Headache

APPROACH TO HEADACHE

Dr Surya Kumar

Headaches in ChildrenHeadaches in ChildrenObjectiveObjective

Learn the Causes of Headaches in Learn the Causes of Headaches in Children.Children.

Learn common causes of chronic Learn common causes of chronic headache and common causes of severe headache and common causes of severe headache.headache.

Learn to evaluate a patient with Learn to evaluate a patient with headache.headache.

Understand parental concerns.Understand parental concerns.

INTRODUCTION The term headache should encompass all

aches and pains located in the head, but in practice its applications is restricted to discomfort in the region of the cranial volt.

Headache, or cephalalgia, is defined as diffuse pain in various parts of the head, with the pain not confined to the area of distribution of a nerve

Incidence of Chronic or recurrent headacheIncidence of Chronic or recurrent headache40% by age 7 years.40% by age 7 years.75% by age 15 years.75% by age 15 years.

Accounts for 10% referrals to NeurologistAccounts for 10% referrals to Neurologist. .

CLASSIFICATION

(International headache society)

1. Migraine:•Migraine without aura.•Migraine with aura. •Ophthalmoplegic migraine.•Retinal migraine.

2.Tension type headache3.Cluster headache

4.Miscellaneous headache not associated with structural lesion: Idiopathic stabbing headache. Cold stimulus headache . Benign cough headache . Headache associated with sexual activity .5.Headache associated with head trauma.6.Headache associated with vascular disorder. Acute ischaemic (CVD) Intracranial haematoma . SAH Arteritis- Giant cell arteritis. Venous thrombosis. Arterial hypertension.

Classification contd..

7. Headache associated with non vascular intracranial disorder.8. Headache associated with substances or their withdrawal.9. Headache associated with non cephalic infection10. Headache associated with metabolic disorder.

11.Headache or facial pain associated withdisorders of facial or cranial structures.

12.Cranial neuralgias ,nerve trunk pain13.Headache not classified

RECURRENT HEADACHE

TENSION TYPE HEADACHE.

CLUSTER HEADACHE.

MIGRAINE.

Case history 1Case history 1 7 year old boy with history of frequent 7 year old boy with history of frequent

headaches for the last 4 monthsheadaches for the last 4 months Not responding to paracetamole and Not responding to paracetamole and

Ibuprofen and CodeineIbuprofen and Codeine Not associated with vomitingNot associated with vomiting CNS , eye, ears, and systemic examination CNS , eye, ears, and systemic examination

were normalwere normal Cranial CTCranial CT More anxietyMore anxiety

TENSION TYPE HEADACHE

The word "tension" implies that this type The word "tension" implies that this type of headache can be attributed entirely to of headache can be attributed entirely to tension or stress, which may make tension or stress, which may make people with this type of headache people with this type of headache reluctant to consult a physician. reluctant to consult a physician.

. . International Headache Society International Headache Society diagnostic criteria for tension-type diagnostic criteria for tension-type headacheheadache

Primary diagnosisPrimary diagnosis1.1. Headache has Headache has at leastat least two of the following two of the following characteristicscharacteristics::      Bilateral painBilateral pain   Pressure   Pressure   Mild to moderate pain   Mild to moderate pain   No increased pain with physical exertion   No increased pain with physical exertion2. 2. AndAnd no more than one of the following: no more than one of the following:      Sensitivity to lightSensitivity to light   Sensitivity to sound   Sensitivity to sound3. 3. AndAnd neither of the following*: neither of the following*:     Nausea Nausea   Vomiting   Vomiting4. 4. AndAnd duration of 30 minutes to 7 days duration of 30 minutes to 7 days

Subdivision diagnosisSubdivision diagnosis

1.1. Episodic (<15 days/mo) Episodic (<15 days/mo) oror chronic ( chronic (>>15 15 days/mo for >6 mo)days/mo for >6 mo)2.2. Associated with Associated with oror not associated with not associated with coexisting pericranial muscle tenderness**coexisting pericranial muscle tenderness**

**Chronic tension-type headache may include one Chronic tension-type headache may include one of these symptoms.of these symptoms.

