1. Approach to the diagnosis
and management of
primary headache
disorders
PROF. FRANK OJINI
CMUL/LUTH

2. Introduction
Headache classification
Common primary headache disorders
Approach to the diagnosis of headaches (headache history, exam and inv)
Primary vs secondary headaches
Treatment of primary headache disorders
Approach to headache in the ER
Summary

3. INTRODUCTION
• Headache disorders are among the most common disorders of the nervous system
• Half to three-quarters of the adult population have had a headache at least once in the
last year
• Recurrent headaches are associated with personal and society burdens of pain, disability,
damaged quality of life, and financial cost
• Headache has been underestimated, under-recognized and under-treated throughout the
world

4. THE INTERNATIONAL CLASSIFICATION OF
HEADACHE DISORDERS - III
• Part one:The primary headaches
• Part two:The secondary headaches
• Part three: Painful cranial neuropathies, other facial pains and
other headaches

5. THE PRIMARY HEADACHES
1. Migraine
2. Tension-type headache (TTH)
3. Trigeminal autonomic cephalalgias (TACs)
4. Other primary headaches

6. THE SECONDARY HEADACHES
5. Headache attributed to head and/or neck trauma
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 homeostasis
11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth,
mouth, or other facial or cranial structures
12. Headache attributed to psychiatric disorder

7. MIGRAINE
• Migraine is a familial disorder characterized by recurrent attacks of headache,
widely variable in intensity, frequency, and duration
• Attacks are commonly unilateral and are usually associated with anorexia, nausea
and vomiting
• In some cases, they are preceded by or associated with neurologic and mood
disturbances
(World Federation of Neurology)

8. DIAGNOSTIC CRITERIA FOR MIGRAINE
• Headache attacks lasting 4-72 hrs
• Headache has at least 2 of the following characteristics:
Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by routine physical activity
• During headache at least 1 of the following:
Nausea and/or vomiting
Photophobia and phonophobia
• Not better accounted for by another ICHD-3 diagnosis

9. TENSION-TYPE HEADACHE
• TTH is the most common form of headache (affects more than 40 percent of the adult
population worldwide)
• Characterized by bilateral mild to moderate pressure pain without other associated
symptoms (“featureless headache”)
• Pain is usually diffusely felt all over the head but may be located on the vertex or
forehead or the neck
• Experienced as a sense of pressure, feeling of tightness, or as a heavy weight pressing
down on the crown

10. DIAGNOSTIC CRITERIA FOR TTH
• Headache lasting from 30 mins to 7 days
• Headache has at least 2 of the following characteristics:
Bilateral location
Pressing/tightening (non-pulsating) quality
Mild or moderate intensity
Not aggravated by routine physical activity
• Both of the following:
No nausea or vomiting (anorexia may occur)
No more than one of photophobia or phonophobia
• Not better accounted for by another ICHD-3 diagnosis

11. TRIGEMINAL AUTONOMIC CEPHALALGIAS (TACs)
Strictly unilateral headaches accompanied by prominent cranial autonomic features,
which are lateralised and ipsilateral to the headache
• Cluster headache
• Paroxysmal hemicrania
• Short-lasting unilateral neuralgiform headache attacks
• SUNCT
• SUNA
• Hemicrania continua

12. CLUSTER HEADACHE
• Relatively rare, and characterized by brief episodes of severe head pain with associated autonomic symptoms
• Pain most commonly occurs in the retro-orbital area, followed by the temporal region, upper teeth, jaw, cheek,
lower teeth, and neck
• Ipsilateral autonomic symptoms such as eyelid edema, nasal congestion, lacrimation, or forehead sweating usually
accompany the pain
• There may be several (up to 8) episodes in the same day, with each episode lasting between 15 and 180 minutes
• Headache episodes occur daily for a number of weeks followed by a period of remission
• On average, a period of CH lasts 6 to 12 weeks, with remission lasting up to 12 months (Episodic CH)
• In Chronic CH episodes occur without significant periods of remission

