Headache: An Overview

Danish Ejaz Bhatti

History of headache
• 7000 BC
– Trepanation

• 1500 BC
– Egyptians

• 400 BC
– Hippocrates

• 17th Century
– Thomas Willis


Burden of Headache
• • > 13,000 tons of aspirin consumed annually worldwide Headaches account for 1-2% of ER visits and up to 4% of visits to physicians • “First-or-Worst Syndrome” • “Last Straw Syndrome” Lifetime prevalence for any type of headache > 90% for men & 95% for women 23 million Americans with migraine: 18% women, 6% men

• • •

Headache Burden

Primary vs. Secondary Headache
2. • • Definitions headache the primary manifestation headache a secondary manifestation of an underlying disease process Goals of the clinician • • • make an accurate headache diagnosis provide emergency therapy provide patient with means of long-term care


Primary Headache Classification
• • •
• • • • • • •

International Headache Society, 1988 Migraine Tension-type headache Cluster headache & chronic paroxysmal hemicranias
Headache associated with head trauma Headache associated with vascular disorders Headache associated with nonvascular intracranial disorders Headache associated with substances and their withdrawal Headache associated with non-cephalic infection Headache associated with metabolic abnormality Headache or facial pain associated with disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures

• • •

Cranial neuralgias, nerve trunk pain, & de-afferentiation pain Other types of headache or facial pain Headache not classifiable

Vascular Muscular/Myogenic Cervicogenic Traction/Inflammatory

Headaches: Pathophysiology
• Nociceptors • Familial Hemiplegic Migraine • The Migraine Generator • Final Common Pathway

• Pain sensitive structures include: – Skin and its blood supply – Muscles of the head and neck – Great venous sinuses and tributaries – Portions of the meninges including the dura mater at the base of the skull – Dural arteries – Intracerebral arteries – Cervical nerves – Cranial nerves

Familial Hemiplegic Migraine
• Autosomal Dominant • Calcium channel a subunit • Na/K ATPase gene • Sodium channel a subunit

The Migraine Generator

Ice cream headache

• History: • Onset • Duration • Frequency • Course • Character • Severity • Location • Associated symptoms • Precipitants or triggers • Prodromes • Past headache history – (including meds tried) • Past medical history • Family history • Social history (including alcohol and drugs, sleep, eating and exercise habits, how headache affects function)

Headache Diary

Asking the patient to complete a headache diary documenting headaches, possible triggers, and treatment tried is often very helpful in clarifying details of the history

Physical Examination
• KEY POINTS: • • • • • • Vitals Fundoscopy Palpation of areas of head and neck Auscultation of eyes, neck Nuchal rigidity and meningeal signs Complete neurological exam

Imaging in Headache

Imaging in Headache

Thunderclap Headache

Thunderclap Headache

Coital Headache

• Typical headache is unilateral or bilateral, throbbing, worse with activity and associated with nausea, vomiting, photophobia, and phonophobia. • Can be variable, however, and some believe that the IHS criteria are too strict

IHS Criteria
Migraine without aura (MO) diagnostic criteria • A. At least five headache attacks lasting 4 - 72 hours (untreated or unsuccessfully treated), which has at least two of the four following characteristics: – 1. Unilateral location – 2. Pulsating quality – 3. Moderate or severe intensity – 4. Aggravated by walking stairs or similar routine physical activity • B. During headache at least one of the two following symptoms occur: – 1. Phonophobia and photophobia – 2. Nausea and/or vomiting

IHS Criteria
Migraine with aura (MA) diagnostic criteria • A. At least two attacks fulfilling with at least three of the following: – 1. One or more fully reversible aura symptoms – 2. At least one aura symptom develops gradually over more than four minutes, or two or more symptoms occur in succession – 3. No aura symptom lasts more than 60 minutes; – 4. Headache follows aura with free interval of at least 60 minutes (it may also simultaneously begin with the aura • B. At least one of the following aura features : – 1. Homonymous visual disturbance – 2. Unilateral paresthesias and/or numbness – 3. Unilateral weakness – 4. Aphasia or unclassifiable speech difficulty

Migraine: treatment
Principles of Treatment: – Goal is to stop headache and progression of the pain – Migraine specific and non-specific – Best to treat early in the course of the headache to prevent central sensitization and treatment refractory pain – Use different agents for different intensities of pain and limit abortive therapies to 2 times per week to avoid medication rebound headache – If requiring more frequent abortive therapies need to recommend prophylaxis

