1. Approach to Headaches AIMGP Seminar October 2004 Manaf Qahtani

2. Outline: 1. Learning Objectives 2. Case Studies 3. General Principles 4. IHS Classification 5. “Red Flags” 6. The Headache Diary 7. Therapy 8. Review Case Studies 9. Summary 10. Resources

3. 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

7. 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”.

8. IHS Diagnostic Classification 1- Primary Headache: 90% 2-Secondary Headaches: 10%

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

11. Physical Exam Blood pressure Fundoscopy Auscultation for bruits in H/N Temporal artery inspection and palpation Meningismus Neurologic exam: motor, sensory, coordination and gait

12. Primary Headache 1. Migraine without aura 2. Migraine with aura 3. Tension headache 4. Combination headache 5. Cluster headache

13. Primary Headache 1. Migraine without aura; > 5 attacks with: A- duration 4-72 hours B- > 2 of: i.unilateral ii.pulsating iii.interferes with daily activity iv.aggravated by routine activity C- > 1 of: i.nausea and/or vomiting and/or ii.photophobia and/or phonophobia D- No secondary cause

14. Primary Headache 2- Migraine with aura; > 2 attacks of: A- Any 3 or more of: 1-one or more reversible aura symptoms 2-At least one aura symptom develops over > 4 min., or two or more symptoms in succession 3-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.

15. Primary Headache 3. 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. Bilateral iv. 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.

16. Primary Headache 4. Combination Headache Tension-type headache + migraine. The tension headache may precipitate a migraine.

17. Primary Headache 5. 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

18. 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

19. “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

20. The Headache Diary Purpose: To aid diagnosis To identify triggers To provide a self-monitoring tool for patients

21. 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

23. Therapy of Primary Headaches Principles 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.

24. Therapy Migraine – 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

34. Tension-type headaches For moderate attacks NSAIDS useful For severe attacks triptan drugs effective Non-pharmacologic Therapy

35. 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.)

46. 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.

47. Resources www.migraine.ca http://www.zomigconsumer.com/talk/midas Survey.html 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”