13. DIAGNOSTIC CRITERIA FOR CLUSTER HEADACHE
• Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting
15-180 mins if untreated
• HD is accompanied by at least 1 of the following:
Ipsilateral conjunctival injection and/or lacrimation
Ipsilateral nasal congestion and/or rhinorrhoea
Ipsilateral eyelid oedema
Ipsilateral forehead and facial swelling
Ipsilateral miosis and/or ptosis
A sense of restlessness or agitation
• Attacks have a freq from 1 every other day to 8 per day
• Not better accounted for by another ICHD-3 diagnosis

14. STRUCTURED HEADACHE HISTORY: history is crucial to effective
diagnosis of primary headaches as the examination is essentially normal
“Time questions”
• Why consulting now?
• How recent in onset?
• How frequent, and what temporal pattern (distinguishing
between episodic and daily or unremitting)?
• How long lasting?
“Character questions”
• Nature and quality of pain
• Intensity of pain
• Site and spread of pain
• Associated symptoms
“Cause questions”
• Predisposing and/or trigger factors
• Aggravating and/or relieving factors
• Family history of similar headache
“Response questions”
• What does the patient do during the headache?
• How much is activity (function) limited or prevented?
• What medication has been and is used, and in what manner?
State of health between attacks
• Completely well, or residual or persisting symptoms?
• Concerns, anxieties, fears about the HD

15. PRIMARY HEADACHES vs SECONDARY HEADACHES
• In evaluating a patient with headache, the first task is to determine whether the headache is primary in origin or reflects
underlying neurologic or systemic disease (ie, secondary headache)
• Distinguishing dangerous headaches from benign or low-risk headaches is a significant challenge because the symptoms can
overlap
• Done by eliciting any warning features (red flags) in the history
• A high index of suspicion exists for secondary headache
✓ headache reaches full intensity rapidly
✓ associated with abnormal neurologic signs
✓ progressive in intensity and duration over time
✓ increased by Valsalva maneuver
✓ worse upon standing
✓ develops after the age of 50 years
✓ coexisting systemic and neurologic disorders

16. RED FLAGS IN PATIENTS PRESENTING WITH
HEADACHE
SNOOP4 can act as a useful aide-memoire in remembering the red-flag features
Systemic symptoms/signs: fever, weight loss (infection, malignancy)
Neurologic symptoms/signs: stroke, SOL, intracranial infection
Onset sudden (thunderclap): SAH, RCVS
Older age of onset (>50yrs): temporal arteritis, glaucoma, SOL
Papilloedema: raised ICP
Positional: relief when supine (intracranial hypotension); relief when up-right (SOL)
Precipitated byValsalva, cough, bending forward: SOL
Progressive headache or change in headache pattern: any secondary cause
(Pregnancy)

17. MIGRAINE vs TTH
• A positive response to the presence of the following symptoms can ‘‘PIN’’ the diagnosis
of migraine:
Photophobia: Does light bother you when you have a headache?
Impairment: Do you experience headaches that impair your ability to function?
Nausea: Do you feel nauseated when you experience a headache?
A positive answer to two or three of these three questions results in a 93% and 98%,
respectively, positive predictive value for a diagnosis of migraine

18. CLUSTER HEADACHE vs MIGRAINE
• Cluster headache is uncommon and often misdiagnosed
Only 25 percent of patients with cluster headaches are diagnosed correctly within one year of
symptom onset, and more than 40 percent report a delay in diagnosis of five years or longer
The most common incorrect diagnoses reported in one study were migraine (34 percent), sinusitis
(21 percent), and allergies (6 percent)
• A useful point to distinguish between migraine and CH is that patients with migraine typically
lie down or sit still (often in a dark room), whereas patients with a CH are often agitated and
pace around the room, often at night when headaches occur

