Headache, primary and secondary and emergencies associated with headache

1. HEADACHE
& associated emergencies
Dr Ahmad Shahir bin Mawardi
Neurology Registrar,
Neurology Department
Hospital Kuala Lumpur
17th
October 2016

2. Myths about Headache
Headache = Migraine
Headache = CT scan

3. 1. Introduction
2. Classification of headache
3. Red flag for headache
4.Diagnosis of headache
• History, Examination, Ix
1. Common causes of headache
• Migraine, TTH, CH,MOH
1. Management
Outlines

4. ∗ lifetime prevalence of over 90% of the general
population in the United Kingdom (UK)
∗ It accounts for 4.4% of consultations in primary care
and 30% of neurology outpatient consultations
Headache

5. ∗ Migraine occurs in 15% of the UK adult population
∗ women more than men in a ratio of 3:1
∗ >100,000 people are absent from work or school
because of migraine every working day.
∗ migraine costs the UK almost £2 billion a year
∗ Most frequent causes of consultation in GP and
neurological clinics.
Introduction

6. ∗ Healthcare professionals often find the diagnosis of
headache difficult
∗ but treatments can cause headache themselves
∗ Most primary headache can be managed in primary
care and investigations are rarely needed
∗ When to refer?

7. ICH Disorders, 3 rd
Edition
HEADACHEHEADACHE
Primary Secondary
Neuralgias &
other headaches
not associated with an
underlying pathology
attributed to an
underlying
pathological
condition
> 200 headache types> 200 headache types

8. ICH Disorders, 3 rd
Edition
HEADACHEHEADACHE
Primary Secondary
Neuralgias &
other headaches
1. Migraine (+ aura)
2. Tension-type headache
3. Trigeminal autonomic cephalalgias
(CH, Paroxysmal hemicrania, Short-lasting unilateral neuralgiform headache
attacks-SUNCT/SUNA, Hemicrania continua)
4. Other primary headache disorders

9. 1. Primary cough headache
2. Primary exercise headache
3. Primary headache associated with sexual activity
4. Primary thunderclap headache
5. Cold-stimulus headache
6. External-pressure headache
7. Primary stabbing headache
8. Nummular headache
9. Hypnic headache
10. New daily persistent headache (NDPH)
4. Other primary headache disorders

10. ICH Disorders, 3 rd
Edition
HEADACHEHEADACHE
Primary Secondary
Neuralgias &
other headaches
1. Migraine (+ aura)
2. Tension-type headache
3. Trigeminal autonomic cephalalgias
(CH, Paroxysmal hemicrania, Short-lasting unilateral neuralgiform headache
attacks-SUNCT/SUNA, Hemicrania continua)
4. Other primary headache disorders

11. ICH Disorders, 3 rd
Edition
HEADACHEHEADACHE
Primary Secondary
Neuralgias &
other headaches
6. Headache attributed to cranial or cervical vascular disorder
7. Headache attributed to non-vascular intracranial disorder
8. Headache attributed to a substance or its withdrawal
9. Headache attributed to infection
10. Headache attributed to disorder of homoeostasis
11. Headache or facial pain attributed to disorder of the cranium, neck,
eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure
12. Headache attributed to psychiatric disorder

12. ICH Disorders, 3 rd
Edition
HEADACHEHEADACHE
Primary Secondary
Neuralgias &
other headaches
13. Painful cranial
neuropathies and other
facial pains
14. Other headache
disorders

13. ∗ Patients may have more than one type of primary headache
∗ each headache type should be dealt with separately
∗ secondary headache is rare
∗ primary headache, findings on neurological examination are
usually normal
∗ Ix are not helpful for diagnosis

14. Diagnosis of headache
1)History
2)Physical examination
3)Investigations

15. 1) History of headache
∗ The history is all-important
∗ Headache diary- pattern of headache
∗ Excludes sinister causes of headcahe
∗ Intracranial tumor
∗ Meningitis
∗ Sudarachoid Haemorrhages
∗ Giant Cell Arteritis
∗ Primary angle-glaucoma
∗ Idiopathic Intracranial Hypertension
∗ Carbon Monoxide posioning

16. Weekly Headache Diary

17. 1) History of headache

18. Red Flag of Headache (I)
1. new onset or change in headache in patients aged > 50
2. thunderclap: rapid time to peak headache intensity (seconds to 5 mins)
3. focal neurological symptoms (eg limb weakness, aura <5 min or >1 hr)
4. non-focal neurological symptoms (eg cognitive disturbance)
5. change in headache frequency, characteristics or associated symptoms
6. abnormal neurological examination
7. headache that changes with posture

19. Red Flag of Headache (II)
8. headache wakening the patient up
9.headache precipitated by physical exertion or valsalva manoeuvre (eg
coughing, laughing, straining)
10.patients with risk factors for cerebral venous sinus thrombosis
11.jaw claudication or visual disturbance
12. neck stiffness
13. fever
14. new onset headache in a patient with a history of HIV infection
15. new onset headache in a patient with a history of cancer.

