Headaches

• Headache or Cephalalgia is pain anywhere in the region of the head and neck.
• The brain itself is not a pain-sensitive organ since it lacks pain receptors.
• HA pain - due to pain-sensitive structures located in the head and neck region.

Primary

• Migraine
• Migraine without aura (common migraine)
• Migraine with aura (classic migraine)
• Cluster Headache (recurrent severe periorbital attacks)
• Tension-type headache (e.g., posterior neck muscle contraction)

Secondary HA

• Associated with vascular disorders:
  • Subarachnoid hemorrhage (Emergency!)
  • Temporal arteritis (risk of blindness)
  • Venous thrombosis
  • Intracranial hematoma (including epidural, subdural)
  • Severe arterial hypertension
• Associated with nonvascular intracranial disorders:
  • Infection (meningitis, abscess, sinusitis)
  • Increased CSF pressure (intracranial mass lesion or hydrocephalus)
• Miscellaneous:
  • Medication: side effect of nitroglycerin or withdrawal (analgesics)
  • Psychological disorders

• Onset (Acute vs slowly progressive), frequency, duration (hours, days?), quality, intensity (worse ever?), location,
• Triggers (worse with exertion?, food? menstruation?) and ameliorating factors, associated symptoms (pulsatility, photophobia, phonophobia)
• Functional impairment (work, IADLs)
• Red flags (neurological symptoms, severity of disability) for serious disease to differentiate between the causes of headache.
• Select patients in need of immediate management based on red flags on history and physical signs. Clinical history, diagnostic imaging, laboratory findings
• Vitals, Level of consciousness, Head and neck, Neurological exam (especially visual, motor, reflex, sensory, speech, or cognitive). If positive finding, investigation is warranted.
• Identify patients that require referral/brain imaging:
1. New/explosive onset
2. Change in pattern
3. Jaw claudication
4. Limb girdle pain
5. Worse with stooping over, straining, coughing
6. Neurological signs on exam
7. Temporal artery tenderness
• X-rays and other tests may also be used if sinusitis is suspected.

Diagnostic Alarm Signs for Serious Headache (Red Flags)

• Sudden onset
• Onset after 50 years
• Increased frequency and severity
• New onset in HIV or cancer patients
• Associated with systemic illness – hypertension, diabetes, neck aches, fever, rash
• Altered consciousness, focal neurologic deficit
• Papilledema
• Trauma

• Migraine without aura (common migraine)
• Migraine with aura: Aura are transient focal neurological symptoms that often precede or accompany the headache.
• Cluster Headache: Involves recurrent severe periorbital attacks.
• Tension-type headache: Involves posterior neck muscle contraction.

• Intracranial hemorrhage
• Subdural hemorrhage
• Subarachnoid hemorrhage
• Meningitis
• Hypertensive encephalopathy

Management of Headache

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Management of Headache

Clinical, Diagnostic Imaging, Laboratory Findings

• Lumbar puncture if subarachnoid hemorrhage, encephalitis, high- or low-pressure headache symptoms, or meningitis is suspected.
• Laboratory tests (on an individual basis)
• ESR for suspected temporal arteritis
• Endocrine, biochemical, infection work-up
• Search for malignancy if indicated
• Facial pain may need a thorough assessment by a dental specialist familiar with headaches and facial pain and/or an ENT specialist if sinus or other ENT disorders are suspected.

• Symptomatic treatment- Analgesics:
• Ibuprofen, naproxen, and ASA or acetaminophen with or without codeine and/or butalbital, are used for mild to moderate h/a pain.
• Non-opioid meds should be used less than 15 days per month (to prevent rebound h/a).
• Medication over-use h/a can result from overuse of analgesics/rebound/dependency, which limits their long-term potential.
• Ergot derivatives:
• Ergotamine acts on serotonin receptors and is classically used for migraines and cluster h/a but use is limited by side effects. They may cause rebound h/a if used 10 days per month or more.
• Triptans:
• They act on the serotonin (HT-5) subclass 1B and 1D receptor, on extracerebral blood vessels and neurons, and the mechanism of action is prevention of neurologically sterile inflammatory responses around vessels and vasoconstriction.
• They are contraindicated in patients with cardiac disorders, sustained hypertension, basilar and hemiplegic migraine.
• Other classes of drugs:
• Corticosteroids can be useful in many h/a disorders, including status migraine, cluster h/a, and cerebral neoplasms with edema (especially metastatic lesions, temporal arteritis).
• Other drugs include metoclopramide (maxeran), phenothiazines, Ketorolac, meperidine, indomethacin, dimenhydrinate, and domperidone.

Indication for Migraine Prophylaxis

• Interferes with patient's daily routine/QOL.
• >2 attacks/month
• Acute medications ineffective or contraindicated.
• Presence of uncommon migraine conditions:
• Hemiplegic migraine
• Basilar migraine
• Migraine with prolonged aura.
• Beta blockers
• Tricyclics
• Calcium channel blockers
• AED-valproate, topiramate, and gabapentin
• Methylsergide

Patient Education and Counseling for Management of Benign Headache Syndrome:

• A calendar or diary of headaches is useful for follow-up assessment.
• A record of medications (usefulness, dosage, side effects) should be kept.
• Reassurance and explanation are most important to the patient in the long term.
• Always offer hope to the patient with chronic headaches even if no cure is available; most primary headaches can be controlled.
• For tension headaches, attempt to modify or eliminate the stressor with behavior modification, biofeedback, relaxation therapy, yoga, exercise, and so on.