19. NEUROLOGICAL EXAMINATION
• It is unnecessary to check every aspect of neurological function (a brief neurological screen
should take no more than 5-10 min)
• Particular attention should be paid to examination of the cranial nerves, tendon reflexes, and
optic discs
• If the history suggests that there is a more sinister cause for the headache, a full neurological
examination is necessary
• It is of great comfort to patients when told that the findings are ‘‘normal’’
When time is short, a minimum examination should include blood pressure and
examination of the optic fundi

20. INVESTIGATIONS
• Investigations rarely contribute to the diagnosis of headache when the history and examination have not
suggested an underlying cause
• The only role for neuroimaging (preferably MRI) in the diagnosis of headache is to confirm or exclude
causes of secondary headache that are suspected on the basis of red flags in the medical history and/or
physical examination
• Neuroimaging for reassurance is not recommended and can lead to harmful and unnecessary
investigations and treatment
• MRI can reveal clinically insignificant abnormalities (e.g, white matter lesions, arachnoid cysts), which can
alarm the patient and lead to further unnecessary testing
All patients with suspected trigeminal autonomic cephalalgia (e.g. cluster headache) should have neuroimaging

21. ACUTETREATMENT OF MIGRAINE
Drug class Drug Dosage and route Contraindications
First line medication
NSAIDs ASA
Ibuprofen
Diclofenac Potasium
900-1000 mg oral
400-600 mg oral
50 mg oral (soluble)
GI bleeding, HF
Other simple analgesics
(if NSAIDs are
contraindicated)
PCM 1000 mg oral Hepatic disease, renal
failure
Anti-emetics (when
necessary)
Domperidone
Metoclopramide
10 mg oral or
suppository
10 mg oral
GI bleeding, epilepsy,
renal failure
PD, epilepsy, mechanical
ileus

22. ACUTETREATMENT OF MIGRAINE ii
Drug class Drug Dosage and route Contraindications
Second-line medication
Triptans Sumatriptan 50 or 100 mg oral or 6
mg subcutaneous or 10
or 20 mg intranasal
Cardiovascular or
cerebrovascular disease,
uncontrolled
hypertension, hemiplegic
migraine, migraine with
brainstem aura
Zolmitriptan 2.5 or 5 mg oral or 5 mg
intranasal
Almotriptan 12.5 mg oral
Elitriptan 20, 40 or 80 mg oral
Frovatriptan 2.5 mg oral
Naratriptan 2.5 mg oral
Rizatriptan 10 mg oral tablet or
mouth-dispersible wafers

23. ACUTETREATMENT OF MIGRAINE iii
Drug class Drug Dosage and route Contraindications
Third-line medication
Gepants Ubrogepants 50 mg, 100 mg oral Co-administration with
strong CYP3A4
inhibitors
Rimegepants 75 mg oral Hypersensitivity, hepatic
impairment
Ditans Lasmiditan 50, 100 or 200 mg oral Pregnancy, concomitant
use with drugs that are
P-glycoprotein
substrates

24. PROPHYLACTIC TREATMENT OF MIGRAINE
First-line preventive medications
Beta blockers
Propranolol 80–320 mg daily
Metoprolol 50–200 mg daily
Atenolol 25–200 mg daily
Bisoprolol 5–10 mg daily
ARB
Candesartan 16-32 mg daily
Anti-convulsants
Topiramate 25–100 mg daily

25. PROPHYLACTIC TREATMENT OF MIGRAINE ii
Second-line preventive medications
Tricyclic anti-depressants (in cases with depression, sleep disturbance, concomitant tension-type headache)
Amitriptyline 10–150 mg daily
Desipramine 100–300 mg daily
Nortriptyline 10–150 mg daily
Protriptyline 5–60 mg daily
Anti-convulsants
Sodium valproate 300–2000 mg daily
Gabapentin 300–2400 mg daily
Serotonin antagonist
Methysergide 2–6 mg daily
Pizotifen 1.5–6 mg daily
Calcium antagonist
Flunarizine 5-10 mg orally once daily

