Approach to HEADACHE

Approach to HEADACHE 

The gold standard for diagnosis and management of headache is a careful interview and clinical examination. 

Headache Red Flags—“SNOOP”

• Systemic Symptoms : (fever, weight loss) or 
• Secondary Risk Factors : (HIV, systemic cancer) 
• Neurological Symptoms or abnormal signs (confusion, impaired alertness or consciousness) 
• Onset : sudden, abrupt, or split-second 
• Older : new onset and progressive headache, especially in middle age >50 yr (giant cell arteritis) 
• Previous Headache History : first headache or different (change in attack frequency, severity, or clinical features) 

RED FLAG SYMPTOMS 

A red flag symptom means that a headache warrants further investigations. 

•  New or different headache in someone over 50 years old 
•  Headache that develops within minutes (thunderclap headache) 
•  Inability to move a limb or abnormalities on neurological examination 
•  Mental confusion 
•  Being awakened by headache 
•  Headache that worsens with changing posture 
•  Headache that worsens by exertion or Valsalva maneuver (coughing, straining) 
•  Visual loss or visual abnormalities 
•  Jaw claudication 
•  Neck stiffness 
•  Fever 
•  Headaches in people with HIV 
•  Headaches in people with cancer or risk factors for thrombosis 

History : 

• Onset of Headache 
• Temporal Profile 
• Time of the Day 
• Location 
• Quality of Pain 
• Aggravating Factors 

Physical Examination

• A general examination, with a focus on the head and neck, and a full neurologic examination are done. The body habitus should be seen 

• The eyes and periorbital area are inspected for lacrimation, flushing and conjunctival injection. Pupillary size and light responses, extraocular movements and visual fields are assessed. 

• The nares are inspected for purulence (infected sinuses). 

• The oropharynx is inspected for swellings, and the teeth are percussed for tenderness. 

• Neck is flexed to detect discomfort, stiffness or both, indicating meningismus. 

• The cervical spine is palpated for tendernes.

CLASSIFICATION OF HEADACHE (BY INTERNATIONAL HEADACHE SOCIETY)

1. Primary Headaches , The most common types of headache are the primary headache disorders. Primary headaches are usually recurrent.
2. Secondary Headaches 

Primary headache disorders

Migraine
Frequently unilateral, pulsating/throbbing, lasting for 4–72 hours, occasionally with aura, photophobia, phonophobia, osmophobia, worse with activity, preference to lie in the dark, resolution with sleep

Tension-type headache 

Frequent or continuous, mild, bilateral, ban-like holocranial, occipital or frontal pain that spreads to entire head, worse at the end of the day

Cluster headache 

Unilateral orbitotemporal attacks at the same time of day, deep, severe lasting 30–180 min, often with lacrimation, facial flushing, Horner’s syndrome, restlessness, cannot sit still in a place.

Secondary Headache Disorders

Extracranial disorders

• Carotid or vertebral artery dissection (associated neck pain) 
• Dental disorders (infection, temporomandibular joint dysfunction 
• Glaucoma Sinusitis
   

Intracranial disorders

• Brain space occupying lesion (SOL’s) 
• Chiari Type 1 malformation 
• Cerebrospinal fluid leak with low-pressure headache 
• Hemorrhage (intracranial, subdural, subarachnoid) 
• Idiopathic intracranial hypertension

Infections 

• meningitis
• encephalitis
• abscess
• subdural empyema

Noninfectious meningitis

• carcinomatous
• chemical
• obstructive hydrocephalus 
• vascular disorders
• vascular malformations
• vasculitis
• venous sinus thrombosis

Systemic disorders

• Acute severe hypertension 
• Fever 
• Giant cell arteritis 
• Hypercapnia 
• Viral infections

Drugs and toxins

• Analgesics overuse 
• Caffeine withdrawal 
• Carbon monoxide Hormones (estrogen) 
• Nitrates 
• Proton pump inhibitors

Treatments : 

•  Analgesics: Aspirin, acetaminophen 
•  NSAIDs: Naproxen, ibuprofen 
•  5-HT1 agonists-oral: Ergotamine, rizatriptan, naratriptan, zolmitriptan 
•  5-HT1 agonists-nasal: Dihydroergotamine, sumatriptan, zolmitriptan 
•  5-HT1 agonists-parenteral: Dihydroergotamine, sumatriptan 
•  Dopamine antagonists: Metoclopramide, prochlorperazine.

To sum up, headache management involves multimodality treatment especially in chronic patients. Every individual patient is a challenge in himself/herself. The most important component is careful patient listening and reaching a correct diagnosis. Investigations are at best ancillary and should not be the primary focus in reaching a diagnosis.

Source : The Association of Physicians of India