Headache Disorders

Ain Shams University

Faculty of Medicine

RRM, Oct 2020

Intended Learning outcomes

• Recognize primary vs. secondary headaches

• Recognize the prevalence and burden of headache disorders
• Understand that headaches are specific neurologic disorders that include pain
• Recognize frequency/prevalence of main headache types in clinic and in the community
• Recognize symptoms of main types of headaches
• Recognize red flags in headaches
• Understand the workup in cases of headache
• Understand the main lines of management (acute, preventative, lifestyle)
 Headache
Classification

Primary Headaches Secondary Heahaches

Tumors
Trigeminal
Tension-Type
Migraine Autonomic
headache Sinus-related
Cephalagia
headache

Cluster headache Cervicogenic

Headache
Paroxysmal
Hemicrania Medication Overuse
headache
SUNCT

Hemicrania Continua
Primary Headache
• Intrinsic dysfunction of the nervous system
• Most patients presenting to PCP with headache have primary
headache syndromes
• Episodic headache: more common
• Chronic headache: attacks occurring more frequently than 15
days/month for more than 6 months
Secondary Headache Disorders
• <2% of headaches in primary care offices
• Head trauma
• Vascular disease
• Neoplasms
• Substance abuse or withdrawal
• Infection/Inflammation
• Metabolic disorders
• others
Location of different types
Migraine

• Episodic, progressive head pain

• Pulsating, throbbing, stabbing
• Attacks: 4-72 hours
• Unilateral in 60%
• Up to 75% may have neck pain
Migraine
• 3 : 1 female : male
• 6% of males, 18% of females, 4% of children
• Family history + in 80-90%
• Onset typically during adolescence or young adulthood
• Onset after age 40 possible
Migraine Subtypes
• Migraine with aura (20%)
• Neurologic event precedes migraine
(usually by 30-60 minutes)
• Visual, auditory, olfactory disturbances
• Migraine without aura
• No aura or other warning symptoms
• Chronic migraine
Chronic Migraine
• Starts as episodic migraine
• Attacks occur at increasing frequency
• Eventually 15+ attacks/month
• Frequent association with medication overuse
• Psych comorbidity common
Patient Interview 1
Tension-Type Headache
• Episodic or chronic; possible
migraine variant
• Episodic form affects up to 38%
of US adults annually
• Less disability and morbidity
than migraine, so less seen by
MDs
Tension-Type Headache
• “Bandlike”
• Bilateral: frontal, temporoparietal
• Referred (myofascial) pain from neck to head
• Neck structures may contribute to pain (“cervicogenic
headache”)
Patient Interview 2
Cluster Headache
• Rare disorder
• M:F 3:1; genetic predisposition
• Cycles/clusters lasting weeks to months
• Repetitive headaches during a cluster
• 1-3 hours; always unilateral
• Focal facial and eye pain, lacrimation, rhinorrhea
• Often occur when sleeping or napping
Paroxysmal Hemicranias
• Chronic and episodic varieties
• Uniquely sensitive to
indomethacin!
Cervicogenic Headache
• Differentiate from migraine or other syndromes
• Analgesics may be tried as for migraine
• Reserve triptans/ergots for refractory cases
• Rebound often a significant issue
• Therapy directed at neck may help
• Facet blocks, trigger point injections, nerve blocks, TENS, physical therapy
Medication Overuse Headache
• Persistent, recurring headache
in the setting of regular
analgesic use
• Continues until medication is
stopped
• Often responsible for
“transformation” of episodic
into chronic headache Ingredients: Succinic acid, fumaric acid,
dextrose and bioflavonoids
Red Flags
• Neurologic Symptoms/Signs • General Symptoms/signs
• Weakness/hemiparesis • Fever
• Ataxia • Repeated vomiting
• Diplopia • High blood pressure
• Disturbed consciousness • Lymphadenopathy
• Meningism
• Seizures
Basic Principles of headache management

• Thorough history and physical

• Rule out potentially dangerous (secondary) headache
• Neoplasm, infection, hemorrhage, etc.Diagnose headache type
• Implement treatment
• Monitor outcome
Treatment of Headache
Acute Preventive

• Simple analgesics • To prevent attacks

• Ergots
• To prevent transformation to chronic
• Migraine-specific (for example, triptans) headache
Lifestyle
• Anti-epileptics
• Good Sleep
• Anti-hypertensives
• Regular meals • Tricyclic anti-depressants
• Hydration • Migraine specific (for example, Anti-
• Low caffiene
CGRP)