**Diagnosed by manual palpation or **Diagnosed by manual palpation or electromyographic studies. electromyographic studies.

Adapted from Headache Classification Committee of the International Adapted from Headache Classification Committee of the International Headache Society (2).Headache Society (2).

Synonym: Raeder’s syndrome, Histamine cephalalgia, Red migraine, paroxysmal nocturnal cephalagia. Age – 20 to 50 yrs. Sex – men are affected 7 to 8 times more than women. The pain begins without warnings & reaches a crescendo within 5 minutes. Each attack last for 30 min to 2 hours.1 – 3 short-lived attacks/day over a 4 – 8 weeks period, followed by a pain free interval that average one year.

CLUSTER HEADACHE

CLUSTER HEADACHE

Almost always the same orbit is involved during attacks.

The pain is excruciating in intensity & deep, non-fluctuating and explosive in quality.

Associated with - homolateral lacrimation, red eye, miosis, lid ptosis, nasal stuffiness & nausea.

Onset is nocturnal is about 50% of the cases & then pain usually awakens the patients within 2 hours of falling asleep.

Diagnostic Criteria for Cluster HeadacheDiagnostic Criteria for Cluster Headache A At least five attacks fulfilling criteria B through D A At least five attacks fulfilling criteria B through D

B Severe unilateral orbital, supraorbital and/or B Severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes (untreated)temporal pain lasting 15 to 180 minutes (untreated)C .Headache associated with at least one of the C .Headache associated with at least one of the following signs on the pain side: following signs on the pain side:

Conjunctival Conjunctival injection injection LacrimationLacrimation Nasal congestion Nasal congestion RhinorrheaRhinorrhea Forehead and facialForehead and facial

sweating sweating MiosisMiosis Ptosis Ptosis Eyelid edemaEyelid edema

D. Frequency of attacks: one attack every other D. Frequency of attacks: one attack every other day to eight attacks day to eight attacks

Contd.. Treatment: Inhalation of 100% O2 for 10 – 15 minutes. Intranasal lidocaine/sumatriptane.

Prophylaxis Ergotamine Prednisolone Verapamil Lithium – Methysergide.

CLUSTER HEADACHE

Case history 2Case history 2 A 10 year old boy with history of headache for 4 A 10 year old boy with history of headache for 4

weeksweeks Started as funny feeling inside his abdomenStarted as funny feeling inside his abdomen Pain round the right eyePain round the right eye Pain spread all over his headPain spread all over his head VomitVomit PhotophobiaPhotophobia Fatigue, lethargic and want to sleepFatigue, lethargic and want to sleep

MIGRAINE

Periodic, commonly unilateral, often pulsatile headache, begins in childhood, adolescence, or early adult life & recur

with diminishing frequency during advancing years.

Associated with nausea, vomiting and/or other symptomsof neurological dysfunction of varying admixture.

The attacks cease during pregnancy in 75-80% of women.

Migraine: contd.

Some patients link their attacks to certain dietary items – chocolate, cheese, fatty foods, orange, tomatoes, onions.

In others headache are consistently induced by – exposure to glare or other strong sensory stimuli – worry. Sudden jarring of the head. Rapid change in barometric pressure. Lack of sleep.

Migraine with aura:

Premonitory symptoms: Changes in mood (surge of energy & feeling of well being), appetite (hunger or anorexia). Aura: Visual disturbance – Unformed flashes of white or multicoloured light (Photopsia), An enlarging blind spot with a shimmering edge (scintillating scotoma), formation of dazzling zigzag lines-, (fortification spectra), blurred or cloudy vision. Sensory disturbance – Numbness & tingling of the lips face & hand. Motor disturbance – Weakness of an arm or leg, mild aphasia or dysarthria.

Migraine Variants: Ophtlamoplegic migraine : Recurrent unilateral associated with weakness of the extra ocular muscle – A transient 3rd or 6th nerve palsy. More common in children. Retinal migraine: Headache associated with monocular blindness due to retinal or ant. optic nerve ischaemia. Basilar migraine: The patient first develop total blindness which is accompanied by admixture of – vertigo, ataxia, dysarthria, tinnitus, & distal or perioral paresthesia. The neurological symptoms are followed by throbbing occipital headache.

