Approach to Headache

Who hasn’t had one?

Pain sensitive struc. in skull

Skin, muscles, periosteum Eye, ear, paranasal sinuses Venous sinuses & veins Dura at base of skull Arteries in dura & pia arachnoid Nerves- V, IX, X, C1-3

Causes of headache Spasm/trauma/inflammation of muscles Distention of cranial arteries Traction of intracranial veins/sinuses Compression/traction/inflammation of

nerves Meningeal irritation Increased intracranial pressure Diseases of eye/ear/paranasal sinuses

History Onset Progression Frequency Duration Location Character Severity

Aura Eye/ear/nose symp. Precipitating factors Relieving factors Effective treatment Other medical

problems

Focused general examination

Vital signs Extracranial structures- muscles,

arteries, paranasal sinuses Evidence of meningeal irritation Neck flexion Kernig sign Brudzinski sign

Focused neurological exam. Consciousness, coherence, orientation Pupils- symmetry, reactivity Ocular motility, visual fields, optic fundi Facial sensation & symmetry Muscle tone, strength, DTR Response to painful stimuli Plantar response Gait & coordination

Warning signs New or different headache Progressive headache New headache after 50 Headache of maximum severity at onset Headache precipitated by Valsalva

maneuver Associated seizures Associated focal neurological deficit Associated fever, HT, myalgia,

scalp tenderness

Investigations, if required

CT scan or MRICSF examination

Angiography

Tension headache

Usually bilateral Over temple, cranium or back of neck Described as tightness or pressure Gradual onset & progression Worsens over the day Asso. with depression or anxiety Relieved with NSAIDs, TCA, anxiolytics

Migraine Periodic, hemicranial, throbbing pain More in young females Associated with nausea/vomiting Aura +/- Family history +ve in 60% May have neurologic symptoms/signs Treatment- NSAIDs &/or Triptans,

opioids Prophylaxis- Propranolol, Amitriptyline,

SSRI, Verapamil

Cluster headache More in young men Episodic, onset when asleep Bouts lasting 4-8 weeks Unilateral, periorbital, constant,

nonthrobbing Asso. with lacrimation, rhinorrhoea etc. Treatment- 100% oxygen, Triptans Prophylaxis- Lithium carbonate, Verapamil,

Valproate, Topiramate

Giant cell arteritis

Elderly Headache, with systemic symptoms Tenderness over temporal artery &

scalp May cause loss of vision ESR raised Treatment- steroids

Trigeminal neuralgia More in women Episodes of unilateral sudden

lancinating facial pain Limited to distribution of Vth cranial n. Suspect multiple sclerosis in young Treatment- Oxcarbazepine,

Carbamazepine, Gabapentin Surgical exploration/ gamma

radiosurgery help in intractable cases