HEADACHE

HEADACHE

• Headache is pain or discomfort anywhere in the head, scalp, or neck.

• It is common, but usually does not indicate serious disease.
• the history is the key to distinguish causes in patients with chronic or recurrent headache.
• The causes may be divided into primary (benign) and secondary
 ONSET OF HEADACHE

ACUTE CHRONIC
Serious causes to be considered include : Chronic daily headache
• Meningitis • Defined as headache on within or more than 15
• Subarachnoid haemorrhage days per month for at least 3 months

• Epidural or subdural hematoma • there are many possible causes, including

secondary headache disorders, in practice primary
• Glaucoma headache disorders, particularly migraine, are
• Tumour responsible for the majority. Where migraine is
the cause, the term chronic migraine is now
• Purulent sinusitis preferred.
• Overuse of analgesic medication or triptans
(termed medication overuse headache) is often a
major factor leading to and maintaining
chronicity, particularly in those with migrainous
biology.
• Sudden-onset headache is always a red flag and should prompt rapid assessment in hospital for possible
subarachnoid hemorrhage or other sinister disease.
• International Headache Society (IHS) has developed criteria to divide headaches into :
• Primary type : headaches without specific cause
• Secondary type : headaches with underlying structural or metabolic cause
PRIMARY HEADACHE
 1- MIGRAINE

• Migraine is the commonest cause of episodic headache (15–20% of women and 5–10%
of men); in 90%, onset is before 40 years of age.
• Episodes of headache are associated with sensory sensitivity such as to light, sound or
movement, and sometimes with nausea and vomiting.

• Movement makes the pain worse and patient prefer to lie in quiet, dark room.
• Triggered by : alcohol, cheese, chocolate, bright lights, stress, exercise or travel.
• There is a spectrum of severity between individuals and from one attack to another.
• Headache frequency in migraine varies from an occasional inconvenience to frequent.
Typical symptoms during prodrome stage :

• Constipation or diarrhea
• Difficulty concentrating
• Excessive yawning
• Fatigue
• Feeling cold
• Fluid retention, bloating
• Food cravings
• Increased frequency of urination
• Mood changes involving sadness, irritability, or
anxiety
• Muscle stiffness or soreness, especially in the neck
• Nausea
• Sensitivity to light, sounds, or smells
SIMPLIFIED DIAGNOSTIC CRITERIA FOR
MIGRAINE
 2- TENSION TYPE HEADACHE

• Commonly bilateral, occurs over the frontal, occipital or temporal areas

• Sensation of tightness that lasts for hours and recurs often.
• Not made worse by walking.
• No associated symptoms such as nausea, vomiting, weakness or paraesthesias
(tingling in the limbs), photophobia, phonofobia
• Does not usually wake the patient at night from sleep.
• Pain can be managed generally with simple analgesics ( acetaminophen, aspirin,
NSAID ).
• Often related to stress ; responds to behavioural approaches including relaxation.
 3- CLUSTER HEADACHE

• Cluster headache is distinct from migraine and rare form of primary headache (1 per
1000) and affects adults, mostly males aged between 20 and 40.
• Patients describe recurrent bouts (clusters) of excruciating unilateral retro-orbital
pain with parasympathetic autonomic activation in the same eye causing redness or
tearing of the eye, nasal congestion or even a transient Horner’s syndrome.
• Attacks are shorter than migraine, usually 30–90 minutes, and may occur several
times per day, especially during sleep.
• Clusters last one to two months with attacks most nights before stopping completely
and typically recurring a year or more later, often at the same time of year.
• Tend to move during attacks, pacing or rubbing their head for relief.
 SECONDARY HEADACHE

1- SYSTEMIC INFECTION : MENINGITIS

• Acute
• Severe headache with stiff neck and fever
• Striking pain with eye movement
• Can be easily mistaken for migraine
• Cardinal symptoms (frequently present) : pounding headache, photophobia, nausea, vomiting

