1. APPROACHE TO HEADACHE
Hamad Emad H. Dhuhayr

2. DEFINITION
• Headache, or cephalalgia, is Defined as diffuse pain in Various parts of the
head, With the pain not confined To the area of distribution Of a nerve.
• Headache is among the Most common pain problems encountered In family
practice.
• Headache, which is a very common symptom, can be caused by a serious
Underlying abnormality but is usually a primary headache disorder, such as
Migraine headache, tension-type headache, cluster headache, and paroxysmal
Hemicrania.
• About 90% of all adults experience headache at some time in their lives, and
more than 75% of children have reported significant headaches by the age of 15
years.

3. GENERAL MECHANISMS OF
HEADACHE
Traction on major intracranial vessels.
Distention, dilation of intracranial arteries
Inflammation near pain sensitive structures
Direct pressure on cranial or cervical nerves
Sustained contraction of scalp or neck
muscles
Stimulation from disease of eye, ear, nose
and sinuses (referred pain)

4. EPIDEMIOLOGY
Primary Headache Lifetime Prevalence
TENSION
MIGRAINE
COLD STIMULUS HEADACHE
CLUSTER
69%
15%
15%
0.1%
Hangover
Fever
Metabolic disorder
Disorders of nose/sinuses
Head trauma
Disorders of eyes
Vascular disorders
72%
63%
22%
15%
4%
3%
1%
Secondary Headache

5. HEADACHE IN THE
ED
TENSION
MIGRAINE
CLUSTER
32 %
22 %
< 1 %
Primary Headache
Subarachnoid Hemorrhage
Meningitis
Temporal Arteritis
Subdural Hematoma
CNS tumor
Miscellaneous illness
No specific diagnosis
< 1 %
< 1 %
< 1 %
< 1 %
3 %
33 %
7 %
Secondary Headache

6. PRIMARY HEADACHE
Migraine
Tension
Cluster

7. TENSION HEADACHE
International Headache Society Diagnostic Criteria

8. Duration
30 min to 7 days
Pain characteristics (at least 2)
Pressing/tightening quality
Mild to moderate severity
Bilateral location
No aggravation by routine physical activity
Associate symptoms (must have both)
No vomiting
No more than one of: nausea, photophobia, phonophobia
H&P and diagnostic tests do not suggest underlying
organic disease

9. MIGRAINE WITHOUT AURA
International Headache Society Diagnostic Criteria

10. At least 6 or more periodic attacks
Duration
4-72 h if untreated or unsuccessfully treated
Pain characteristics (at least 2)
Unilateral location
Pulsating quality
Moderate to severe intensity
Aggravation by walking stairs or similar physical activity
Associated symptoms (at least 1)
Nausea, vomiting, or both
Photophobia or phonophobia
H&P and diagnostic tests do not suggest underlying organic
disease

11. MIGRAINE WITH AURA
International Headache Society Diagnostic Criteria

12. At least 3 periodic attacks
Aura characertistics (at least 3 )
One or more fully reversible aura symptoms indicating focal
cerebral cortical or brain-stem dysfunction
At least 1 aura symptom develops gradually over >4
minutes or 2 or more symptoms occur in succession
No single aura symptom lasts > 60 minutes
Headache begins within 60 minutes of aura onset
History, physical, and diagnostic tests do not suggest
underlying organic disease

13. CLUSTER HEADACHE
International Headache Society Diagnostic Criteria

14. Duration
15 to 180 minutes untreated
Pain characteristics
Severe unilateral orbital, supraorbital, or temporal pain
Associated symptoms (at least 1, ipsilateral to pain)
Conjunctival injection, lacrimation
Nasal congestion, rhinorrhea
Forehead and facial swelling
Miosis, ptosis
Eyelid edema
Frequency:
 Between 1 every other day to 8/day

15. SECONDARY HEADACHE
Intracranial hemorrhage
– Subarachnoid hemorrhage
– Intracerebral hemorrhage
– Subdural/epidural hematoma
Meningitis/encephalitis
Hypertensive encephalopathy
Ischemic stroke
Venous sinus thrombosis
Hypoxia, hypercarbia, carbon monoxide

16. Temporal arteritis
Mass lesions
Tumor, abscess, arteriovenous malformation
Altitude sickness
Metabolic
Hypoglycemia, fever, hypothyroid, anemia
Glaucoma
Pseudotumor cerebri (benign intracranial
hypertension)

