HEADACHES IN EMERGENCY DEPARTEMENTTroeboes PoerwadiDepartement NeurologyDr Soetomo General HospitalAirlangga Medical School

IntroductionHeadache is a nearly universal experienceTop complaints in PHCSome is serious health concernLife time prevalence of headache: 93%Severe headache impacting :20% population 2% of all visits in ED

Differential Diagnosis of HeadachePrimary HeadachesMigraineCluster Tension typeOther benign headacheSecondary HeadachesHead/neck traumaCVDIntracranial tumorIntracranial infection

Differential Diagnosis of HeadacheSecondary Headaches (Cont)CSF abnormalitiesSubstance abuse or withdrawalSystemic diseaseDisease of extracranial structuresCranial neuralgia

Headache Danger SignalsHistorySudden onset of new severe headacheProgressive worsening headacheOnset with exertion, coughing, straining, and/or sexual activityAssociated symptoms such as:Drowsiness, confusion, memory lossChronic malaise, myalgia, antralgiaFeverProgressive visual disturbancesWeakness, clumsiness, loss of balanceOnset of first headache after the age of 50 years

Headache Danger SignalsOn examination:Abnormal vital sign especially fever or hypertensionAltered consciousness or cognitionMeningeal irritation (stiff neck)Papiloedema or fundal haemorrhagePupils unequal and/or poorly reactiveWeakness of sensory loss in face or limbsReflex asymetry or abnormal plantar responseClumsiness or loss of balanceTender, poorly-pulsatile cranial arteries

Headache Danger SignalsSudden onset of new, severe headacheProgressively worsening headacheOnset headache after exertion, straining, coughing or sexual activityPresence of associated symptomsOnset of first headache after the age of 50 yearsAny abnormality on neurological or general physical examinationEdmeads J, 1991

Headache Danger SignalsThe Washington Manual Neurology Survival Guide, 2004Headaches that awaken the patient from sleepHeadaches witj particularly sudden onset and explosive characterNew-onset headache in patients > 50 yrsHeadaches associated with focal neurologic deficits, papilledema or seizuresAny significant change in headache pattern:Increased intensityIncreased frequencyChange in qualityHeadaches that worsen with the Valsava maneuver or changes in posture

Headache Danger SignalsThe Washington Manual Neurology Survival Guide, 2004Headaches that in context of recent trauma or cervical manipulation,Headaches occuring in immunocompromised patient ( eg. HIV, cancer)Meningeal signs or symptomsSymptoms of increased ICP: nausea, vomiting, blurry vision, decreased sensoriumHeadaches that are particulary worse in the morning or with prolonged recumbencyAny mental status changesHeadaches with sudden onset during sexual activities or exertion (although benign varieties exist for both)

Indications for the Dx EvaluationNasty NineFirst/worst severe headachesAbrupt-onset headacheProgressive headache patternHeadache with neurologic symptoms > 1 hourAbnormal examination finding

Indications for the Dx EvaluationNasty NineHeadaches with syncope or seizuresNew headaches in children < 5 years of age, adults > 50 years of ageNew headache in patient with cancer, immunosuppresion, or preganancyHeadaches worsening with exertion, sex, valsavaKanlecki R, AAN 2003

ED Evaluation - HistoryPatient with headache of presents to ED:The headaches is newDifferent from former headache in intensity, quality or refractory to standard treatmentWe must separate benign disorders from the serious secondary headacheComplete & detailed history, thorough analysis, careful review or prior headaches, outline past medical history must be done

ED Evaluation - HistorySpecific details which may be helpful:Lenght of headache history, and subsequent courseProvocative or palliative factorsWarning symptoms as prodromes or auraHeadache duration,both treated and untreatedHeadache location, quality, intensity, onset, develompment

ED Evaluation - HistorySpecific details which may be helpful:Associated symptoms: nausea, sensitivity to sensory exposures, visual changes, neck stiffness, tearing or rhinorrheaMedication or toxin exposurePostdrome or hangover symptomsPrior response to medicationPrior testing and results

ED Evaluation Physical ExaminationQuick Look TestDoes the patient look well (comfortable), sick (uncomfortable), or critical (about to die ?)Airway and Vital SignsWhat is the temperature?What is the blood pressure?What is the pulse rate?

ED Evaluation Physical ExaminationSelective History and Chart ReviewWhat is quality of pain?Where is the located?What time of day do the headaches occurs?Do warning symptoms occurs before the headaches begin?

