HEADACHE

HEADACHE in Primary Care Aye Arzu Akaln MDFamily Medicine

11Not eklemek iin tklatnIn the end of this lecture the students will be able to;differentiate primary and secondary headachelist the characteristics of most common headache types in primary careexplain the warning features in history and physical examlist the common headache triggers2DefinitionHeadache or cephalalgia is pain or discomfort perceived in the head, neck or both.Primary headache disorders are recurrent benign headaches.Secondary headaches result from an underlying pathology caused by a distinct condition. (eg., aneurysm, infection, inflammation, or neoplasm)

3EpidemiologyAnnual prevalence may be as high as 90%, with a minority of those sufferers pursuing medical evaluation.Headache is the second most common pain syndrome in primary care ambulatory practice.

4Epidemiology In children the rate of the patients who seek care for headache has a negative correlation with the age. The prevalance increases with age significantly and the pain is less in severity and duration compared with adults.

Incidence is between 20%-54% in the pre-adolescence period based to the epidemiologic studies.

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Pain Insensitive Structures in BrainBrain parenchymaDura over convexity of skull (Dura around vascular sinuses and vessels is sensitive to pain)EpendymaChoroid plexusArachnoidPia matter

6Pain Sensitive Structures in Head INTRACRANIALCranial venous sinuses with afferent veinsArteries at base of brain and arteries of dura including middle meningeal arteryDura around venous sinuses and vesselsFalx cerebri

7Pain Sensitive Structures in Head EXTRACRANIAL & NERVESSkinScalp appendagesPeriosteumMusclesArteriesMucosa

Trigeminal (V. CN)Facial (VII. CN)Vagal (X. CN)Glossopharyngeal (IX. CN)Optic and oculomotor CNs (II & III: CN)

8Causes of Headaches.1. Traction or dilatation of intracranial or extracranial arteries.2. Traction of large extracranial veins3. Compression, traction or inflammation of pain sensitive intracranial structures4. Spasm and trauma to cranial and cervical muscles.5. Meningeal irritation and raised intracranial pressure6. Eye, ear, nose and throat pathologies

9Classification of International Headache SocietyA- Primary Headaches (90%)1. Migraine including:1.1 Migraine without aura1.2 Migraine with aura2. Tension-type headache, including:2.1 Infrequent episodic tension-type headache 2.2 Frequent episodic tension-type headache2.3 Chronic tension-type headache2.4 Probable tension-type headache3. Cluster headache and other trigeminal autonomic cephalalgias, including:3.1 Cluster headache3.2 Other primary headaches10Classification of International Headache SocietyA- Primary Headaches (90%)4. Other primary headaches4.1. Primary stabbing headache4.2. Primary cough headache4.3. Primary exertional headache4.4. Primary headache associated with sexual activity4.4.1. Preorgasmic headache4.4.2. Orgasmic headache4.5. Hypnic headache4.6. Primary thunderclap headache4.7. Hemicrania continua4.8. New daily persistent headache (NDPH)11Primary Headache Definition None of the primary headaches is associated with demonstrable organic disease or structural neurologic abnormality.Laboratory and imaging test results are generally normal. The physical and neurologic examinations are also usually normal

12Primary Headache Definition Should an abnormality be found on testing, by definition, it most likely is not the cause of the headache. During the headache attack however, patients might have some abnormal clinical findings13

B- Secondary Headaches (10%)

5. Headache attributed to head and/or neck trauma, including:5.2 Chronic post-traumatic headache6. Headache attributed to cranial or cervical vascular disorder, including:6.2.2 Headache attributed to subarachnoid hemorrhage6.4.1 Headache attributed to giant cell arteritis7. Headache attributed to non-vascular intracranial disorder, including:7.1.1 Headache attributed to idiopathic intracranial hypertension7.4 Headache attributed to intracranial neoplasm

14B- Secondary Headaches8. Headache attributed to a substance or its withdrawal, including:8.1.3 Carbon monoxide-induced headache8.1.4 Alcohol-induced headache8.2 Medication-overuse headache8.2.1 Ergotamine-overuse headache8.2.2 Triptan-overuse headache8.2.3 Analgesic-overuse headache9. Headache attributed to infection, including:9.1 Headache attributed to intracranial infection15B- Secondary Headaches10. Headache attributed to disorder of homoeostasis10.1. Headache attributed to hypoxia and/or hypercapnia10.2. Dialysis headache10.3. Headache attributed to arterial hypertension10.4. Headache attributed to hypothyroidism10.5. Headache attributed to fasting10.6. Cardiac cephalalgia10.7. Headache attributed to other disorder of homoeostasis

16B- Secondary Headaches11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures, including:11.2.1 Cervicogenic headache11.3.1 Headache attributed to acute glaucoma12. Headache attributed to psychiatric disorder

1717Secondary Headache DefinitionSecondary headaches are usually of recent onset and associated with abnormalities found on clinical examination.

