1. Primary Headache Diagnosis RCGP 28.4.2009
Dr David PB Watson
GPwSI Headache
Hamilton Medical Group
Aberdeen

2. Primary Headaches Tension Type headache Migraine
Trigeminal Autonomic cephalalgias
Others

3. Headache types Primary headache Secondary headache
Episodic primary headaches
Chronic primary headaches
Primary headache
No underlying medical cause:
Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drug-induced
Secondary headache
Underlying medical cause:
Headache can be a primary disorder or a secondary symptom of another disease. Primary headache may also be secondary to another disorder, for example, the relationship between cervical spine disorders and migraine headaches.
The headache classification system of the International Headache Society (IHS), first published in 1988 but recently revised (2004), lists >100 types of headache, many of which are attributable to pathological conditions (IHS 1988, 2004).
Secondary headaches are common in patients with an intracranial process, including tumour, haemorrhage, infection or vascular disorders. They may also be associated with systemic infections, the use/overuse of various drugs and head injury.
Primary headaches (eg episodic primary headache, chronic primary headache, migraine, tension-type headache [TTH] and cluster headache) have no obvious underlying cause.
Accurate diagnosis of headache type is critical to the therapeutic recommendation. Secondary headache to an underlying disorder must be excluded, followed by a correct primary headache diagnosis and treatment plan.

4. Episodic primary headaches
Probable
Migraine
Tension-type headache (TTH)
TACs
There are four types of episodic primary headaches (IHS 2004):
Cluster: episodic cluster headaches occur in periods lasting from 7 days to 1 year and are separated by pain-free periods lasting 1 month. Pain is severe and unilateral. Attacks are associated with 1 of the following signs: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and eyelid oedema.
Tension-type: episodes of headache lasting days to months. The pain is typically bilateral, pressing or tightening in quality, of mild-moderate intensity and does not worsen with physical activity. There is no nausea, but photophobia may be present.
Migraine ± aura: patients have periods of severe impairment followed by return to a normal neurological baseline. Headache pain is often unilateral, of moderate intensity and pulsating quality. The headache is worsened by physical activity and is frequently associated with nausea, photophobia and phonophobia.
Probable migraine: previously categorised as ‘migrainous headache’. This diagnosis is given if the headache is missing 1 features of migraine ± aura.

5. Diagnosis is by history, history, history
T timing
O other associated symptoms
S site
S severity
I influences aggravating/relieving factors
T type: what it feels like

6. Key points Episodic disabling headache is migraine
Over diagnosis of sinus headache and TTH
40% migraineurs miss ICHD-II criteria

7. Abbreviated diagnostic checklist based on IHS 2004 criteria
Migraine
Probable migraine
Tension-type
Essential (3)
Essential (2)
Essential (1)
Recurrent
No organic disease
Duration 4-72 h
Unilateral
Pulsating
Moderate / severe
Aggravated by movement
Nausea / vomiting
Photo / phonophobia
Recurrent
No organic disease
Duration 4-72 h
Moderate / severe
+ one other
Recurrent
No organic disease
Duration 0.5 h-7 days
Generalised
Pressure / tightness
Slight / moderate
Photo / phonophobia
Although migraine, migrainous headache and tension-type headache are all primary episodic headaches, each has characteristic differentiating features. The IHS has used these features to develop diagnostic criteria for each of these headache types (IHS 2004).
This slide presents an example of how an abbreviated diagnostic checklist for headaches can be derived from the clinical criteria provided within the International Classification of Headache Disorders (IHS 2004). The checklist was developed by Dr Robert Smith in order to facilitate use of the IHS criteria in the primary care setting (unpublished).
Essential (3) = all items essential for diagnosis; Essential (2) = two items from list essential for diagnosis; Essential (1) = one item from list essential for diagnosis
IHS 2004

8. Migraine Epidemiology High impact 6 million people in the UK
Women 3x men
Most sufferers 20 to 50
High impact
WHO disability
Personal impact

9. The migraine attack Symptom intensity Associated symptoms Prodrome
For any given patient, or any given attack, migraine attacks typically progress through several phases:
prodrome;
aura;
headache phase ± associated symptoms;
postdrome.
Not all patients will experience every phase.
Migraine attacks will differ in severity and characteristics for each patient.
Prodrome
Aura
Headache
Postdrome
Time

10. Prodrome 60% of migraine sufferers experience premonitory phenomena
Excitatory
Irritability
Elation
Hyperactivity
Yawning
Food cravings
Photophobia / phonophobia
Increased bowel / bladder activity
Inhibitory
Mental / physical slowing
Poor concentration
Word finding difficulty
Weakness / fatigue
Constipation / abdominal bloating
Anorexia
Chill
The prodrome phase may occur between a few minutes to 48 hours before the onset of a headache pain.
Approximately 25% of migraine sufferers experience premonitory feelings (elation, irritability, depression, hunger, thirst, or drowsiness) (Silberstein and Young 1995), which are generally classified as excitatory or inhibitory in origin (Waelkens 1985).
Premonitory symptoms are not always well defined; some migraine sufferers only have a vague feeling that a migraine attack is imminent. More than half of all migraine sufferers can identify some premonitory phenomenon, but this information tends not to be volunteered or thought about unless patients are specifically asked about it.
Headache diaries can therefore be invaluable for patients and clinicians to fully understand the migraine syndrome.