ED Evaluation Physical ExaminationSelective History and Chart ReviewDo any factors precipate the headaches and what makes better?Are any symptoms or associated condition or risk factor associated with headache?Is there a history of chronic or recurring headaches?Are other any other associated symptoms with these headaches? ( detailed under Primary Headache Disiorders)Do headaches run in family?

ED Evaluation Physical ExaminationHead, Eyes, Ears, Nose, Throat (HEENT)Sinus tenderness (sinusitis)Temporal artery tenderness ( temporal arteritis)Conjunctival injection (cluster headaches)NeckNeck muscles spasm (tension headaches)Meningeal sign (meningitis, SAH)

ED Evaluation Physical ExaminationNeurologic ExaminationLevel of consciousnessConfussion or disorientationPupil symmetryPapil edema and spontaneus venous pulsations)Retinal hemorhages (flame or subhyloid)Pronator driftsDeep tendon and plantar reflexesGait

Diagnostic TestingCT scan:Acute, extremely severe headache (thunderclap headache)Headache with progressive onset over days to weeks that is not similar to previous headachesAltered mental status (even if intoxicated)Focal neurologic signsPapil edemaCT scan: useful in presentations involving trauma or abrupt headache, acute fracture & hematoma are best visualized by CT

Diagostic EvaluationMRI scanningGreater sensitivity&capability of visualization of the sinuses, posterior fossa, skull base and preferable for all subacute or chronic presenta-tions of headacheMRaMay be added in cases where vascular dissection, malformation, occlusion, or aneu-rysm is suspected

Diagnostic EvaluationLumbar punctureMandatory in cases possible SAH (whwn neuroimaging alone is only 90%)InfectiousNeoplastic meningoencephalitisPseudotumor cerebriCSF should be sent for:cell count, protein, glucosa, cultures, cytology or special studies

Diagnostic EvaluationLumbar punctureCt scanning prior to LP is mandatory in patients with depressed level of cons-ciousness, neurologic focality, papil-ledema or AIDS, because of the high likelihood of detecting mass lesion in these patients.Empirical Rx of suspected meningitis: ceftriaxone 1 g IV every 12 hours and ampi-cillin IV 2 g every 6 hours

Diagnostic EvaluationSerum studiesComplete blood count: indicated on patients with fever, meningismus, or suspected anemiaErythrocyte sedimentation rate(ESR) should be check in all individual > age 50 with or different headacheCarboxyhemoglobin level CO exposureArterial blood gases (ABGs) should be performed in cases hypoxia, hypercapnia or acidosis

Diagnostic EvaluationEKG and EEG are indicated in cases headache with any loss of conscious-nessIn cases suspected ocular etiology: consult to opthalmologist

Differential Diagnosis and ManagementSecondary Headache SyndromeSubarachnoid hemorrahageMeningoencephalitisIntracranial mass lesionPosttraumatic headacheDisorders of CSF volume or flowCerebrovascular diseaseInflammatory disordersOther secondary headache syndrome

Differential Diagnosis and ManagementSecondary Headache SyndromeSubarachnoid hemorrhage [SAH]Symptom : the worst headache of my life, the abrupt nature is actually more characteristic than its severityThe abrupt onset of severe occipital or generalized headache (thunderclap headache) in patient with no previous history of headacheSyncope or seizure, confussion, neck stiffness, focal deficits, or coma may be presentSigns of localizing neurologic dysfunction may be absentOcular hemorrhage (Subhyaloid hemorrhage)

Differential Diagnosis and ManagementSecondary Headache SyndromeSubarachnoid hemorrhage [SAH]Approximately half patients have warning symptoms within a month of rupture, including generalized headache, cranial nerve palsies, and setinel bleeding50% patients with aneurysms have warning symptoms, usually 6-20 days before SAH

Differential Diagnosis and ManagementSecondary Headache SyndromeSubarachnoid hemorrhage [SAH]Emergency CT is procedure of choice, but unremarkable (10% of cases), a lumbar puncture is mandatoryCSF xanthochromicTreatment : 60 mg nimodipine po every 4 hoursNeurosurgical consultations will be necessary

