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HEADACHE in Primary Care

HEADACHE in Primary Care. Ayşe Arzu Akalın MD Family Medicine. In the end of this lecture the students will be able to;. d ifferentiate primary and secondary headache list the characteristics of most common headache types in primary care

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HEADACHE in Primary Care

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  1. HEADACHE in PrimaryCare Ayşe Arzu Akalın MD FamilyMedicine

  2. In the end of thislecturethe students will be able to; • differentiate primary and secondary headache • list the characteristics of most common headache types in primary care • explain the warning features in history and physical exam • list the common headache triggers

  3. Definition • Headache or cephalalgia is pain or discomfort perceived in the head, neck or both. • Primary headache disorders are recurrent benign headaches. • Secondary headaches result from an underlying pathology caused by a distinct condition. (eg., aneurysm, infection, inflammation, or neoplasm)

  4. Epidemiology • Annual prevalence may be as high as 90%, with a minority of those sufferers pursuing medical evaluation. • Headache is the second most common pain syndrome in primary care ambulatory practice.

  5. Epidemiology • Inchildrenthe rate of thepatientswhoseekcareforheadache has a negativecorrelationwiththe age. • Theprevalanceincreaseswithagesignificantlyandthepain is less in severityanddurationcomparedwithadults. • Incidence is between 20%-54% in the pre-adolescence period based to the epidemiologic studies.

  6. Pain InsensitiveStructures in Brain • Brainparenchyma • Dura over convexity of skull(Dura around vascular sinuses and vessels is sensitive to pain) • Ependyma • Choroid plexus • Arachnoid • Piamatter

  7. Pain Sensitive Structures in Head INTRACRANIAL • Cranial venous sinuses with afferent veins • Arteries at base of brain and arteries of dura including middle meningeal artery • Dura around venous sinuses and vessels • Falxcerebri

  8. Pain Sensitive Structures in Head EXTRACRANIAL & NERVES • Skin • Scalp appendages • Periosteum • Muscles • Arteries • Mucosa • Trigeminal (V. CN) • Facial (VII. CN) • Vagal (X. CN) • Glossopharyngeal(IX. CN) • OpticandoculomotorCNs (II & III: CN)

  9. Causes of Headaches. 1. Traction or dilatation of intracranial or extracranialarteries. 2. Traction of large extracranialveins 3. Compression, traction or inflammation of painsensitiveintracranial structures 4. Spasm and trauma to cranial and cervical muscles. 5. Meningeal irritation and raised intracranial pressure 6. Eye, ear, noseandthroatpathologies

  10. Classification of International HeadacheSocietyA- PrimaryHeadaches(90%) 1. Migraineincluding: 1.1 Migraine without aura 1.2 Migrainewithaura 2. Tension-type headache, including: 2.1 Infrequent episodic tension-type headache 2.2 Frequent episodic tension-type headache 2.3 Chronic tension-type headache 2.4 Probabletension-typeheadache 3. Cluster headache and other trigeminal autonomic cephalalgias, including: 3.1 Cluster headache 3.2 Other primary headaches

  11. Classification of International HeadacheSocietyA- PrimaryHeadaches(90%) 4. Other primary headaches 4.1. Primary stabbing headache 4.2. Primary cough headache 4.3. Primary exertional headache 4.4. Primary headache associated with sexual activity 4.4.1. Preorgasmic headache 4.4.2. Orgasmic headache 4.5. Hypnic headache 4.6. Primary thunderclap headache 4.7. Hemicrania continua 4.8. New daily persistent headache (NDPH)

  12. PrimaryHeadacheDefinition • None of theprimary headaches is associated with demonstrable • organic disease or • structural neurologic abnormality. • Laboratory and imaging test results are generally normal. • Thephysical and neurologic examinations are also usually normal

  13. PrimaryHeadacheDefinition • Should an abnormality be found on testing, by definition, it most likely is not the cause of the headache. • During the headache attack however, patients might have some abnormal clinical findings

