Dr. amal Alkhotani Frcpc neurology, epilepsy Approach to Headache Dr. amal Alkhotani Frcpc neurology, epilepsy

Headache Headache is one of the 10 most common reasons for health care visits in USA. It also account for 4.5% of ER visits.

Types of headache Primary :- benign headache syndromes in which there are no structural cause for the headache e.g. migraine, tension, cluster. Secondary :- headache is a symptom of underlying disease e.g. tumor. Careful evaluation is required to recognize secondary causes of headache.

Secondary Headache Headache attributed to head or neck trauma Headache attributed to cranial or cervical vascular disorder Headache attributed to nonvascular, noninfectious intracranial disorder Headache attributed to a substance or its withdrawal Headache attributed to infection Headache attributed to disturbance of homeostasis Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures Headache attributed to psychiatric disorder Cranial neuralgias and central causes of facial pain Other headache, cranial neuralgia, central or primary facial pain

History Types of headaches. Onset of headaches. Frequency & periodicity of episodic headaches. Temporal profile. Time of day & precipitating factors. Location. Quality & severity. Aura & accompanying symptoms. Aggravating factors. Family history of headaches. Other medical or neurological problems.

68 year old female present to ER with headache. What historical points will let you worry about this headache?

Red Flags For Worrisome Headaches New onset headache or onset of new type of headache or change of preexisting headache. Progressive worsening headache. Worst ever pain. Age > 50. Abrupt onset headache. Headache initiated by exertion or valsalva. Head trauma. Neurological symptoms & signs. Systemic symptoms & signs. Secondary risk factors.

Examination Vital signs General appearance Meningeal signs Full neurological examination DO NOT FORGET THE FUNDUS EXAMINATION Skull and c spine examination Palpate the paranasal sinuses Temporal artery

High risk examination finding Abnormal vital signs:- fever, severe hypertension Toxic appearance Localizing neurological finding Decrease level of consciousness Meningeal signs

High risk examination finding Abnormal vital signs:- fever, severe hypertension Toxic appearance Localizing neurological finding Decrease level of consciousness Meningeal signs Ophthalmic finding Traumatic finding Abnormalities of the temporal artery

Sudden severe headache Non contrast CT brain Normal Abnormal Lumbar Puncture for xnthochromia Neurosurgery Yes NO

What is Xanthochromia? Xanthochromia ( yellow or pink discoloration) represent Hg degradation. The presence of xanthochromia is indicative that the blood has been present in CSF for at least 2hours prior to the tape. Highly suggestive of SAH What causes of xanthochromia other than SAH?

68 ear old female with one month history of headache and jaw pain while eating. What other historical points will you consider? What specific examination and investigation you will consider?

Constitutional symptoms Visual symptoms Shoulder and hip aching and stiffness

Examination of temporal artery ESR Temporal artery biopsy In presence of high clinical suspicion and high ESR start steroid awaiting temporal artery biopsy

Temporal Arteritis Chronic vasculitis of large and medium sized vessels. Prevalence 1 in 500 individual. Classification criteria:- - Age above or equal to 50 year of age - Localized headache of new onset - Tenderness or decrease pulse of the temporal artery - ESR >50 - Biopsy revealing a necrotizing vasculitis Why temporal arteritis should be treated promptly?

Primary Headache Migraine Tension headache Cluster headache Other primary headache

Take home messages Carful evaluation is necessary when evaluating a patient with headache. Be alert about headache red flags.