11. Aura Affects 33% of migraine sufferers, but not in all attacks
Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve visual, sensory or motor systems
Can occur before or during headache phase
Slow evolution of symptoms
Lasts for minutes
Can be confused with transient ischaemic attack
Although aura affects around 33% of patients, it does not present with every migraine attack they experience. The typical onset of aura is 5-20 minutes and it generally lasts <60 minutes (Ferrari 1998); it is not always clearly demarcated and may extend into the headache phase.
Visual aura is the most common aura symptom and include loss of vision (eg scotoma), a blind spot that progresses or enlarges across the visual field, or less commonly, complete loss of vision in one visual field (hemianopia) (Spierings 2003; Russell and Olesen 1996).
Sensory aura include paresthesia (tingling) typically starting in one hand, spreading to the arm, elbow, face, lips and tongue. Motor aura is typically experienced on one side and affects the hand and arm (Russell and Olesen 1996).
A rare form of aura involves the brainstem, resulting in quadraplegia, loss of consciousness or cranial nerve deficits.
Young children with migraine may experience confusion, ataxia or aphasia. Elderly patients may experience aura without headache, sometimes called acephalic migraine, that at times may be difficult to distinguish from transient ischaemic attacks.
A non-vascular pattern and stereotyped recurrence, along with a prior history of migraine, can be reassuring for patients who experience aura.
Ferrari 1998
Spierings 2003
Russell & Olesen 1996

12. Aura v TIA AURA TIA Sequential Progression 20-60 minute duration
Positive and negative symptoms
Headache occurs in 50%
Visual
Sensory
Simultaneous occurrence
<15 minute duration
Negative symptoms
Headache uncommon

13. Headache phase Throbbing or pounding quality
If left untreated, headache pain will progress to moderate / severe intensity
Duration hours in adults
Exacerbated by movement*
One-sided temporo-orbital* (but can be any site)
Abated by sleep*
Resolves spontaneously
Headache is often the first phase of the migraine to be recognised by the patient, as it is generally the most debilitating part of a migraine attack. The pain may build up gradually to a peak over a period of minutes or hours, or it may plateau and then gradually subside. Many migraine sufferers will have an occasional attack that wakens them at night with full-blown headache pain.
If untreated, the headache pain generally lasts for 4-72 h in adults and 2-8 h in children. The severity of the headache pain can vary greatly between attacks. Most migraine sufferers, however, report pain of 5 on a scale of 0 to 10.
Migraine headache pain is usually one-sided, although attacks may occur on alternate sides of the head. The site of maximal pain is usually temporo-orbital but often radiates into the ipsilateral occiput and neck, and may spread to the opposite side of the head (Pryse-Phillips et al 1997).
Abatement with sleep can be a characteristic of migraine pain (Pryse-Phillips et al 1997). Exacerbation of pain by head movement or routine physical activity, such as climbing stairs, are also characteristic features.
Left untreated, the pain of migraine will spontaneously resolve.
*Usually

14. Postdrome Estimated to affect 90% of migraine sufferers
Phase after pain relief
duration up to 24 hours
Sufferers may experience: hyperaesthesia, mood changes, muscular weakness, fatigue, difficulty in concentrating
Extends period of migraine-related disability
The postdrome phase occurs after pain relief is achieved and may persist for 24 hours (Blau 1982).
Sufferers experience characteristic symptoms such as hyperaesthesia (scalp sensitivity, valsalva-induced headache), lethargy and depression. Other symptoms include mood changes, muscular weakness, fatigue and difficulties concentrating.
These feelings may be attributed to migraine medications or may be caused by the migraine itself.
The postdrome phase extends the migraine-related disability that is often associated with the headache, but is not actually associated with headache pain.
Blau 1982

16. Cutaneous Allodynia
Perception of pain when non-noxious stimulus applied to normal skin
central sensitization of neurons in the trigemino-vascular system
wind-up
up to 70% migraineurs
treat early

17. What features make migraine more likely?
episodic severe headache that causes disability11, 23, 24
nausea16, 23
sensitivity to light during migraine headache16, 23
sensitivity to light between migraine attacks 25
aura16, 18
sensitivity to noise16
exacerbation by physical activity16
positive family history of migraine16
The features which give the greatest sensitivity and specificity are Disability, Nausea and Sensitivity to light23
ID Migraine validation study (Level 3)

19. Trigeminal Autonomic Cephalalgias
Cluster headache
Paroxysmal Hemicrania
SUNCT

20. Cluster Headache Men smokers severe pain (Eagle’s Claw) high impact
autonomic features

21. Cluster IHS Criteria
Severe or very severe unilateral,supraorbital and or temporal pain lasting min if untreated
Headache accompanied by one of the following
Ipsilateral conjunctival injection and or lacrimation
Ipsilateral nasal congestion and or rhinorrhoea

22. Cluster IHS Attack frequency 1 every other day to 8 per day
Forehead and facial sweating
Ipsilateral eyelid oedema
Ipsilateral forehead and facial sweating
Ipsilateral miosis and ptosis
A sense of restlessness or agitation
Attack frequency 1 every other day to 8 per day

23. Cluster
Episodic occurs in periods 7 days to 1 year separated by pain free periods lasting one month or more
Chronic attacks occur for > 1 year without remission or remission lasting less than a month

24. What features make TACs more likely?
The following features differentiate trigeminal autonomic cephalalgias from migraine: 16, 26 (Level 4)
Onset: rapid in TAC, gradual in migraine
Duration: TACs < 3 hours, migraine hours
Frequency: multiple attacks may occur daily in TACs
Restlessness during an attack: 100% in cluster headache, 50% in paroxysmal hemicrania
Prominent ipsilateral autonomic features in TACs

25. Other Primary Headaches
Primary Stabbing Headache
Primary Cough Headache
Primary Exertional Headache
Primary Headache Associated with sexual Activity
Hypnic Headache
Hemicrania Continua

26. Any Questions?