HEADACHE

RED FLAGS

Severe sudden ‘thunder clap’ or ‘worst’ headache (Eg – SAH)

Early morning headache that aggravated by coughing or straining (↑ ICP)

Syncope or vomiting, even though vomiting can also occur in migraine attack.

Altered mental status or seizure, Focal neurological deficit, Fever or neck pain (meningism). Head injury

Visual disturbance (eg; eye pain in glaucoma)

Patient’s age >60 years old with new onset of headache (eg: temporal arteritis)

Immunocompromised patient - HIV, Malignancy

On anti-coagulant

Previous ventriculo-peritonial shunt

 PRIMARY HEADACHE

TENSION HEADACHE MIGRAINE CLUSTER HEADACHE

+/- AURA (MIGRAINOUS NEURALGIA)
F>M F>M M>F
Peak: affect young people & elderly
Muscle contraction (tightness) Why cluster headache? As it occur in
At least 10 attacks OCP may exacerbate migraine & cluster
Assc w cervical dysfxn & stress/ increase risk of stroke in pt w
tension migraine + aura p/s: it’s so painful that you feel nk
hentuk kepala kt dinding!
TYPE
Common migraine → NO AURA Hallmark - acyclical nature of attack of
(at least 5 attacks) at least 5 attack
Classic migraine → HAS AURA
(at least 2 attack) iHS criteria –
At least 5 attacks
TRIGGERING FACTORS Severe, unilateral
ENDOGENOUS EXOGENOUS Last 15 – 180 mins (unterated)
Tiredness, Stress* Circadian/ circannual pattern
oversleeping, Food, alcohol, Assc w ipsilateral sx (atleast one) –
pregnancy, drug, glare/ lacrimation, conjunctival injection,
menstrual, bright light, nasal congestion, rhinorrhea, ptosis
hunger strong +/- miosis, edema of eyelid or face,
perfumes, sweating of forehaed +/- face
climate change,
excessive noise

Site Symmetrical, bilateral Temporo-frontal region Unilateral

Frontal, over forehead, temples then (unilat > bilateral) Over/ about one eye, always same
radiate to occipital side, radiate to frontal & occipital
Radiate to retro-orbital & occipital

Headache + vomiting + visual aura

(unilat) Retro-orbital headache +
Headache + no vomiting, nausea
rhinorrhea + lacrimation
Onset After rising, get worse during days
Duration minutes - days
Character Dull ache, like a ‘tight pressure
feeling’, ‘heavy weight on top of
head’, ‘tight band around head’
(may be tightness or vice-like feeling
rather than pain)
Aggravate Stress, overwork w skipping meals
Relieving Alcohol
Frequency Almost daily
Assc Perfectionist personality
features Lightheadedness
Fatigue
Neckache/ stiffness (occiput to
shoulders)
Anxiety/ depression
P/e Muscle tension (frowning)
Scalp often tender to touch
+ve ‘invisibile pillow’
Conserva- Patient edu – explain that scalp
tive muscle might get tight like calf muscle
when climbing stairs
Counselling & relevant advice
(Cognitive Behavioral Therapy (CBT) –
Learn how to relax yr mind & body
During attack, relax by lying down in
hot bath & practice meditation
Be less perfectionist
Don’t bottle things up, stop feel
guilty, approve yrself to re-express
yrself & yr anger
Advise stress reduction, relaxation
therapy & yoga/ meditation classes
Paroxysmal, often wakes w it Sudden, during night (same time),
about 2-3h after falling asleep
*the ‘alarm clock’ headache*
hours – days 10 min – 2 hours
Intense & throbbing Severe
Tension, Activity, Alcohol, Pill Alcohol (during cluster)
Sleep, Vomiting Drugs
1-2x / months Every 2 days to 8 attack/ day
Nausea, vomiting (90%) Family hx
irritability
Assc w ipsilateral sx (atleast one) –
AURAL SYMPTOM lacrimation, conjunctival injection,
Visual Distorting, jumbling of nasal congestion, rhinorrhea, ptosis
lines, dot, zig-zag, +/- miosis, edema of eyelid or face,
scotoma, hemianopia sweating of forehaed +/- face
Somato- Paresthesia spreading
sensory from finger to toe
Motor Dysarthria, ataxia,
ophthalmoplegia,
hemiparesis
Speech Dysphasia, paraphasia
OTHERS
Abdominal pain in childhood
Fam hx of migraine
Asthma & eczema
i. Patient Education
-Provide explanation & reassurance
esp if there’s bizzarre visual &
neurological sx
ii) Counselling & advise
- Avoid known trigger factors (fatigue,
diet, alcohol, drugs, tension)
- Advise keeping a diary of foodstuffs/
drinks that trigger migraine
- Avoid chocolate, cheese, red wine,
walnuts, tuna, spinach & liver.
- rest in quiet, dark, cool room
- place coolpack on forehead/ neck
- Practise a healthy lifestyle,
relaxation programs, meditation
techniques & biofeedback training.
- Be open to non-drug therapies
 Advice & demonstrate massage of the (eg: trial of acupuncture,
affected area w a soothing analgesic hypnotherapy)
rub