2- INTRACRANIAL HAEMORRHAGE
• Acute
• Severe headache with stiff neck but without fever
• Ruptured aneurysm, arteriovenous malformation (AVM), or intraparenchymal haemorrhage may
also present with headache alone
3- RAISED INTRACRANIAL PRESSURE HEADACHE – BRAIN TUMOUR
• Any headache present on waking and made worse by coughing, straining or sneezing may be
due to raised intracranial pressure (ICP) caused by a mass lesion.
• Vomiting often accompanies pressure headaches.
• Visual obscurations (momentary bilateral visual loss with bending or coughing) are
characteristic and seen in the presence of papilloedema.
• Occasionally, where ICP rises quickly, papilloedema may not be present.
• Neuroimaging is mandatory where raised ICP is suspected.
4- MEDICATION OVERUSE HEADACHE (MOH)

• Most frequent culprits are compound analgesics (particularly codeine and other opiate-
containing preparations) and triptans.
• MOH usually associated with use on more than 10-15 days per month.
• Management is by withdrawal of the responsible analgesics.

5- GIANT CELL ARTERITIS

• Headache is almost invariable in giant cell arteritis (GCA).

• Pain develops over inflamed superficial temporal and/or occipital arteries.
• Touching the skin over an inflamed vessel (e.g. combing hair) causes pain.
• Arterial pulsation is soon lost; the artery becomes hard, tortuous and thickened. The scalp
over inflamed vessels may become red. Rarely, gangrenous patches appear
 INVESTIGATION

 1. Laboratory Assessment
 2. Cerebrospinal Fluid Examination
 3. Focused Neuroimaging Studies
 4. Electroencephalogram ** not cover in this slides
 1. LAB ASSESSMENT

 Indicated in patients with symptoms suggestive of secondary headache

 Indicated in patients who present with signs or symptoms of headache with
increased risk of intracranial pathology
 Not indicated in patients with recurrent headaches with clinical features of migraine,
normal neurological examination, and no red flags for potential causes of secondary
headache
 1. LAB ASSESSMENT

 Serum electrolyte
 Complete blood count/ ESR OR CRP
 Hepatic studies (Confusion and headache are common complaints for patients with
cirrhosis)
 Endocrine studies (Pituitary headache/Sheehan Syndrome/DM)
 2. CEREBROSPINAL FLUID EXAMINATION
 Examination of the cerebrospinal fluid for infection, bleeding, and abnormal cells
 Indicated in patients with certain red flags (eg headache triggered by cough and exertions,
sexual intercourse, personality changes, neck stiffness/meningismus, papilledema, sudden
onset headache, headache with systemic illness, and patients with cancer, Lyme disease or
human immunodeficiency virus)

 Infectious diseases of the brain and spinal cord, including meningitis and encephalitis.
 Autoimmune disorders, such as Guillain-Barré Syndrome and multiple sclerosis (MS). CSF tests for
these disorders look for high levels of certain proteins in the cerebrospinal fluid.
 Bleeding in the brain
2. CEREBROSPINAL FLUID EXAMINATION
 3. FOCUSED NEUROIMAGING STUDIES

 Numerous noninvasive imaging options are available to clinicians evaluating patients

with neurologic disorders. These include:
 Skull X-Ray
 Non-contrast Cranial Computed Tomography (CT) Scan
 Cranial Magnetic Resonance Imaging (MRI)
 Cranial Magnetic Resonance Angiogram (MRA)
 SKULL X-RAY
Plain skull radiographs are indicated in the following instances

ii. Clinical suspicion of iv. Head

skull fracture e.g. trauma in
iii. Foreign children less
i. Penetrating depressed fracture, even
bodies in the than 2 years,
skull injuries without neurological
scalp even without
symptoms
neurological
symptoms.
 CT SCAN

INDICATIONS FOR CT BRAIN

PRINCIPLE OF MANAGEMENT OF MIGRAINE

 Treatment of acute attacks

 Simple analgesia with aspirin, paracetamol or NSAIDs (Naproxen).
 Nausea – antiemetic such as metoclopramide and domperidone
 Ergotamine (caution is needed because they may lead to dependence)

 Treatment of severe attacks

 Triptans (sumatriptan) – administered via oral, subcutaneous or nasal route
 Used when simple analgesics are not efficient
 Should be avoided in patient with vascular disease
 REFERENCE

 Davidson’s principles and practice of medicine 23RD edition

 Kumar & Clarks clinical medicine, 9th edition
 CPG management of ischaemic stroke