Differential Diagnosis and ManagementSecondary Headache SyndromeSubarachnoid hemorrhage [SAH]Risk factors: hypertension, cigarette smoking, oral contraceptive, alcohol (debatable), diurnal variations in blood pressure, pregancy, cocaine abuse10-20% patients die before reaching medical careMortality is 10% within first few daysOverall mortality 50-60% in the first 30 days after hemorrhage

Differential Diagnosis and ManagementSecondary Headache SyndromeMeningoencephalitisSymptoms aside from headache, fever, neck stiffness, photophobia, nausea, while the presence of Kernigs and Brudzinskis sign may help establish meningeal irritationIf suspected CNS infection demands emergent CT followed by LP

Differential Diagnosis and ManagementSecondary Headache SyndromeMeningoencephalitisThere is a subacute or an acute onset of contant, increasingly severe painThe headache is ussualy generalized but may be worse in the occipital areaIt increased with physical activityAltered conciousness may be presentPhotophobia, strasbismus, ptosis, or pupilary inequality may be presentLP is mandatory

Differential Diagnosis and ManagementSecondary Headache SyndromeIntracranial mass lesionsCause: epidural &subdural hematoma, brain abscesses, brain tumorsHistory of trauma:epidural or subduralHistory of infection, and present sub-acutelyBrain tumors may present more chronic picture

Differential Diagnosis and ManagementSecondary Headache SyndromeIntracranial mass lesionsComplaints of nausea, visual blurring or obscurations, dizziness, unsteadiness, and exacerbations of pain activity or valsava may be notedImpairment in the level of consciousness, particularly when accompanied by focal neurologic findings or papilledema

Differential Diagnosis and ManagementSecondary Headache SyndromeIntracranial mass lesionThe most important diagnostic clue is a bilateral, nonthrobbing headache that is worse in the morningThe headache is an initially mild and intermittent, increasing in severity to steady, nonthrobbing pain.It may awaken the patient at night

Differential Diagnosis and ManagementSecondary Headache SyndromeIntracranial mass lesionIt is worse with the Valsava maneuverWhen severe, it is associated with vomitingPapil edema is present earlierIt is often associated with focal neurologic signs ( asymetric reflexes, palsy of extraocular muscles, pupilary asymmetry)

Differential Diagnosis and ManagementSecondary Headache SyndromePosttraumatic headacheOccur after significant head trauma (loss of conciousness) and have both organic and psychologic components.It may be indistinguisable from chronic, recurring tension headacheThe duration is usually no longer than 6 monthsMay be associated with a sensation of dizzinessIt may be part of postconcussionsyndrome, which characteristic by anxiety, fatique, irritability, and inability to concentrate

Differential Diagnosis and ManagementSecondary Headache SyndromeDisorders of CSF volume or flowHydrocephalus & pseudotumor cerebri may be present with symptoms and signs of increased intracranial pressureAcute obstructive hydrocephalus may be pre-sent as: a sudden increased in intracranial pressure with headache, gait and visual dis-turbance, incontinence and syncope

Differential Diagnosis and ManagementSecondary Headache SyndromeDisorders of CSF volume or flowChronic hydrocephalus andpseudotumor cerebri present with more subacute picturesPseudotumors, or benign intracranial hyper-tension, often presents as an idiopathic con-dition in young, overweight women, although it may associated with pregnancy or the use of vitamin A, tetracycline, or steroids; papillede-ma, signs of meningismus and focal neurologic signs such as sixth nerve palsies may be present

Differential Diagnosis and ManagementSecondary Headache SyndromeDisorders of CSF volume or flowAcute hydrocephalus is diagnosed by ventricu-lomegaly on CT and neurosurgical consulta--tion Pseudotumor is generally diagnosed by an ele-vated CSF opening pressure following a nor-mal CT, LP is temporarily therapeutic, while a diuretic as acetolamide should be instituted

Differential Diagnosis and ManagementSecondary Headache SyndromeDisorders of CSF volume or flowHeadache of intracranial hypotension is characterized by its postural nature. It is aggravated in the upright position and often accompanied by nausea, dizziness, visual change, or neck stiffnessPost LP headache: precipitated by sitting or standing and relieved promptly by lying down; it isoften frontal or occipital, may be generalized; it is occurs within 1 to 2 days of LP cause by leakage of CSF

Differential Diagnosis and ManagementSecondary Headache SyndromeCerebrovascular disease: Either arterial (stroke) or venous (cerebral vein/sinus thrombosis) may result in acute headache and neurologic symptomsThe headache rapid develompment, isolation to a single vascular territory, presence of negative phenomena without positive component (numbness without paresthesias, visual loss without scintlillation), and duration greater than 60 minutes

