SYMPTOM ANALYSIS - HEADACHE

Dr. JYOTHI RESHMA S

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.

CLASSIFICATION (ICHD)

Primary headaches• Migraine • Tension type headache• Trigeminal autonomic

cephalgias (TAC)Cluster headacheParoxysmal hemicraniaShort lasting unilateral neuralgiform headache attacks: SUNCT/SUNA

• Other primary headache disorders

1 cough headache⁰1 exercise headache⁰1 h/a associated with ⁰sexual activity1 thunderclap headache⁰Cold stimulus headacheExternal pressure headache1 stabbing headache⁰Nummular headacheHypnic headacheNew daily persistent headache

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

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

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

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

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

Migraine

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.

Negative scotoma. Loss of local awareness of local structure

Positive Scotoma. Additional structures One side loss of perception.

Zigzag structure

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

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

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

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

• 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

DIZZINESS• 40% peripheral vestibular dysfunctionBPPV, labyrinthitis, vestibular neuritis, meniere’s disease, drugs, toxins

• 10% central brain stem vestibular lesionVertiginous migraine, TIA, vertigo as aura of seizure

• 15% psychiatric disorder• 25% presyncope, disequilibrium• 10% unknown

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

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