Migraine: treatment
• Treatment of the acute headache • NSAIDs • Hydration/ IV fluids • Triptans – contraindicated in those with a history of CAD • DHE – Most common side effect is nausea therefore pre treat with an anti emetic • Neuroleptics (metoclopromide, promethazine, prochlorperazine, chlorpromazine) – Can cause hypo tension when given iv therefore give with saline • Corticosteroids – Used in status migrainosis

Red Wine Headache

Chronic Daily Headache
• Headache for more than 15 days per month for longer than 3 months • A category that contains many disorders representing primary and secondary headaches • 70-80% of patients presenting to headache clinics • have daily or near-daily headaches • Transformed migraine and medication-overuse headaches are among the most common

Chronic Daily Headache
• Risk factors – obesity, – history of frequent headache (more than 1 per week), – Caffeine consumption, – overuse (more than 10 days per month) of acute headache medications, including analgesics, ergots, and triptans • Greater than 50% of patients have sleep disturbances and mood disorders • Most patients with transformed migraine are women, have a history of episodic migraine, have a period of transformation in which the headaches became more frequent until the current pattern developed

Medication Overuse Headache
• In medication overuse headaches, there are varying intervals from the time of frequent intake of medications to the development of chronic daily headache: • Triptans: 1.7 years • Ergots: 2.7 years • Simple analgesics: 4.8 years • Accurate diagnosis and treatment requires the • withdrawal of these medications; if an episodic pattern of headache recurs within 2 months of withdrawal, medicationoveruse headache is diagnosed

Chronic Daily Headache
• Treatment strategies: • Lifestyle modification: • Limiting caffeine consumption • Regular exercise • Regular mealtimes • Regular sleep schedule • Preventative medications: • Tricyclic antidepressants, low dose • Gabapentin • Topiramate, low dose • Botulinum toxin type A

Medication overuse Headache
• With withdrawal from acute headache medications, there are a few strategies to limit withdrawal symptoms : – Use NSAIDS and DHE to treat breakthrough • • • • headaches as these are considered at lower risk of medication overuse headache – Prednisone 100 mg daily for 5 days may reduce the number of hours of severe withdrawal headache. – Antiemetics (metoclopramide or prochlorperazine)

Cluster Headache
A. At least five attacks of severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes untreated, with one or more of the following signs occurring on the same side as the pain – 1. Conjunctival injection – 2. Lacrimation – 3. Nasal congestion – 4. Rhinorrhoea – 5. Forehead and facial sweating – 6. Miosis – 7. Ptosis – 8. Eyelid edema B . Frequency of attacks from one every other day to eight per day

Tension Type Headache
A. Headache lasting from 30 minutes to seven days B. At least two of the following criteria:
– 1. Pressing/tightening (non-pulsatile) quality – 2. Mild or moderate intensity (may inhibit, but does not prohibit activity) – 3. Bilateral location – 4. No aggravation by walking, stairs or similar routine physical activity

C . Both of the following:
– 1. No nausea or vomiting (anorexia may occur) – 2. Photophobia and phonophobia are absent, or one but not both are present

Cervicogenic Headache
A. Pain localized to the neck and occipital region. May project to forehead, orbital region, temples, vertex or ears B. Pain is precipitated or aggravated by special neck movements or sustained postures C. At least one of the following: – 1. Resistance to or limitation of passive neck movements – 2. Changes in neck muscle contour, texture, tone or response to active and passive stretching and contraction – 3. Abnormal tenderness of neck muscles D. Radiological examination reveals at least one of the following – 1. Movement abnormalities in flexion/extension – 2. Abnormal posture – 3. distinct pathology (not spondylosis or osteochondrosis)

Post LP Headache
• Defined as : – a bilateral headache that develops within 7 days after LP and disappears within 14 days after LP • Headache characteristic : – worsens within 15 minutes of assuming the upright position and disappears or improves within 30 minutes of resuming the recumbent position • Headache is located – the frontal or occipital areas, and may also involve the neck and upper shoulders • Visual symptoms • Hearing alteration • How to reduce incidence • Treatment – Conservative – Blood patch

Research Article

Migraine and Risk of Cardiovascular Disease in Women

Tobias Kurth et al JAMA. 2006;296:283-291.


To evaluate the association between migraine with and without aura and subsequent risk of overall and specific CVD.

In this large, prospective cohort of women, active migraine with aura was associated with increased risk of major CVD, myocardial infarction, ischemic stroke, and death due to ischemic CVD, as well as with coronary revascularization and angina. Active migraine without aura was not associated with increased risk of any CVD event.

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