1. HEADACHE Presentation By Dr. Asha Rani Natarajan
23-July-2016

2. HEADACHE HISTORY Headache attacks How it begins
Precipitating event, illness, injury
Headache attack descriptions
Frequency and patterns
Location
Time to peak intensity
Duration
Quality and intensity
Warning symptoms and aura
Associated symptoms and level of disability
Triggers and aggravating or relieving factors

3. SYMPTOMS THAT SUGGEST A SERIOUS UNDERLYING DISORDER
Sudden-onset headache
First severe headache
"Worst" headache ever
Vomiting that precedes headache
Subacute worsening over days or weeks
Paininduced by bending,lifting, cough
Pain that disturbs sleep or presents immediately upon awakening
Abnormal neurologic examination
Pain associated with local tenderness, e.g. region of temporal artery

4. WHEN A SCAN IS NOT RECOMMENDED FOR HEADACHE
Patient with established history of episodic headache
Current headache is consistent with previous headaches or is consistent with different manifestation of a primary headache.
Normal neurological exam

5. COMMON CAUSES OF HEADACHE
Primary Headache
Type %
Migraine 16
Tension-Type 69
Cluster
0.1
Stabbing 2
Exertional 1
Secondary Headache
Type %
Systemic Infection 63
Head Injury 4
Vascular Disorder 1
SAH
<1
Brain Tumor
0.1

6. PRIMARY HEADACHE SYNDROME
Migraine
Headache + Associated Features
Tension Type
Featureless Headache

7. 1. MIGRAINE
Benign and recurring syndrome of headache associated with other symptoms of neurological dysfunction
Symptom
Patients Affected %
Nausea 87
Photophobia 82
Lightheadedness 72
Scalp Tenderness 65
Vomiting 56
Visual Disturbances 36
Paresthesias 33
Vertigo
Photopsia 26
Alteration of consciousness 18
Diarrhea 16
Fortification Spectra 10
Syncope
Seizure 4
Confusional State

8. MIGRAINE – A MULTISYMPTOM COMPLEX
AURA
SENSORY SYMPTOMS
LANGUAGE SYMPTOMS
VISUAL SYMPTOMS
MOTOR
DYSFUNCTION
COGNITIVE
PATHOPHYSIOLOGICAL
MECHANISMS
FATIGUE,
MOOD CHANGE
YAWNING,
POLYURIA
NAUSEA,
VOMITING
DIZZINESS,
VERTIGO
HEADACHE

9. SIMPLIFIED DIAGNOSTIC CRITERIA FOR MIGRAINE
Repeated attacks of headache lasting 4-72 hours in patients with a normal physical examination, no other reasonable cause for the headache and:
At Least 2 of the Following Features:
Plus at-least one of the Following Features
Unilateral Pain
Nausea / Vomiting
Throbbing Pain
Photophobia and Phonophobia
Aggravation by movement
Moderate or severe Intensity

10. MIGRAINOUS AURA

11. CLASSIFICATION - MIGRAINE
Migraine without aura
Migraine with aura
Migraine with typical aura
Typical aura with headache
Typical aura without headache
Migraine with brainstem aura
Hemiplegic migraine
Familial hemiplegic migraine (FHM)
FHM Type 1,Type 2, Type 3
Sporadic hemiplegic migraine
Retinal migraine

12. CHILDHOOD PERIODIC SYNDROME THAT ARE COMMONLY PRECURSORS OF MIGRAINE
Cyclical Vomiting Syndrome
Abdominal Migraine
Benign Paroxysmal Vertigo
Benign Paroxysmal Torticollis

13. COMPLICATIONS OF MIGRAINE
Chronic Migraine
Status
Migrainosus
(> 72 Hours)
Persistent Aura
(30 to 60 Minutes) Without Infarction
Migraine Triggered Seizures

