1. Approach to Headache
Dr. Dua’a Hiasat. Family Medicine Specialist.

2. EPIDEMIOLOGY Headaches are quite common! Not all seek medical help.
90% of all headaches fall under a few categories.
4.5% of emergency department visits.

3. Types of headaches primary
Migraine
Tension-type Headache
Cluster Headache
Other

4. Primary Headaches - Migraine
Epidemiology - Most common headache seen in primary care.
Twice as common in women than men.
Pathophysiology - Vasoconstriction/Vasodialation, Cortical spreading Depression.
Presentation - Variable.
Diagnostic Criteria
Triggers
Four Phases of Migraine

5. Phases of Migraine

6. Migraine without aura International Headache Society Diagnostic Criteria 
Headache lasts 4 to 72 hours With at least two of the following:
Unilateral location
Moderate or severe.
Pulsating.
Aggravation by or causing avoidance of routine physical activity (e.g., walking, climbing stairs)
During headache, at least one of the following:
Nausea and/or vomiting
Photophobia and phonophobia
Not attributed to another disorder
History of at least five attacks fulfilling above criteria

7. Migraine with aura Diagnostic criteria:
Aura consisting of at least one of the following, but no motor weakness:
Fully reversible dysphasic speech disturbance.
Sensory symptoms that are fully reversible, including positive features (pins and needles) and/or negative features (numbness)
Visual symptoms that are fully reversible, including positive features (flickering lights, spots, lines) and/or negative features (loss of vision)

8. Migraine with aura At least two of the following:
Homonymous visual symptoms and/or unilateral sensory symptoms
At least one aura symptom develops gradually over five minutes or different aura symptoms occur in succession over five minutes
Each symptom lasts at least five minutes, but no longer than 60 minutes
Headache fulfilling criteria for migraine without aura begins during the aura or follows aura within 60 minutes
Not attributed to another disorder
History of at least two attacks fulfilling above criteria

9. Common Migraine Triggers

10. Primary Headaches – Tension-type Headache
Epidemiology - Most common cause of headache overall.
Pathophysiology - Muscle tension around head and neck, malfunctioning pain filter in brainstem.
Characteristics
Causes - Stress, sleep deprivation,
bad posture, hunger, eyestrain. Aggravated by
TMJ dysfunction.

11. Socrates for tension headache
S:Often bifrontal pain
O: episodic, occurring with variable frequency
C: The pain is described as pressure or tightness around the head like a tightening band.
R: no radiation A:
T: few hours
E: Stress and fatigue are well-known trigger factors.
S: not severely disabling
Other than the headache there are no other features (e.g. no photophobia)
Poorly responsive to ordinary analgesia

12. Primary Headaches - Cluster Headache
Epidemiology - Not so common
Pathophysiology - Unknown
Characteristics - “Suicide headaches”
Associated symptoms

13. Cluster Headache
It affects men more than women. The headaches occur in ‘clusters’ for about 6–12 weeks every 1–2 years, hence the name.
Attacks tend to occur at exactly the same time every day or night.
The pain is focused over one eye. The pain is intense and causes the patient to wake up and can be so severe that suicide is contemplated, until the pain diminishes, around 20–30 minutes later.
They will probably have a red, watery eye, rhinorrhea, and Horner’s syndrome, suggested by a history of ptosis.
These headaches are very disabling

14. Secondary Headaches Sinusitis
Withdrawal from caffeine, opiates, alcohol
Arthritis/joint disease: osteoarthritis of cervical spine, TMJ disease
Posttraumatic headache
Viral syndrome
Ophthalmologic (Glaucoma, eye strain)
Meningitis
Encephalitis
Temporal arteritis
Subarachnoid hemorrhage
Subdural hematoma
Intracranial malignancy
Disorders of cerebrospinal fluid circulation

15. Secondary Headaches – Sinusitis and “Sinus Headache”
Facial pain does not necessarily mean sinusitis
Symptoms suggesting sinus etiology: Purulence in nasal cavity, nasal obstruction, altered smell, and/or fever.
70-80% of patient presenting with “sinusitis causing a headache” may actually have Migraine

16. Sinus Headache facial pain consistent with the infection.
tight, as in tension headaches
 to frontal region or teeth
over hours to days
often exacerbated by movement
moderately severe but not disabling.
Fever, redness of nose, cheeks, or eyelids ,Postnasal discharge, blocked nose , Persistent coughing or pharyngeal irritation.

18. Evaluation CC: Headache Take good HX: SOCRAETS
Role out sinister causes: VIVID
Look for RED FLAGS
Do Physical examination and investigation
Diagnosis

19. Red Flags Severity of headache (“worst headache of my life”)
Onset of symptoms (abrupt vs. slow)
Accompanying symptoms (Fever, rash, etc…)
History of recent trauma
Presence of neurological deficits

20. Physical Examination General appearance and vital signs
Ear, nose and throat exam
Kernig, Brudzinkski and neck stiffness
Neurological Evaluation
Fundoscopy for papilledema
Palpation of temporal artery, TMJ and neighboring muscles

22. Diagnostic Testing History and Physical Exam are the best tools
Lumbar Puncture in case of meningitis or SAH
CT scan in certain non-traumatic cases:
Recent change in pattern, frequency or severity
Progressive worsening despite treatment
Focal neurological signs
Onset with exertion, cough or sexual activity
Orbital Bruit (Aneurysm, carotid artery stenosis/thrombosis)
Onset after 50 years of age

23. Management Treat underlying cause for secondary headaches
Goals of treatment:
Treat the headache and provide symptomatic relief
Minimize use of 2nd line drugs
Minimize hospitalization
Minimize adverse effects
Prevent recurrence

24. Management: Migraine 1. Migraines: Abortive treatment:
Mild to moderate migraine: Combination analgesics containing aspirin, caffeine, and acetaminophen or NSAID are an effective first-line abortive treatment,Triptans-oral or intranasal- is a second line.
Moderate to severe migraines: Triptans are first-line therapy, then dihydroergotamine
Prophylactic treatment if necessary

25. Management: Migraine
Medications containing opiates or barbiturates should be avoided for acute migraine
Intravenous metoclopramide is effective for acute migraine treatment

26. Migraine prophylaxis:
Identify and avoid headache triggers. Prophylaxis treatment is indicated when: 1- frequency: more than 2 attacks per month 2- duration more than 24 hrs. 3- Abortive therapy fails or is overused. 4- Use of abortive medications more than twice a week. 5- the attack affect pt’s life style, with significant disability that lasts 3 or more days.

28. Tension Headaches: Management
Acetaminophen or NSAIDs suffice due to non-debilitating nature
Acupuncture, spinal manipulation and electrotherapy differ in effectiveness
Amitriptyline prophylaxis with 15+ episodes per month

29. Management Cluster Headaches:
High-flow oxygen or triptans as first line treatment
Verapamil as prophylaxis

30. Management 4) Chronic Daily Headache:
Amitriptyline is the mainstay of treatment
May improve with acetaminophen or NSAIDs, but overuse could induce chronic headaches
Headache questionnaires are useful in determining the severity of headaches and response to treatment

32. :Indications for Neuroimaging
Headache of recent onset (<6 months)
Headache beginning after 50 years of age
Worsening headaches
Headache that does not fit primary headache pattern
Associated seizure
Focal neurologic signs or symptoms
Personality change
Severe headaches unresponsive to therapy
History of significant trauma
New headache in a cancer patient