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Headache is among the most common reasons patients seek medical attention.
Diagnosis and management is based on a careful clinical approach augmented by an understanding of the anatomy, physiology, and pharmacology of the nervous system pathways that mediate the various headache syndromes.
2. Tension headache (muscular contraction headache) 3. Headache associated with intracranial disturbances
Arteriosclerotic brain diseases, vascular anomalies, aneurysms, tumor,
infections
5. Headache associated with cranial trauma 6. Hypertension, allergy, arteritis (temporal), fevers, infection 7. Psychogenic headaches
Conversion, tension headaches
ICHD-2 Classification
Part 1: Primary headache disorders Part 2: Secondary headache disorders Part 3: Cranial neuralgias, central and primary facial pain and other headaches
Tension-type
Migraine Idiopathic stabbing
69
16 2
Systemic infection
Head injury Vascular disorders
63
4 1
Exertional
Cluster
1
0.1
Subarachnoid hemorrhage
Brain tumor
<1
0.1
The large intracranial vessels and dura mater and the peripheral terminals of the trigeminal nerve that innervate these structures
The caudal portion of the trigeminal nucleus, which extends into the dorsal horns of the upper cervical spinal cord and receives input from the first and second cervical nerve roots (the trigeminocervical complex) Rostral pain-processing regions, such ventroposteromedial thalamus and the cortex as the
The pain-modulatory systems in the brain that modulate input from trigeminal nociceptors at all levels of the pain-processing pathways
nerve
is
known
as
the
Cranial autonomic symptoms, such as lacrimation and nasal congestion, are prominent in the trigeminal autonomic cephalalgias, including cluster headache and paroxysmal hemicrania, and may also be seen in migraine. These autonomic symptoms reflect activation of cranial parasympathetic pathways, and functional imaging studies indicate that vascular changes in migraine and cluster headache, when present, are similarly driven by these cranial autonomic systems
Intensity of pain rarely has diagnostic value. Headaches are usually benign, but sometimes severe and disabling. Its very important to distinguise serious from benign illnesses.
is also
PRIMARY HEADACHE
1.) Migraine 2.) Tension-type headache 3.) Cluster headache
Migraine Facts
Burden Of Migraine
World - 15-20% of women and 10-15% of men suffer from migraine In India, 15-20% of people suffer from migraine Adults Female: Male ratio is 2 : 1 In childhood migraine, boys and girls are affected equally until puberty, when the predominance shifts to girls.
Migraine - Definition
Migraine is a familial disorder characterized by recurrent attacks of headache widely variable in intensity, frequency and duration. Attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting
-World Federation of Neurology
Migraine Triggers
Visual stimuli
Auditory stimuli Olfactory stimuli
Weather changes
Hunger Psychological factors
PRODROME
Vague premonitory symptoms that begin from 12 to 36 hours before the aura and headache Symptoms include Yawning Excitation Depression Lethargy Craving or distaste for various foods Duration 15 to 20 min
AURA
Aura is a warning or signal before onset of headache Symptoms
Flashing of lights
Zig-zag lines Difficulty in focussing
HEADACHE
Headache is generally unilateral and is associated with symptoms like:
Anorexia
Nausea Vomiting
Photophobia
Phonophobia Tinnitus
MIGRAINE CLASSIFICATION
According to Headache Classification Committee of the International Headache Society, Migraine has been
classified as:
Migraine without aura (common migraine) Migraine with aura (classic migraine) Complicated migraine
MIGRAINE - PATHOPHYSIOLOGY
VASCULAR THEORY
Intracerebral
SEROTONIN THEORY
Decreased serotonin
PRESENT UNDERSTANDING Neurovascular process, in which neural events result in activation of blood vessels, which in turn results in pain and further nerve activation
Brainstem pathways that modulate sensory input. The key pathway for pain in migraine is the trigeminovascular input rom the meningeal vessels, which passes through the trigeminal ganglion and synapses on second-order neurons in the trigeminocervical complex. These neurons in turn project in the quintothalamic tract and, after decussating in the brainstem, synapse on neurons in the thalamus. Important modulation of the trigeminovascular nociceptivedorsal raphe nucleus, locus input comes from the coeruleus, and nucleus raphe magnus.
