1. Prof. Abdelmoniem Sahal Elmardi
Headache
Prof. Abdelmoniem Sahal Elmardi

2. Parts of the talk Introduction Classification
Consultation of a person with headache

3. Introduction

4. Headache is the symptom of pain anywhere in the head or neck
Introduction
Headache is the symptom of pain anywhere in the head or neck
It can be the only symptom of some diseases (primary headache)
It can be one of the symptoms of other diseases (secondary headache)

5. Most headaches can be managed in PHC
Introduction
Most headaches can be managed in PHC
History is a crucial step in the correct diagnosis
Funduscopy is mandatory for anyone presenting with headache
Diary cards aid diagnosis and management
The presence of warning symptoms in the history and/or physical signs warrant investigation
May indicate appropriate specialist referral

6. Classification

7. A number of different classification systems for headaches
The most widely used is the International Classification of Headache Disorders (3rd edition)
Issued by the International Headache Society (IHS)

8. Cranial neuralgias & facial pain Other headaches
Classification
Primary headache
Secondary headache
Cranial neuralgias & facial pain
Other headaches

9. Is headache a presentation of a condition?

10. primary headaches

11. Represents 90% of all headaches They are not life-threatening
Primary headaches
Represents 90% of all headaches
They are not life-threatening
Have different but similar pathologies

12. Tension type headache (TTH) Trigeminal autonomic cephalalgias (TACs)
Primary headaches
Migraine
Tension type headache (TTH)
Trigeminal autonomic cephalalgias (TACs)

14. Causes of secondary headaches
Trauma or injury to the head and/or neck
Cranial or cervical vascular disorder
Non-vascular intracranial disorder
A substance or its withdrawal
Infection
Disorder of homoeostasis
Disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other structures
Psychiatric disorder

15. Migraine headaches

16. Migraine headaches A common disabling primary headache disorder
High prevalence and socio-economic and personal impacts
Ranked as the third most prevalent disorder and seventh-highest specific cause of disability worldwide

17. Migraine headaches Was believed to be of a vascular origin
Now confirmed to be due to alterations in the sub-cortical aminergic sensory modulatory systems
Involving metabolic shift directing tyrosine metabolism toward the decarboxylation pathway
Resulting in a production of noradrenaline and dopamine along with increased synthesis of traces amines

18. Migraine without aura Migraine with aura Chronic migraine
Migraine headaches
Migraine without aura
Migraine with aura
Chronic migraine
Probable migraine

19. Migraine without aura Recurrent headache disorder
Attacks lasting 4-72 hours.
Unilateral location,
Pulsating quality,
Moderate or severe intensity,
Aggravation by routine physical activity
Association with nausea and/or photophobia and phonophobia.

21. Migraine with aura
Recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory or other CNS symptoms (aura)
usually develop gradually
Usually followed by headache and associated migraine symptoms.
Auras need to be distinguished from TIAs
Further subtypes according to type and characteristics of the aura

24. Chronic Migraine
Headache occurring on 15 or more days per month
For more than 3 months,
Has the features of migraine headache on at least 8 days per month.

25. epidemiology

26. Migraine-like attacks
Probable migraine
Migraine-like attacks
Missing one of the features required to fulfil all criteria for a subtype of migraine
Not fulfilling criteria for another headache disorder.

27. Tension type headache

28. Tension-type headaches
very common, with a lifetime prevalence between 30% and 78% in different studies
Has a very high socio-economic impact
Aetiology not known but studies strongly suggest a neurobiological basis
Peripheral pain mechanisms are most
likely to play a role in 2.1 Infrequent episodic tensiontype
headache and 2.2 Frequent episodic tension-type
headache, whereas central pain mechanisms play a
more important role in 2.3 Chronic tension-type headache.
Increased pericranial tenderness recorded by
manual palpation is the most significant abnormal finding
in patients with tension-type headache. The tenderness
is typically present interictally, is further increased
during actual headache and increases with the intensity
and frequency of headaches. Pericranial tenderness is
easily recorded by manual palpation by small rotating
movements and a firm pressure (preferably aided by use

29. Infrequent episodic tth
Infrequent episodes of headache
Typically bilateral,
Pressing or tightening in quality
Mild to moderate intensity
Lasting minutes to days.
Does not worsen with routine physical activity
Not associated with nausea, but photophobia or phonophobia may be present.
Some types associated with pericranial tenderness

31. Frequent episodes of headache Typically bilateral,
frequent episodic tth
Frequent episodes of headache
Typically bilateral,
Pressing or tightening in quality
Mild to moderate intensity
Lasting minutes to days.
Does not worsen with routine physical activity
Not associated with nausea, but photophobia or phonophobia may be present.
Some types associated with pericranial tenderness

32. Chronic Tension-type headaches
A disorder evolving from frequent episodic TTH
With daily or very frequent episodes of headache
Same characteristics of episodic TTH

33. Probable Tension-type headaches
Tension-type-like headache missing one of the features required to fulfil all criteria for a subtype of TTH
Not fulfilling criteria for another headache disorder.

34. Trigeminal autonomic cephalalgias (TACs)

35. Trigeminal autonomic cephalgias
TACs share the clinical features of headache,
Usually lateralized,
Often prominent cranial parasympathetic autonomic features
Lateralized and ipsilateral to the headache

36. Trigeminal autonomic cephalgias
Studies suggests that these syndromes activate a normal human trigeminal parasympathetic reflex,
Clinical signs of cranial sympathetic dysfunction being secondary.
Typical migraine aura can be seen

37. Attacks of severe, strictly unilateral pain
Cluster headache
Attacks of severe, strictly unilateral pain
Orbital, supraorbital, temporal or in any combination of these sites
Lasting 15–180 minutes
Occurring from once every other day to eight times a day.

38. Facial sweating, miosis, ptosis and/or eyelid oedema,
Cluster headache
The pain is associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead
Facial sweating, miosis, ptosis and/or eyelid oedema,
And/or with restlessness or agitation.

40. Approaching a patient with headache

41. Approaching a patient with headache
After recording the epidemiologic features
Careful history is most important
The SOCRATES of pain helps establishing the pattern
Physical examinations helps excluding secondary headache & red flags

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51. Management discussed with CBS & CBT

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