Approach to Headache

Bayalpata Hospital
th CME
Last updated: *19 of MAY 2017*
Contributors: *Dr.Abhishesh Wagle*, Dr. Stephen
Mehanni
Objectives
After this session, participants should be able to
1) Distinguish between the common types of
headaches
2) Evaluate a patient with headache
3) Recognize danger signs of headache
4) Describe the treatment of the primary headaches
5) List pros and cons of medicines available to
prevent migraines
Clinical Case
A 23 year old female presented to opd with complain
of headache.She says she has been having such
headache multiple episodes the last few months...
Questions
What are other things you would like to ask?
History
Site
Onset
Severity
Character
Associated factors
Aggravating factors
Relieving factors
Classification of headaches
Primary headaches
Migraine
Tension
Cluster

Secondary headache
caused by something else
Migraine features
Aura +/-
Unilateral
Duration 4 hrs to 72 hrs
Pulsatile,throbbing
Associated with photophobia, phonophobia
Aggravated on movement
Tension headache features
Frontal,forehead and temples
Dull ache,light pressure feeling, heavy weight on
top of head
Daily
Last upto days
Associated with fatigue,neck ache
Gets worse during the day
Cluster headache features
Unilateral
Retroorbital pain
Associated with autonomic symptoms
rhinorrhea,lacrimation
Occurs in the same time of the day...
Causes of secondary headache
Sinusitis
URTI
Cervical spondylosis
Meningitis
Subarachnoid Hemorrhage
Glaucoma
Medication overuse headache
Key Point #1

Unilateral pulsatile severe headache associated

with photophobia,phonophobia
nausea is mostly migraine headache...
Goal of evaluation
Determine if headache is primary or secondary
Evaluate for danger signs
Other signs of secondary
headache
Impaired vision or seeing halos around light
Relieved with recumbency aggravated with upright
posture
Blurring of vision on forward bending of head,
headache upon waking early in the morning
Sudden severe unilateral vision loss

Key Point #2
A complete history is the single most important
factor for establishing a headache diagnosis
Danger signs
Sudden onset of severe headache/New onset
Headache associated with neurological deficits
Systemic symptoms
H/o trauma to head,illicit drug use,or toxic exposure
Previous headache history with headache
progression or change in attack frequency...
Exam
Most patients have a NORMAL physical exam
There may be neck tenderness in tension headache

Abnormalities may indicate secondary headache

What should you examine?
Pulse
Blood pressure
Examine the neck for tenderness
Auscutate in the neck for bruit
Palpate in the temporal region for vessels
Examine the cervical spine
Neuro exam
Key Point #3

Patients with danger signs should

usually be referred for CT or MRI
Clinical Case
She says her headache is unilateral and
pulsatileand she needs to take rest in the quiet
surrounding for the relief
O/E Pulse=90/min,BP=120/80 mm of HG
Other neurological examination are normal...
Question for HA and CMAs
What is your diagnosis ?
How would you treat the case in our emergency?
Treatment of primary headaches
Tension headache
Explain
Stress reduction, relaxation techniques and yoga or
meditation classes
Massage with soothing analgesic rub
Medications : Paracetamol, Ibuprofen
Acute migraine
Rest in a quiet and darkened room
Avoid drinking coffee, tea
Donot read or watch television
Medications
Paracetamol,Ibuprofen,naproxen,diclofenac
Antiemetics
Flunarizine
Cluster headache
High flow oxygen(100%)
NSAIDS
Prophylactic
CCB
Sodium valproate

Key Point #4
Rest in a quiet room and simple analgesic
medications(Paracetamol and Ibuprofen) ususally
relieves an episode of headache...
Clinical Case
She says she has been having 2 to 3 episodes of
headache in the last few months
She says she feels the regular medications
Are not working?
Question for doctors
What would you do now?
When do you add medicine to
prevent migraines?
Frequent attacks causing disruption to patients
lifestyle
2 or more severe migraine attacks per month
Decreased responsiveness to acute attack

Migraine prevention: counseling

Sleep hygiene
Routine meal schedules
Regular physical activity
Avoiding migraine triggers (what are these?)
Migraine triggers
What are medication options
available for preventing
migraines?
What are medication options
available for preventing
migraines?
Amitriptyline
Propranolol
Valproic acid
Amitriptyline: pros and cons
Start from 10 mg OD
Upto 50mg daily effective
Bed time
Side effects: Sedation,Dry mouth,
constipation,tachycardia,palpitations, blurred
vision
Propranolol: pros and cons
20 mg BD
Upto 160mg per day
Avoid in Asthmatics, Diabetes, Depression and
hypotension...
Valproate: pros and cons
500 mg daily
Upto 1500mg daily
Side effects: weight gain, alopecia,
Contraindicated in pregnancy...
Key Point #5
Give prophylaxis for recurrent disabling Migraine
headache...
Bonus Cases
A 32 year old female came to your OPD with
headache around the eyes
She has been having nasal congestion for the last few
days
She says her headache worsens as the day
progresses
What is your diagnosis?
Bonus Cases
A 34 year old male underwent Hernioplasty under
spinal anesthesia At BH 5 days back complains of
severe occipital headache that is aggravated on
sitting upright and relieved on recumbent position
What is your diagnosis?
How would you manage?
Summary of Key Points
1)Unilateral pulsatile severe headache associated
with photophobia,phonophobia is mostly migraine
headache
2)A complete history is the single most important
factor for establishing a headache diagnosis.
3)Patient with danger signs should be referred for CT
or MRI
.
Summary of Key Points

4)Rest in a quiet room and simple analgesic

medications(Paracetamol and Ibuprofen) ususally
relieves an episode of headache
5)Give prophylaxis for recurrent disabling Migraine
headache...
Additional Reading
Murtaghs text book of General
Practice:Headache...
UpToDate: Evaluation of headache in adults
Thank you!