NEUROVASCULAR PROCESS
Arterial Activation
Release of Neurotransmitter
Worsening of Pain
MIGRAINE: DIAGNOSIS
Medical History
Headache diary Migraine triggers
Aggravation by movement
Moderate or severe intensity
Source: Adapted from the International Headache Society Classification (Headache Classification Committee of the International Headache Society, 2004).
Patients with acephalgic migraine experience recurrent neurologic symptoms, often with nausea or vomiting, but with little or no headache. Vertigo can be prominent; it has been estimated that one-third of patients referred for vertigo or dizziness have a primary diagnosis of mgraiine.
Strictly unilateral Tension headaches: Do not have the associated features like nausea, vomiting, photophobia, phonophobia. The muscle contraction leads to headache. Headache quality is of a tightening (non-pulsating) quality. Usually bilateral. Intensity is mild or moderate Cluster headaches: Severe unilateral pain. Headache associated with lacrimation, nasal congestion, rhinorrhea, facial sweating or eyelid edema. Pain lasts for 15 to 180 minutes. More common in men
the disorder
Improving the patients quality of life
MIGRAINE MANAGEMENT
Non-pharmacological treatment
Pharmacotherapy
Abortive therapy
Specific
Preventive therapy
Dose
500-650 mg 500 mg-4 g 200- 300 mg 50-100 mg 500-750 mg
Route
Oral Oral Oral Oral/IM Oral
Dose
Route
times a week
Long-term prophylaxis improves quality of life by
2.
3.
4.
Betablockers Propranolol Calcium Channel Blockers Flunarizine Verapamil TCAs Amitriptyline SSRIs Fluoxetine
10-20 120-480
10-20 20-60
Dose (mg/d)
600-1200 4-8
Anti-convulsant
6.
Anti-histaminic
Tension Headache
Most common type of headache Higher prevalence in middle aged women Usual frequency is 5 episodes per month Clinical features include -tight, band-like discomfort around the head -intensity of pain is not severe and thus not debilitating -headache does not worsen with physical activity -coexisting anxiety and depression are common
Tension headache-Treatment
Aspirin, acetaminophen, NSAIDs
T/t-Amytriptyline Exercise program Nonpharmacologic regimen like massage, mediation,
CLUSTER HEADACHE
Rare form of primary headache
More common in men Recurrent, deep, nocturnal, unilateral, retroorbital searing
pain
Awackening 2-4hrs after sleep onset with severe pain,
and
nasal
and
conjunctival
Visual complaints,nausea,or vomitting are rare. Tend to move during attacks (unlike migrain) Presence of periodicity Pain last 30-210 min but tend to recurat the same time of night or several times each 24 h over 4-8 weeks (a cluster) A pain free period of months or years may be followed by another cluster of headaches. T/t: High flow oxygen of 7-10 l/min Prophylaxis with Verapamil Lithium Prednisolon
Site
Attack frequency Duration of attack Autonomic features
Orbit, temple
1/alternate day8/d 15180 min Yes
Orbit, temple
140/d (>5/d for more than half the time) 230 min Yes
Periorbital
3200/d 5240 s Yes (prominent conjunctival injection and lacrimation)a Yes No Yes Lidocaine (IV)
Migrainous featuresb Alcohol trigger Cutaneous triggers Indomethacin effect Abortive treatment
Yes Yes No Sumatriptan injection or nasal spray Oxygen Verapamil Methysergide Lithium
Prophylactic treatment
Indomethacin
Lamotrigine Topiramate
Gabapentin
Some patients may have headache >4 h/d. Abbreviations: SUNA, s hort-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms; SUNCT, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing.
