HEADACHE

& associated emergencies

Case I: 40 yrs. F-brought to the ER by
EMS, c/o severe HA. Describes HA as
pounding in nature, diffuse, sudden onset,
associated with N/V X 3 over the last
several hours. Also c/o dizziness &
blurry vision.
 Outlines

1.Introduction
2.Classification of headache
3.Red flag for headache
4.Diagnosis of headache
• History, Examination, Ix
5.Common causes of headache
• Migraine, TTH, CH,MOH
6.Management
 Headache

 headache is a common medical disorder about

one-half of the adult population worldwide
 vast majority of headaches are primary
 only a small minority are medically serious
 It accounts for 4.4% of consultations in primary
care and 30% of neurology outpatient
consultations
 Healthcare professionals often find the diagnosis
of headache difficult
 but treatments can cause headache themselves

 Most primary headache can be managed in

primary care and investigations are rarely needed

 When to refer?
 HEADACHE

Neuralgias &
Primary Secondary other headaches

attributed to an
not associated with an underlying
underlying pathology pathological
condition
 Primary Headaches

 do not have red flag signs and symptoms

 low risk of serious headache.
 Additionally, they should have primary
headache characteristics
 Patients at low risk of serious headache do not
require neuroimaging
 Criteria for Low-Risk Headaches
 Age younger than 30 years
 Features typical of primary headaches
 History of similar headache
 No abnormal neurologic findings
 No concerning change in usual headache pattern
 No high-risk comorbid conditions (e.g., human
immunodeficiency virus infection)
 No new, concerning historical or physical examination
findings
 Diagnosis of headache

1)History
2)Physical examination
3)Investigations
 1) History of headache

 The history is all-important

 Headache diary- pattern of headache

 Excludes sinister causes of headcahe

 Intracranial tumor
 Meningitis
 Sudarachoid Haemorrhages
 Giant Cell Arteritis
 Primary angle-glaucoma
 Idiopathic Intracranial Hypertension
 Carbon Monoxide posioning
Weekly Headache Diary
 Red Flag of Headache (I)

1.1- onset or change in headache in patients aged > 50

2.thunderclap: rapid time to peak headache intensity
(seconds to 5 mins)
3.focal neurological symptoms (eg limb weakness, aura <5
min or >1 hr)
4.non-focal neurological symptoms (eg cognitive
disturbance)
5.change in headache frequency, characteristics or
associated symptoms
6.abnormal neurological examination
7.headache that changes with posture
 Red Flag of Headache (II)
8. headache wakening the patient up
9.headache precipitated by physical exertion or valsalva
manoeuvre (eg coughing, laughing, straining)
10.patients with risk factors for cerebral venous sinus
thrombosis
11.jaw claudication or visual disturbance
12. neck stiffness
13. fever
14. new onset headache in a patient with a history of
HIV infection
15. new onset headache in a patient with a history of
cancer.
 2) Examination of headache

Neurological examination in patients first presenting with

headache:

1.fundoscopy
2.cranial nerve assessment, especially pupils, visual fields,
eye movements, facial power and sensation and bulbar
function (soft palate, tongue movement)
3.assessment of tone, power, reflexes and coordination in
all four limbs
4.plantar responses
5.assessment of gait, including heel-toe walking.
 3) Headache: Investigations
 majority of primary headaches do not require neuroimaging
 3) Headache: Investigations
Q:When is neuroimaging required?
 individual basis
 Neuroimaging is not indicated in patients with a clear
history of migraine, without red flag features for
potential secondary headache, and a normal
neurological examination.
 Patient reassurance
 Indications for Neuroimaging
in Patients with Headache Symptoms
 Focal neurologic finding on physical examination
 Headache starting after exertion or Valsalva’s maneuver
 Acute onset of severe headache
 Headache awakens patient at night
 Change in well-established headache pattern
 New-onset headache in patient >35 years of age
 New-onset headache in patient who has HIV infection
or previously diagnosed cancer
CT versus MRI?
 The European Federation of Neurological Societies
guidelines
 MRI is the imaging modality of choice because of this
greater sensitivity
 The US headache consortium
 MRI may be more sensitive than CT in identifying
clinically insignificant abnormalities,
 but not more sensitive in identifying clinically significant
pathology relevant to the cause of the headache.
Common types of headache
 Migraine