14. DISABILITY ASSESSMENT
EPIDEMIOLOGY
Migraine accounts for 64% of severe Headache in Females and 43% of Severe Headache in Males
Individuals >12 Years incidents increases with age, reaching a peak at 30 – 40 Years
F:M – 3.5:1 at 40 Years
FAMILY HISTORY
Aprox 70% of the patients have a first degree relative with a history of migraine
Migraine in inherited disorders – MELAS, CADASIL, Genetic Vasculopathies
DISABILITY ASSESSMENT
Simple questionnaire like MIDAS (Migraine Disability Assessment Score) cab be used to quantify the disability and for follow-up

15. MIGRAINE TRIGGERS Stress Excessive or insufficient Sleep
Medications (OCP, Vasodilators)
Strong Odors(Perfumes, Cologne)
Hormonal Changes (Pregnancy and Menstruation)
Weather Changes
Foods containing Tyramine (Cheese, Yoghurt, Banana)

16. WORK UP MANAGEMENT Migraine is a clinical Diagnosis
Diagnostic Investigations are performed to rule out any structural and metabolic causes of headache
Visual Field Testing should be performed in patients with persistent visual phenomenon
MANAGEMENT
Acute Attack
Preventive

17. ACUTE ATTACK MANAGEMENT
Simple Analgesics : Acetaminophen, Aspirin, Caffeine
NSAIDs: Naproxin,Ibuprofien
Tryptans (Serotonin 1B/1D receptor agonist)
a. Drug of Choice for patients with moderate to severe migraine
b. Routes- Oral,Nasal,SC
c. Drugs- Sumatriptan – 50 to 100mg tablet at onset, May repeat after Hours (max 200 mg/D)
* Rizatriptan and Eletriptan – Most Efficaious
* Others – Naratriptan,Almotriptan,Zolmitriptan
d. Not be used > 3 days weekly to avoid medication over-use headache
4. Ergot alkaloids (Non Selective 5HT1 agonists): Ergotamine
5. Dopamine Antagonists: Cholrpromozine, Metachlopramide, Prochlorparazine

18. PREVENTIVE TREATMENT When to consider ? Pharmaco Therapy
Frequency of Migraine > 2/Month
Duration of individual attack longer than 24 Hrs
Major disruption in lifestyle
Migraine variants such as Hemiplegic migraine
Pharmaco Therapy
PIZOTIFEN
BETABLOCKER: Propranolol
Tricyclics: Amitriptyline, Nortriptyline
Anticonvulsants: Topiramate, Valproate, Gabapentin
Serotonergic Drugs: Methysergide, Flunarizine

19. 2. Tension-type headache
Infrequent episodic tension-type headache
Frequent episodic tension-type headache
Chronic tension-type headache
3.Trigeminal autonomic cephalalgias
Cluster headache
Episodic cluster headache
Chronic cluster headache
Paroxysmal hemicrania
Episodic paroxysmal hemicrania
Chronic paroxysmal hemicrania
Short-Iasting unilateral neuralgiform headache attacks
Short-Iasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)
Short- Iasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)
Hemicrania continua

20. MIGRAINE HEADACHE TENSION HEADACHE CLUSTER HEADACHE
Characteristics of pain
Deep throbbing and pulsating pain
Dull and pressure-like pain in the head or tight band on the head and/or around the neck.
Stabbing pain
Gender predominance
More common in women
More common in females
More common in men
Sensitivity to light or sound
Typical
Rare
Location of pain
Pulsating pain in temporal region and around the eye usually Unilateral
The pain is typically generalized, with areas of more intense pain in the scalp, forehead, temples or the back of the neck. Usually bilateral.
pain located near the eye on affected side. Usually unilateral.
Severity of pain
Ranging from moderate to quite severe
Mild to moderate in severity
Very severe
Time of onset
Long; headache gradually peaks in around 4-24 hours
Pain develops gradually, fluctuates in severity and then can remain for several days
Short; headaches peak within 45 minutes
Triggers
Bright lights, loud noises, changes in sleep patterns, exposure to smoke, skipping meals etc.
Stress
Nitroglycerin, Hydrocarbons and Alcohol
Prodromal Aura before headache
Present
Absent
Nausea or vomiting
Common