SECONDARY HEADACHE
meningeal nocireceptors causing occipital pain and meningismus. SAH accounts for 10% of all strokes and is most common cause of death from a stroke. Causes are saccular aneurysms (80%), blood dyscrasias, arteriovenous malformations, mycotic aneurysms, cavernous angiomas. Risk factors include increased age,hypertension, smoking, excessive alcohol consumption and sympathomimetic drugs.
headache Can be associated with exertional activities Nausea/vomitng-75% Neck stiffness-25% Seizures-10%
hemorrhages Oculomotor nerve pulsy with dilated pupil Restlessness and altered level of consciousness
Prognosis
It depends on neurological
Grade Condition
0
I II
Unruptured Aneurysm
No symptoms or minimal headache
Moderate/Severe HA, nuchal rigidity, no neuro deficit other than CN pulsy
status at the time of presentation Hunt and Hess scale Grades I and II have good prognosis Grades IV and V have grave prognosis
III
IV
Diagnostic Studies
Emergent CT scan of head
CT is greater than
90% sensitive for acute bleeding-less than 24 hr Sensitivity decreases to 50% by the end of the first week
Diagnostic Studies
When CT is negative a lumbar
puncture should be performed The CSF should be spun and the supernatant fluid should be observed for xanthochromia (develops after 12 hrs)
CSF xanthochromia with
Diagnostic Studies
Patients with persistent bloody CSF without
xanthochromia should go vascular imaging Up to 90% of patients with SAH have cardiac arrhythmias or EKG findings suggestive of ischemia Typical EKG changes include ST-T wave changes, U waves, and QT prolongation
Treatment
Airway, breathing, circulation and neurosurgical
consultation. Patients with Grade III SAH usually require endotracheal intubation Nimodipine 60 mg PO or NG to lessen the chance of ischemic stroke due to vasospasm Anticonvulsants for patients with evident seizure
Intracranial Infection
Severe HA, nuchal rigidity, HA is common meningismus complaint in meningitis, Encephalitis HA, confusion, brain abscess, fever, change of encephalitis or AIDS mental status, Diagnostic tools include seizures CT of head and LP Brain HA, vomiting, focal Abscess neurological signs, depressed level of consciousness AIDS Toxoplasmosis, CMV, Cryptococcus Meningitis
Brain Tumor
In elderly, brain tumor is usually metastatic from lung
or breast carcinoma. Primary brain tumor are more common in adults younger than 50 years HA is caused either by direct pressure on the brain or elevated ICP Typical presentation is headache that worsens over over weeks to months HA is usually present on awakening initially, then it becomes continuous.
Brain Tumor
HA is often worse with sneezing, bending, coughing.
Diagnostic tools include CT with IV contrast or MRI(best test)
process of small and medium size arteries. Mean age of onset is 71 years, rare before 50 Headache is intermittent, worse at night or on exposure to cold Associated symptoms include jaw claudication, fever, anorexia, pain and stiffness in joints aka polymyalgia rheumatica
of temporal artery. Its a medical emergency because long term sequelae is permanent visual loss. Diagnostic tests include ESR, CRP, LFTs, platelet count Definite diagnosis is by temporal artery biopsy Treatment is prednisone 60120mg daily.
Acute Glaucoma
Sudden onset of eye pain Due to congenital
radiating to head, ear, teeth, and sinuses. Visual symptoms include blurriness, halos around lights, and scotomas. Nausea and Vomiting
narrowing of the anterior chamber angle that leads to elevated intraocular pressure (IOP) Medications that elevate IOP include mydriatics, sympathomimetics
Acute Glaucoma
Physical exam shows a red
eye with a fixed middilated pupil and shallow anterior chamber (separates it from cluster HA) IOP in the range of 60 to 90 mmHg ( not found in iritis) Treatment includes topical miotics, b-blockers, carbonic anhydrase inhibitors, optho consult
Posttraumatic Headache(PTHA)
Estimated that 30-50% of 2 Chronic PTHA may last
million closed head injuries per year develop headache. Associated with dizziness, fatigue, insomnia, irritability, memory loss, and difficulty with concentration. Acute PTHA develops hours to days after injury and may last up to 8 weeks.
from several months to years. Patients have normal neurological examination and imaging Treatment for acute PTHA is symptomatic while for chronic PTHA, adjunct therapies include betablockers and antidepressants.
