HEADACHEDEPARTMENT OF FAMILY MEDICINE
POST GRADUATE INTERNS 2016:PROCIANOS, GELEEN ANNE
RODRIGUEZ, JISAGEMORA, KATRINA
OBJECTIVES:
• To classify headache according to:– Acute– Subacute– Chronic
• To identify the precipitating factors, prodomal symptoms, and its location and characteristics
• To identify pediatric and adult headache and their managements
Reference:
- Clinical Neurology 6th edition , Greenberg, David et al.
- Nelson Textbook of Pediatrics 19th Edition, Kliegman, Robert et al.
History Taking in Children:
• Location• Character• Triggering factors• Relieving factors• Time and duration• Nausea, vomiting• Aura, prodromal period
Reference: Nelson’s Textbook of Pediatrics, 19th edition
Danger Signals in Children:• Progressive headache• Sudden onset of severe headache,
unrelieved by rest or analgesics• Headache precipitated or aggravated by
exertion, coughing or straining• Presence of fever, seizures or neurologic
deficits
Reference: Nelson’s Textbook of Pediatrics, 19th edition
Danger Signals in Children:• Occur in early morning then quickly
improve• Exacerbated by Valsalva maneuver• Presence of signs of ICP• Any change in gait, behavior, personality
Reference: Nelson’s Textbook of Pediatrics, 19th edition
Indications for Neuroimaging Studies:• History is not compatible with a known
headache disorder• Points in the history are consistent with a
serious pathology• Any focal finding in the history or neurologic
exam• Any abnormality in the neuro exam
Reference: Nelson’s Textbook of Pediatrics, 19th edition
MIGRAINE
• Episodic headache• Intensity: moderate or severe• Location: focal• Quality: throbbing• Associated with: nausea, vomiting, light
sensitivity, sound sensitivity and aura (typical or atypical)
Reference: Nelson’s Textbook of Pediatrics, 19th edition
CLASSIFICATION AND CLINICAL MANIFESTATIONS: MIGRAINE W/O AURA
Reference: Nelson’s Textbook of Pediatrics, 19th edition
CLASSIFICATION AND CLINICAL MANIFESTATIONS: MIGRAINE W/ AURA
Reference: Nelson’s Textbook of Pediatrics, 19th edition
Stages in Migraine with Aura
I. Aura: lasts for 15 to 30 minutes
II. Headache Phase: nausea, vomiting, photophobia, phonophobia
III.Post Headache: area on the side of the attack remains tender patient may feel exhausted
Reference: Nelson’s Textbook of Pediatrics, 19th edition
Migraine Variants• Cyclic Vomiting - recurrent monthly bouts of vomiting
• Acute Confusional State - confusion,hyperactivity, disorientation, unresponsiveness, memory disturbances, vomiting and lethargy
• Benign Paroxysmal VertigoReference: Nelson’s Textbook of Pediatrics, 19th edition
Complicated Migraine• Basilar Artery Migraine– vertigo, tinnitus, diplopia, blurred vision, ataxia
and an occipital headache– alterations in consciousness and generalized
seizures may result
• Ophthalmoplegic Migraine– a third nerve palsy ipsilateral to the headache
Reference: Nelson’s Textbook of Pediatrics, 19th edition
Complicated Migraine• AmaurosisFugax– transient monocular blindness
• Hemiplegic Migraine– unilateral sensory or motor signs during the
headache
Reference: Nelson’s Textbook of Pediatrics, 19th edition
Management of Migraine
Non-pharmacologic• - Reassurance• - Elimination of trigger factors• - Modification of stress• - Regular diet• - Sufficient sleep
Reference: Nelson’s Textbook of Pediatrics, 19th edition
Management of MigrainePharmacologic
- Analgesics- Antiemetics
(prophylactic)- Beta blockers- Calcium channel blockers- Tricyclicantidrepressants
Reference: Nelson’s Textbook of Pediatrics, 19th edition
Classification
• Primary – Migraine, Cluster, Tension; 90% of headaches
• Secondary – associated with underlying organic lesion or systemic illnesses; 10%
Classification
ACUTENew in onsetSubarachnoid Hemorrhage-Bleeding into the subarachnoid space is usually due to a ruptured saccular aneurysm or AVM-75 % due to anuerysm , 15 % AVM-Aneurysm : females 50-60y.0-AVM : males , 20-40 y.o