Differential Diagnosis and ManagementSecondary Headache SyndromeCerebrovascular disease: Arterial dissection may be spontaneous or traumatic in nature, and is more common among migraineus.Carotid dissection is severe, periorbital, and accompanied by anterior neck pain, transient or persistent neurologic complaints, ipsilateral carotid bruit or Horners syndrome

Differential Diagnosis and ManagementSecondary Headache SyndromeCerebrovascular disease: Vertebral dissection often involves posterior headache that may be unilateral, accompanied by neck pain and transient or persistent neuro-logic complaints.Neuroimaging studies and vascular investiga-tion (angiography, MRA, MRV or ultrasound) are warranted, and anticoagulation or thrombo-lytic therapy may be necessary

Differential Diagnosis and ManagementSecondary Headache SyndromeInflammatory disordersGiant cell arteritis, or temporal arteritisThe onset of severe, continous unilateral head pain in an elderly people over age 50-55 and femaleTender swollen nonpulsatile temporal arteries are often, but not always, presentApproximately half will present with symptoms of polymyalgia rheumatica: antralgias,myalgias, fever, night sweats, and weight lossElevated ESR often in the range of 50-100Diagnostic temporal arteritis biopsy

Differential Diagnosis and ManagementSecondary Headache SyndromeInflammatory disordersTemporomandibular neuralgia(TM synd)Unilateral,severe.constant,aching fascial pain around temporomandibular joint, radiating to the jaws associated with tenderness over man-dibular jointsPain is exacerbated by movement of the lower jawsAssociated clicking or grating sound

Differential Diagnosis and ManagementSecondary Headache SyndromeInflammatory disordersTemporomandibular neuralgia(TM synd)May be associated with bruxism during sleep, depression or insomniaCommonly in young women or in elderly patients with severe overbite resulting from the loss of back teethPalpation of the temporalis muscles or direct pressure on temporomadibular jointspainX-ray degenerative changes in the cartilage

Differential Diagnosis and ManagementSecondary Headache SyndromeInflammatory disordersAcute bacterial sinusitis sinus headacheFrontal, nonthrobbing headache, with fascial tenderness and pain, purulent or colored nasal discharge with congestion and often feverThey may uni or bilateral, the location depends on the sinus involvedMaxillary pain is often in the cheek or upper jaw, ethmoid pain between the eyes, frontal pain in the forehead, spenoid pain at the vertex or any cranial locationCT scan more sensitive than plains film

Differential Diagnosis and ManagementSecondary Headache SyndromeOther secondary headache syndromeOcular headache: glaucoma, diplopia, orbital tumor or retroocular inflamationFeeling heaviness in the eyes, gradually more severeIts absent on awakening, appears in afternoon and gradually worsensPain may be dull, bursting,sharp,throbbing and its often due to persistent muscle contractionThe pain is bifrontal or periorbital in locationMay be associated with prolonged reading

Differential Diagnosis and ManagementSecondary Headache SyndromeOther secondary headache syndromeTrigeminal neuralgia (tic douloureux)Recurrent pain in the distribution of one or more branches of N.VPain radiate to the jaws or teeth and present as a dental problemPrecipitated by minimal sensory stimuli to the affected side of the faceIt occurs after 40 years of age; suspect MS when the onset is earlierThere is no sensory loss in the trigeminal distribution; if there is sensory loss or decreased corneal reflex maybe tumors or vascular abnormalities

Differential Diagnosis and ManagementSecondary Headache SyndromeOther secondary headache syndromeToxic headacheToxic headache has characteristic as vascular headacheCause by drugs: phenacetin, amyl nitrite, reserpine, lithium, dextroamphetamine, ephedrine, disulfiram, digitalis, imipramineMay result after excessive intake of alcohol or coffeMay after discontinuation of corticosteroid, barbiturate, ergot or narcoticsOccupational hazard: insecticides, CO ect

Differential Diagnosis and ManagementPrimary Headache SyndromeTension-type headacheCluster headacheMigraine headacheChronic Paroxysmal HemicraniaDrug Rebound Headache