  14. B- SecondaryHeadaches(10%) 5. Headache attributed to head and/or neck trauma, including: 5.2 Chronic post-traumatic headache 6. Headache attributed to cranial or cervical vascular disorder, including: 6.2.2 Headache attributed to subarachnoid hemorrhage 6.4.1 Headache attributed to giant cell arteritis 7. Headache attributed to non-vascular intracranial disorder, including: 7.1.1 Headache attributed to idiopathic intracranial hypertension 7.4 Headache attributed to intracranial neoplasm

  15. B- SecondaryHeadaches 8. Headache attributed to a substance or its withdrawal, including: 8.1.3 Carbon monoxide-induced headache 8.1.4 Alcohol-induced headache 8.2 Medication-overuse headache 8.2.1 Ergotamine-overuse headache 8.2.2 Triptan-overuse headache 8.2.3 Analgesic-overuse headache 9. Headache attributed to infection, including: 9.1 Headache attributed to intracranial infection

  16. B- SecondaryHeadaches 10. Headache attributed to disorder of homoeostasis 10.1. Headache attributed to hypoxia and/or hypercapnia 10.2. Dialysis headache 10.3. Headache attributed to arterial hypertension 10.4. Headache attributed to hypothyroidism 10.5. Headache attributed to fasting 10.6. Cardiaccephalalgia 10.7. Headache attributed to other disorder of homoeostasis

  17. B- SecondaryHeadaches 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures, including: 11.2.1 Cervicogenic headache 11.3.1 Headache attributed to acute glaucoma 12. Headache attributed to psychiatric disorder

  18. Secondary Headache Definition • Secondary headaches are usually of • recent onset and • associated with abnormalities found on clinical examination. • Laboratory testing or imaging studies confirm the diagnosis.

  19. Secondary Headache Definition Recognizing headaches related to an underlying condition or disease is critical: • because treatment of the underlying problem usually eliminates the headache • the condition causing the headache may be life-threatening.

  20. C- Cranial Neuralgias, Central and Primary Facial Pain and Other Headaches 13. Trigeminal neuralgia 14. Other headache, cranial neuralgia, central or primary facial pain

  21. Headache in Primary Care

  22. Taking a Diagnostic History • The history is all-important in the diagnosis of the primaryheadache disorders and of medication-overuse headache • There are no useful diagnostic tests. • The historyshould elicit any warning features of a serious secondaryheadache disorder.

  23. Warning Features in History Any new headache in an individual patient, or a significantchange in headache characteristics, should be treated withcaution. "I havenever had a headachelikethisbefore" "This is theworstheadache I have ever had"

  24. Specific WarningFeaturesin History (1/5) • Thunderclap headache (intense headache with “explosive”or abrupt onset) ͢→subarachnoid hemorrhage) Estimated prevalence of subarachnoidhemorrhagein the setting of thunderclap headache is 43%

  25. Specific WarningFeaturesin History (2/5) • Headache with atypical aura (duration >1 hour, or includingmotor weakness) ͢→ symptoms of transient ischemic attack (TIA) or stroke • Aura without headache in the absence of a prior history ofmigraine with aura ͢→ symptoms of TIA or stroke • Aura occurring for the first time in a patient during use ofcombined oral contraceptives ͢→ risk of stroke

  26. Aurais a subjective sensation or motor phenomenon that precedes and marks the onset of a neurological condition, particularly an epileptic seizureor migraine

  27. Specific WarningFeatures in History (3/5) • New headache; in a patient older than 50 years →symptom ͢of temporal arteritis or intracranial tumour, in apre-pubertal child ͢→ requires specialist referral and diagnosis in a patient with a history of cancer, HIVinfection or immunodeficiency ͢→ secondaryheadache

  28. Specific WarningFeatures in History (4/5) • Progressive headache, worsening over weeks or longer͢→ intracranial space-occupying lesion • Headache aggravated by postures or maneuvers that raiseintracranial pressure ͢→ intracranial tumour, CNS infection

  29. Specific WarningFeatures in History (5/5) • Headache first occuring with exercise ͢→ ruptured aneurysm • Headache hours to weeks after a history of trauma, especially in an older person ͢→ subdural hematoma • Similar new onset of headaches in an acquaintance or family member ͢→ environment exposure such as carbon monoxide

  30. Questions to Ask in the History(1/7) How many different headache types does the patient have? Aseparate history is needed for each. Any change in character or intensity? Is thisyourfirstorworstheadache? Is thisheadacheliketheonesyouusuallyhave?

