MANAGEMENT OF HEADACHEDR SUDHIR KUMAR MD DM (NEUROLOGY)CONSULTANT NEUROLOGIST, APOLLO HOSPITALS, HYDERABAD

SCOPE OF MY TALKEpidemiology of headaches,Diagnosis of primary headache syndromes,When to do brain imaging in a case of

headache,Other investigations in headache evaluation,Treatment of headache syndromes.

EPIDEMIOLOGYHeadache is the commonest disorder

encountered in Neurology OP clinics,Prevalence varies across studies,The median one-year prevalence found in a

recent study were- migraine (9%); tension type headache (16%) and chronic daily headache (3%). (Headache, 2014)

Lifetime prevalence- migraine (18%), TTH (52%)

Migraine is more common in women than men after puberty (2-3:1)

PRIMARY HEADACHE SYNDROMESMigraine,Tension type headache,Cluster headache,Medication overuse headache.

MIGRAINE (1) A. At least five attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hours, C. Headache has at least two of the following:1. Unilateral location, 2. Pulsating quality, 3.

Moderate or severe pain intensity, 4. Aggravation by routine physical activity.

D. During headache, at least one of the following:1. Nausea and/or vomiting, 2. photophobia and phonophobia.

MIGRAINE (2)Chronic migraine- headaches occurring 15 or

more days in a month for three months or more.

Status migranosus- Headache attack lasting for more than 72 hours.

Migraine with aura- Aura (for 5-60 min) preceding an attack of headache.

TENSION TYPE HEADACHE (1)Headache lasts for 30 min to 7 days,Headache has at least two of the following:1. Bilateral location, 2. Pressing/tightening (non

pulsatile) quality, 3. Mild or moderate intensity, 4. Not aggravated by routine physical activity.

Both of the following:1. No nausea or vomiting, 2. Either phonophobia or photophobia (not both)

TENSION TYPE HEADACHE (2) Infrequent TTH- <1 headache per month,Frequent TTH- 1-15 headaches per month,Chronic TTH- >15 headaches per month for

three months or more.

CLUSTER HEADACHE (1)A. At least 5 attacks fulfilling criteria B-D.B. Severe or very severe

orbital/supraorbital/temporal headache, lasting for 15-180 min,

C. Headache is accompanied by at least one of:1. Conjunctival injection or lacrimation, 2. Eye

lid oedema, 3. Nasal congestion, 4. forehead or facial sweating, 5. miosis or ptosis, 6. restlessness or agitation

D. Attack frequency every other day to 8/day.

CLUSTER HEADACHE (2)Episodic CH- Headaches occurring during

periods of 7-365 days, separated by pain free period of one month or more,

Chronic CH- Attacks occur over >1 year, without remission periods or remission periods of <1 month.

OTHER PRIMARY HEADACHESCough headache,Exercise induced headache,Headache related to sexual activity,Headache related to cold stimulus,External pressure induced headache,Hypnic headache (occurs during sleep)

MEDICATION OVERUSE HEADACHEHeadache present on >15 days per month,Regular overuse for >3 months of one or more

pain killers for headache,Headache has worsened during medication

overuse.(Pain killers may include triptans, ergotamines, opioids, other analgesics; use >10 days per month)

SECONDARY HEADACHE DISORDERSTrauma/head injury,Vascular disorder (Ischemia, hemorrhage,

CVST)Non vascular intracranial disorder (IIH, low

pressure, inflammatory disease, neoplasm), Infection (CNS, systemic, others)Related to psychiatric disorder

WHEN TO ORDER BRAIN IMAGING? Brain scan is expected to be normal in most

patients with headaches; also, fundus examination may be normal in patients with brain tumors.

Red flags, where MRI may be needed:1. New onset headache,2. Abrupt onset,3. Progressive symptoms,4. Abnormal neurological signs,5. Headache with exertion,6. Change with head position,7. Change with valsalva maneuver, such as cough,

sneeze, strain

CAN LUMBAR PUNCTURE BE DONE IF FUNDUS EXAM IS NORMAL?Patient with headache and suspected

meningitis/IIH would require lumbar puncture to confirm/exclude the diagnosis.

Papilledema may be absent in brain tumors (JNNP, 1975)

Absence of papilledema does not mean that ICP is normal in an acute setting. It may take a few days to develop. (Ophthalmology, 1996)

So, it is always good to do a brain scan before doing lumbar puncture in these situations.

TREATMENT OF HEADACHESMigraine: Acute attacks- triptans, ergot,

NSAIDSMigraine: Prevention- propranolol, divalproex,

topiramate, BOTOXTTH- Acute attacks- Ibuprofen, diclofenac,

aspirin, paracetamol, naproxen (Level A evidence)

TTH- prevention: Amitriptyline (Level A); Mirtazapine, venlafaxine (Level B)

CASE 160-year old woman,New onset headache of one month duration,Throbbing, bilateral,Associated generalized aches and pains.Diagnosis??

CASE 1 (cont’d) Jaw claudication noted while chewing, Intermittent visual blurring,Tenderness in temporal region,Elevated ESR/CRPTemporal artery biopsy- suggestive of giant cell

arteritisResponded to steroids.

CASE 225-year old overweight woman,Headache of three months duration,Headache more in mornings,Horizontal diplopia,Transient visual obscurations,Diagnosis?

CASE 2 (cont’d)Fundi- bilateral papilloedema,Rest of neurological examination normalNormal MRI/MRV,CSF opening pressure- elevated.Diagnosis- Idiopathic intracranial hypertension. Treated with acetazolamide and steroids.

CASE 3- POST LP HEADACHE Bilateral headaches starting within 7 days of LP, Worsens within 15 minutes of assuming upright

position, Disappears within 30 min of lying down, Usually resolves in a few days, but may last for upto

19 months(!) Diagnosis is usually clinical; if LP is done-low CSF

pressure, high protein and lymphocyte count MRI if done- diffuse enhancement, with descent of

brain and brainstem.

CASE 3 (cont’d) Factors reducing the incidence of post LP headaches-

small needle diameter, direction of needle, atraumatic needles, replacement of stylet, fewer LP attempts.

Factors not influencing the incidence of Post LP headaches- volume of spinal fluid removed, rest after LP, hydration after LP, lying down vs sitting position while performing LP, CSF characteristics (such as pressure, cell counts, infection, etc).

Conservative treatment- rest, hydration, analgesics Epidural blood patch, if conservative treatment fails.

CONCLUSIONSThe causes of headache are varied.Systematic history and examination are the

most valuable tools in the correct diagnosis of underlying cause.

Brain imaging and LP are useful in final confirmation of certain important causes.

Management depends on the exact cause of headache identified.

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