20. 2) Examination of headache
Neurological examination in patients first presenting with
headache:
1. fundoscopy
2. cranial nerve assessment, especially pupils, visual fields, eye
movements, facial power and sensation and bulbar function
(soft palate, tongue movement)
3. assessment of tone, power, reflexes and coordination in all
four limbs
4.plantar responses
5. assessment of gait, including heel-toe walking.

21. 3) Headache: Investigations
∗ majority of primary headaches do not require neuroimaging

22. 3) Headache: Investigations
Q:When is neuroimaging required?
∗ individual basis
∗ Neuroimaging is not indicated in patients with a clear history
of migraine, without red flag features for potential
secondary eadache, and a normal neurological examination.
∗ Patient reassurance

23. 3) Headache: Investigations
Q: CT versus MRI?
∗ The European Federation of Neurological Societies guidelines
∗ MRI is the imaging modality of choice because of this greater
sensitivity
∗ The US headache consortium
∗ MRI may be more sensitive than CT in identifying clinically
insignificant abnormalities,
∗ but not more sensitive in identifying clinically significant pathology
relevant to the cause of the headache.
∗ Recomendation:
Brain CT should be performed in patients with abnormal neurological
signs, unless the clinical history suggests MRI is indicated.
Brain MRI should be considered in patients with cluster headache,
paroxysmal hemicrania or SUNCT.

24. Headache assessment tools
1. Headache Impact Test (HIT /HIT 6)
www.headachetest.com
2. Migraine Disability Assessment (MIDAS)
www.midasmigraine.net/edu/question/Default.asp
3. ID Migraine
www.migraineclinic.org.uk

25. Types of headache
∗ Migraine
∗ Tension-type headache (TTH)
∗ Cluster headache (CH)
∗ Medication overuse headache (MOH)

26. Common types of headache

27. Migraine
∗ 1/3 of migraine sufferers
∗ Recurrent headache disorder
∗ 4-72 hours.
∗ Typical characteristics : unilateral location, pulsating quality,
moderate or severe intensity, aggravation by routine
physical activity and association with nausea and/or
photophobia and phonophobia.

28. Migraine with aura
∗ Aura:
∗ Visual blurring and “spots”
∗ progressive, last 5-60 minutes prior to headache
∗ transient hemianopic disturbance/ scintillating scotoma
∗ can occur with:
∗ unilateral paraesthesia,of hand, arm or face
∗ dysphasia
∗ functional cortical manifestations
∗ disturbance of one cerebral hemisphere
∗ may occur without migraine
∗ aura persisting after resolution of the headache/aura involving
motor weakness-> further Ix
∗ familial hemiplegic migraine

29. Scintillating scotoma

30. Migraine with aura: Diagnostic criteria
∗ Recurrent attacks, lasting
minutes
∗ unilateral
∗ fully reversible visual, sensory
or other central nervous
system
∗ symptoms develop gradually
and are usually followed by
headache and associated
migraine symptoms.

31. Migraine without aura: Diagnostic criteria

32. Migraine
∗ Migraine headache in children and adolescents is
more often bilateral, unilateral pain usually emerges
in late adolescence or early adult life.
∗ Migraine headache is usually frontotemporal.

33. Possible Triggers of a Migraine Attack
Food and food
additives
Bright lights/glare
Smells/odors
Dieting/hunger
Loud noises/sounds
Changes in altitude/
air travel
Stress
Weather changes
Caffeine
Alcoholic beverages
Changes in sleep
habits
Hormonal
fluctuations/
menstrual cycleWober C et al. J Headache Pain. 2006;7(4):188-195.
Friedman DI and De Ver Dye T. Headache. 2009;49(6):941-
952.

