1. SYMPTOM ANALYSIS - HEADACHE
Dr. JYOTHI RESHMA S

2. HEADACHE
• Headache is among the most common reasons patients
seek medical attention.
• Primary headaches
• Benign
• Recurrent
• No organic disease as their cause
• Secondary headaches
• Underlying organic disease
• Primary headache often results in considerable disability
and a decrease in the patient's quality of life.

3. CLASSIFICATION (ICHD)
Primary headaches
• Migraine
• Tension type headache
• Trigeminal autonomic
cephalgias (TAC)
Cluster headache
Paroxysmal hemicrania
Short lasting unilateral
neuralgiform headache
attacks: SUNCT/SUNA
• Other primary headache
disorders
1⁰ cough headache
1⁰ exercise headache
1⁰ h/a associated with
sexual activity
1⁰ thunderclap headache
Cold stimulus headache
External pressure
headache
1⁰ stabbing headache
Nummular headache
Hypnic headache
New daily persistent
headache

4. SECONDARY HEADACHE DISORDERS
• H/a attributed to trauma or injury to head and/or
neck
• H/a attributed to cranial or cervical vascular disorder
• H/a attributed to nonvascular intracranial disorder
• H/a attributed to a substance or its withdrawal
• H/a attributed to infection
• H/a attributed to disorder of homeostasis
• H/a or facial pain attributed to disorder of the
cranium, neck, eyes, ears, nose, sinuses, teeth,
mouth or other facial or cervical structures
• H/a attributed to psychiatric disorder
PAINFUL CRANIAL NEUROPATHIES, OTHER
FACIAL PAINS AND OTHER HEADACHES

5. HISTORY
• Pattern or frequency of headache
• Duration of individual attacks
• Location
• Pain quality
• Severity
• Time of the day
• Precipitating or aggravating factors
• Accompanying features

6. EXAMINATION
• Blood pressure, fundi, meningeal signs
• TMJ tenderness and restriction of neck movements
• RED FLAG SIGNS:
Headache characteristics
Headache precipitated by Valsalva like manoeuvres
Haedache that is associated with systemic or neurological
signs and symptoms

7. INVESTIGATIONS
• ROUTINE: ESR, CRP
• CT : trauma or abrupt onset
• MRI : angiography or venography – vascular pathology
• CSF : SAH, infections, inflammation

8. DIAGNOSIS
“Every headache is a migraine until proven otherwise”
• Rule out secondary headaches
• Evaluate the patient for the possibility of migraine
• Look out for features that are atypical for migraine
• Other headache: new onset/first headache, h/a < 4 hours,
strictly unilateral, disability levels, nausea

9. Migraine

10. 1)Migraine without Aura or common migraine
Does not give any warning signs before the onset of
headache.
It occurs in about 70 to 80% of migraine patients
2)Migraine with Aura
Give some warning signs “ called aura” before the actual
headache begins. Approximate, 20 to 30% migraine
sufferers experience aura.
The most common aura is visual and may include both
positive and negative (visual field defects) features.

11. Negative scotoma. Loss of local
awareness of local structure
Positive Scotoma. Additional structures One side loss of perception.
Zigzag structure

12. 3)Retinal migraine- It involves attacks of monocular scotoma
or even blindness of one eye for less than an hour and
associated with headache.
4)Childhood periodic syndromes that involve cyclical
vomiting (occasional intense periods of vomiting), abdominal
migraine (abdominal pain, usually accompanied by nausea),
and benign paroxysmal vertigo of childhood (occasional
attacks of vertigo). They may be precursors or associated
with migraine.
5)Complications of migraine describe migraine headaches
and/or auras that are unusually long or unusually frequent, or
associated with a seizure or brain lesion

14. Acute attack
Drugs Dosage
Actaminophen 1000mg po
Ibuprofen 400mg po
Diclofenac sodium 100mg po
Sumatriptan 25-100mg po
Zolmitriptan 5mg po
Ergotamine 1-2mg po
DHE 1-2mg SC,IM,IV
Metoclopramide 10mg po
Prochlorperazine 5-25mg po

15. Prophylaxis
Drugs Dosage
Amitryptilline 10-150mg po
Fluoxetine 20-40mg po
Valproate 500-1200mg po
Topiramate 50-200mg po
Gabapentin 900-2400mg po
Propranalol 40-240mg po
Atenolol 100mg po
Flunarizine 5-15mg po

16. Pharmacological management
• Tension type headache: analgesics – ibuprofen,
acetaminophen, diclofenac, prophylaxis: amitryptylline,
SSRI, BZD
• Trigeminal autonomic cephalgias: oxygen inhalation
(100% - 10-12L/min – 20minutes), sumatriptan,
prophylaxis: lithium, verapamil
• PHC: indomethacin
• SUNCT/SUNA: lamotrigene, topiramate, gabapentin

17. • Chronic daily headache: ≥ 15 headache
days/month for 3 consecutive months.
• Long duration : >4 hours / short: < 4 hours
• CDH – long duration – c/c migraine, c/c TTH,
NDPH, HC
• Medication overuse: simple analgesics ≥ 15days/
month x 3 months / ≥10days/month ergots,
triptan, opioids

18. DIZZINESS
• 40% peripheral vestibular dysfunction
BPPV, labyrinthitis, vestibular neuritis, meniere’s disease,
drugs, toxins
• 10% central brain stem vestibular lesion
Vertiginous migraine, TIA, vertigo as aura of seizure
• 15% psychiatric disorder
• 25% presyncope, disequilibrium
• 10% unknown

19. History
• Onset, time course and length of attacks
• Associated cochlear symptoms: hearing loss, tinnitus,
sensation of aural fullness
• History of head injury, viral syndrome, headache
• Any neurological symptoms
• History of drugs
• History of psychiatric illness

20. DD based on common triggers
• Change of head posture
• Change of postion from
lying or sitting to standing
• Nausea, vomiting
• Menstruation, sleep
deprivation
• Elevators, closed spaces
• Worsened by loud noise,
coughing, sneezing
• BPPV, migraine
• Presyncope
• Peripheral > central
• Migraine
• Panic attacks
• Perilymphatic fistula