History and Examination

Headache

Date of clerking: 11/1/2013

History of Presenting Illness• Mr Y is a 40 years old Malay man with complains of

sudden onset of headache since this morning when he woke up from sleep. He do not have any known co-morbid.

• The pain was throbbing on his right side of the head• The pain was constant. The severity of the pain was

4/10.• The pain was associated with visual disturbance.

Patient experience blurry vision .• Bright light would trigger his headache to become

worse.• No aura. No previous history of migraine.

• However , the pain did not associate with any nausea , vomiting , weakness or sensory disturbance.

• Mr. Y did not had any fever or neck stiffness, but he do have neck tenderness.

• He do had sleep deprivation(sleep for 2 hours) last night because he being took care of his 3 month baby.

• He did not on regular painkillers.

History of Presenting Illness

Physical examination

• General examination:– Pt conscious and alert.– Vital signs:

• Capillary refill time <2 seconds.• Pulse rate: 78 bpm with regular rhythm and good volume.• Temperature: 37• Blood pressure: 130/80 mmHg• Respiratory rate about 16 breath per minute.

– Lung and airway are clear– CVS: dual rhythm no murmur

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 Headache

2- 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 Headache

4. Combination Headache

Tension-type headache + migraine.

The tension headache may precipitate a migraine.

Primary Headache

5. 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 Headaches

Principles 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.

Therapy

Migraine – 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.)