Prof. Abdelmoniem Sahal Elmardi Headache Prof. Abdelmoniem Sahal Elmardi

Parts of the talk Introduction Classification Consultation of a person with headache

Introduction

Headache is the symptom of pain anywhere in the head or neck Introduction Headache is the symptom of pain anywhere in the head or neck It can be the only symptom of some diseases (primary headache) It can be one of the symptoms of other diseases (secondary headache)

Most headaches can be managed in PHC Introduction Most headaches can be managed in PHC History is a crucial step in the correct diagnosis Funduscopy is mandatory for anyone presenting with headache Diary cards aid diagnosis and management The presence of warning symptoms in the history and/or physical signs warrant investigation May indicate appropriate specialist referral

Classification

A number of different classification systems for headaches The most widely used is the International Classification of Headache Disorders (3rd edition) Issued by the International Headache Society (IHS)

Cranial neuralgias & facial pain Other headaches Classification Primary headache Secondary headache Cranial neuralgias & facial pain Other headaches

Is headache a presentation of a condition?

primary headaches

Represents 90% of all headaches They are not life-threatening Primary headaches Represents 90% of all headaches They are not life-threatening Have different but similar pathologies

Tension type headache (TTH) Trigeminal autonomic cephalalgias (TACs) Primary headaches Migraine Tension type headache (TTH) Trigeminal autonomic cephalalgias (TACs)

Causes of secondary headaches Trauma or injury to the head and/or neck Cranial or cervical vascular disorder Non-vascular intracranial disorder A substance or its withdrawal Infection Disorder of homoeostasis Disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other structures Psychiatric disorder

Migraine headaches

Migraine headaches A common disabling primary headache disorder High prevalence and socio-economic and personal impacts Ranked as the third most prevalent disorder and seventh-highest specific cause of disability worldwide

Migraine headaches Was believed to be of a vascular origin Now confirmed to be due to alterations in the sub-cortical aminergic sensory modulatory systems Involving metabolic shift directing tyrosine metabolism toward the decarboxylation pathway Resulting in a production of noradrenaline and dopamine along with increased synthesis of traces amines

Migraine without aura Migraine with aura Chronic migraine Migraine headaches Migraine without aura Migraine with aura Chronic migraine Probable migraine

Migraine without aura Recurrent headache disorder Attacks lasting 4-72 hours. Unilateral location, Pulsating quality, Moderate or severe intensity, Aggravation by routine physical activity Association with nausea and/or photophobia and phonophobia.

Migraine with aura Recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory or other CNS symptoms (aura) usually develop gradually Usually followed by headache and associated migraine symptoms. Auras need to be distinguished from TIAs Further subtypes according to type and characteristics of the aura

Chronic Migraine Headache occurring on 15 or more days per month For more than 3 months, Has the features of migraine headache on at least 8 days per month.

epidemiology

Migraine-like attacks Probable migraine Migraine-like attacks Missing one of the features required to fulfil all criteria for a subtype of migraine Not fulfilling criteria for another headache disorder.

Tension type headache

Tension-type headaches very common, with a lifetime prevalence between 30% and 78% in different studies Has a very high socio-economic impact Aetiology not known but studies strongly suggest a neurobiological basis Peripheral pain mechanisms are most likely to play a role in 2.1 Infrequent episodic tensiontype headache and 2.2 Frequent episodic tension-type headache, whereas central pain mechanisms play a more important role in 2.3 Chronic tension-type headache. Increased pericranial tenderness recorded by manual palpation is the most significant abnormal finding in patients with tension-type headache. The tenderness is typically present interictally, is further increased during actual headache and increases with the intensity and frequency of headaches. Pericranial tenderness is easily recorded by manual palpation by small rotating movements and a firm pressure (preferably aided by use

Infrequent episodic tth Infrequent episodes of headache Typically bilateral, Pressing or tightening in quality Mild to moderate intensity Lasting minutes to days. Does not worsen with routine physical activity Not associated with nausea, but photophobia or phonophobia may be present. Some types associated with pericranial tenderness

Frequent episodes of headache Typically bilateral, frequent episodic tth Frequent episodes of headache Typically bilateral, Pressing or tightening in quality Mild to moderate intensity Lasting minutes to days. Does not worsen with routine physical activity Not associated with nausea, but photophobia or phonophobia may be present. Some types associated with pericranial tenderness

Chronic Tension-type headaches A disorder evolving from frequent episodic TTH With daily or very frequent episodes of headache Same characteristics of episodic TTH

Probable Tension-type headaches Tension-type-like headache missing one of the features required to fulfil all criteria for a subtype of TTH Not fulfilling criteria for another headache disorder.

Trigeminal autonomic cephalalgias (TACs)

Trigeminal autonomic cephalgias TACs share the clinical features of headache, Usually lateralized, Often prominent cranial parasympathetic autonomic features Lateralized and ipsilateral to the headache

Trigeminal autonomic cephalgias Studies suggests that these syndromes activate a normal human trigeminal parasympathetic reflex, Clinical signs of cranial sympathetic dysfunction being secondary. Typical migraine aura can be seen

Attacks of severe, strictly unilateral pain Cluster headache Attacks of severe, strictly unilateral pain Orbital, supraorbital, temporal or in any combination of these sites Lasting 15–180 minutes Occurring from once every other day to eight times a day.

Facial sweating, miosis, ptosis and/or eyelid oedema, Cluster headache The pain is associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead Facial sweating, miosis, ptosis and/or eyelid oedema, And/or with restlessness or agitation.

Approaching a patient with headache

Approaching a patient with headache After recording the epidemiologic features Careful history is most important The SOCRATES of pain helps establishing the pattern Physical examinations helps excluding secondary headache & red flags

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Management discussed with CBS & CBT

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