Headache We

8/6/2019 Headache We

1/34

Headache

Muhammad Safwan

0717129


2/34

Nearly everyone has had a headache.


3/34

Introduction

` Study in Singapore: overall lifetime prevalence of headacheis 82.7% which did not vary between racial groups.

` 39.9% episodic tension type headache

` 9.3% migraine

` 2.4% chronic tension type headache` 31.2% cannot be classified


4/34

Fun Facts

` 85% of the population will have experienced headache within 1 year and38% of adults will have had a headache within 2 weeks.

` Migraine affects at least 10% of the adult population and 1/4 of thesepatients require medical attention.

` 5% of children suffer from migraine by the age of 11 years.

` 70% of sufferers have a positive family history of migraine.

` Drug-induced headaches are common and must be considered in thehistory.

` In children the triad of symptoms - dizziness, headache and vomiting -indicates medulloblastoma of the posterior fossa until proved otherwise.

` A typical triad of symptoms in an adult with a cerebral tumour (advanced)is headache, vomiting and convulsions.

` Eye strain is not a common cause.` Bronchial carcinoma is the commonest cause of intracerebral malignancy.


5/34


6/34

` P = Probability diagnosis

` Acute: respiratory infection

` Chronic: tension-type headache combinationheadache migraine transformed migraine

` R = Serious disorders

` Cardiovascular subarachnoid haemorrhage intracranial

haemorrhage carotid or vertebral artery dissection temporal arteritis cerebral venous thrombosis

` Neoplasia cerebral tumour pituitary tumour

` Severe infections meningitis, esp. fungal encephalitis intracranial abscess

` Haematoma: extradural/subdural` Glaucoma

` Benign intracranial hypertension


7/34


8/34

` M = masquerades

` Depression

` Diabetes

` Drugs

` Anaemia

` Thyroid disorder

` Spinal dysfunction

` UTI

` Is the patient trying to tell me something?

` Underlying psychogenic disorder.


9/34

Clinical approach

` History

` Physical examination

` Investigation


10/34

History

` A full description of the pain including a pain analysisshould be obtained` radiation

` quality

`

severity` frequency

` duration

` onset and offset

` precipitating factors

` aggravating and relieving factors` associated symptoms

` Similar to SOCRATES


11/34

Diurnal

patterns

Relative

intensity of painis plotted on thevertical axis


12/34

Diurnal patterns

` Plotting the fluctuation of headache during the day` Provides vital clues to the diagnosis.

` The patient who wakes up with headache could have

vascular headache (migraine), cervical spondylosis, depressive

illness, hypertension or a space-occupying lesion.

` It is usual for migraine to last hours, not days, which is

more characteristic of tension headache.


13/34

` The pain of frontal sinusitis follows a typical pattern,namely onset around 9 am, building to a maximum by

about 1 pm, and then subsiding over the next few hours.

` The pain from combination headache tends to follow a

most constant pattern throughout the day and does notusually interrupt sleep.


14/34

Key questions

` Can you describe your headaches?

` How often do you get them?

` Can you point to exactly where in the headyou get them?

` Do you have any pain in the back of yourhead or neck?

` What time of the day do you get the pain?

` Do you notice any other symptoms whenyou have the headache?

` Do you feel nauseated and do you vomit?

` Do you experience any unusual sensationsin your eyes, such as flashing lights?

` Do you get dizzy, weak or have any strangesensations?

` Does light hurt your eyes?

Do you get any blurred vision?

Do you notice watering or redness of one orboth of your eyes?

Do you get pain or tenderness on combingyour hair?

Are you under a lot of stress or tension? Does your nose run when you get the

headache? What tablets do you take?

Do you get a high temperature, sweats orshivers?

Have you had a heavy cold recently?

Have you ever had trouble with your sinuses?

Have you had a knock on your head recently?

What do you think causes the headaches?


15/34


16/34

Physical examination

` Tools: thermometer, sphygmomanometer, pen torch, anddiagnostic set, including the ophthalmoscope and thestethoscope.

` Inspect the head, temporal arteries and eyes.

` Palpate the temporal arteries, the facial and neck muscles, the

cervical spine and sinuses, the teeth and temporomandibularjoints. Search especially for signs of meningeal irritation andpapilloedema.

` A mental state examination is mandatory. Look for alteredconsciousness or cognition and assessment of mood, anxiety-tension-depression, and any mental changes.

