Approach to Headaches

AIMGP Seminar

October 2004

Manaf Qahtani

Outline:1. Learning Objectives2. Case Studies3. General Principles4. IHS Classification5. “Red Flags”6. The Headache Diary7. Therapy8. Review Case Studies9. Summary10. Resources

Learning Objectives

1. Become aware of the IHS classification

2. Be able to diagnose and treat the common types of Primary headache

3. Be able to recognize the “Red Flags” of dangerous Secondary Headaches

General Principles There are lots of pain sensitive

structures in the head and neck

The key to proper management is to make an accurate diagnosis.

Recognize the features of “dangerous” headaches, and know how to “rule out”.

IHS Diagnostic Classification

1- Primary Headache: 90%

2-Secondary Headaches: 10%

HISTORY Headache Characteristics:

Temporal profile: acute vs chronic, frequency Location and radiation Quality Alleviating and exacerbating factors Associated symptoms

Constitutional symptoms PMH: HTN, DM, hyperlipidemia, smoking

Physical Exam Blood pressure Fundoscopy Auscultation for bruits in H/N Temporal artery inspection and palpation Meningismus Neurologic exam: motor, sensory,

coordination and gait

Primary Headache1. Migraine without aura 

2. Migraine with aura

3. Tension headache

4. Combination headache

5. Cluster headache

Primary Headache1. Migraine without aura; > 5 attacks with:

A- duration 4-72 hours B- > 2 of:

i. unilateralii. pulsatingiii. interferes with daily activityiv. aggravated by routine activity

C- > 1 of:i. nausea and/or vomiting

and/orii. photophobia and/or phonophobia

D- No secondary cause

Primary Headache2- Migraine with aura; > 2 attacks of:

A- Any 3 or more of:1-one or more reversible aura symptoms2-At least one aura symptom develops over > 4 min., or

two or more symptoms in succession3-No single symptom lasts > 60 min.4-Headache follows aura with free interval < 60 min, or

begins before or with aura.

B- No evidence of secondary cause.

Primary Headache3. Tension-type headache: At least 10 attacks of:

A- Duration 30 min – 7 days.B- > 2 of the following characteristics:

i. Pressing/ tightening (non-pulsating)ii. Mild/Moderate intensity. “Inhibits but doesn’t prohibit

activity”.iii. Bilateraliv. Not aggravated by routine activity

C- Both of:i. absence of nausea and vomiting (anorexia may occur)ii. absence of photophobia or phonophobia

N.B. > 15 days/ month = Chronic Tension Headache.

Primary Headache4. Combination Headache

Tension-type headache + migraine.

The tension headache may precipitate a migraine.

Primary Headache5. Cluster headache

Age of onset 25-50 y.o., M>F Features:

Attacks clustered in time (>5) Severe unilateral, orbital or temporal pain Lasting 15 min – 3 h Ipsilateral conjunctival injection, lacrimation,

nasal congestion, rhinorrhea, forehead/facial swelling, miosis, ptosis

Secondary Headache:Pain-sensitive structures in the head and neck

Extra-cranial

Scalp Scalp muscles Skull Carotid and vertebral arteries Paranasal sinuses Eyes and orbits Mouth, teeth, and pharynx Ears Cervical spine and ligaments Cervical muscles

Intracranial

Periosteum Cranial nerves Meninges Meningeal arteries and dural

sinuses Proximal intracranial arteries Sphenoid sinus Thalamic nuclei Brainstem pain-modulating

centers

“Red Flags” New headache especially in over 50 y.o. Abrupt onset, unusually severe Change in usual headache pattern Associated with focal neurologic findings Change in LOC, personality, lethargy Fever, neck stiffness Systemic signs/symptoms Temporal artery tenderness

The Headache Diary

Purpose:

  To aid diagnosis To identify triggers To provide a self-monitoring tool for

patients

The Headache Diary Frequency of pain Quality of pain Duration of pain: Intensity of pain: Use a rating scale 1-5 Accompanying symptoms: Neurologic e.g. visual disturbance, hemiparesis, hemianopsia, etc., and Autonomic e.g. nausea, vomiting, diarrhea Mental, cognitive and mood disturbance Triggers: hormonal, environmental, food, drug

Therapy of Primary HeadachesPrinciples of Therapy:

Stratified approach rather than a stepped care approach i.e. treat according to severity

 Determine level of intensity and frequency of headache to

decide on appropriate acute treatment.  Determine whether to use a combination of pharmacologic and

non-pharmocologic therapies. Determine whether prophylactic therapy is indicated.

TherapyMigraine – Acute Attacks set limits on treatments, i.e. no more than 2

days/week if oral agents not tolerated, use nasal

sprays, suppositories, or injectables for GI dysmotility/ nausea/ vomiting, use

metoclopromide 10mg. Can use”MIDAS” Scale to guide therapy

Tension-type headaches

  For moderate attacks NSAIDS useful

  For severe attacks triptan drugs effective

Non-pharmacologic Therapy

Cluster headache: Rare but debilitating  Carry high risk of suicide  Agent must have rapid onset of action  Acute treatment:  Oxygen 100% (evidence?)

Injectable sumatriptan (6mg.)

Summary Lots more to know about headache IHS classification is the beginning of the

diagnositic pathway. Most headaches will be Primary, but must

recognize the “Red Flags” of serious Secondary Headache.

Use Patient Diary and MIDAS to guide treatment.

Resources www.migraine.ca http://www.zomigconsumer.com/talk/midas

Survey.html http://www.ottawa-headache-centre.com/ www.aan.neurology.org JAMA,march 19,2003-vol 289, No 11

“headache assessment and management”