Headache
- 1. Headache
- 3. Definition • A pain in the head with the pain being above the eyes or the ears, behind the head (occipital), or in the back of the upper neck. Headache, like chest pain or back ache, has many causes. • All headaches are considered primary headaches or secondary headaches. • Primary headaches are not associated with other diseases. Examples of primary headaches are migraine headaches, tension headaches, and cluster headaches. • Secondary headaches are caused by other diseases. The associated disease may be minor or major.
- 4. There are 150 different types of headaches. The most common ones are : • Tension headaches: Also called stress headaches, • chronic daily headaches, or chronic non-progressive headaches, they are the most common type among adults and teens. • They cause mild to moderate pain and come and go over time.
- 5. • Tension Headache Tension headaches are a pressure or tight sensation, he pain is typically mild to moderate, but can become severe. • There is no associated throbbing or pulsing to the pain of a tension headache. Furthermore, there is no exacerbation or increase in the pain with exercise. • Nausea and vomiting are not associated with tension headaches. However, some patients do occasionally describe either light sensitivity or noise sensitivity.
- 6. • Migraines: These headaches are often described as pounding, throbbing pain. • They can last from 4 hours to 3 days and usually happen one to four times per month. • Along with the pain, people have other symptoms, such as sensitivity to light, noise, or smells; nausea or vomiting ; loss of appetite; and gastric pain
- 7. • Cluster headaches: This type is intense and feels like a burning or piercing pain behind the eyes, either throbbing or constant. • Pain frequently develops during sleep and may last for several hours. Attacks occur every day for weeks, or even months, then disappears for up to a year. • Eighty percent of cluster patients are male, most between the ages of 20 and 50. It’s the least common but the most severe type of headache. The pain can be so bad that most people with cluster headaches can’t sit still and will often pace during an attack.
- 8. • Sinus headaches: With these, you feel a deep and constant pain in your cheekbones, forehead, or bridge of your nose. • They happen when sinuses get inflamed. The pain usually comes along with other sinus symptoms, such as a runny nose, feeling of fullness in the ears, fever, and swelling in your face
- 9. • Mixed Tension Migraine This headache type has features of both migraine headache and tension headache. Sufferers describe the pain as dull and constant or throbbing • the severity may be mild, moderate, or severe. • Other symptoms of migraine, including light and sound sensitivity or nausea and vomiting, may be present. There may be neck pain or scalp muscle tension.
- 10. Clinical picture Symptoms History & Examination
- 12. Table 1. Red flags in patients with headache New (recent onset or change in pattern) Effort-induced or positional Late life onset (middle age or later) Meningismus, fever AIDS, cancer, or other known systemic illness Neurologic or psychological symptoms or signs
- 13. • symptoms such as a fever, weakness, vision loss or double vision, or confusion are some of most concerning symptoms. • If you have a new symptom and serious, life-threatening medical problems such as liver, heart or kidney disease, are pregnant, or have a disorder which affects your immune system such as HIV infection, an ER visit may be more essential.
- 14. History-taking in acute headache Mode of onset (fast vs. slow) Exertion during onset or before Location Focal symptoms Current medications and drugs Family history Medical illnesses
- 15. • mode of onset is very important, with a rapid evolution to severe pain suggesting secondary causes. • Exertion during or before onset is also worrisome, although it can be a benign presentation. • Severity is important, but most patients in the ED will probably endorse a high level of pain intensity. Asking the patient if it is the worst headache they have ever had is not particularly useful.
- 16. • Focal neurologic symptoms suggest neurologic disease, such as arterial dissection, intracranial mass or vasculitis. • Current medications (such as sedatives, stimulants, and anticoagulants) and other substances must be known so potential causes of headache as well as potential roadblocks to treatment can be clarified. • The presence of concurrent medical illnesses, such as diabetes, HIV infection and neoplastic disease, must be understood for similar reasons
- 17. Acute narrow-angle glaucoma • An uncommon eye condition that results from blockage of the drainage of fluid from the eye. • Symptoms of acute glaucoma may include headache with a painful red eye and misty vision or haloes, and in some cases nausea. • Acute glaucoma may be differentiated from cluster headache by the presence of a semi-dilated pupil compared with the presence of a constricted pupil in cluster headache
- 18. Bout of cluster headache The duration over which recurrent cluster headaches occur, usually lasting weeks or months. Headaches occur from 1 every other day to 8 times per day. Giant cell arteritis Also known as temporal arteritis, giant cell arteritis is characterised by the inflammation of the walls of medium and large arteries. Branches of the carotid artery and the ophthalmic artery are preferentially involved, giving rise to symptoms of headache, visual disturbances and jaw claudication
- 19. • When going to the ER, be sure to mention: • your symptoms, including any that are new or unusual for you • Any medications you have taken, especially in the last few days; and • if you have had good results from a particular medication regimen, that can be helpful to the ER
- 20. Examination criteria in acute headache Vital signs Meningismus Eye exam including pupillary light response and funduscopy Head and neck exam – sinuses, temporomandibular region, submandibular areas, carotid arteries, superficial nerves Neurologic exam Dix-Hallpike maneuver
