Headache

Headache

Dr. Anmar Aldewachi
Ass. Prof. Of Family Medicine
M.B.Ch.B, MD,MPH,JHSFM

Epidemiology

Headache is a common pain condition.
The reported lifetime prevalence of headache is 66% worldwide.
Headache affects 50% of the general adult population at any given time.
50% of patients with acute headache have tension headaches and 10% of them have migraines.
Chronic daily headache affects around 1.7–4% of the world’s adult population.

Classification

Classification
• Primary headache :
• Migraine
• Tension –type headache.
• Cluster headache.


II. Secondary headache
• Sinusitis .
• Withdrawal from caffeine, opiates, alcohol
• Arthritis / Joint disease osteoarthritis of cervical spine, Tempromandibular joint (TMJ).
• Post traumatic headache
• Medications / Chemicals: vasodilators, nitrates
• Viral syndroms like influenza.
• Ophthalmic (glaucoma, eye strain)
• Meningitis / Encephalitis
• Temporal arteritis
• Subarachnoid / subdural bleeds
• Brain tumor

Migraine headache

Affect about 10% of adults population.
Usually begin in late childhood or early adulthood, but the diagnosis may be delayed several years.
The incidence is much higher in women than men among adults, but the ratio is equal in children.
Migraine headache is associated with a positive family history.
It is characterized with recurrent, non-progressive lifelong attacks.
Headache with or without aura.


Clinical Manifestations
Migraine headache typically occurs 1-2 times per month.
The pain is gradual.
Pulsating.
Lasting 4 - 72 hours.
The pain is unilateral in 60-70% of the times; it can be bi-frontal or global in 30% of the times.
It affects the routine activities of daily living.
It is associated with sensitivity to light and/or sound.
It is associated with nausea and/or vomiting.
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Triggering factors for migrain

• Environmental: heat or cold, weather changes, bright lights, head or neck injury, odors.
• Lifestyle: chronic stress, disturbed sleep, skipping meals, smoking.
• Emotional: anxiety, anger, depression, excitement.
• Dietary: citrus fruit, chocolate, aspartame, aged cheese, beer or red wine.
• Medications: oral contraceptives, estrogen therapy, nifedipine, nitroglycerin
• Relieving factors
• The pain is relieved by rest, darkness and quiet environment.

Migraine Aura

• Migraine aura can be present with or without headache.
• Migraine aura :
Fully reversible
Develops over 5 minutes and lasts 5 to 60 minutes
The patient have at least one of the following features, but no motor symptoms:
• Visual symptoms(flash lights, spots or lines) and/or transient partial loss of vision.
• Sensory symptoms: numbness and/or pins and needles sensation.
• Speech disturbance.


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Acute Management

Medication should be started as early as possible after the headache onset.
Medications:
Ibuprofen or other NSAID medications.
Acetaminophen combined with caffeine(Acetaminophen alone is not beneficial).
Acetylsalicylic acid
Oral Triptans. (sumatriptan, rizatriptan)
Metoclopramide or Domperidone can be used for nausea.
Rectal NSAIDs are preferred in acute treatment because of gastric stasis associated with migraine.
Do not offer opioids such as tramadol for acute pain.
Medications for the treatment of acute migraine headache should not be used more than 9 days per month.
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Medications- Migraine Acute Management

• Migraine acute therapy

• First line

•
• Acetylsalicylic acid 600-1000mg
• Ibuprofen 400-800mg
• Acetaminophen + caffeine +/- Acetylsalicylic acid
• Second line
• Oral triptans:
• Sumatriptan100mg:repeat once after 2 hours if needed
• Rizatriptan10 mg: every 2 hours, maximum of 30mg/day
• Contraindicated in patients with coronary artery disease & uncontrolled HTN.
• Third line
• Combination Acetaminophen, NSAIDS plus triptans
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• Prophylactic Management
Medications
• B- blockers (propranolol, timolol, nadolol …..etc).
• Anticonvulsants (Valproic acid, Gabapentin,Topiramate, Pregabalin).
• Antidepressants (tricyclic antidepressant like amitryptylin).
• Muscle relaxants.

It is indicated for patients having ≥3 or more migraine headache attacks per month.
It is prescribed usually for 4 to 6 months.
It aims at reducing the number of attacks.

Patient Education- Migraine

Avoid triggering factors.
Follow regular eating and sleeping schedules.
Practice regular aerobic exercise.
Keep a headache diary to identify triggers and response to treatment.

Tension-Type Headache

The most common primary headache disorder.
The prevalence of headache between 30% and 80% in the general community.
Affect women more than men.
It occurs less than 15 days per month.
It often begins during the teenage years. The attacks of tension-type headache usually last a few hours, but can persist for several days.
Organic disorder should be ruled out first by diagnostic evaluation.


Clinical Manifestations
Headache is mostly bilateral.
Usually mild or moderate in severity.
Pressure or tightness feeling.
Sometimes it spreads into or from the neck.
It is associated with stress, fatigue and sometimes musculoskeletal problems in the neck.
Nausea is rare .

Acute Management

Medications: Acetylsalicylic acid 1000 mg, Acetaminophen 1000 mg or Ibuprufen 400-800 mg.
Adding caffeine to the above medications increases efficacy.
Do not offer opioids for the acute treatment of tension – type headache.
Do not use analgesic medications for more than 9 days per month.

Cluster Headache

Cluster headaches are not common
The prevalence estimated 0.3%-0.4%
It is more common in men.
It starts at the age of 20 years or older.
Attacks of cluster headache usually occur in bouts, or clusters, lasting for weeks or months, separated by remissions lasting months or years
It has an abrupt onset; it is not a gradual pain
The patient present with severe, intense, unilateral pain lasting from several seconds to many minutes.