Laboratory testing or imaging studies confirm the diagnosis.

18Secondary Headache DefinitionRecognizing headaches related to an underlying condition or disease is critical:

because treatment of the underlying problem usually eliminates the headache

the condition causing the headache may be life-threatening.19

C- Cranial Neuralgias, Central and Primary Facial Pain and Other Headaches13. Trigeminal neuralgia14. Other headache, cranial neuralgia, central or primary facial pain

20Headache in Primary Care2121Taking a Diagnostic History

The history is all-important in the diagnosis of the primary headache disorders and of medication-overuse headache

There are no useful diagnostic tests.

The history should elicit any warning features of a serious secondary headache disorder.22Warning Features in History

Any new headache in an individual patient, or a significant change in headache characteristics, should be treated with caution.

"I have never had a headache like this before""This is the worst headache I have ever had"

23Specific Warning Features in History (1/5)Thunderclap headache (intense headache with explosive or abrupt onset) subarachnoid hemorrhage)

Estimated prevalence of subarachnoid hemorrhage in the setting of thunderclap headache is 43%24Specific Warning Features in History (2/5)Headache with atypical aura (duration >1 hour, or including motor weakness) symptoms of transient ischemic attack (TIA) or strokeAura without headache in the absence of a prior history of migraine with aura symptoms of TIA or strokeAura occurring for the first time in a patient during use of combined oral contraceptives risk of stroke

25Aura is a subjective sensation or motor phenomenon that precedes and marks the onset of a neurological condition, particularly an epileptic seizure or migraine

26Specific Warning Features in History (3/5)New headache; in a patient older than 50 years symptom of temporal arteritis or intracranial tumour, in a pre-pubertal child requires specialist referral and diagnosisin a patient with a history of cancer, HIV infection or immunodeficiency secondary headache

27Specific Warning Features in History (4/5)Progressive headache, worsening over weeks or longer intracranial space-occupying lesion

Headache aggravated by postures or maneuvers that raise intracranial pressure intracranial tumour, CNS infection

28Specific Warning Features in History (5/5)Headache first occuring with exercise ruptured aneurysm

Headache hours to weeks after a history of trauma, especially in an older person subdural hematoma

Similar new onset of headaches in an acquaintance or family member environment exposure such as carbon monoxide29

Questions to Ask in the History (1/7)How many different headache types does the patient have? A separate history is needed for each.

Any change in character or intensity?

Is this your first or worst headache?Is this headache like the ones you usually have?

3030Questions to Ask in the History (2/7)Time questionsWhy consulting now?How recent in onset? When did this headache begin? How did it start (gradually, suddenly, other)? How frequent, and what temporal pattern(episodic or daily and/or unremitting)? Do you have headaches on a regular basis? How long lasting?

31Questions to Ask in the History (3/7)Character questions Intensity of pain? How bad is your pain on a scale of 1 to 10?Nature and quality of pain? What kind of pain do you have (throbbing, stubbing, dull, other)? Site and spread of pain?Where is your pain? Does the pain seem to spread to any other area? If so, where? 32Questions to Ask in the History (4/7)Character questions Associated symptoms? What symptoms do you have before the headache starts?What symptoms do you have during the headache? What symptoms do you have right now?

33Questions to Ask in the History (5/7)Cause questions Predisposing and/or trigger factors?Aggravating and/or relieving factors?Family history of similar headache?34Common Headache TriggersAlcohol Caffeine Food additives (MSG, aspartame, tyramine (found in aged cheeses, some red wines, smoked fish, etc.), sodium nitrite (found in processed meats).35Common Headache TriggersFoods (Chocolate, fruits, dairy, onions, beans, nuts) Environmental changes (Light, odors (perfume, paint, etc.), travel, abrupt changes in weather or altitude) 36Common Headache TriggersLifestyle factors (Insufficient, excessive, disrupted, or irregular sleep; tobacco or alcohol use; fasting; physical activity; head injury; schedule changes; stress or release from stress; anger; or exhilaration) Hormone changes, or addition of estrogen- containing medication(Timing of headache with menses or change/ addition of hormones)

37Questions to Ask in the History (6/7)Response questions What does the patient do during the headache?How much is activity (function) limited orprevented?What medication has been and is used, inwhat manner and with what effect?Do you take any medicines? If so, what?