Differential Diagnosis and ManagementPrimary Headache SyndromeTension Type HeadacheHIS Diagnostic Criteria2 of the following pain characteristics:Pressing / tightening (nonpulsating) qualityMild or moderate intensity-may inhibit but does not prohibit activitiesBilateralNot aggravated by physical activity (eg walking stairs)Both of the following:No nausea or vomitingPhotophobia and phonophobia are absent, or one but not the other is present

Differential Diagnosis and ManagementPrimary Headache SyndromeClinical Features of Tension Type Headache

Differential Diagnosis and ManagementPrimary Headache SyndromeCluster headachesIHS Diagnostic CriteriaA> 5 attack B-DB. Severe unilateral orbital, supraorbital, and /or temporal pain listing 15-180 mins when untreatedC . Headache is associated with>1 of the following ipsilateral signs: conjuctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, eyelid edemaD.Frequency: Attack occur 1 every other day up to 8 per day

Differential Diagnosis and ManagementPrimary Headache SyndromeCluster headachesEpisodic cluster headache:occurs in periods lasting 7 days to 1 yr, separated by pain-free periods lasting >14 daysChronic cluster headache: occurs for > 1 yr without remission or with remissions lasting < 14 days

Differential Diagnosis and ManagementPrimary Headache SyndromeCluster headachesAdditional FeaturesOne unique is a male predominance (9:1)Typical onset is 20-40 yrsAs detailed above, the classic cluster headache is periorbital and unilateral, with relatively rapid onset and associated with sharp and excruciating painCluster refers to distinguishing time course of these headachesMay be identified in the waiting roomAlcohol is an especially common trigger

Differential Diagnosis and ManagementPrimary Headache SyndromeClinical Features of Cluster Headaches

Differential Diagnosis and ManagementPrimary Headache SyndromeMigraine HeadachesIHS Diagnostic CriteriaMigraine without Aura. A.>5 attacks fulfilling criteria B-D.B.Untreated or unsuccessfully treated headache that last 4-72 hrs.C.Headache with .2 of the following characteristic:UnilateralPulsating qualityModerate or severe intensity (interference with daily activities)Aggravated by routine physical activity (eg.walking up stairs)

Differential Diagnosis and ManagementPrimary Headache SyndromeMigraine HeadachesIHS Diagnostic CriteriaMigraine without Aura. D.During headache,>2 of the following:Nausea and/for vomitingPhotophobia and phonophobia.E. >1 of the following:History and physical exam do not suggest headache secondary to organic or systemic metabolic diseaseHistory and/or physical exam suggest a secondary disorder that has been ruled out by appropriate investigationsA secondary disorder is present, but migraine attacks do not occur for the first time in close temporal relation to the disorder

Differential Diagnosis and ManagementPrimary Headache SyndromeMigraine HeadachesIHS Diagnostic CriteriaMigraine Aura. A.> 2 attacks fulfilling criterion B. B.> 3 of the following four characteristics:> 1 fully reversible aura symptom indicating focal cerebral cortical and/or brainstem dysfunction> 1 aura symptom that develops gradually over > 4 mins or > 2 symptoms occuring in successionNo single aura symptom lasting > 60 secsHeadache follows aura with free interval of < 60 mins. It may also begin before or stimulataneously with aura

Differential Diagnosis and ManagementPrimary Headache SyndromeMigraine HeadachesIHS Diagnostic CriteriaMigraine Aura. C. > 1 of the following:History and physical exam do not suggest headaches secondary to organic or systemic metabolic diseaseHistory and/or physical exam suggest such a disorders, but it is ruled out by appropriate investigationsSuch disorder is present, but migraine attacks do not occur for the first time in close temporal relation to the disorder

Differential Diagnosis and ManagementPrimary Headache SyndromeMigraine HeadachesIHS Diagnostic CriteriaLess Common VariantsOpthalmologic migraines: which present with third nerve palsies, but can affect cranial nerve III-IVRetinal migraines: rare potentially serious spasms of retinal artery with corresponding visual loss or obscuration

Differential Diagnosis and ManagementPrimary Headache SyndromeMigraine HeadachesMigraine PhasesProdormeOccurs in 30-40% of the patientsLenght may vary in patients from minutes to hours, or even daysStereotypical symptoms in patients include vaque sensations of discomfort, drowsiness, depression, photophobia, impaired concentration and changes in bowel or bladder functions

Differential Diagnosis and ManagementPrimary Headache SyndromeMigraine HeadachesMigraine PhasesAuraVisual:Fortification spectra:zigzag lines across the visual fieldScintillating scotomaPhosphenes: bright flashes of linesMetamorphopsia: alteration in the size or shape of objects in the visual field