21. TREATMENT TENSION TYPE CLUSTER TYPE
Simple Analegisics: Actaminophen,Aspirin or NSAIDs
Oxygen Inhalation Therapy
Behavioral Approaches including relaxation
Sumatriptan: Injection or Nasal Spray
Chronic TTH: Amitriptyline
Preventive Management: Verapamil,Lithium,Methysergide
___
Deep Brain or Occipital Nerve stimulation

22. PAROXYSMAL HEMICRANIA SUNCT Gender F=M F~M Pain Type Severity Site
CATEGORIZATION
PAROXYSMAL HEMICRANIA
SUNCT
Gender
F=M
F~M
Pain
Type
Severity
Site
Unilateral: Throbbing,Boring,Stabbing
Excruciating
Orbit, Temple
Unilateral:
Burning,Stabbing,Sharp
Severe to excruciative
Periorbital
Frequency
> 5 attacks/D
At least 20 attacks/D
Duration
2 -30 Mins
Seconds
Autonomic Features
Lacrimination & Conjuctival Injection
Present
Prominent  If absent Then it is SUNA
Cutaneous Triggers No
Yes
Indomethacin Effect
Abortive Treatment
No Effective Treatment
Lidocaine (IV)
Prophylactic Treatment
Indomethacin
Lamotrigine, Topirimate, Gabapentin
* SUNCT: Short lasting unilateral neuralgiform headache attacks with conjunctival injection & tearing
* SUNA: Short lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms

23. CHRONIC DAILY HEADACHE
Headache on 15 Days or more per month
Medication Overuse Headache :
- Due to Over use of Analgesic medication or using preventive medication along with analgesics
- Can be avoided by reducing the medication by 10% every one to two weeks
New Daily Persistent Headache (NDPH):
- Present on most of the days and patient typically recall the exact day and circumstance of the onset of headache
1. Primary NDPH:
Migrainous Type – Same as Preventive Therapy for migraine
Featureless Type – Most Refractory to treatment

24. 2. Secondary NDPH:
Low CSF Volume Headache
Raised CSF Pressure Headache
M.C.C –CSF Leak Following LP
M.C.C-SOL, Pseudo Tumor Cerebri
Patient Feels Better on reclining
Worsens on reclining
Worsens during day
Improves as day progress
Treatment – Bed Rest , Blood Patch
Initially Acetozolamide if ineffective topiramite
3. Post Traumatic Headache
Developed headache following injury to the head or an infectious episode like viral meningitis or parasitic infection or after SAH
Treatment – Management is emperical. TCA and anticonvulsants can be added

25. 4. OTHER PRIMARY HEADACHE DISORDERS
Primary cough headache
Primary exercise headache
Primary headache associated with sexual activity
Primary thunderclap headache
Cold-stimulus headache
Headache attributed to external application of a cold stimulus
Headache attributed to ingestion or inhalation of a cold stimulus
External-pressure headache
External-compression headache
External-traction headache
Primary stabbing headache
Nummular headache
Hypnic headache
New daily persistent headache (NDPH)

26. SECONDARY HEADCHES
MENANGITIS : Suggested if acute and severe headache with stiff neck and fever
2. INTRACRANIAL HEMORRHAGE:
- A Ruptured aneurysm, AV malformation or intra parenchymal hemorrhage
- Suggested if acute and severe headache with stiff neck but without fever
3. BRAIN TUMOURS: Rule out pitutory Adenoma or any cerebral metastasis
4. TEMPORAL ARTERITIS: Most Common in elderly patients with age of onset 70 years
Suggested if Jaw Clawdication, fever, weight loss and malaise are present
5. GLAUCOMA: Prostating Headache with severe eye pain associated with nausea & vomiting