APPROACH TO HEADACHE

• MODERATOR : DR. RASHI SRIVASTAVA

• PRESENTED BY : DR JINAL PATEL
DR ARUN SINGH
 HEADACHE
• Headache is pain in any part of the head,
including the scalp, face, orbitotemporal area
and interior of the head.
• Headache is one of the most important
reasons patient seeks medical attention.
• Its due activation of pain sensitive structures
in or around the brain, skull, face, sinuses or
teeth.
1. What is most common type of headache?

A. medication overuse headache

B. Tension type headache
C. Migraine without aura
D. Cluster headache
 2. What is the most common cause of
secondary headache?

A. Head injury
B. Systemic infection
C. Vascular disorders
D. Brain tumor
3.Which of the following case scenarios do
not depict tension type headache?
A. 34 yrs old women presenting with a chronic
headache for> 15 days per month
B. 41yrs old man presenting with a b/l headache
lasting for 4-6 hours
C. 38yrs old man presenting with a tight band
like discomfort around the head
D. 34yrs old woman presenting with a pulsatile
headache associated with nausea
4.pt comes with complains of non pulsatile
headache of tightening quality on both sides of his
forehead.he describes it as wearing a tight. he has
no nausea, photophobia or phonophobia. All of
following drugs can be used in treatment of this
condition expect?

A. Aspirin
B. Sumatriptan
C. Acetaminophen
D. Naproxen
5.41 yr old man has a 4 yr history of severe left sided
excruciating episodic headaches.most episodes are
accomanined by ipsilateral lacrimation,conjuctival injection and
rhinorrhea .there are no cutaneous triggers.it does not respond
to indomethacin and attacks get triggered by alcohol.what is
the likely diagnosis?

A. Trigeminal neuralgia
B. Cluster headache
C. SUNCT
D. Paroxysmal hemicranias
 PAIN PRODUCING CRANIAL STRUCTURES

o Scalp
o Meningeal arteries
o Dural sinuses
o Falx cerebri
o Proximal segment of large pial arteries
 How to approach headache ?
• HISTORY
• AGE OF ONSET
 Childhood and Adolescent - Secondary to sinusitis,
Pharyngitis, Otitis media and Primary headache like
migraine
 Adult – Tension type headache, Medication overuse
 Elderly – Glucoma, Hypertension, Stroke, Brain
tumor or Brain metastasis
 Duration and frequency of pain
• Vascular headache and Trigeminal neuralgia –
episodic pattern.
• Cluster headache – Seasonal and its range in
minutes.
• Migraine – in hours.
• Headache of organic origin ( ocular disease
sinusitis, brain tumor) are continous with acute
exacerbate caused by exercise ,change in
position.
 Onset to peak time
• Rapid onset to peak (seconds to minutes) –
suspicion of organic disease
• Tension headache evolve over period of hours
to days and then remain constant
• Cluster headache rapid onset to peak time
• Migraine evolve over several hours
 Location
• Vascular headache – Unilateral, side may change from
attack to attack
• Cluster headache – Localized to ocular and retro ocular
region
• Migraine – Involve entire hemi cranium
• Tension type headache – Typically bilateral involving
frontal, temporal and occipital region – band like or
cap like tightness
• Trigeminal neuralgia involve one division of trigeminal
nerve
 Character and severity of pain
• Vascular headache – throbbing and pulsatile in
nature with intense pain
• Cluster headache – deep boring and burning pain
• Trigeminal neuralgia – paroxysmal shock like pain
• Tension type – persistent dull aching pain, band
like ,occasional exacerbations
• Headache associated with lumbar puncture will
worsen when pt assumes the recumbent position
PREMONITORY SYMPTOM AND AURAE

• In migraine premonitory symptoms precedes

2-48 hours.