` Neurological examination includes assessment of visual fieldsand acuity, reactions of the pupils and eye movements inaddition to sensation and motor power in the face and limbs.


17/34

Special signs in PE

Upper cervical pain sign: Palpate over the C2 and C3 areas of thecervical spine, especially two finger-breadths out from thespinous process of C2. If this is very tender and even provokesthe headache it indicates headache ofcervical origin.

Ewing's sign for frontal sinusitis. Press your finger gently upwardsand inwards against the orbital roof medial to the supraorbitalnerve.Pain on pressure is a positive finding and indicatesfrontal sinusitis

The invisible pillow sign.The patient lies on the examination tablewith head on a pillow.The examiner then supports the headwith his or her hands as the pillow is removed.The patient is

instructed to relax the neck muscles and the examinerremoves the supporting hands. A positive test indicatingtension from contracting neck muscles is when the patient'shead does not readily change position.This is uncommon.


18/34

Investigations`

Haemoglobin: anaemia` WCC: leucocytosis with bacterial infection

` ESR: temporal arteritis

` Radiography` chest X-ray, if suspected intracerebral malignancy

` cervical spine

`

skull X-ray, if suspected brain tumour,Paget's disease, deposits in skull

` sinus X-ray, if suspected sinusitis

` CT scan

` detection of brain tumour (most effective)

` cerebrovascular accidents (valuable)

` subarachnoid haemorrhage

` radioisotope scan (technetium-99) to localise specific tumours and haematoma

` magnetic resonance imaging: very effective for intracerebral pathology but expensive;produces better definition of intracerebral structures than CT scanning but not assensitive for detecting bleeding.

` lumbar puncture

` diagnosis of meningitis

` suspected SAH (only if CT scan normal)


19/34

Management of common causes

` Tension-type headache` Migraine headache


20/34

` Tension-type headache


21/34

Tension-type headache

` How to diagnose?` Clinical characteristics by International Headache Society (IHS)

` The patient should have had at least ten of these headaches.

` The headaches last from 30 minutes to 7 days.

` The headaches must have at least 2/4:

` non-pulsating quality` mild or moderate intensity

` bilateral location

` no aggravation with routine physical activity

` The headaches must have both of the following:

` no nausea or vomiting

` photophobia and phonophobia are absent, or either one is present.

` There should be less than 15 days of headache per month and less than180 days per year.

` Secondary causes are excluded.


22/34


23/34

Management of tension headache

` Careful patient education: explain that the scalp muscles gettight like the calf muscles when climbing up stairs.

` Counselling and relevant advice, e.g.

` Learn to relax your mind and body.

` During an attack, relax by lying down in a hot bath and practise

meditation.` Be less of a perfectionist: do not be a slave to the clock.

` Don't bottle things up, stop feeling guilty, approve of yourself, expressyourself and your anger.

` Advise and demonstrate massage of the affected area with a

soothing analgesic rub.` Advise stress reduction, relaxation therapy like meditation

classes.


24/34

` Medication` Use mild analgesics such as aspirin or paracetamol.

` Discourage stronger analgesics.

` Avoid tranquillisers and antidepressants if possible, but

consider these drugs if symptoms warrant medication, e.g.Amitriptyline 10-75 mg increasing to 150 mg if necessary.

` Diazepam (short-term use) appears to be very effective in

middle-aged men; it is prone to cause depression in women.

`

The general aim is to direct patients to modify their lifestyleand avoid tranquillisers and analgesics.


25/34

` Migraine headache


26/34

Migraine headache

` IHS criteria for common migraine` The IHS criteria for migraine without aura involves this

checklist.` The patient should have had at least five of these headaches.

` The headaches last 4-72 hours.

` The headache must have at least two of the following:` unilateral location

` pulsing quality

` moderate or severe intensity, inhibiting or prohibiting daily activities

` headache worsened by routine physical activity

` The headache must have both:` nausea and/or vomiting` photophobia and phonophobia

` Secondary causes of headache are excluded (e.g. normal examand/or imaging study)


27/34

` IHS criteria for migraine with typical aura (classic)` There should be at least two attacks, including at least three of

the following:

` reversible brain symptoms (cortical or brain stem)

`

gradual development over 4 minutes` aura duration less than 60 minutes

` headache follows aura in less than 1 hour

` Note: If the aura lasts longer than 1 hour, it is migraine with

prolonged aura. If it lasts longer than 24 hours, it is a

migrainous infarction (stroke).


