Approach to the Patient with Headache - PowerPoint Presentation

1. Approach to the Patient with HeadacheDr. Ahmed A. SalimLecturer and Neurologist Basrah College of Medicine

2. Headache is one of the most common reasons for presentation to an emergency department.Headache is classified as primary and secondary.

3. Primary HeadachesPrimary headaches are biologic disorders of the brain that are differentiated on the basis of clinical criteria

4. Types of primary HeadachesMigraineTension-Type HeadacheTrigeminal Autonomic CephalalgiasOther Primary Headache Disorders (like primary cough headache, primary exercise headache and primary headache associated with sexual activity )

5. Secondary HeadachesSecondary headache disorders are defined by identifiable organic causation and typically display one of the clinical “red flags.”

6. Red flags for headache(S) New headache in patients with cancer or immunosuppression or in pregnant women or if there is systemic symptoms and signs(N) Neurologic symptoms and signs(O) New headache in persons younger than 5 years or older than 50 years(O) Sudden-onset or thunderclap attack(P) Progression or fundamental change in headache pattern

7. Types of secondary headachesPosttraumatic headacheHeadache attributed to cranial or cervical vascular disorderIschemic stroke or transient ischemic attackParenchymal or subarachnoid hemorrhageBrain neoplasiaMedication overuse headacheHeadache attributed to infection like (meningitis, encephalitis, brain abscess, systemic bacterial infection and viral syndrome)

8. Thunderclap HeadacheThe term thunderclap headache is applied to severe headaches that reach maximum intensity within 1 minute. The patient characteristically describes an attack as “the worst headache of my life.”

9. Although many benign primary headache syndromes can present with severe pain, the abrupt onset and rapid escalation of thunderclap headache signal the potential for serious intracranial disorders, most commonly subarachnoid hemorrhage (SAH)

10. Migraine headacheA. At least five attacks fulfilling criteria B-DB. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)C. Headache with at least two of the following four characteristics: 1. Unilateral location 2. Pulsating quality 3. Moderate or severe pain intensity that inhibits or prohibits daily activities 4. Aggravation by walking up or down stairs or similar routine physical activityD. During headache, occurrence of at least one of following symptoms: 1. Nausea/vomiting 2. Photophobia/phonophobiaE. Not better accounted for by another ICHD-3 diagnosisMigraine headache criteria

11. Migraine auraThe aura of migraine is present in as many as 30% of migraine episodes and may precede, occur concurrently with, or occur outside the context of a headache attack. Aura symptoms generally develop gradually and last between 5 and 60 minutes. Both positive (visual lights, paresthesias) and negative (visual loss, numbness) symptoms are typically described.

12. Tension-Type HeadacheTension-type headache is the most prevalent primary headache disorder. Despite its common occurrence, tension-type headache is an uncommon reason for medical consultation.

13. The clinical classification identifies tension-type headache largely by the absence of disabling features . By definition, pain is never severe, nausea is absent (or possibly mild, with the chronic form), and photophobia and phonophobia are never present together. Neurologic and autonomic features are lacking. Basically, tension-type headache is defined by the absence of migraine

14. Tension Headache criteriaA. At least 10 attacks fulfilling criteria B-DB. Headache attacks (untreated or unsuccessfully treated) lasting from 30 minutes to 7 daysC. Headache with at least two of the following four characteristics: 1. Bilateral location 2. Pressing/tightening (nonpulsating) quality 3. Mild or moderate intensity 4. Not aggravated by walking or climbing stairs or similar routine physical activityD. Headache characterized by both of the following: 1. No nausea/vomiting 2. No more than one episode of photophobia or phonophobiaE. Not better accounted for by another ICHD-3 diagnosis

15. Cluster HeadacheCluster headache is considered the most severe of the primary headache syndromes and is the most common of the headaches classified as trigeminal autonomic cephalgias. These disorders are characterized by severe unilateral pain, typically in the first division of the trigeminal nerve (periorbital, frontal, temporal), and are accompanied by ipsilateral cranial autonomic symptoms

16. the term “cluster” is derived from this disorder's characteristic short cycles of headache activity (weeks) interrupted by long periods of complete remission (month or years).

17. A. At least five attacks fulfilling criteria B-DB. Severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15–180 minutes (when untreated)C. Either or both of the following: 1. At least one of the following symptoms or signs, ipsilateral to the headache: a) conjunctival injection and/or lacrimation b) nasal congestion and/or rhinorrhea c) eyelid edema d) forehead and facial sweating e) forehead and facial flushing f) sensation of fullness in the ear g) miosis and/or ptosis 2. A sense of restlessness or agitationD. Attack frequency from 1 every other day to 8 per day when the disorder is activeE. Not better accounted for by another ICHD-3 diagnosisCluster headache Criteria

18. Chronic paroxysmal hemicrania (CPH) and short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT) have phenotypic features identical to cluster headache but differ in attack frequency and duration.CPH attacks occur at least five times daily and last between 5 and 30 minutes. Diagnosis of CPH is confirmed by absolute response to indomethacin. SUNCT typically recurs dozens or even hundreds of times per day, with durations of 1 second to 5 minutes.