• Tumors involving the occipital lobe may

produce symptoms similar to migranous aura.
 ASSOCIATED SYMPTOMS
• In migraine associated symptoms are:
o Photophobia
o phonophobia
o Nausea, vomiting, aversion to strong odors.
• Cluster headache :
o horner syndrome, Including lacrimation, heavy
rhinorrhea.
• Tinnitus or hearing loss in trigeminal neuralgia
patients indicates an underlying brainstem tumor.
 PRECIPITATING FACTORS
• Migraine headache triggered by :
o change in diet or sleep habits
o tyramine containing foods
o nitrates, alcohol, stress and bright sunlight.
• Tension type headache triggered by :
o environmental or physiological stress
o depression,
o abnormalities of the cervical spine.
• Cluster headache triggered by :
o Alcohol and high attitude .
 MEDICAL / SURGICAL HISTORY
• Headache can be a symptom of systemic
illness of hypertension, anemia, thyroid
disease, depression etc.
• Drugs like nitrates, analgesic overuse, disease
of eye, ear, nose, throat and cervical spine
diseases.
• History of head injury, cranial surgery, recent
lumbar puncture may reveal important clues
 PHYSICAL EXAMINATION
 Should take less than 5 minutes The mandatory
elements are:
1. Ultra Quick Mental Status Examination
• Orientation • Attention and
calculation
• Memory • Speech
2. Cranial nerve examination and looking for signs of
meningitis
o Neck stiffness, kernig and brudzinski sign
3. Examination of motor, sensory system, reflexes, gait,
cerebellar function and pronator drift
4. Examination of ear, nose and throat • Ear and nasal
discharge, nasal polyps, pharyngitis, tonsillitis, sinus
and mastoid tenderness.
5. Examination of eye
• Diminished visual acuity suggestive of refractive error,
glaucoma, optic neuritis or temporal arteritis.
6. Fundoscopic examination –absent retinal artery
pulsations or papilledema- sign of elevated intracranial
pressure.
7. Examination of mouth and dental portions.
8. Examination of cervical spine- passive
movement and spine tenderness.
9. Looking for any tenderness over TM joint.
10. Examination of scalp and superfical temporal
artery tenderness –patient older than 60 years
11. Vitals to be checked- Temperature in case of
infection
12. BP measurement.
 INVESTIGATION
• Laboratory
o CBC when systemic or intracranial infection is
suspected
o ESR when temporal arteritis is a possibility.
• Neuroimaging
o CT scanning is recommended to identify acute
hemorrhage.
o MRI studies are recommended to evaluate the
posterior fossa.
• Lumbar Puncture
o preferred to rule out SAH within the first 48
hours.
o LP is useful : CSF for blood, infection.
o Headaches are associated with low CSF pressure
(e.g. post-traumatic leakage of CSF) and elevated
CSF pressure (e.g. idiopathic intracranial HTN and
CNS space-occupying lesions)
 CRITERIA FOR LOW RISK HEADACHE
• Age younger than 30 years
• Features typical of primary headaches
• History of similar headache
• No abnormal neurological 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
Headache Symptoms That Suggest a Serious
Underlying Disorder
• Sudden-onset headache
• First severe headache
• "Worst" headache ever
• Vomiting that precedes headache
• Subacute worsening over days or weeks
• Pain induced by bending, lifting, coughing
• Pain that disturbs sleep or presents immediately upon awakening
• Onset after age 55
• Fever or unexplained systemic signs
• Abnormal neurologic examination
• Pain associated with local tenderness, e.g., region of temporal
artery.
 CAUSE FOR SERIOUS HEADACHE
• Primary brain tumor
• Meningitis
• Metastatic brain tumor
• Brain abscess
• Stroke
• Glaucoma
• Hydrocephalus
• Subarachnoid hemorrhage
 COMMON CAUSES OF HEADACHE
1. PRIMARY HEADACHE 2. SECONDARY HEADACHE

Tension type (69%) Systemic infection (63%)

Migraine (16%) Head injury (4%)
Idiopathic stabbing (2%) Vascular disorders (1%)
Exertional (1%) Subarachnoid hemorrhage <1%
Cluster ( 0.1%) Brain tumor (0.1)
 PRIMARY HEADACHE
• TENSION TYPE HEADACHE
Frequent or continuous, mild, bilateral, band-
like holocranial, occipital or frontal pain the that
spreads to entire head, worse at the end of the
day.
• MIGRAINE
Frequently unilateral, pulsating/throbbing type
lasting for 4-72 hours, occasionally with aura,
phonophobia, photophobia, worse with activity,
preference to lie in the dark, resolution with
sleep
Treatment of acute attack
Rest in dark quite room until symptoms subsides
Analgesics-asprin,ibuprofen,naproxen
• Preventive therapy
Necessary if migraine occurs more freq than 2or3 times a month
• CLUSTER HEADACHE
Unilateral orbitotemporal attacks at the same
time of day, deep, severe lasting 30-180 min,
often with facial flushing, lacrimation, Horner’s
syndrome, restlessness, cannot sit still in a place.
 TENSION MIGRAINE CLUSTER
HEADACHE HEADACHE
LOCATION B/L U/L U/L

DURATION >30MIN (4-6HRS) 4-72HRS 15-3HRS

FEATURE STEADY PAIN PULSATING PAIN HEADACE WITH

EXCRUCIATING
PERIORBITAL PAIN
ASSOCIATIONS NO PHOTOPHOBIA NAUSEA ,PHOTOPH LACRIMATION ,
NO PHONOPHOBIA OBIAS RHINORRHEA
NO AURA PHONOPHOBIA PREASENT
PRESENT

TREATMENT ANALGESICS , NSAIDS,TRIPTANS,DI SUMATRIPTAN ,100

NSAIDS HYDROERGOTAMIN % O2
E
PROPHYLAXIS AMITRIPTYLINE LIFE STYLE
CHANGES,B-
BLOCKERS,AMITRIP
TYLINE
 SECONDARY HEADACHE
• SYSTEMIC INFECTIONS
o Viral infections
o Fever
o Acute severe hypertension
o Giant cell arteritis
o Hypercapnia
• EXTRA CRANIAL DISORDERS
o Glaucoma
o Sinusitis
o Dental disorders
o Temporomandibular joint dysfunction
o Carotid or vertebral artery dissection
• INTRACRANIAL DISORDERS
o Infections (meningitis, encephalitis, abscess,
Subdural empyema)
o Noninfectious meningitis (carcinomatous,
chemical)
o Brain space occupying lesion
o Cerebrospinal fluid leak with low-pressure
headache
o Hemorrhage (Intracranial, subdural, subarachnoid)
• VASCULAR DISORDERS
o vascular malformations, vasculitis, venous sinus
thrombosis.
• DRUGS AND TOXINS
o Analgesics overuse
o Nitrates
o Caffeine withdrawal
o Hormones (estrogen)
o Carbon monoxide
o Proton pump inhibitors
 NEW DAILY PERSISTENT HEADACHE
• New daily persistent headache (NDPH) is a clinically distinct syndrome.
• Clinical Presentation :
o NDPH presents with headache on most if not all days, and the patient
can clearly, and often vividly, recall the moment of onset.

• Secondary NDPH: Low CSF Volume

Headache
o In these syndromes, head pain is positional: it begins when the patient
sits or stands upright and resolves upon reclining.
o The pain, which is occipitofrontal, is usually a dull ache but may be
throbbing.
o Patients with chronic low CSF volume headache typically present