28/34


29/34

Management of migraine

` Patient educationprovide explanation and reassurance,especially if bizarre visual and neurological symptoms arepresent.Patients should be reassured about the benign natureof their migraine.

` Counselling and advice` Avoid known trigger factors, especially tension, fatigue, hunger and

constant physical and mental stress.

` Advise keeping a diary of foodstuffs or drinks that can be identifiedas trigger factors. Consider a low amine diet: eliminate chocolate,cheese, red wine, walnuts, tuna, vegemite, spinach and liver.

` Practise a healthy lifestyle, relaxation programs, meditationtechniques and biofeedback training.

` Be open to non-drug therapies, e.g. trial of acupuncture,hypnotherapy.


30/34

` Treatment of the acute attack

` Commence treatment at earliest impending sign.

` Mild headaches may require no more than conventional treatment with'2 aspirin (or paracetamol), and a good lie down in a quiet dark room'.

` Rest in a quiet, darkened, cool room.

` Place cold packs on the forehead or neck.

` Avoid drinking coffee, tea or orange juice.` Avoid moving around too much.

` Do not read or watch television.

` For patients who find relief from simply 'sleeping off' an attack, considerprescribing temazepam 10 mg or diazepam 10 mg in addition to thefollowing measures.

` For moderate attacks use oral ergotamine or sumatriptan and for severeattacks use injection therapy.

` Avoid pethidine and similar drugs of dependence.


31/34

Medication for migraine`

First-line medication` Aspirin or paracetamol + antiemetic: e.g. soluble aspirin 600-900 mg (o) and

metoclopramide 10 mg (o)

` Paracetamol (for children)

` Consider NSAIDs, e.g. ibuprofen

` Alternatives` Choose an ergotamine preparation or sumatriptan (a serotonin receptor agonist).

` Ergotamine (helps about 80% of patients)` oral: e.g. ergotamine 1 mg + caffeine 100 mg (Cafergot)

2 tabs at 1st warning then 60 minutes if necessary (maximum 6 per day)May need metoclopramide (o), IM or IV

` Sumatriptan` 50-100 mg (o) at the time of prodrome, repeat in 2 hours if necessary to maximum dose 300 mg/24

hours or nasal spray 10-20 mg per nostril or 6 mg, SC injection, repeat in 1 or more hours tomaximum dose 12 mg/24 hours

` Avoid sumatriptan in patients with coronary artery disease, Prinzmetal angina, uncontrolled hypertension orduring pregnancy. Do not use it with ergotamine simultaneously and cease if chest pain develops, albeittransient in a young patient.

` zolmitriptan 2.5 mg (o), repeat in 2 hours if necessary


32/34

Prophylaxis`

Consider prohylactic therapy for frequent attacks that cause disruption tothe patient's lifestyle and well-being, a rule of thumb being two or moremigraine attacks per month

` Do not give ergotamine.

` The most commonly used drugs include:` beta-blockers: propranolol, metoprolol, atenolol

`

pizotifen 1.5-2.0 mg at night` cyproheptadine (ideal for children)

` tricyclic antidepressantsamitriptyline

` clonidine

` methysergide (reserve for unresponsive severe migraine) 1 mg tds after foodup to 4 months only

`

calcium channel blockers: nifedipine, verapamil` NSAIDs: naproxen, indomethacin, ibuprofen

` MAO inhibitors: phenelzine, moclobemide

` sumatriptan

` sodium valproate


33/34

Guidelines`

Select the initial drug according to the patient's medical profile.if low or normal weightpizotifen` if hypertensivea beta-blocker

` if depressed or anxiousamitriptyline

` if tensiona beta-blocker

` if cervical spondylosisnaproxen

`

food-sensitive migrainepizotifen` menstrual migrainenaproxen or ibuprofen

` Commonly prescribed first-line drugs are` Propranolol 40 mg (o) bd or tds (at first) increasing to 240 mg daily (if

necessary)

` Pizotifen 0.5-1 mg (o) nocte (at first) increasing to 3 mg a day (if necessary)

`

Each drug should be tried for 2 months before it is judged to be ineffective.Amitriptyline 50 mg can be added to propranolol, pizotifen (beware ofweight gain) or methysergide and may convert a relatively poor responseto very good control.


34/34

Date post:	07-Apr-2018
Category:	Documents
Upload:	safwan-ozil
View:	219 times
Download:	0 times

Headache We

Documents