Hemiplegic migraine: Childhood periodic syndrome: Instead of complaining of headache, the child appears limp & pale & complains of abdominal pain. Vomiting is more common than in the adult..

Complicated migraine: Migraine with dramatic transient focal neurologic features. Or, migraine attack that leaves a persisting residual neurologic deficit.

Status migrainosus: Migraine patient who lapses into a condition of daily or virtually continuous migraine.

Modified Diagnostic Criteria for Migraine

Episodic attacks of headache lasting 4-72hr

With two of the following symptoms:•Unilateral pains•Throbbing/pulsating•Aggravation on movement.•Pain of moderate or severe intensity.

And one of the following symptoms:•Nausea or vomiting.•Photophobia or Phonophobia.

Diagnostic Criteria for Migraine Diagnostic Criteria for Migraine Migraine without auraMigraine without aura At least five attacks fulfilling criteria B through D At least five attacks fulfilling criteria B through D Headache lasting 4 to 72 hours (untreated or unsuccessfully treated) Headache lasting 4 to 72 hours (untreated or unsuccessfully treated) At least two of the following pain characteristics: At least two of the following pain characteristics:

Unilateral location Unilateral location Pulsating quality Pulsating quality Moderate or severe intensity Moderate or severe intensity Aggravation by walking stairs or similar physical activity Aggravation by walking stairs or similar physical activity

During headache, at least one of the following: During headache, at least one of the following: Nausea and/or vomiting Nausea and/or vomiting Photophobia and phonophobia Photophobia and phonophobia

Migraine with auraMigraine with aura At least two attacks fulfilling criterion B At least two attacks fulfilling criterion B At least three of the following characteristics: At least three of the following characteristics:

One or more fully reversible aura symptoms indicating focal cerebral cortical One or more fully reversible aura symptoms indicating focal cerebral cortical and/or brain-stem dysfunction and/or brain-stem dysfunction

At least one aura symptom develops gradually over more than 4 minutes, or two At least one aura symptom develops gradually over more than 4 minutes, or two or more symptoms occur in succession. or more symptoms occur in succession.

No aura symptom lasts more than 60 minutes; if more than one aura symptom is No aura symptom lasts more than 60 minutes; if more than one aura symptom is present, accepted duration is proportionally increased. present, accepted duration is proportionally increased.

Headache follows aura, with a free interval of less than 60 minutes (headache Headache follows aura, with a free interval of less than 60 minutes (headache may also begin before or simultaneously with aura). may also begin before or simultaneously with aura).

B. Pharmacologic therapy:Staged approach to migraine pharmacotherapy:

StageStage DiagnosisDiagnosis TherapiesTherapies

MildMild Occasional throbbing Occasional throbbing headache (less than one headache (less than one attack per month)attack per month)

No major impairment of No major impairment of functioningfunctioning..

Control of Control of migraine attacks migraine attacks ––

ModerateModerate Some impairment of Some impairment of function.function.

Moderate or severe Moderate or severe headache (1-3 attacks headache (1-3 attacks per month)per month)

Nausea commonNausea common

Control of Control of migraine attacks migraine attacks – –

SevereSevere Severe headache (>3 Severe headache (>3 attacks per month)attacks per month)

Marked nausea and/or Marked nausea and/or vomiting.vomiting.

Significant functional Significant functional impairment.impairment.

Control of Control of migraine attacksmigraine attacks

Prophylactic Prophylactic medicationmedication

Control of acute migraine attacks:

The drugs should be taken as soon as the headache component of the attack is recognized. Drugs used in the control of migraine attacks are Analgesics Combination analgesics5HT agonist (Oral, Nasal, SC, IM, or IV)Dopamine antagonists (Oral, IM or IV).

The vast majority of migraine attacks can be treated solely with mild analgesics such as – Acetaminophen – Aspirin -

Other NSAIDs – Ibuprofen – Naproxen.Indomethacin -.

Combination analgesics:The combination of Acetaminophen, Aspirin & Caffeine has been approved for use by the FDA for the treatment of mild to moderate migraine.The combination of Acetaminophen, Dichloral phenazone & Isometheptene has been classified by the FDA as “possibly” effective in the treatment of migraine.