Differential Diagnosis and ManagementPrimary Headache SyndromeMigraine HeadachesMigraine PhasesOther common symptoms:Paresthesia: Cheiro-oral paresthesia refers to the most common phenomenon of numbness, which begins in the hand but travels proximally until it reaches the corner of the mouthAphasiaMotor weakness (unilateral)Dysarthria

Differential Diagnosis and ManagementPrimary Headache SyndromeMigraine HeadachesHeadache PhasesPain:Common description include throbbing, dull, boring, pulsating, and lacinatingMore often unilateral, lasting 4-72 hrs in adultsCommon associated symptoms include nausea, vomitting, photophobia, sonophobia, blurry vision, scalp tenderness, abndominal pain, irratability, anxiety and depressionThe most exacerbating and relieving factors are physical activity and sleep, respetively

Differential Diagnosis and ManagementPrimary Headache SyndromeClinical Features of Migraine Headaches

Differential Diagnosis and ManagementPrimary Headache SyndromeChronic Paroxysmal Hemicrania (CPH)A very rare headache syndromCPH resembles cluster headache in that it presents as multiple, short, severe periorbital headaches that occurs on a daily basisThe headaches can be associated with autonomic featuressuch as ipsilateral nasal stuffiness or rhinorrhoea, ptosis, tearing and/or conjunctival injection

Differential Diagnosis and ManagementPrimary Headache SyndromeChronic Paroxysmal Hemicrania (CPH)The patient are almost always femaleThe headache attacks are shorter (average duration 1-2 minutes) and much more frequent, with attacks occuring on avarage 14 times per dayThe tendency for attacks to cluster is not as pronouced, and the condition responds completely to indomethacin, and nothing elseThe pathogenisi completely obscureReferal to a specialist is recommended

Differential Diagnosis and ManagementPrimary Headache SyndromeClinical Features of Chronic Paroxysmal Hemicrania (

Differential Diagnosis and ManagementPrimary Headache SyndromeDrug Rebound HeadacheAnalgesics as being abused by headaches patients and causing daily headaches if it taken in chronic mannerDRHPrevalence unknown; analgesic abuse has been estimated at 2 %)More common in women than in man, probably reflects the fact that more women suffer from headache than menAmongst headache patients, it seems about 4% are likely to be drug absusers (ie taking analgesics or ergotamine every day)

Differential Diagnosis and ManagementPrimary Headache SyndromeDrug Rebound HeadacheThe headache typically persists throughout the whole day, although it fluctuates in intensityIt is present on waking and described as mild to moderate, dull, bilateral, frontal-occipital or diffuse.Headaches are not normally associated with visual disturbances or autonomic symptoms, but migraine attacks are commonly superimposed upon the rebound headache with of the usual symptomatologyPatients self medicate throughout the day, often every 3-4 hrs, since after that time headache generally worsens as analgesia begins to wear off Pain relief, if gained at all, is trasient and rarely complete

Differential Diagnosis and ManagementPrimary Headache SyndromeDrug Rebound HeadachePathogenesisDependency on ergotamine or the simple analgesics may have both a physiological and a psychological componentErgot has been shown to be active within the CNS, which may result in a pharmacological dependenceSimple analgesics, frequently formulated in combination with caffeine and/or opioids which have well documented abuse potential, are thought, by some, to eventually supress pain control mechanism after chronic useDRH should be suspected in all patients who prolonged daily headaches and especially in those patients who say they have headache all day, every day

Differential Diagnosis and ManagementPrimary Headache SyndromeDrug Rebound HeadachesManagement PrinciplesPrompt and complete withdrawal of the analgesicIf a narcotic analgesics is involved, withdrawal must be gradual and concomitant use of neuroleptics is commonMay require supportive care for some days upon cessation of therapyMay need fluid replacement, use of anti-emetics, hypnotics and sedatives for up to 14 daysDuring rebound headache, all analgesics should be avoidedPrevent habituation againUsed a headache diary for the following 2 monthsPrognosisThe success rate of withdrawal therapy reported in the literature is between 40-100%, with a mean rate of 70% depending of the time follow up, the drugs taken and the original type of headache

Differential Diagnosis and ManagementPrimary Headache SyndromeClinical Features of Drug Rebound Headache

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