two cups of coffee or caffeine 60 mg orally at bedtime may be helpful. 2- verapamil at night (160 mg). 3- lithium carbonate (200–600 mg) at bed time. 4- flunarizine 5 mg at night.

Medication Overuse Headache Headache more than 15 days/month for successive 3 months

Red Flags Sudden onset Worsening pattern Systemic illness Focal signs Papilledema Triggered by cough, exertion, Valsalva Pain associated with local tenderness, such as of the temporal artery Not SNOOP

Differential Diagnosis of Migraine Intensity & disability Patterns… Frequency Duration Autonomic After Kolbe 2004

Finally…. Headache Diagnosis is a heuristic or pattern…. If you have seen it then you can diagnose it…. Spend time with primary cases…..see lots of patients.. Learn from secondary headaches: how you diagnosed them and where you went wrong! Pattern recognition

Last Red Flag…. The end…. Thanks very much….