17. Trigeminal neuralgia
Post-concussion syndrome
Sinusitis without complication
Post-lumbar puncture
Diet
Medications
Fatigue, postexertion, postcoital

18. OVERALL APPROACH
Chief Complaint: Headache
Headache Alarms
Evidence of serious headache disorder
by history or physical exam
NO YES
Diagnosis of
Primary Headache Disorder
Work-up to identify/exclude
secondary headache etiology
YES NO
Treat Primary Headache
Consider work-up for
secondary headache

20. PHYSICAL EXAM
• Vital signs
• Fever, hypertension, hypoxia
• Head/face
• Trauma, bruits, tenderness
• Eyes
• Conjunctiva, cornea, pupils,
fundi:papilledema
• Ears
• OM or hemotympanum
• Mouth
• Teeth, TMJ
• Neck
• Pain/stiffness/tenderness
• Carotid and/or vertebral bruits
• Skin
• Rash
• Neurologic
• Mental status
• Pupils, EOM, visual fields
• Focal deficits
• Horner's syndrome
• Ataxia

21. INVESTIGATION
CBC ESR
URINE R/E
S.CREATININE
RBC
CSF
X-RAY SKULL.
X-RAY PNS.
CT
MRI

23. OVERALL APPROACH
Chief Complaint: Headache
Headache Alarms
Evidence of serious headache disorder
by history or physical exam
NO YES
Diagnosis of
Primary Headache Disorder
Work-up to identify/exclude
secondary headache etiology
YES NO
Treat Primary Headache
Consider work-up for
secondary headache

24. ED TREATMENT OF PRIMARY
HEADACHE
Tension
Oral analgesics (NSAIDS, acetaminophen)
Migraine
Serotonin agonists
Ie, sumitriptan 50 mg PO or 6.0 mg SQ
Narcotics IV or IM
Cluster
100% oxygen
Intranasal lidocaine ?
NSAIDS
Migraine specific therapies

25. PROPHYLAXIS TREATMENT OF
PRIMARY HEADACHE
Tension
Reassurance
Antidepressant &/or anxiolytic drugs
(Tricyclic antidepressant or/& SSRI)
Migraine
Betablockers: proponolol
Ca channel blocker: verapamile
Antidepressant: (tricyclic antidepressant or/& SSRI)
Anticonvulsant: na valproate, topiramate,
Methysergid.
Pizotifine.
Cluster
Steroid
Lithium carbonate
Verapamile

26. OVERALL APPROACH
Chief Complaint: Headache
Headache Alarms
Evidence of serious headache disorder
by history or physical exam
NO YES
Diagnosis of
Primary Headache Disorder
Work-up to identify/exclude
secondary headache etiology
YES NO
Treat Primary Headache
Consider work-up for
secondary headache

27. DIAGNOSTIC STUDIES
• Computerized tomography
• Hemorrhage, tumor, abscess, AVM
• Lumbar puncture
• Hemorrhage, infection, increased CSF pressure
• Limited indications for MRI, MRA, or angiography
• Laboratory studies based on suspected etiologies
• ESR: temporal arteritis
• Carboxyhemoglobin: carbon monoxide

28. SUBARACHNOID
HEMORRHAGE
• Approximately 50% of have "sentinal bleed"
• 50% with "sentinal bleed" will rebleed within 2-6 wks
• Rebleed
• 50% mortality
• > 50% of survivors have significant neurologic deficits
• Head CT negative in 1-10% of cases
• Sensitivity decreases with time from onset of sx
• LP if head CT negative (rbc's 3 hrs, xanthochromia 12 hrs)
• Angiography if postive CT or LP

29. TEMPORAL ARTERITIS
• Rare before age 50
• Temporal artery tenderness, swelling, redness, nodularity
• Visual disturbance
• Visual loss in 7-60% if untreated
• Jaw claudication
• Systemic symptoms
• Fever, wt loss, anorexia, malaise
• Polymyalgia rheumatica (prox muscle pain/tend./Stiffness)
• ESR usually > 50 (mm/hr)
• Temporal artery biopsy
• Multinucleated giant cells / inflammation
• Therapy: high dose steroids

30. OVERALL APPROACH
Chief Complaint: Headache
Headache Alarms
Evidence of serious headache disorder
by history or physical exam
NO YES
Diagnosis of
Primary Headache Disorder
Work-up to identify/exclude
secondary headache etiology
YES NO
Treat Primary Headache
Consider work-up for
secondary headache

31. REFERENCES
• KUMAR
• CECIEL
• WEBSITE