 1/3 of migraine sufferers

 Recurrent headache disorder
 4-72 hours.
 Typical characteristics : unilateral location, pulsating
quality, moderate or severe intensity, aggravation by
routine physical activity and association with nausea
and/or photophobia and phonophobia.
 Migraine with aura

 Aura:
 Visual blurring and “spots”
 progressive, last 5-60 minutes prior to headache
 transient hemianopic disturbance/ scintillating scotoma
 can occur with:
 unilateral paraesthesia,of hand, arm or face
 dysphasia
 functional cortical manifestations
 disturbance of one cerebral hemisphere
 may occur without migraine
 aura persisting after resolution of the headache/aura
involving motor weakness-> further Ix
 familial hemiplegic migraine
Scintillating scotoma
 Migraine with aura: Diagnostic criteria

 Recurrent attacks, lasting

minutes
 unilateral
 fully reversible visual,
sensory or other central
nervous system
 symptoms develop
gradually and are usually
followed by headache and
associated migraine
symptoms.
Migraine without aura: Diagnostic criteria
 Migraine

 Migraine headache in children and adolescents

is more often bilateral, unilateral pain usually
emerges in late adolescence or early adult life.

 Migraine headache is usually frontotemporal.

 Possible Triggers of a Migraine
Attack

 Food and food additives  Stress

 Bright lights/glare  Weather changes
 Smells/odors  Caffeine
 Dieting/hunger  Alcoholic beverages
 Loud noises/sounds  Changes in sleep habits
 Changes in altitude/  Hormonal fluctuations/
air travel menstrual cycle
hanges in altitude/
air travel
 Tension type Headache

 Episodic, very low frequency and short-lasting (< several

hours)
 Generalised but can be unilateral
 Nature of pain:
 pressure or tightness,/tight band around the head
 spreads into or arises from the neck
 can be disabling for a few hours
 lacks of specific features and associated symptom
 May be stress-related or a/w functional or structural cervical
or cranial musculoskeletal abnormality.
 Chronic TTH: >15 days a month, and may be daily
 Diagnostic criteria: TTH

*Frequent episodic tension-type headache often coexists

with Migraine without aura.
 TAC: Cluster headache

 Severe, strictly unilateral pain.

 The pain is located in one or a combination of orbital,
supraorbital, or temporal regions.
 Restless during an attack.
 Starts and ceases abruptly
 Duration: 15 minutes to three hours
 Frequency: EOD day to eight per day.
 Striking circadian rhythm;

‘attacks often occur at the same time each day and

clusters occur at the same time each year'.
 TAC: Cluster headache

 a/w ipsilateral conjunctival

injection, lacrimation,
nasal congestion,
rhinorrhoea, forehead and
facial sweating, miosis,
ptosis and/or eyelid
oedema
 and/or with restlessness or
agitation
 TAC : Cluster headache (CH)

 CH affects mostly men

 (male to female ratio 6:1)

 Age 20s or older and very often smokers.

 Medication overuse headache (MOH)

 > 15 or more days per

month
 developing as a consequence
of regular overuse of acute
or symptomatic headache
medication for more than 3
months.
 It usually, but not invariably,
resolves after the overuse is
stopped
Overused meds frequency/month duration

ergotamine >10 days >3 months

Triptan >10 days >3 months
paracetamol >15 days >3 months
acetylsalicylic acid >15 days >3 months
NSAIDs >15 days >3 months
opioid >10 days >3 months

combination analgesic medication >10 days >3 months

multiple drug classes not individually overused >10 days >3 months

unverified overuse of multiple drug classes >10 days >3 months

one or more medications other than

>10 days >3 months
those described above
 Medication overuse headache (MOH)

 Mechanisms: not clear

 probably as a results in down-regulation of 5-
HT1B/1D receptors
 addictive properties
 changes in neural pain pathways
 may take weeks to months for the headache to resolve
after withdrawal.
 Medication overuse headache (MOH)

 Small amounts are sufficient to induce MOH

 >15 days a month or of codeine-containing analgesics,
 >10 or more days a month of ergot or triptans
 Frequency is important:
 low doses daily carry greater risk than larger doses weekly.
 Nature of pain
 worst on awakening in the morning
 increases after physical exertion
 In the end-stage, headache persists all day, fluctuating with
medication use repeated every few hours.
 Medication overuse headache (MOH)

 Prophylactic medication aggravate the condition

 Headache diary

 The (presumptive) diagnosis made based on

symptoms and drug used.

