1. Headache

3. The responsibility of the EP
rule out life threatening causes of headache,
provide prompt effective pain management and other indicated treatment
appropriately use resources in the evaluation of the headache
arrange early and easy follow up.

4. Stable?
Acute or chronic ?
With danger signs?
How to treatment?

5. Headache History
Is this your first or worst headache? How bad is your pain?
Is this headache like the ones you usually have?
What symptoms do you have before ,during the headache?
When did this headache begin? How did it start (gradually, suddenly, other)?

6. Headache History
Where is your pain? Does the pain seem to spread to any other area?
What kind of pain do you have (throbbing, stabbing, dull, other)?
Do you have other medical problems?
Do you take any medicines? If so, what?
Have you recently hurt your head or had a medical or dental procedure

7. Danger signs (1)
Sudden onset of headache, or severe persistent headache
The absence of similar headaches in the
A worsening pattern of headache
Focal neurologic symptoms other than typical visual or sensory aura
Fever associated with headache

8. Danger signs (2)
Any change in mental status, personality, or fluctuation in the level of consciousness
The rapid onset of headache with strenuous exercise, especially when minor trauma has occurred,
New headache in patients under the age of five or over the age of 50
Headache during pregnancy or postpartum suggests possible cortical vein or venous sinus thrombosis, carotid dissection, and pituitary apoplexy.

9. Indication of neuroimage
Recent significant change in the pattern, frequency or severity of headaches
Progressive worsening of headache despite appropriate therapy
Focal neurologic signs or symptoms
Onset of headache with exertion, cough, or sexual activity
Orbital bruit
Onset of headache after age 40 years

10. Types of headache primary headaches:
migraine headaches,
tension headaches
cluster headaches.
Secondary headaches : caused by associated disease.

11. Tension headache the most common type of primary headache
are more common among women than men
often begin in the back of the head and upper neck as a band-like tightness or pressure.
as a band of pressure encircling the head with the most intense pain over the eyebrows.
not associated with an aura and
seldom associated with nausea, vomiting, or sensitivity to light and sound.

12. Migraine headache(1)
are the second most common type of primary headache, more women than men are affected
an intense, throbbing or pounding pain that involves one temple
The pain usually is unilateral (on one side of the head), although about a third of the time the pain is bilateral
The unilateral headaches typically change sides from one attack to the next.

13. Migraine headache(1)
20% of migraine headaches are associated with an aura. 1) flashing, 2) a hole (scotoma) in the visual field
commonly associated with Nausea, vomiting, facial pallor, cold hands, cold feet, and sensitivity to light and sound

14. Treatment Non-specfic ： Aanalgesic Aspirin、Acetaminophen、 NSAIDs
Opioid Codeine、Morphine，
Specfic :
Ergot : Cafergot® , 2# stat , repeat 1 # q 30 min , max 6 #

15. Complicated migraines
Vertebrobasilar migraines :dysfunction of the brainstem : include fainting as an aura, vertigo and double vision.
Hemiplegic migraines :paralysis or weakness of one side of the body, mimicking a stroke. The paralysis or weakness is usually temporary, but sometimes it can last for days.

16. Symptom Migraine headache Tension headache Cluster headache Location
Unilateral in 60 to 70 percent;
bifrontal or global in 30 percent
Bilateral
Always unilateral, usually begins around the eye or temple
Characteristics
Gradual in onset, crescendo pattern; pulsating; moderate or severe intensity; aggravated by routine physical activity
Pressure or tightness which waxes and wanes
Pain begins quickly, reaches a crescendo within minutes; pain is deep, continuous, excruciating, and explosive in quality
Patient appearance
Patient prefers to rest in a dark, quiet room
Patient may remain active or may need to rest
Patient remains active
Duration
4 to 72 hours
Variable
30 minutes to 3 hours
Associated symptoms
Nausea, vomiting, photophobia, phonophobia; may have aura (usually visual, but can involve other senses or cause speech or motor deficits)
None
Ipsilateral lacrimation and redness of the eye; stuffy nose; rhinorrhea; pallor; sweating; Horner's syndrome; focal neurologic symptoms rare; sensitivity to alcohol

17. Other possibility
Chronic nasal stuffiness or chronic respiratory infection sinusitis,
Impaired vision or seeing "holes" around light glaucoma.
Visual field defects  pituitary mass
The presence of nausea, vomiting, worsening of headache with changes in body position (particularly bending over), an abnormal neurologic examination,  tumor
Sudden, severe, unilateral vision loss optic neuritis.
Headache, fatigue, generalized aches and pain, and night sweats in subjects age 55 years or older temporal arteritis.
Intermittent headaches with high blood pressure pheochromocytoma