34. Tension type Headache
∗ Episodic, very low frequency and short-lasting (< several hours)
∗ Generalised but can be unilateral
∗ Nature of pain:
∗ pressure or tightness,/tight band around the head
∗ spreads into or arises from the neck
∗ can be disabling for a few hours
∗ lacks of specific features and associated symptom
∗ May be stress-related or a/w functional or structural cervical or cranial
musculoskeletal abnormality.
∗ Chronic TTH: >15 days a month, and may be daily

35. Diagnostic criteria: TTH
*Frequent episodic tension-type headache often coexists
with Migraine without aura.

39. Trigeminal Autonomic cephalalgias
∗ rare
∗ characterised by attacks of severe unilateral pain in a trigeminal
distribution.
∗ a/w prominent ipsilateral cranial autonomic features.
Types
1. Cluster headache is the most common (1 in 1,000).
2. Paroxysmal hemicrania (1 in 50,000)
3. Short-lasting unilateral neuralgiform headache attacks with
conjunctival injection and tearing (SUNCT)
4. Short-lasting unilateral neuralgiform headache attacks with
cranial autonomic symptoms (SUNA) .
very rare

40. TAC: Cluster headache
∗ Severe, strictly unilateral pain.
∗ The pain is located in one or a combination of orbital, supraorbital,
or temporal regions.
∗ Restless during an attack.
∗ Starts and ceases abruptly
∗ Duration: 15 minutes to three hours
∗ Frequency: EOD day to eight per day.
∗ Striking circadian rhythm;
'attacks often occur at the same time each day and
clusters occur at the same time each year'.

41. ∗ a/w ipsilateral conjunctival
injection, lacrimation, nasal
congestion, rhinorrhoea,
forehead and facial
sweating, miosis, ptosis
and/or eyelid oedema
∗ and/or with restlessness or
agitation
TAC: Cluster headache

42. TAC : Cluster headache (CH)
∗ CH affects mostly men
∗ (male to female ratio 6:1)
∗ Age 20s or older and very often smokers.

43. TAC : Short-lasting unilateral
neuralgiform headache attacks
∗ Attacks of moderate or
severe, strictly unilateral
head pain
∗ Duration: seconds to
minutes,
∗ Frequency: at least once a
day
∗ usually a/w prominent
lacrimation and redness of
the ipsilateral eye

44. Trigeminal Autonomic
cephalalgias
Short-lasting unilateral neuralgiform
headache attacks with conjunctival
injection and tearing (SUNCT)
Short lasting unilateral neuralgiform
headache attacks with cranial
autonomic symptoms (SUNA)

45. Features distinguishing TACs from migraine

46. Medication overuse headache (MOH)
∗ > 15 or more days per month
∗ developing as a consequence
of regular overuse of acute
or symptomatic headache
medication for more than 3
months.
∗ It usually, but not invariably,
resolves after the overuse is
stopped

47. Overused meds frequency/month duration
ergotamine >10 days >3 months
Triptan >10 days >3 months
paracetamol >15 days >3 months
acetylsalicylic acid >15 days >3 months
NSAIDs >15 days >3 months
opioid >10 days >3 months
combination analgesic medication >10 days >3 months
multiple drug classes not individually overused >10 days >3 months
unverified overuse of multiple drug classes >10 days >3 months
one or more medications other than
those described above
>10 days >3 months

48. Medication overuse headache (MOH)
∗ Mechanisms: not clear
∗ probably as a results in down-regulation of 5-HT1B/1D receptors
∗ addictive properties
∗ changes in neural pain pathways
∗ may take weeks to months for the headache to resolve after
withdrawal.

49. Medication overuse headache (MOH)
∗ Small amounts are sufficient to induce MOH
∗ >15 days a month or of codeine-containing analgesics,
∗ >10 or more days a month of ergot or triptans
∗ Frequency is important:
∗ low doses daily carry greater risk than larger doses weekly.
∗ Nature of pain
∗ worst on awakening in the morning
∗ increases after physical exertion
∗ In the end-stage, headache persists all day, fluctuating with
medication use repeated every few hours.

50. Medication overuse headache (MOH)
∗ Prophylactic medication aggravate the condition
∗ Headache diary
∗ The (presumptive) diagnosis made based on symptoms and
drug used.
∗ Confirmed when symptoms improve after medication is
withdrawn.