Cluster Headache
Concurrent symptoms include ipsilateral lacrimation, rhinorrhea, and ptosis.
The headache is also always on the same side.
It does not improve on Acetaminophen.
Acute Management
Treatment options for acute episodes include 100% oxygen therapy (first-line treatment), triptans, ergot derivatives.
Verapamil may be used for prophylaxis in a dose of 240-480mg.

Medication overuse headache

The most common secondary headache.
The pain is persistent, and at its worst on awakening. It is present on more than 15 days per month.
It is caused by chronic and excessive use of headache medications for >3 months as per the below frequency:
Triptans, opioids, or a combination for 10 or more days per month.
Acetaminophen, Acetylsalicylic Acid or an NSAID alone or any combination for 15 days or more per month.
Headache usually develops or markedly worsens during medication overuse.

Management

Identify and treat the cause of primary headache for which the patient is taking the medications (migraine or tension).
Start an individualized prophylactic therapy accordingly.
Stop the overused medication.


Evaluation

History

Age at onset
Pain history (site, severity, character, duration, aggravating and relieving factors, Associated symptoms and abnormalities …..etc)
Frequency, intensity and duration of attack
Number of headache days per month.
Presence or absence of aura
Family history of migraine
Relationship with food/alcohol
Any recent change in vision
Any recent changes in sleep, exercise, weight, or diet
Response to treatment
Drug Hx. (OCCP, vasodilators, nitrate)

Examination

The majority of patients with headache complaints have a completely normal physical and neurologic examination.
Complete physical (throat, ears, eyes, temporal arteries …etc
Examination for neck stiffness,Kernig and Brudzinski signs
Full neurological examination. ( motor, sensory, reflexes)
Fundoscopy examination
Otoscopy examination


• Migraine with or without aura
• Tension Type headache
• Cluster headache
• Location
• 60-70% Unilateral
• 30% bi-frontal or global
• Mostly bilateral
• Always unilateral, begins around the eye
• Characteristics
• ♀ > ♂ Gradual; Pulsating;
• Positive family history
• ♀ > ♂ Pressure or tightness; Sometimes it starts from the neck.
• ♂>> ♀ Abrupt onset;
• Deep and stabbing
• Duration
• 4 - 72 hours
• Variable
• 30 minutes to 3 hours
• Associated symptoms
• Sensitivity to light +/- sound
• Nausea +/- vomiting
• Aura: fully reversible; develop over 5 minutes; lasts 5−60 minutes; include visual symptoms(flickering lights, spots or lines);and/or partial loss of vision; sensory symptoms (numbness and/or pins and needles);and/or speech disturbance.
• Stress;
• Fatigue;
• Nausea is rare;
• Sometimes musculoskeletal problems in the neck
• Same headache side:
• Red+/-watery eye;
• nasal congestion;
• and/or runny nose;
• swollen eyelid;
• facial sweating;
• and/or drooping eyelid
• Effect on
• activities
•
• Aggravated by, or causes
• avoidance of, routine
• activities of daily living
• Not aggravated by
• routine activities of daily living
•
• Restlessness or
• agitation
• Exacerbating factors
• Activity, exertion, bright
• light, loud noise, fasting, and valsalva
• Stress
• Alcohol or
• nitroglycerin use
• Relieving factors
• Rest
• Darkness, quiet
• Relaxation
• Biofeedback
• None
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Diagnosis of Common Primary Headaches


Diagnosis of Common Secondary Headaches
• Serious secondary headaches: These may demand immediate intervention

• Intracranial neoplasm

• A history indicative of raised intracranial pressure
• On physical exam focal neurological signs are present
• Meningitis
• Patients have signs of fever and neck stiffness
• Later accompanied by nausea and disturbed consciousness
• Subarachnoid hemorrhage
• Abrupt onset
• Often described as the worst headache ever
• Unilateral at onset and accompanied by nausea, vomiting and impaired consciousness
• Demands urgent investigation
• Giant cell (temporal) arteritis
• Suspected in patients >50 years of age with new headache
• Jaw claudication is highly suggestive
• If suspected, immediate steroids is recommended
• Primary angle-closure glaucoma
• Rare before middle age
• May present with acute ocular hypertension, a painful red eye with the pupil mid-dilated and fixed and, essentially, impaired vision
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Red Flags for Possible Secondary Headaches
Progressive headaches worsening over months.
A new or different headache.
Any headache of maximum severity at onset.
Headache of new onset after age of 50 years.
Persistent headache triggered by a Valsalva maneuver.
Systemic disorder signs: fever, hypertension, myalgia, weight loss or scalp tenderness.
Presence of neurological signs that may suggest a secondary cause.
Seizures.

Diagnostic testing

Detailed history and complete physical and neurological examination are sufficient to diagnose common primary headache syndromes.
There is limited need for imaging or laboratory tests in the diagnosis of headache.
Neuroimaging be considered in the following situations in patients with non-traumatic headache:
• Focal findings on neurologic examination
• Abrupt onset of headache
• Change or alteration in the characteristics of headache
• Increased intensity and frequency of headaches
• Persistence despite analgesics.
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Treatment

Patient Education - Headache

• Patient education:
Reduce stress.
Keep regular eating and sleeping schedules.
Practice aerobic exercise regularly.
Keep a headache diary; this can help identify frequency, severity, triggers, and response to treatment.
Avoid taking headache treatment medications for more than 9 days per month.
Adhere to prophylactic treatment medication; this can lead to less frequent and less severe headache attacks.
Acknowledge that it may not be possible to eliminate the primary headache completely.
• Treatment method depend on individual cause of headache

Thanks