Headache

Diagnosis & Management

Dr Sumera
Discomfort in the region of the cranial
vault.

Headache is usually a benign symptom

but occasionally it is the manifestation
of a serious illness.
 International Classification of
headache Disorders

Part 1 Primary headache Disorders- migraine

- tension –type headache
-cluster headache& other

trigeminal autonomic cephalgias

Part 2 Secondary headache disorders

Part 3 Cranial neuralgias, central and primary facial pain

& other headaches
 SNOOP-T
Red flags for secondary headache
Flag Description/example
Systemic symptom or Fever/weight loss or known cancer,
Secondary risk factors HIV,immunosuppression or
thrombotic risk
Neurological symptoms or abnormal Confusion ,drowsiness or persistent
signs focal signs>1hr

Onset “First and worst headache” , sudden

Older
Previous headache history
Triggered headache
or abrupt from sleep, or
progressively worsening.
New and progressive >50 Consider
TA
First headache or fundamental
change in characteristics of h/a
By valsalva /exertion or sexual
intercourse
 Headache Evaluation
History (duration, onset, frequency)
Is there a family history of headache?
Are there any known causes of headache?
What is the typical location(s)?
What does the pain feel like?
What makes it worse?
What makes it better?
What are the results of past evaluations?
Are there associated symptoms? Exam findings?
What is the patient’s sex?
 MIGRAINE

A diagnosis of migraine can be given to a

patient presenting with episodic headache
(≤15 days per month) that interferes
significantly with their everyday activities
(work, housework, and leisure activities).
Diagnostic criteria for migraine without
aura
Attacks lasting 4-72hrs

At least two of the At least one of the

following: following:

Unilateral Nausea
Pulsating Photophobia
Moderate to severe Phonophobia
Aggravated by
exercise
Diagnostic criteria for migraine with
aura
Migraine without aura plus

One or more transient focal neurological

signs:- visual/sensory/aphasic/motor
Gradual development of aura symptom
Aura lasts 4-60 mins followed by or
accompanied by headache within 60 mins
Predisposing factors & triggers
Family history Relaxation after
h/o travel sickness stress-”weekend
h/o cyclical vomiting migraine”
in childhood Change of habit-missed
Stress meals /sleep
Bright lights
Menstrual cycle
Loud noise
Menopausal
Smells-perfume /petrol
Head & neck trauma
Dietary-- <10%
Strenuous exercise
 Acute Management
Paracetamol Opiate –based and mixed
NSADIs –orally /rectally/im analgesics should be
avoided.
Anti-emetic
/prokinetics
metclopramide or
domperidone-orally/rectally
/im/ buccal mucosa
Combinations-eg
migraleve/
Specific anti-migraine
therapy- triptans
 Triptans-
5-HT1 class 1B/1D agonists
Sumariptan
Zolmitriptan
Rizatriptan
Eletriptan
Almotriptan
Naratriptan
Frovatriptan
Consider formulation eg s/c injection/nasal
spray /wafer sublingual
 Migraine
Which triptan?
Compared with sumatriptan 100

2hr relief Sustained consistency tolerability

triptan
Pain free
sumatriptan
50
= = - +
Zolmitriptan
2.5
= = = =
Rizatriptan 10
+ + + =
Eletriptan 40
= = = =
Almotriptan
12.5
+ + + ++
Naratriptan
2.5
- - - ++
frovatriptan
- - -
 Management of migraine
Lifestyle modifications-

Regular sleep
Regular meals
Moderate amount of exercise
Drink plenty of water
Limit caffeine, alcohol and other drugs
Reduce stress
Stop cocp
Acute management-principles
Use correct dose
Use correct formulation
Stepped treatment-simple analgesia-combinations-
triptans
Early intervention
Use at least 3 times before judging
effectiveness
Use a maximum of 2-3 days per week and
8/month
 Migraine- preventive therapies
When to use
Frequent headaches >3-4/month

Migraine significantly interferes with

patient’s daily life despite abortive
treatment
Acute/abortive therapies contra-indicated,
ineffective, not tolerated or OVERUSED
Migraine – preventive treatments

Antidepressants- tricyclic amitriptyline

Betablockers- propranolol LA 80-160mg
Anticonvulsants- sodium valproate topiramate
Seretonin antagonists–pizotifen; methylsgide
Calcium channel antagonists – verapamil
Anticonvulsants- gabapentin; pregabalin
Migraine –emerging therapies
CGRP antagonists “PANTS”-olcegepant
Botox injections
Greater occipital nerve blocks
Occipital nerve stimulation

Closure of PFO- study failed to meet primary endpoint

 Hormones & migraine
Until puberty boys=girls
Year of 1st menses 15% women have 1st
migraine
Fertile years women: men=3:!
 Tension-type headache
Featureless headache
Often tight band around head / bitemporal
Mild nausea
Mild to moderate intensity
episodic
 Chronic daily headache
Headache present >15 days /month for at
least 2 months.
Exclude “red flag”

Think analgesia –overuse headache

usually dull, generalised . Early morning worsening
 Medication overuse headache
clinical features
Chronic daily headache> 15days/mth
Regular intake for >3mths

May differ depending on drug being overused:

Triptans- daily migrainous headache

develops on using triptans for >/= 10days/mth

Analgesics- diffuse featureless headache

On using opiate or combination analgesics for > /= 10 days/month

On using simple analgesics for >/= 15 days /month

 Cluster headache
Strictly unilateral
Ipsilateral autonomic symptoms –at least one of:
conjunctival injection, nasal blockage, facial
sweating, miosis,ptosis
Bouts-typically 1/year lasting 6-12 weeks with
discrete headaches 1-8times /day each lasting
30-60 mins
Age 20-40 M>F=7:1
Headache severe/excrutiating- restless “banging
head against wall”
 Cluster headaches-abortive
treatment
Subcutaneous sumatriptan 6mg
High dose/high flowrate oxygen
Intranasal triptans- not so effective
 Cluster headache- preventive
treatments
Verapamil 240-960mg/day ( ECG)-
bradycardia,hypotension,arrythmias,constipation,fatigue,oedema

Lithium 400-2000mg/day hypothyroidism,Diabetes insipidus, tremor,nausea, wt

gain ataxia drowsiness, confusion seizure

Methylsergide 3-12mg/day vascular constrictive phenomena, fibrotic

reactions ,muscle cramps, abdominal discomfort weight gain, mood change

Transitional treatments:
High dose corticosteroids- 1mg/kg ( up to 60mg daily for 5
days tapering over 2-3 weeks
rapid onset of action. Attack recurs once dose reduced. Initial add-on
until other preventatives are effective
 THANKYOU

QUESTION?