38Questions to Ask in the History (7/7)State of health Completely well, or residual or persistingbetween attacks symptoms?Concerns, anxieties, fears of recurrentattacks and/or their cause? Do you have other medical problems? If so, what?Have you recently hurt your head or had a medical or dental procedure?39Diagnostic Diary

Once serious causes have been ruled out, a headache diary kept over a few weeks clarifies the pattern of headaches and associated symptoms as well as medication use or overuse.40Physical ExaminationPhysical examination is mandatory when the history is suggestive of secondary headache.General appearance, Does s/he look unwell?Vital signs, Measure BPHead and neck exam including palpation Neurological exam including fundoscopyENT exam, Ophtalmologic exam (astigmatism, glocoma)

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Warning Features on ExaminationPyrexia

Blood Pressure (sist >200 mmHg / diast >120 mm Hg) hypertensive encephalopathy, A palpable tender temporal artery Temporal arteritis

Papilledema increased intracranial pressure

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Warning Features on ExaminationFocal neurological signs Stiff neck, rush, fever, photophobia, vomiting and other systemic signs meningitis, encephalitis

Headache aggravated by postures or maneuvers raising intracranial pressure intracranial tumour, subdural hematoma, epidural bleeding

43InvestigationsInvestigations, including neuroimaging, are indicated when the history or examination suggest headache may be secondary to another condition.

44Primary HeadachesThe most common primary headaches in primary care are: Migraine (with aura / without aura)Tension-type headacheCluster headache

Medicine-associated headache45MigraineEpisodic attacks with specific features of which nausea is the most characteristic.Attack frequency between once a year and once a week (most commonly once a month). In children, attacks tend to be of shorter duration and abdominal symptoms more prominent.

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Migraine without aura: IHS criteria5 attacks ofHeadache lasting 4-72 hours.Must be associated with nausea or vomiting or photophobia and phonophobiaMust have 2 of the followingUnilateralPulsatingModerately / severe.Aggravated by physical activity

47Migraine

Primary headache disorder with genetic basis.

Activation of a mechanism deep in the brain causes release of pain-producing inflammatory substances around the nerves and blood vessels of the head. Why this happens periodically, and what brings the process to an end in spontaneous resolution of attacks, are to a large extent uncertain. 48MigraineStarting at late childhood or puberty, Affects those aged between 35 and 45 years but also younger people, including children. Prevalence in Europe and America: 6-8% in men and 15-18% in women Prevalence in Turkey: 10% in men and 22% in women. 49MigraineIn children:attacks may be shorter-lastingheadache is more commonly bilateral and less usually pulsatinggastrointestinal disturbance is more prominent.50Migraine with typical auraMigraine with aura affects one third of people with migraine and accounts for 10% of migraine attacks overall.

Aura is a subjective sensation or motor phenomenon that precedes and marks the onset of a neurological condition, particularly an epileptic seizure or migraine

51Migraine with typical auraCharacterized by aura preceding headache, one or more neurological symptoms that develop gradually over >5 minutes and resolve within 60 minutes: hemianoptic visual disturbances, or a spreading scintillating scotoma (patients may draw a jagged crescent if asked) and/or unilateral paresthesia of hand, arm and/or face and/or (rarely) dysphasia.

52Migraine with typical auraDiagnostic CriteriaAura consisting of at least one of the following, but no motor weakness:Fully reversible visual symptoms including positive features (e.g., flickering lights, spots, or lines) and/or negative features (i.e., loss of vision) Fully reversible sensory symptoms including positive features (e.g., pins and needles) and/or negative features (i.e., numbness)Fully reversible dysphasic speech disturbance_______________________________________________________________________________________________Headache begins during the aura or follow the aura within 60 minutes_______________________________________________________________________________________________Diagnostic Criterion: Must have at least 2 attacks fulfilling the above criteria and no signs of Secondary headache disorder

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55Scintillating scotoma

56Tension-type headachePericranial tendernessHeadache usually generalized most intense about neck or back of the headNo focal neurologic symptomsNonspesific symptomsNo family history

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Tension-type headacheMost common headache 25-35%Most misdiagnosed headacheAge: 20Gender: F / M = 3 / 1Mild to moderate in severity, often self-treated

58Tension-type headacheTriggering factorsPhysical and / or psychological stressNoise GlareChanges in sleep or nutrition MenstruationBad postureOromandibulary disturbances 59Tension-type headache Associating symptomsSensitivity in head and neck musclesSleep disturbancesBalance disturbancesLimitation in conjugated eye movementsPsychiatric disorders60Tension-type headache

Infrequent episodic tension-type headacheFrequent episodic tension-type headache Chronic tension-type headacheProbable tension-type headache61Cluster headacheoccurs in two subtypes,Episodic cluster headache occurs in bouts (clusters), typically of 6-12 weeks duration, once a year or two years, and then remits until the next cluster.

Chronic cluster headache, which persists without remissions (>12 months or remission