HEADACHE

MANAGEMENT
Dr. Pawan Bhusal.
 Introduction 4

A headache is a pain or discomfort in the head ,

scalp , or neck
One of the most common of all human physical
complaints.
Headache is actually a symptom rather than a disease
It is stress response, vasodilation (migraine),skeletal
muscle tension (tension headache), or a combination
of factors.
 Classification 7

I. PRIMARY HEADCHE
 A headache that is not caused by another
underlying disease, trauma or medical condition.
 Accounts for about ninety percent of all
headaches.
 8

 Episodic headache: more common

 Chronic headache: attacks occurring more
frequently than 15 days/month for more than 6
months
 II. SECONDARY HEADCHE
9

 <2% of headaches in primary care

offices
 Caused by exogenous disorders:
o Head trauma
o Vascular disease
o Neoplasms
o Substance abuse or withdrawal
o Infection/Inflammation
o Metabolic disorders
o
 11

 PRIMARY HEADACHE SYNDROMES

 Tension type headache
 Migraine
 Trigeminal Neuralgia
 Cluster headache
 I- TENSION TYPE 12

 Most common-69%
 Episodic or chronic
 Primary disorder of CNS pain
modulation
 seen equally in both sexes
 13

 Precipitating factors
 Stress: usually occurs in the afternoon after long stressful
work hours or after an exam
 Sleep deprivation
 Uncomfortable stressful position and/or bad posture
 Irregular meal time (hunger)
 Eyestrain
 Caffeine withdrawal
 Dehydration
 Symptoms & Signs 14

 Gradual onset , radiate forward from occipital

 Bilateral, dull, tight, band like pain
 Less in morning, pain increase as day goes on
 No throbbing, sensitivity to light, sound or
movement
 Nonpharmacological Management

Avoid headache triggers: foods, drugs, activities

Avoid frequent abortive treatment
Stop smoking
Normalize sleeping and eating
Exercise
Massage
Behavioral Interventions:
Relaxation and biofeedback therapy
Psychotherapy
 16

 Pharmacological
Management
Chronic management
Emergency management
 II- CLUSTER HEADACHE 38

 Headaches occur during a short time span.

 The cluster then recurs periodically in one
side of head/unilateral.
 A typical cluster of headaches may last 4-
8weeks with 1-2 headaches/day during
the cluster.
 Patient may be free 6months to 1year
before another cluster of headache occurs.
 Male to Female ratio 5:1
Emergency management
 Medication Overuse Headache 43

 Persistent, recurring headache in the setting of regular

analgesic use
 Continues until medication is stopped
 Often responsible for “transformation” of episodic into
chronic headache
Thank
YOU
 II- MIGRAINE 17

 2nd most common-16%

 15% women and 6% men
 Severe, episodic, unilateral,throbbing pain
 Nausea,Vomiting
 Sensitivity to light ,sound, movement
 Genetic predisposition
 Diagnosis
23

 Simplified Diagnostic Criteria for MIGRAINE

At least 2 of the following + At least 1 of the following:
o Unilateral pain o Nausea/vomitting
o Throbbing pain o Photophobia and phonophobia
o Aggravation by
movement
o Moderate or severe
intensity
 25

Management
 Non drug treatment
 Preventive therapy
 Abortive therapy
 26

Management
 Non drug treatment
 Avoid headache triggers: foods, drugs,
activities
 Avoid frequent abortive treatment
 Stop smoking
 Normalize sleeping and eating
 Exercise
 Relaxation and biofeedback
 Psychotherapy
 27

Management
 Preventive Treatment
 Tricyclic antidepressants (first-line)
o Amitriptyline
 Beta-blockers (first-line)
o Atenolol, nadolol
 Ca++ channel blockers – less effective
o Verapamil most commonly used
 28

Management
 Preventive Treatment
 Anticonvulsants (second-line; valuable)
 Valproate and topiramate are quite effective
 Gabapentin
 Lamotrigine, levetiracetam
 Pregabalin
 29

Management
 Preventive Treatment
 Ergots: Rarely used for prevention
o Side effects may be problematic
o Methylsergide: fibrosis (use 6 months
max)
 MAOIs: Can be very effective
o Tyramine-free diet a must
o Numerous drug interactions
 30

Management
 Abortive Treatment
 Simple and combined analgesics e.g NSAIDs.
 Mixed analgesics (barbiturate plus simple
analgesics)
 Ergot derivatives
 Triptans
 Opioids
 31

Management
 Triptans:
 Serotonin 5-HT1 agonists
 Reduce neurogenic inflammation
 Most effective if used at onset of headache or aura, though
may be helpful at other phases
 Used specifically for migraine
 For nonresponders, try ergots (also act on NE, DA,
other receptors)
 32

Management
 Other Agents
 Antiemetics/Neuroleptics:
o often combined with abortive agents
o Prochlorperazine, hydroxyzine, promethazine,
metoclopramide
 III- Trigeminal Neuralgia 34

divisions of

and 3rd
Lancinating pain in 2nd

trigeminal nerve
 >50yrs
 Severe, brief ,repetitive pain causing patient to flinch

 Precipitated by touching trigger zones: washing, shaving, eating,

cold wind
 Management
37

 Carbamazepine
 Intolerant-Gabapentin/Pregabalin
 Injection of alcohol into peripheral branch of nerve
 Posterior craniotomy to relieve vascular compression of
trigeminal nerve
44