Thought to be due to
complication following lumbar puncture (up to 40%) Most common in 18 to 30 year old patients It can last up to 5 days Bilateral throbbing HA that worsens with upright position
persistent leak of CSF that exceeds its production Treatment includes rest, fluids, and blood patch, caffeine or theophylline for persistent HA
Medication-Induced Headache
Medication use, abuse or
withdrawal s the cause. Common in patients with chronic headache disorders like migraine or tension-type. Most common meds include ASA, NSAIDs, Tylenol, barbiturateanalgesic combinations, caffeine, and ergotamine
to the meds and subsequently require higher doses for symptomatic relief. Treatment includes withdrawal of the overused medications
associated with nausea, chest pain. Symptoms may wax and wane as patients may enter and leave the area of carbon monoxide Exposure to engine exhaust, old or defective heating systems, most common in winter months. Non focal neurological exams. Diagnosis is made by elevated carboxyhemoglobin Treatment is oxygen
Hypertensive Headache
Elevated blood pressure is
not as important in HA as the rate by which the blood pressure increases Nonetheless, HA with severe HTN is well documented especially in hypertensive encephalopathy Treatment is directed at lowering blood pressure slowly HA may last for days until brain edema has resolved
COUGH HEADACHE
Transient severe pain with coughing,bending,sneezing or stooping Last for sec to few min Usually benign Posterior fossa mass lesion in 25% cases Indomethacin 25-50mg tid
Key Concepts
HA is a challenging yet common complaint in ED Diseases that we cannot afford to miss are SAH, CO poisoning, temporal arteritis, bacterial meningitis/encephalitis Be liberal with use of CT Remember CT doesnt rule out SAH-need LP. If CT and LP are negative think of temporal arteritis if older than 50 years, and CO poisoning. Dont forget the eyes!
Case Studies
Headache Case #1
40-year-old man presents with a history of headache
since adolescence Over the past two years, headaches gradually have increased in frequency and severity; daily head pain for past 6 months Functionally incapacitated by headache 7 days per month
nonpulsatile, nonlateralized, pressure-like, and not accompanied by nausea, vomiting, photophobia or phonophobia Most severe headaches last 1 to 2 days and involve pain that is pulsatile, lateralized to the left, increased by routine physical activity, and accompanied by nausea, vomiting, photophobia, and phonophobia
and bright flashes at the periphery of both visual fields Severe attacks typically begin with an intensification of the usual headache, with severe tightness, stiffness, pain of the left lateral neck Physical examination was notable only because of marked tenderness to palpation at the left occipital skull base in the region of the greater occipital nerve
Headache Case #2
46-year-old woman presented for evaluation and
management of chronic daily headache Significant headaches started at 12 years of age Since then, she has had head pain with features characteristic of migraine with and without sensory or visual aura
years ago, her headaches became more of a problem; she has had daily headaches for 5 years She is functionally incapacitated by headache almost every day
times within the last month, and called her physician 1 week prior to her initial appointment to request acute headache medication Past medical history is otherwise notable for borderline personality disorder, chronic anxiety/depression, and 2 hospitalizations for suicidal ideation (no attempt)
Headache Case #3
31-year-old women with a long-standing history of
episodic migraine without aura comes to see her physician for urgent evaluation of a new problem: while at work, she abruptly developed an out-of-body sensation and a metallic taste in her mouth According to onlookers, she stared blankly and straight ahead for 45 seconds, failed to respond to questions, and swallowed repeatedly; she did not lose postural tone or exhibit tonic-clonic activity
was confused for a few minutes Reviewing her past, she claimed that she may have had this experience about 12 times over the previous 13 years, though the episodes were less intense She reported no recent change in the character or frequency of her headache syndrome
previous 30 days; 6 of these were functionally incapacitating headaches, despite aggressive treatment with oral sumatriptan, subcutaneous sumatriptan, and oral oxycodone/aspirin Her medical history is otherwise unremarkable Family history: her maternal grandmother and mother have had migraine; a maternal aunt and cousin have epilepsy
Headache Case #4
45-year-old man presents for evaluation and
management of chronic daily headaches Experienced his first significant headaches at age 36; these headaches resolved spontaneously after 2 months but then recurred 1 year later and have been daily since then
typically lasting 30 to 45 minutes and involving pain that is often prominent in the right eye, extending to the temple Treatment with propranolol, amitriptyline, oral sumatriptan, oral rizatriptan, and naproxen sodium have been ineffective for headache Medical history: unremarkable The patient smoked 1 pack of cigarettes per day for at least 20 years