5HT agonist (Oral, Nasal, SC, IM, or IV):Ergot derivatives – Ergotamine & Dihydro ergotamine (DHE) Ergot preparation can be taken – Orally, Sublingually, Rectally, IM, IV, Inhalers.

Indications for migraine prophylaxis 

Attacks occur >2-4 times per month

Disability occurs > 3 days per month

Duration of attack > 48 h

Medications for acute attack are ineffective, C.I or overused

Attacks produce prolonged aura or true migrainous infarction Patient preference

Duration of prophylactic therapy  

The optimum duration of prophylactic therapy is uncertain

The approach is to treat for 6-12 months and then taper over the course of several weeks.

Data are limited on the effectiveness of preventive agents in children

DRUGS USED FOR PROPHYLAXIS OF MIGRAINEDRUGS USED FOR PROPHYLAXIS OF MIGRAINE

Propranolol.Propranolol. Timolol.Timolol. Sodium valproateSodium valproate Methyserzide.Methyserzide.These drugs are approved by FDA, USA. These drugs are approved by FDA, USA.

Others:Others: Amitryptyline, Nortryptilline.Amitryptyline, Nortryptilline. Phenelzine, Cyproheptadine.Phenelzine, Cyproheptadine.Under research:Under research: Gabapentine Gabapentine TopiramateTopiramate

•Accurate history taking is fundamental

•Need for further investigation is determined by red flag symptoms

•Or symptoms that do not corresponding to a recognised primary headache pattern

DIAGNOSIS

HISTORY TAKING:1.Age, sex, occupation: Migraine headache – more frequent in teenagers & young adults, higher occurrence in female. Cluster headache – almost exclusively in males.Cranial arteritis – more frequently in late middle age & in elderly.2. Duration: Tension headache -often has long duration. Headache due to expanding of intracranial disease – usually short duration. Headache due to meningeal cause – acute in onset. Migraine headache – recur over a long period of time, with symptoms free interval between attacks

DIAGNOSTIC APPROACH: Contd..3. Location of headache:

As a general rule localized headache is of greater significance than diffuse headache.Tension headache – typically generalized, band like or bioccipital.Migraine with aura – often unilateral & frequently more prominent interiorly. Migraine without aura – frequently bilateral. Cluster headache – invariably limited to the same side of the head in any given attacks & usually periorbital.

APPROACH: Contd

8. Frequency, duration & diurnal variation: Tension headache – often persist & may worsen as the day progress. Migraine headache – the frequency is variable & unpredictable. Although usual variation is from 4 - 72 hrs, they may persist for days. Cluster headache – occur repetitively over a period of weeks or months. Often there are 1 or 2 attacks daily. The headache typically nocturnal & of brief duration (30 min to a few hours).

9. Family history:

Migraine headache – strong family history. Cluster headache – are not familial.

Red flag for secondary headache - Silberstein SD et al

Flag Descriptios/exampleSystemic symptoms or secondary risk factors

Fever,W. Loss,or known cancer,HIV, immunosupression or thrombotic risks

Nerological symptoms or abnormal signs

Confusion,impaired alertness/drowsy, persistent focal signs> 1 H

onset First and worst headache,sudden abrupt from sleep, or progressively worsening

older New onset and progressive-Giant cell arteritis

Previous headache history Significant change in features, freq. or severity

Triggered headache By valsalva, exertion, sexual intercourse

When to scan a patient with headacheWhen to scan a patient with headache

First or worst headache, particularly if of sudden First or worst headache, particularly if of sudden onset.onset.

Headache of increasing frequency or severity.Headache of increasing frequency or severity. Increased frequency of vomiting and headache on Increased frequency of vomiting and headache on

waking.waking. Headache triggered by coughing, straining or Headache triggered by coughing, straining or

postural changes.postural changes. Persistent physical symptoms or signs after attack Persistent physical symptoms or signs after attack

(neurological or endocrine)(neurological or endocrine) Meningism, confusion,impairment of Meningism, confusion,impairment of

consciousness or seizures.consciousness or seizures.

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