Approach to Headache

Approach to Headache

1. APPROACH TO HEADACHE Dr. Navin Adhikari

2. Headache T he most common presentation for medical attention. R esponsible for more disability than any other neurologic problem Primary headaches are those in which headache and its associated features are the disorder itself. Secondary headaches are those caused by underlying p athology.

3. As many as 90 percent of all primary headaches fall under a few categories, including migraine, tension-type, and cluster headache. E pisodic tension-type headache (TTH) is the most frequent headache type in population-based studies. M igraine is the most common diagnosis in patients presenting to primary care physicians with headache.

4. PRIMARY HEADACES

5. MIGRANE affects 12 to 15 percent of the general population. more frequent in women than in men, with attacks occurring in up to 17 percent of women and 6 percent of men each year. is a major cause of disability and ranked second after low back pain worldwide

6. Clinical Features Progresses through four phases : the prodrome , the aura, the headache, and the postdrome Migraine prodrome occurs in up to 77 percent of migraineurs appear 24 to 48 hours prior to the onset of headache symptoms include increased yawning, euphoria, depression, irritability, food cravings, constipation, and neck stiffness

7. AURA 25 percent of people with migraines experience it. characterized by gradual development, duration no longer than one hour, a mix of positive and negative features, and complete reversibility p ositive symptoms can be visual ( eg , bright lines, shapes, objects), auditory ( eg , tinnitus, noises, music), somatosensory ( eg , burning, pain, paresthesia ), or motor ( eg , jerking or repetitive rhythmic movements). Negative symptoms indicate an absence or loss of function, such as loss of vision, hearing, feeling, or ability to move a part of the body.

8. Migraine Headache

9. Migraine postdrome   sudden head movement transiently causes pain in the location of the antecedent headache. patients often feel drained or exhausted, although some report a feeling of mild elation or euphoria.

10. Trigger factors

11. Emotional stress (80 percent) Hormones in women (65 percent) Not eating (57 percent) Weather (53 percent) Sleep disturbances (50 percent) Odors (44 percent) Neck pain (38 percent) Lights (38 percent) Alcohol (38 percent) Smoke (36 percent) Sleeping late (32 percent) Heat (30 percent) Food (27 percent) Exercise (22 percent) Sexual activity (5 percent )

12. Com p lications Status migrainosus is a debilitating migraine attack lasting for more than 72 hours Persistent aura without infarction is defined by aura symptoms persisting for one week or more with no evidence of infarction on neuroimaging . Migrainous infarction is defined by a migraine attack, occurring in a patient with migraine with aura, in which one or more aura symptoms persist for more than one hour and neuroimaging shows an infarction in a relevant brain area. Migraine aura-triggered seizure is a seizure triggered by an attack of migraine with aura

13. MIGRAINE SUBTYPES  Migraine with brainstem aura  Hemiplegic migraine  Retinal migraine Vestibular migraine Menstrual migraine

14. Neuroimaging in Migraine Patients with an unexplained abnormal finding on neurologic examination. Patients with atypical headache features or headaches that do not fulfill the strict definition of migraine or other primary headache disorder or have some additional risk factor, such as immune deficiency.

15. Differentials O ther types of primary headaches, such as tension-type headache and trigeminal autonomic cephalalgias such as cluster headache and secondary headaches. F or migraine aura includes transient ischemic attack (TIA), seizure, syncope, and vestibular disorders

16. Tension-type headache Previously known as stress or tension headache, muscle-contraction headache, psychomyogenic headache, and psychogenic headache Ty p es 1. Infrequent episodic TTH, with headache episodes less than one day a month 2. Frequent episodic TTH, with headache episodes 1 to 14 days a month 3. Chronic TTH, with headaches 15 or more days a month

17. CLINICAL FEATURES  mild to moderate intensity, bilateral, nonthrobbing headache without other associated features. Descriptions of TTH pain are characteristically nondescript: "dull," "pressure," "head fullness," "head feels large," or, more descriptively, "like a tight cap," "band-like," or a "heavy weight on my head or shoulders. Increased pericranial muscle tenderness is the most important abnormal finding in patients with TTH Manual palpation is performed by applying firm pressure with the second and third finger and making small rotating movements on the pericranial muscles, including the frontal, temporal, masseter , pterygoid , sternocleidomastoid , splenius, and trapezius muscles

18. TRIGEMINAL AUTONOMIC CEPHALALGIAS primary headaches including cluster headache, paroxysmal hemicrania (PH) and SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing), and hemicrania continua. ACs are characterized by relatively short-lasting attacks of head pain associated with cranial autonomic symptoms, such as lacrimation , conjunctival injection, aural fullness, or nasal congestion

19. Differential Trigeminal neuralgia — Classic trigeminal neuralgia is an important consideration in the differential diagnosis of cluster headache and SUNCT. In trigeminal neuralgia, unlike cluster and SUNCT syndrome, autonomic symptoms are not prominent. Unlike short-lasting unilateral neuralgiform headache attacks, triggered attacks in trigeminal neuralgia have a clear refractory period. Other primary headaches. Secondary cluster headaches; Meningiomas , Pituitary macroadenomas , Intracranial large artery aneurysms.