51. Treatment for migraine: history

52. Aretaeus A.D. 81?
For the treatment of
headache, Aretaeus
recommended
inducing sneezing by
placing testicle of
beaver powder
intranasally to “bring
off phlegm”

53. Management- General
During consultation:
1. Explanation of the diagnosis and reassurance that other
pathology has been excluded
2. the options for management
3. recognition that headache is a valid medical disorder
with significant psychosocial impact
*headache diary (minimum of 8/52)

54. MIGRAINE WITH OR WITHOUT AURA
Acute treatment
Monotherapy:
oral triptan, NSAID, aspirin(900 mg) or
paracetamol
Combination:
Oral triptan + an NSAID/
Oral triptan + paracetamol.
Consider an anti-emetic even in the
absence of nausea and vomiting.
Do not offer ergots or opioids
If ineffective or not tolerated:
IV NSAID or IV triptan + IV
metoclopramide or prochlorperazine

55. Migraine

56. Triptans
∗ Triptans provide
significant pain
relief to patients
with acute
migraine within
two hours &
improve
patients’ QoL

57. ∗ Anti-emetics
∗ prochlorperazine 3-6 mg buccal tablets or
∗ domperidone 10 mg oral or 30 mg rectal
∗ metoclopramide 10 mg or *
∗ domperidone 20 mg *
∗ are also useful as a prokinetic to promote gastric emptying
Caffeine??
∗ Evidence was limited to the inclusion of caffeine with
combinations of other therapies

58. MIGRAINE WITH OR WITHOUT AURA
Prophylactic treatment
First line: Topiramate or
propranolol
Review the meds after 6
months.
Diet: riboflavin (400 mg OD)
may be effective in reducing
migraine frequency and
intensity for some people

61. MIGRAINE WITH OR WITHOUT AURA
Other meds
Amitriptyline is widely used, off-label, to treat chronic painful disorders,
including migraine. Inadequate evidence. If effective--> continue the
current treatment
Pizotifen is a popular treatment for migraine prevention, been in use
since the 1970s and appears to be well tolerated. Inadequate evidence.
Treatment of migraine during pregnancy: PCM

62. TENSION-TYPE HEADACHE
∗ Acute treatment
∗ Aspirin, paracetamol or an NSAID
∗ Do not offer opioids
∗ Prophylactic treatment
∗ Acupuncture (10 sessions over 5–8 weeks)

63. CLUSTER HEADACHE
Acute treatment
Offer oxygen and/or a subcutaneous 6 mg
or nasal triptan (if cannot tolerate
subcute).
use 100% oxygen at a flow rate of at least 12 litres
per minute with a non- rebreathing mask and a
reservoir bag
Do not offer paracetamol, NSAIDS,
opioids, ergots or oral triptans
Prophylactic treatment
Verapamil 240-960 mg/day

64. Medication overuse headache
∗ Treated by withdrawing overused medication--> Explain, explain,
explain!!!
∗ Advise:
∗ to stop all overused meds abruptly rather than gradually for < 1 month
∗ headache symptoms are likely to get worse in the short term before they improve
∗ + withdrawal symptoms
∗ Consider prophylactic treatment for the underlying primary headache
disorder
∗ Consider specialist referral for people who are using strong opioids
withdrawal (Addiction team)
∗ Review the diagnosis & mx 4–8 weeks after the start of withdrawal of
overused medic

71. Headaches That Require Emergency
Attention
∗ Stroke
∗ (focal neurological deficit, nausea, vomiting)
∗ Aneurysm
∗ (The worst headache ever!)
∗ subarachnoid hemorrhage (SAH)
∗ Meningitis
∗ (fever & neck pain)

72. Subarachnoid hemorrhage
∗ severe and sudden, peaking
in seconds (thunderclap
headache) or minutes.
∗ mortality rate is 40–50%
∗ 10–20% of patients die
before arriving at hospital;
∗ 50% of survivors are left
disabled

73. Subarachnoid hemorrhage

74. Subarachnoid hemorrhage
∗ Plain CT scan,
∗ sensitivity of 98% in the first 12 hours after onset
∗ 93% at 24 hours
∗ 50% at 7 days)
∗ Lumbar puncture (if CT results are non-diagnostic)
∗ Xanthochromia 100% of cases if collected between 12 hours
and 2 weeks
∗ MRI is not indicated
∗ FLAIR and gradient-echo T2-weighted images may be useful
when the CT is normal and the CSF abnormal.

75. Subarachnoid hemorrhage
∗ SAH is a neurointerventional
emergency.
∗ the next urgent step is to
identify a ruptured
aneurysm (80% of cases -
ruptured saccular
aneurysms).

76. References

77. Subarachnoid hemorrhage

78. Thank you