26. PROPHYLACTIC TREATMENT OF MIGRAINE iii
Third-line preventive medications
Botulinum toxin OnabotulinumtoxinA 155–195 units to 31–39 sites
every 12 weeks
Calcitonin gene-related peptide
(CGRP) monoclonal antibodies
Erenumab
Fremanezumab
Galcanezumab
Eptinezumab
70 or 140 mg subcutaneous
once monthly
225 mg subcutaneous once
monthly or 675 mg
subcutaneous once quarterly
240 mg subcutaneous, then 120
mg subcutaneous once monthly
100 or 300 mg intravenous
quarterly

27. NON-PHARMACOLOGICAL MANAGEMENT OF
MIGRAINE
• Includes lifestyle modification and identifying the triggers and avoiding or managing them
• Physical activity and sports have a protective effect in patients with migraine
• No evidence-based dietary recommendations available for patients with migraine,
however unhealthy food habits possibly a risk factor
• The chronification of migraine and the number of migraine attacks can be prevented by
improving sleep quality or treating sleep disorder if present

28. MANAGEMENT OFTTH
• Tension-type headaches are rarely disabling
• OTC analgesics such as ASA and NSAIDs (ibuprofen, naproxen) are effective treatment for
infrequent episodes
PCM has been shown to be less effective, but can be considered in those intolerant of NSAIDs
• For chronic or frequently occurring TTH, a low-doseTCA such as amitriptyline is the
treatment choice
• Care must be taken to educate patients on use of analgesics to prevent progression to
medication overuse
SSRIs, benzodiazepines, codeine, dihydrocodeine not recommended

29. NON-PHARMACOLOGICAL MANAGEMENT OFTTH
• The initial step is to provide reassurance to the non-harmful, self-limiting nature of the
condition
• Chronic TTH can be associated with depression which should be managed as appropriate to
prevent treatment failure
• General exercise is recommended alongside referral for physiotherapy for patients with
musculoskeletal neck pain
• Yoga and meditation could be suggested for stress management
• Acupuncture and osteopathy have some evidence of benefit in chronic TTH
• Medication overuse should be sought for and treated, if present

30. MANAGEMENT OF CLUSTER HEADACHE
• An acute cluster attack responds well to sumatriptan 6 mg SC (intranasal sumatriptan and zolmitriptan can be used but not
as effective)
• Oxygen 100% 10–15 L per minute through a special mask can terminate a cluster attack in 10–20 minutes
• Prophylactic treatment should be commenced early in a CH with verapamil 80mgTDS
This should be gradually uptitrated (up to 960 mg)
A baseline ECG should be obtained prior to commencement, as verapamil can lead to bradyarrhythmia
• A rapid and effective remission can be achieved in some cases with a short course of a high-dose steroid for a few days
(allows the preventive treatment with verapamil to take effect)
Prednisolone 60 mg per day for 5 days with a reduction of 5–10 mg every day
• Lithium and methysergide may be effective second line for cluster headache
• Other drugs with some indication of efficacy include topiramate, gabapentin,melatonin and pizotifen

31. Approach to the diagnosis and management of
primary headache disorders
Step 1: History and Examination
Step 2: Identify red flags for secondary headache
Step 3: Neuroimaging (if secondary headache is considered) ± other invs
Step 4: Categorise the primary headache disorder
Step 5: Treatment strategies (pharmacological and nonpharmacological)

32. SMART Headache Management
Sleep Regular and sufficient sleep
Meals Regular and sufficient meals, including
breakfast and good hydration
Activity Regular (but not excessive) exercise
Relaxation Relaxation and stress reduction
Trigger avoidance Avoid identified triggers (stress, sleep
deprivation, excessive caffeine, etc)

33. Approach to the diagnosis
and management of
primary headache
disorders
END OF LECTURE
QUESTIONS??