Pharmaco Ibuprofen/ PCM PCM → NSAID 100% O2 12 L/min for 15 min via non
Diclofenac rebreather facemask (HFM)
anti-emetic (+ w NSAID)
*Avoid tranquillizers & IV metochlopromide 10mg Sumatriptan 6 mg SC injection (or 20
antidepressants if possible IM prochlopromazine 12.5mg mg intranasal)

specific drug for migraine

MOA – vasoconstriction ^^
Ergotamine
S/E – tachycardia, nausea, vomiting

Sumatriptan
Cafergot (ergotamine sulfate +
caffeine)
S/E – chest pain, stomach upset, N/V,
insomnia

*women w aura should avoid

estrogen rx (OCP or HRT), even risk of
ischemic stroke is minimal
Prophy- Amitriptyline 10-75 mg for who?
lactic pt who have >2 attacks/month
those who has severe attack, fail to
acute rx, has comorbidities or
prolonged aura sx
1) b-blocker - propranolol, atenolol
2) antidepressant – amitriptyline,
dosulepin
3) antiepileptic – valproate,
topiramate
notes ^^
start at low dose & titrate upwards
gradually
each rx given for at least a month
Verapamil SR 160 mg (o) daily up to
320 mg
Sodium valproate
Prednisolone 50 mg/day for 10 days
then taper over 3 weeks (as a bridging
treatment)
Methysergide 1 mg (o) OD up to 3 mg
bd
Lithium 250 mg (o) bd
Indomethacin (helps confirm
diagnosis)
 CHARACTER OF PAIN MANAGEMENT
Primary stabbing Transient, sharp, jabbing (cause pt to wince)—mild to intense Melatonin (3 - 12 mg daily)
headache/ ice-pick, Occurs anywhere (extrageminal) Indomethacin (75 - 150 mg daily)
opthalmodynia Last for few seconds at irregular interval
periodica, jabs & jolts No cranial autonomic sx
Most of the times associated with coexisting primary headache
disorder

Primary cough Provoked by coughing Investigations:

headache No intracranial disorder MRI– new onset, posterior fossa sign & sx
CT/MRI angiography of intra & extracranial
>40 y/o vessels– recent h/o unilateral cough-
provoked headache + transient focal
neurological sx

Treatment:
Indomethacin (150-250mg daily)

Exercise/ exertional Bilateral, pulsatile, throbbing Investigations:

headache Triggered by physical exercise (hot weather/ high altitude) Brain imaging
(uncommon) Last up to 5 mins -2 days
Prevented by avoidance of physical exertion Treatment:
*need tro other u/l Not assc w nausea/ vomiting Indomethacin (25-150mg/ day) – 30 -60mins
patho before xtvt

Sex-related headache Usually bilateral (occipital/diffuse) Investigations:

(rare) Occur only during sexual xtvt CT/MRI
Associated with neck pain Lumbar puncture
Male > female No autonomic signs & sx Neurovascular imaging
Can last from 1min-24 hours/ 1min-72hours
Treatments:
Sumatriptan intranasal spray 20mg
Indomethacin 25-150mg (30-6-mins before
sexual xtvt)

Thunderclap headache Severe, sudden onset Managements:

Peaks within <1mins Depends on underlying etiologies
+/- meningismus, fever, tinnitus, orthostatic worsening, altered
mental state, seizure, motor/ sensory deficits

New daily persistent Abrupt onset, cont. Daily, unremitting Investigations:

headache syndrome H/o headache MRI
Often resembles: chronic tension headache/migraine CT brain
Rare Duration: years-decades Lumbar puncture
Children > adult Do not improves by medications (effective-early stage)
Female > male Treatments:
According to NDPH phenotypes