20. Other p rimary headaches Primary Cough Headache Primary Exercise Headache Primary Headache Associated with Sexual Activity- are not always benign; 5–12% of cases of subarachnoid hemorrhage are precipitated by sexual intercourse. Cold-Stimulus Headache External Pressure Headache Hypnic Headache

21. mnemonic SNNOOP10 is a reminder of the danger signs ("red flags") for the presence of serious underlying disorders that can cause acute or subacute headache. S ystemic symptoms including fever N eoplasm history N eurologic deficit (including decreased consciousness) O nset is sudden or abrupt O lder age (onset after age 50 years) P attern change or recent onset of new headache P ositional headache P recipitated by sneezing, coughing, or exercise P apilledema P rogressive headache and atypical presentations P regnancy or puerperium P ainful eye with autonomic features P ost-traumatic onset of headache P athology of the immune system such as HIV P ainkiller (analgesic) overuse ( eg , medication overuse headache) or new drug at onset of headache

22. Headache requiring emergency evaluation Sudden onset "thunderclap" headache Acute or subacute neck pain or headache with Horner syndrome and/or neurologic deficit Headache with suspected meningitis or encephalitis Headache with global or focal neurologic deficit or papilledema Headache with orbital or periorbital symptoms Headache and possible carbon monoxide exposure

23. A pproach to Headache Rule out serious underlying pathology and look for other secondary causes of headache . Determine the type of primary headache using the patient history as the primary diagnostic tool . There may be overlap in symptoms, particularly between migraine and tension-type headache (TTH) and between migraine and some secondary causes of headache such as sinus disease. A headache diary can be helpful in further clarifying the headache diagnosis, the frequency of headache, potential triggers, and the disability from the headache

24. Suspicion of SAH

25. No suspicion of SAH/thunderclap headache

26. Suspicion of Intracranial lesion

27. Management

28. T reatment of migraine Educate migraine sufferers about their condition and its treatment and encourage them to participate in their own management. Use migraine-specific agents ( eg , triptans , CGRP antagonists, lasmiditan , dihydroergotamine ) for patients with more severe migraine and in those whose headaches respond poorly to NSAIDs or combination analgesics. Select a nonoral route of administration for patients whose migraines present early with significant nausea or vomiting. Consider a self-administered rescue medication for patients with severe migraines that do not respond well to other treatments. Guard against medication overuse headache by educating patients about risk and using prophylactic medications in patients with frequent headaches.

29. M ild to moderate migraine attacks N ot associated with vomiting or severe nausea, initial treatment with simple analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, rather than migraine-specific agents. For patients unresponsive to analgesics, the combined use of an NSAID with a triptan may be effective. When attacks are associated with severe nausea or vomiting, an antiemetic drug can be used along with analgesics

30. MODERATE TO SEVERE MIGRAINE ATTACKS T reatment with a triptan or the combination of sumatriptan -naproxen, rather than other migraine-specific agents. Patients who do not respond well to one triptan Alternative options include calcitonin gene-related peptide (CGRP) antagonists, lasmiditan , antiemetic drug, may respond to a different triptan . M igraine attacks who present to the hospital emergency department (ED), initial treatment with either subcutaneous sumatriptan or a parenteral antiemetic agent metoclopramide or prochlorperazine . T reatment with IV or intramuscular dexamethasone to reduce the risk of early headache recurrence

31. Status migrainosus C ombination of intravenous fluids plus parenteral medications, including ketorolac and a dopamine receptor blocker ( eg , prochlorperazine , metoclopramide , chlorpromazine). Other options include valproate and/or dihydroergotamine

32. Prophylactic treatment Indications Frequent or long-lasting migraine headaches( more than four headaches per month or headaches that last longer than 12 hours Migraine attacks that cause significant disability or diminished quality of life despite appropriate acute treatment Contraindication to acute therapies Failure of acute therapies Serious adverse effects of acute therapies Risk of medication overuse headache Menstrual migraine risk of neurologic damage and/or impairment in the presence of uncommon migraine conditions like hemilegic migraine, Migraine with brainstem aura, Migrainous infarction.

33. Tension-Type Headache Treatment S imple analgesics such as acetaminophen, aspirin, or NSAIDs Behavioral approaches including relaxation can also be effective For chronic TTH, amitriptyline is the only proven treatment.

34. Cluster Headache treatment ACUTE ATTACK TREATMENT 100% oxygen at 10–12 L/min for 15–20 min Sumatriptan 6 mg SC is rapid in onset and will usually shorten an attack to 10–15 min. Oral sumatriptan is not effective for prevention or for acute treatment of cluster headache.

35. Hemicrania Continua Treatment consists of indomethacin , other NSAIDs appear to be of little or no benefit. The IM injection of 100 mg of indomethacin has been proposed as a diagnostic tool. Alternatively, a trial of oral indomethacin , starting with 25 mg tid , then 50 mg tid , and then 75 mg tid , can be given. Up to 2 weeks at the maximal dose may be necessary to assess whether a dose has a useful effect.

36. References Harrison's Principles of Internal Medicine, 20th Edition Kumar & Clark's Clinical Medicine, 7th Edition Uptodate 2020