approach to headaches aimgp seminar october 2004 manaf qahtani
TRANSCRIPT
Approach to Headaches
AIMGP Seminar
October 2004
Manaf Qahtani
Outline:1. Learning Objectives2. Case Studies3. General Principles4. IHS Classification5. “Red Flags”6. The Headache Diary7. Therapy8. Review Case Studies9. Summary10. Resources
Learning Objectives
1. Become aware of the IHS classification
2. Be able to diagnose and treat the common types of Primary headache
3. Be able to recognize the “Red Flags” of dangerous Secondary Headaches
General Principles There are lots of pain sensitive
structures in the head and neck
The key to proper management is to make an accurate diagnosis.
Recognize the features of “dangerous” headaches, and know how to “rule out”.
IHS Diagnostic Classification
1- Primary Headache: 90%
2-Secondary Headaches: 10%
HISTORY Headache Characteristics:
Temporal profile: acute vs chronic, frequency Location and radiation Quality Alleviating and exacerbating factors Associated symptoms
Constitutional symptoms PMH: HTN, DM, hyperlipidemia, smoking
Physical Exam Blood pressure Fundoscopy Auscultation for bruits in H/N Temporal artery inspection and palpation Meningismus Neurologic exam: motor, sensory,
coordination and gait
Primary Headache1. Migraine without aura
2. Migraine with aura
3. Tension headache
4. Combination headache
5. Cluster headache
Primary Headache1. Migraine without aura; > 5 attacks with:
A- duration 4-72 hours B- > 2 of:
i. unilateralii. pulsatingiii. interferes with daily activityiv. aggravated by routine activity
C- > 1 of:i. nausea and/or vomiting
and/orii. photophobia and/or phonophobia
D- No secondary cause
Primary Headache2- Migraine with aura; > 2 attacks of:
A- Any 3 or more of:1-one or more reversible aura symptoms2-At least one aura symptom develops over > 4 min., or
two or more symptoms in succession3-No single symptom lasts > 60 min.4-Headache follows aura with free interval < 60 min, or
begins before or with aura.
B- No evidence of secondary cause.
Primary Headache3. Tension-type headache: At least 10 attacks of:
A- Duration 30 min – 7 days.B- > 2 of the following characteristics:
i. Pressing/ tightening (non-pulsating)ii. Mild/Moderate intensity. “Inhibits but doesn’t prohibit
activity”.iii. Bilateraliv. Not aggravated by routine activity
C- Both of:i. absence of nausea and vomiting (anorexia may occur)ii. absence of photophobia or phonophobia
N.B. > 15 days/ month = Chronic Tension Headache.
Primary Headache4. Combination Headache
Tension-type headache + migraine.
The tension headache may precipitate a migraine.
Primary Headache5. Cluster headache
Age of onset 25-50 y.o., M>F Features:
Attacks clustered in time (>5) Severe unilateral, orbital or temporal pain Lasting 15 min – 3 h Ipsilateral conjunctival injection, lacrimation,
nasal congestion, rhinorrhea, forehead/facial swelling, miosis, ptosis
Secondary Headache:Pain-sensitive structures in the head and neck
Extra-cranial
Scalp Scalp muscles Skull Carotid and vertebral arteries Paranasal sinuses Eyes and orbits Mouth, teeth, and pharynx Ears Cervical spine and ligaments Cervical muscles
Intracranial
Periosteum Cranial nerves Meninges Meningeal arteries and dural
sinuses Proximal intracranial arteries Sphenoid sinus Thalamic nuclei Brainstem pain-modulating
centers
“Red Flags” New headache especially in over 50 y.o. Abrupt onset, unusually severe Change in usual headache pattern Associated with focal neurologic findings Change in LOC, personality, lethargy Fever, neck stiffness Systemic signs/symptoms Temporal artery tenderness
The Headache Diary
Purpose:
To aid diagnosis To identify triggers To provide a self-monitoring tool for
patients
The Headache Diary Frequency of pain Quality of pain Duration of pain: Intensity of pain: Use a rating scale 1-5 Accompanying symptoms: Neurologic e.g. visual disturbance, hemiparesis, hemianopsia, etc., and Autonomic e.g. nausea, vomiting, diarrhea Mental, cognitive and mood disturbance Triggers: hormonal, environmental, food, drug
Therapy of Primary HeadachesPrinciples of Therapy:
Stratified approach rather than a stepped care approach i.e. treat according to severity
Determine level of intensity and frequency of headache to
decide on appropriate acute treatment. Determine whether to use a combination of pharmacologic and
non-pharmocologic therapies. Determine whether prophylactic therapy is indicated.
TherapyMigraine – Acute Attacks set limits on treatments, i.e. no more than 2
days/week if oral agents not tolerated, use nasal
sprays, suppositories, or injectables for GI dysmotility/ nausea/ vomiting, use
metoclopromide 10mg. Can use”MIDAS” Scale to guide therapy
Tension-type headaches
For moderate attacks NSAIDS useful
For severe attacks triptan drugs effective
Non-pharmacologic Therapy
Cluster headache: Rare but debilitating Carry high risk of suicide Agent must have rapid onset of action Acute treatment: Oxygen 100% (evidence?)
Injectable sumatriptan (6mg.)
Summary Lots more to know about headache IHS classification is the beginning of the
diagnositic pathway. Most headaches will be Primary, but must
recognize the “Red Flags” of serious Secondary Headache.
Use Patient Diary and MIDAS to guide treatment.
Resources www.migraine.ca http://www.zomigconsumer.com/talk/midas
Survey.html http://www.ottawa-headache-centre.com/ www.aan.neurology.org JAMA,march 19,2003-vol 289, No 11
“headache assessment and management”