 Confirmed when symptoms improve after medication

is withdrawn.
Treatment for migraine: history
 Management- General
During consultation:

1. Explanation of the diagnosis and reassurance that

other pathology has been excluded

2. the options for management

3. recognition that headache is a valid medical

disorder with significant psychosocial impact
 MIGRAINE WITH OR WITHOUT AURA
Acute treatment
Monotherapy:

oral triptan, NSAID, aspirin(900 mg) or paracetamol

Combination:

Oral triptan + an NSAID/

Oral triptan + paracetamol.

Consider an anti-emetic even in the absence of nausea

and vomiting.

Do not offer ergots or opioids

If ineffective or not tolerated:

IV NSAID or IV triptan + IV metoclopramide or

prochlorperazine
Migraine
Triptans

 Triptans provide
significant pain relief
to patients with acute
migraine within two
hours & improve
patients’ QoL
 Anti-emetics
 prochlorperazine 3-6 mg buccal tablets or
 domperidone 10 mg oral or 30 mg rectal
 metoclopramide 10 mg or *
 domperidone 20 mg *

 are also useful as a prokinetic to promote gastric emptying

Caffeine??
 Evidence was limited to the inclusion of caffeine with
combinations of other therapies
 MIGRAINE WITH OR WITHOUT AURA
Prophylactic treatment

First line: Topiramate or

propranolol
Review the meds after 6
months.
Diet: riboflavin (400 mg
OD) may be effective in
reducing migraine
frequency and intensity
for some people
 TENSION-TYPE HEADACHE
 Acute treatment
 Aspirin, paracetamol or an NSAID
 Do not offer opioids

 Prophylactic treatment
 CLUSTER HEADACHE
Acute treatment
Offer oxygen and/or a subcutaneous 6
mg or nasal triptan (if cannot tolerate
subcute).
use 100% oxygen at a flow rate of at
least 12 litres per minute with a non-
rebreathing mask and a reservoir bag
Do not offer paracetamol, NSAIDS,
opioids, ergots or oral triptans
Prophylactic treatment
Verapamil 240-960 mg/day
 Medication overuse headache

 Treated by withdrawing overused medication--> Explain,

explain, explain!!!
 Advise:
 to stop all overused meds abruptly rather than gradually
for < 1 month
 headache symptoms are likely to get worse in the short
term before they improve
 + withdrawal symptoms
 Consider prophylactic treatment for the underlying
primary headache disorder
 Consider specialist referral for people who are using
strong opioids withdrawal (Addiction team)
 Review the diagnosis & mx 4–8 weeks after the start of
withdrawal of overused medic
 Headaches That Require Emergency
Attention
 Stroke
 (focal neurological deficit, nausea, vomiting)
 Aneurysm
 (The worst headache ever!)
 subarachnoid hemorrhage (SAH)
 Meningitis
 (fever & neck pain)
 SECONDARY HEADACHES
 The main causes of secondary headaches are intracranial
tumours, infections, intracranial haemorrhage, temporal
arteritis and benign intracranial hypertension
 Other causes to be considered include hypertension,
arterial dissection, head injury, brain abscess, subdural
haematoma and medications.
 Secondary headaches may lead to serious consequences
if the underlying cause is not identified and treated.
 INTRACRANIAL TUMOUR

 majority of patients with headache do not have an

intracranial tumour
 clinical features include bursting pain on waking,
increasing over time, worse on coughing/straining
 ·tumours rarely present with headache alone &
usually have FNDs or ICP
 head CT scan is indicated in patients with suspected
SOL
 TA
 headache in TA is intense, focal & localised to the
temples
 temporal arteries may be tender on
palpation··blindness and strokes are major
complications
 both patient’s age and the ESR are generally >60
 Treatment high dose daily steroids for 2-3/12 &
maintenance dose for 18-24/12
 BIH
 presents as headaches, visual disturbances &
papilloedema
 typically occurs in young overweight females taking the
contraceptive pill
 neurological investigations are normal including
neuroimaging
 acute measures include steroids over first 3-5 days and
repeated lumbar punctures
 long-term management includes weight loss, diuretics &
stopping the pill
 trigeminal neuralgia
 trigeminal neuralgia is very painful & affects
branches of trigeminal nerve
 recurring shooting facial pains lasting less than a
second are diagnostic
 pain is triggered by touching, eating, hot & cold,
cleaning teeth & talking··natural history is remission
but both attacks and remissions last months
 carbamazepine taken in adequate doses daily is the
treatment of choice Selected
Thank you