- 21. • Examining the patient with acute headache must include an assessment of meningismus as a clue to meningeal inflammation due to infection or hemorrhage • Head and neck evaluation should include palpation of the paranasal sinuses, temporomandibular joint regions, submandibular tissues, carotids, temporal arteries, and supraorbital regions. • A complete neurologic exam is essential. The Dix-Hallpike maneuver may be helpful when vertigo is a key accompaniment. Provocative maneuvers may help clarify cervical spine disease, including the Spurling maneuver. • Eye examination, including careful pupillary evaluation, is very helpful to exclude ocular disease, such as acute angle-closure glaucoma. Funduscopic evaluation is essential as an indicator of intracranial pressure
- 22. • Routine laboratory testing in acute headache may be of low yield • serum glucose, electrolytes, blood cell counts, and pregnancy testing are generally recommended. • Computed tomography (CT) is essential for patients who have had recent head trauma or in whom a mass lesion or subarachnoid hemorrhage is suspected. Computed tomography may be overused in evaluating acute headache, as approximately 95% demonstrate no abnormality
- 23. Treatment
- 24. Migraine with or without aura Acute treatment • Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol , for the acute treatment of migraine, comorbidities and risk of adverse events. • For young people aged 12–17 years consider a nasal triptan in preference to an oral triptan • For people in whom oral preparations (or nasal preparations in young people aged 12–17 years) for the acute treatment of migraine are ineffective or not tolerated: offer a non-oral preparation of metoclopramide or prochlorperazine andconsider adding a non-oral NSAID or triptan if these have not been tried.
- 25. • For people who prefer to take only one drug, consider monotherapy with an oral Triptan. NSAID, aspirin (900 mg) or paracetamol for the acute treatment of migraine comorbidities and risk of adverse events. • When prescribing a triptan start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans • Consider an anti-emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting
- 26. Prophylactic treatment • Offer topiramate or propranolol for the prophylactic treatment of migraine according to the person's preference, comorbidities and risk of adverse events. • Advise women and girls of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception if needed.
- 27. Tension-type headache Acute treatment Consider aspirin , paracetamol or an NSAID for the acute treatment of tension-type headache,taking into account the person's preference, comorbidities and risk of adverse events. Do not offer opioids for the acute treatment of tension-type headache. Prophylactic treatment Consider a course of up to 10 sessions of acupuncture over 5–8 weeks for the prophylactic treatment of chronic tension-type headache.
- 28. Cluster headache Acute treatment • Discuss the need for neuroimaging for people with a first bout of cluster headache with a GP with a special interest in headache or a neurologist. • Offer oxygen and/or a subcutaneous2 or nasal tripan3 for the acute treatment of cluster headache. When using oxygen for the acute treatment of cluster headache: • use 100% oxygen at a flow rate of at least 12 litres per minute with a non- rebreathing mask and a reservoir bag and arrange provision of home and ambulatory oxygen. When using a subcutaneous or nasal triptan, ensure the person is offered an adequate supply of triptans calculated according to their history of cluster bouts, based on the manufacturer's maximum daily dose.
- 29. Do not offer paracetamol, NSAIDs, opioids, ergots or oral triptans for the acute treatment of cluster headache. Prophylactic treatment Consider verapamil1 for prophylactic treatment during a bout of cluster headache. If unfamiliar with its use for cluster headache, seek specialist advice before starting verapamil, including advice on electrocardiogram monitoring. Seek specialist advice for cluster headache that does not respond to verapamil. Seek specialist advice if treatment for cluster headache is needed during pregnancy
- 30. Interventional procedures NICE has published guidance on the following procedures with special arrangements for clinical governance, consent and audit or research: transcutaneous stimulation of the cervical branch of the vagus nerve for cluster headache and migraine implantation of a sphenopalatine ganglion stimulation device for chronic cluster headache deep brain stimulation for intractable trigeminal autonomic cephalalgias.
- 31. Medication overuse headache • Explain to people with medication overuse headache that it is treated by withdrawing overused medication. • Advise people to stop taking all overused acute headache medications for at least 1 month and to stop abruptly rather than gradually. • Advise people that headache symptoms are likely to get worse in the short term before they improve and that there may be associated withdrawal symptoms, and provide them with close follow-up and support according to their needs.
- 32. • Consider prophylactic treatment for the underlying primary headache disorder in addition to withdrawal of overused medication for people with medication overuse headache. • Consider specialist referral and/or inpatient withdrawal of overused medication for people who are using strong opioids, or have relevant comorbidities, or in whom previous repeated attempts at withdrawal of overused medication have been unsuccessful. • Review the diagnosis of medication overuse headache and further management 4–8 weeks after the start of withdrawal of overused medication.
- 34. Algorithm
- 37. If no relief in step 3
- 40. Common Therapeutic Approach to Severe Migraine • 1L bolus of NS • Prochlorperazine 10 mg IV • Diphenhydramine 25 mg IV • Ketorolac 30 mg IV • Dexamethasone 10 mg IV • Other options include haloperidol, metoclopramide, ergotamine, sumatriptan, analgesics.