Diagnosis of Common Primary Headache Disorders

* Diagnosis of Common Primary Headache Disorders

Dr.Mufeed Akram Taha Board Neurology (FIBMS) Kirkuk College of Medicine Kirkuk - IRAQ

* Headache occurs in all age groups and is the seventh leading reason for medical office visits; Although most often a benign condition (especially when chronic and recurrent), headache of new onset may be the earliest or the principle manifestation of serious systemic or intracranial disease and therefore requires thorough and systematic evaluation.

APPROACH TO DIAGNOSIS

* Headache is caused by traction, displacement, inflammation, vascular spasm, or distention of the pain-sensitive structures in the head or neck. Isolated involvement of the bony skull, most of the dura, or most regions of brain parenchyma does not produce pain.

A. PAIN-SENSITIVE STRUCTURES WITHIN THE CRANIAL VAULT

* These include:- The venous sinuses (eg, sagittal sinus), The anterior and middle meningeal arteries The dura at the base of the skull. The trigeminal (V), glossopharyngeal (IX), and vagus (X) nerves. The proximal portions of the internal carotid artery and its branches near the Circle of Willis. The brainstem periaqueductal gray matter. The sensory nuclei of the thalamus.

B. EXTRACRANIAL PAIN-SENSITIVE STRUCTURES

* These include:- The periosteum of the skull. The skin. The subcutaneous tissues, muscles, and arteries; the neck muscles; the second and third cervical nerves. The eyes, ears, teeth, sinuses, and oropharynx; and the mucous membranes of the nasal cavity.

* Headache Disorders

Headaches are extremely common Two main categories of headachePrimary tension-type, migraine, clusterSecondarySecondary to another disease such as brain tumors, aneurysms, meningitis, etc… Neurology Ambassador Program

Common causes of Headache

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* Blumenthal et al., Headache 2003:43:1026-1031.

N=57
Primary Headaches In ER

* Migraine

Migraine is generally an episodic headache often with sensitivity to light, sound or movement, and with nausea or vomiting accompanying the headache.

Types of Migraine

Migraine with aura(classical). Migraine without aura(common). Vertebrobasilar Migraine. Ophthalmoplegic Migraine. Migraine equivalents : Especially in the elderly, prodromal symptoms may occur without headache. Familial Hemiplegic Migraine. Abdominal Migraine.
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* Features of Aura

About 15% of patients with migraine experience aura Aura symptoms can be: Visual (most common by far) Sensory Speech disturbances Aura mimics include: Stroke/TIA Seizure disorders Tumors Venous thrombosis AVM Carotid artery dissection
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Diagnostic criteria for Migraine
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Headache Precipitating Factors in Migraine

Environment alters the patterns of: Sleep too little or too much; Eating skipping meals, or alcohol in particular; Stress excess stress or in the relaxation phase; Physical activity such as exertion; Weather stormy or barometric pressure change; Hormonal environment such as the menstrual cycle; Afferent stimulation such as bright lights or loud sounds.
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* MIGRAINE ADDITIONAL FEATURES

Abatement with sleep
Stereotyped prodromal symptoms
Characteristic triggers
Positive family history
Childhood precursors (motion sickness, episodic vomiting, episodic vertigo)

Predictable timing around menstruation (or ovulation?)
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Things to Know !!!

Migraine is an inherited tendency to headache; it is a congenital disorder and therefore it cannot be cured
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* Migraine Management
A-Non-pharmacological management B- Pharmacological management include:- Acute attack treatment.(non specific, specific) Prophylactic treatment. (>4 attacks/mon.)

Acute Attack Treatment

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Prphylactic Treatment

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* Botulinium Toxin !!!

* Tension-type Headache
Be careful about diagnosing this one in practice…probably something elseMigraine is more likely causeMaybe TTH, but if migraine history….CNS tumors can present as TTHMore history and more history….

* Tension-type headache

Description:Frequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There is no nausea but photophobia or phonophobia may be present.Chronic TTH is 15 days/month for >3 month…

* Cluster Headache

Think of this as the most interesting…Headache with special clinical featuresMainly male…. Autonomic features and orbital severe painTriggered by Alchohol.Careful if short duration, female or signs…TAC (Trigeminal Autonomic Cephalagia)Secondary causes…


* Cluster Headache
Description: Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15-180 minutes and occurring from once every other day to 8 times a day. The attacks are associated with one or more of the following, all of which are ipsilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis, eyelid oedema. Most patients are restless or agitated during an attack.


* Severe, short-lasting, exclusively unilateral, trigeminal (orbital - temporal pain) pain Prominent attack-related cranial autonomic (parasympathetic) features

Clinical features of the trigeminal autonomic cephalalgias

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Hypnic headache

* Affect pateints aged 67–84 years. Moderately severe nature that typically came on a few hours after going to sleep. These headaches last 15–30 minutes. Typically generalized, although may be unilateral, and can be throbbing. Patients may report falling back to sleep only to be awoken by a further attack a few hours later with up to three repetitions of this pattern over the night. HT shoud be excluded !!! Treated by:-1- One to two cups of coffee or caffeine 60 mg orally at bedtime may be helpful.2- verapamil at night (160 mg).3- lithium carbonate (200–600 mg) at bed time.4- flunarizine 5 mg at night.

Medication Overuse Headache

* Headache more than 15 days/month for successive 3 months

* Red Flags

Sudden onset Worsening pattern Systemic illness Focal signs Papilledema Triggered by cough, exertion, Valsalva Pain associated with local tenderness, such as of the temporal artery



Differential Diagnosis of Migraine
Intensity & disability
Frequency
Autonomic
Duration
After Kolbe 2004


* Finally…. Headache Diagnosis is a heuristic or pattern….If you have seen it then you can diagnose it….Spend time with primary cases…..see lots of patients..Learn from secondary headaches: how you diagnosed them and where you went wrong!

* Last Red Flag…. Thanks very much….