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Approach to Headache

Bayalpata Hospital CME

th

Last updated: *19

of MAY 2017*

Contributors: *Dr.Abhishesh Wagle*, Dr. Stephen

Approach to Headache Bayalpata Hospital CME th Last updated: *19 of MAY 2017* Contributors: *Dr.Abhishesh Wagle*,

Mehanni

Approach to Headache Bayalpata Hospital CME th Last updated: *19 of MAY 2017* Contributors: *Dr.Abhishesh Wagle*,

Objectives

After this session, participants should be able to

1)

Distinguish between the common types of headaches

2)

Evaluate a patient with headache

3)

Recognize danger signs of headache

4)

Describe the treatment of the primary headaches

5)

List pros and cons of medicines available to

prevent migraines

Clinical Case

A 23 year old female presented to opd with complain

of headache.She says she has been having such headache multiple episodes the last few months ...

Questions

What are other things you would like to ask?

History

Site Onset Severity Character Associated factors Aggravating factors Relieving factors

Classification of headaches

Primary headaches

Migraine Tension Cluster

Secondary headache

caused by something else…

Migraine features

  • Aura +/-

  • Unilateral

  • Duration 4 hrs to 72 hrs

  • Pulsatile,throbbing

  • Associated with photophobia, phonophobia

  • Aggravated on movement

Tension headache features

  • Frontal,forehead and temples

  • Dull ache,light pressure feeling, heavy weight on

top of head

  • Daily

  • Last upto days

  • Associated with fatigue,neck ache

  • Gets worse during the day

Cluster headache features

Unilateral Retroorbital pain Associated with autonomic symptoms rhinorrhea,lacrimation Occurs in the same time of the day ...

Causes of secondary headache

Sinusitis URTI Cervical spondylosis Meningitis Subarachnoid Hemorrhage Glaucoma Medication overuse headache

Key Point #1

Unilateral pulsatile severe headache associated

with photophobia,phonophobia nausea is mostly migraine headache ...

Goal of evaluation

Determine if headache is primary or secondary Evaluate for danger signs

Other signs of secondary

headache

Impaired vision or seeing halos around light Relieved with recumbency aggravated with upright posture Blurring of vision on forward bending of head, headache upon waking early in the morning Sudden severe unilateral vision loss

Key Point #2

A complete history is the single most important

factor for establishing a headache diagnosis

Danger signs

Sudden onset of severe headache/New onset Headache associated with neurological deficits Systemic symptoms H/o trauma to head,illicit drug use,or toxic exposure Previous headache history with headache progression or change in attack frequency ...

Exam

Most patients have a NORMAL physical exam

There may be neck tenderness in tension headache

Abnormalities may indicate secondary headache

What should you examine?

  • Pulse

  • Blood pressure

  • Examine the neck for tenderness

  • Auscutate in the neck for bruit

  • Palpate in the temporal region for vessels

  • Examine the cervical spine

Neuro exam

Key Point #3

Patients with danger signs should usually be referred for CT or MRI

Clinical Case

  • She says her headache is unilateral and

pulsatile…and she needs to take rest in the quiet

surrounding for the relief…

  • O/E Pulse=90/min,BP=120/80 mm of HG

  • Other neurological examination are normal ...

Question for HA and CMAs

What is your diagnosis ?

How would you treat the case in our emergency?

Treatment of primary headaches

Tension headache

Explain Stress reduction, relaxation techniques and yoga or meditation classes Massage with soothing analgesic rub Medications : Paracetamol, Ibuprofen

Acute migraine

Rest in a quiet and darkened room Avoid drinking coffee, tea Donot read or watch television Medications Paracetamol,Ibuprofen,naproxen,diclofenac Antiemetics Flunarizine

Cluster headache

High flow oxygen(100%) NSAIDS Prophylactic CCB Sodium valproate

Key Point #4

Rest in a quiet room and simple analgesic

medications(Paracetamol and Ibuprofen) ususally relieves an episode of headache ...

Clinical Case

She says she has been having 2 to 3 episodes of

headache in the last few months…

She says she feels the regular medications

Are not working?

Question for doctors

What would you do now?

When do you add medicine to

prevent migraines?

Frequent attacks causing disruption to patients lifestyle 2 or more severe migraine attacks per month Decreased responsiveness to acute attack

Migraine prevention: counseling

Sleep hygiene Routine meal schedules Regular physical activity Avoiding migraine triggers (what are these?)

Migraine triggers

Migraine triggers

What are medication options

available for preventing migraines?

What are medication options

available for preventing migraines?

Amitriptyline Propranolol Valproic acid

Amitriptyline: pros and cons

  • Start from 10 mg OD

  • Upto 50mg daily effective

  • Bed time

  • Side effects: Sedation,Dry mouth, constipation,tachycardia,palpitations, blurred vision

Propranolol: pros and cons

20 mg BD Upto 160mg per day Avoid in Asthmatics, Diabetes, Depression and hypotension ...

Valproate: pros and cons

500 mg daily Upto 1500mg daily Side effects: weight gain, alopecia, Contraindicated in pregnancy ...

Key Point #5

Give prophylaxis for recurrent disabling Migraine

headache ...

Bonus Cases

A 32 year old female came to your OPD with

headache around the eyes…

She has been having nasal congestion for the last few

days…

She says her headache worsens as the day

progresses…

What is your diagnosis?

Bonus Cases

A 34 year old male underwent Hernioplasty under

spinal anesthesia At BH 5 days back complains of severe occipital headache that is aggravated on

sitting upright and relieved on recumbent position…

What is your diagnosis? How would you manage?

Summary of Key Points

1)Unilateral pulsatile severe headache associated

with photophobia,phonophobia is mostly migraine

headache…

2)A complete history is the single most important

factor for establishing a headache diagnosis.

3)Patient with danger signs should be referred for CT

or MRI…

.

Summary of Key Points

4)Rest in a quiet room and simple analgesic medications(Paracetamol and Ibuprofen) ususally relieves an episode of headache

5)Give prophylaxis for recurrent disabling Migraine headache ...

Additional Reading

Murtagh’s text book of General Practice:Headache ... UpToDate: Evaluation of headache in adults

Thank you!

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