Pathology : Aneurysm•Congenital weakness of the vessel wall at sites of branching•20% multiple•May be associated with other congenital anomalies
Pathology : AV Malformation
•Cause SAH in 10%•Abnormal vessels bypass the capillary system•More often result in IC hematoma than SAH
OTHER CAUSE OF ACUTE HEADACHE
-> SEIZURES as Post Ictal Phenomenon-> Lumbar Puncture – increased in upright position and relieved with recumbency ; due to persistent CSF leak --- Use small gauge needle and get only limited amount of CSF ---- Lying flat after LP Hypertensive EncephalopathyOcular Disorders - Angle Closure Glaucoma
Sexual Headachessexual excitementOrgasmicPost – orgasmicBenign but SAH sometimes be excluded, self limitingMales > FemalesLong foreplay or Abstinence may prevent
ClassificationSUBACUTEWeeks or months
Giant Cell Arteritis• - temporal arteritis• - Subacute granulomatous inflammation (lymphs, neutrophils and giant cells ) • - 2x women } MEN• - 50 Years and above• - scalp tenderness, jaw claudication (pain / stiffness on chewing)• - blindness in 50 % due to involvement of opthalmic artery• - diagnosis – biopsy of thickened , dilated STA
Intracranial Lesions• Brain Abscess – foci of infection, fever may or may not be present•Subdural Hematoma – elderly, alcoholic, ; Hx of trauma ; waxing and waning S/S• Brain tumors•Diagnosis – CT scan and MRI•LT - is contraindicated in most cases and not very helpful
Neuralgia•Trigeminal Neuralgia – V2, V3•Glossopharyngeal Neuralgia – swalllowing, may be associated with syncopal attacks•Post Herpetic Neuralgia – V1, vesicular lesions or scar in distribution of nerve•Diagnosis : Clinical; CT to R/O SOL
Classification Migraine with Aura
Migraine without AuraCluster headache
Tension Type HeadacheCervical Spine Disease
SinusitisDental Disease
P.E : scalp , face, head
Vital signs Temperature, Pulse , cardiac rate, BP
Weight loss, Malignancy
Skin Cutaneous lesions in meningococcemia, herpes zoster, AVM
Scalp Tenderness, nodularity, erythema, signs of trauma, tongue lacerations, bruits, conjunctival injenction, Horners
NEUROLOGIC EXAMINATION
• MSE – confusion in SAH • Focal deficits, in cranial nerve , motor and
sensory examination
Treatment
• Analgesic Withdrawal Headache – Oral Triptans or Parenteral Dihydroergotamine if needed
• Cluster Headache – manage acute pain and prevent subsequent ones with Sumatriptan or Dihydroergotamine
• Tension-type Headache – may be managed using same agents used for migraine; may respond to aspirin, acetaminophen, NSAIDs, or dihydroergotamine
Prophylactic Treatment
1. Beta BlockersEx: Propranolol
2. Tricyclic AntidepressantsEx: Amitriptyline
3. AnticonvulsantsEx: Valproic Acid
4. Calcium Channel Blockers – efficacious in the prophylactic treatment of migraine
Ex: Verapamil, Nicardipine
5. Ergot AlkaloidsEx: Methergine
Prophylactic Treatment
• Indicated for patients who – have frequent headaches– acute attacks that are difficult to manage– those for whom symptomatic therapy is poorly
tolerated
When to Refer
• Frequent migraines not responsive to standard therapy
• Migraines with atypical features• Chronic daily headache due to medication
overuse
When to Refer
• Acute onset of “worst headache in my life”• History of trauma, hypertension, fever, visual
changes• Presence of neurologic siggns or of scalp
tenderness
When to Admit
• Need for repeated doses of parenteral pain meds• To facilitate an expedited work-up requiring a
sequence of neuroimaging and procedures• Monitoring for progression of symptoms and
neurologic consultation when the initial emergency department work-up is inconclusive
When to Admit
• Pain severe enough to impair ADLs or limit participation in follow-up appointments or consultation
• Suspected subarachnoid hemorrhage or structural intracranial lesions