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.

HEADACHE: PEDIATRIC

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

HEADACHE: ADULT

Mechanism of Headache

• Traction• Inflammation• Vascular Spasm • Distention

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

Precipitating Factors

Prodomal Symptoms

Pain Characteristics

Location of Pain

Other features of headache

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

Management

• Treatment should be directed at the cause of acute headache

Treatment

• NSAIDs• 5 Hydroxytriptamine Agonists• High Flow Oxygen

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

THANK YOU