  31. Questions to Ask in the History(2/7) Time questions • Why consulting now? • How recent in onset? Whendidthisheadachebegin? How did it start (gradually, suddenly, other)? • How frequent, and what temporal pattern (episodic or daily and/or unremitting)? Do youhaveheadaches on a regularbasis? • How long lasting?

  32. Questions to Ask in the History(3/7) Character questions • Intensity of pain? How bad is yourpain on a scale of 1 to 10? • Natureand quality of pain? Whatkind of pain do youhave (throbbing, stubbing, dull, other)? • Site and spread of pain? Where is yourpain? Doesthepainseemto spread toanyotherarea? Ifso, where?

  33. Questions to Ask in the History(4/7) Character questions • Associated symptoms? Whatsymptoms do youhavebeforetheheadachestarts? Whatsymptoms do youhaveduringtheheadache? Whatsymptoms do youhaverightnow?

  34. Questions to Ask in the History(5/7) Cause questions • Predisposing and/or trigger factors? • Aggravating and/or relieving factors? • Family history of similar headache?

  35. CommonHeadacheTriggers • Alcohol • Caffeine • Food additives (MSG, aspartame, tyramine (found in aged cheeses, some red wines, smoked fish, etc.),sodium nitrite (found in processed meats).

  36. CommonHeadacheTriggers • Foods (Chocolate, fruits, dairy, onions, beans, nuts) • Environmental changes (Light, odors (perfume, paint, etc.), travel, abruptchanges in weather or altitude)

  37. CommonHeadacheTriggers • Lifestyle factors (Insufficient, excessive, disrupted, or irregular sleep; tobacco or alcohol use; fasting; physical activity; head injury; schedule changes; stress or release from stress; anger; or exhilaration) • Hormone changes, or addition of estrogen- containingmedication (Timing of headache with menses or change/ addition of hormones)

  38. Questions to Ask in the History(6/7) Response questions • What does the patient do during theheadache? • How much is activity (function) limited or prevented? • What medication has been and is used, in what manner and with what effect? Do youtakeanymedicines? Ifso, what?

  39. Questions to Ask in the History(7/7) State of health • Completely well, or residual or persisting between attackssymptoms? • Concerns, anxieties, fears of recurrent attacks and/or their cause? Do youhaveothermedicalproblems? Ifso, what? Haveyourecently hurt yourheador had a medicalordentalprocedure?

  40. Diagnostic Diary • Once serious causes have been ruled out, a headache diarykept over a few weeks clarifies the pattern of headaches andassociated symptoms as well as medication use or overuse.

  41. Physical Examination Physical examination is mandatory when the historyis suggestive of secondary headache. • General appearance, Does s/he look unwell? • Vitalsigns, Measure BP • Head and neck examincludingpalpation • Neurologicalexamincludingfundoscopy • ENT exam, • Ophtalmologic exam (astigmatism, glocoma)

  42. Warning Features on Examination • Pyrexia •  Blood Pressure (sist >200 mmHg / diast >120 mm Hg)  hypertensiveencephalopathy, • A palpable tender temporalartery  Temporalarteritis • Papilledema  increasedintracranialpressure

  43. Warning Features on Examination • Focal neurological signs • Stiffneck, rush, fever, photophobia, vomiting and other systemic signs meningitis, encephalitis • Headache aggravated by postures or maneuvers raisingintracranial pressure  intracranialtumour, subduralhematoma, epiduralbleeding

  44. Investigations Investigations, including neuroimaging, are indicated whenthe history or examination suggest headache may be secondaryto another condition.

  45. Primary Headaches The most common primary headaches in primary care are: • Migraine (with aura / without aura) • Tension-type headache • Cluster headache • Medicine-associated headache

  46. Migraine • Episodic attacks with specific features of which nausea is the most characteristic. • Attack frequency between once a year and once a week (most commonly once a month). • In children, attacks tend to be of shorter duration and abdominal symptoms more prominent.

  47. Migraine without aura: IHS criteria 5 attacks of • Headache lasting 4-72 hours. • Must be associated with nausea or vomiting or photophobia and phonophobia • Must have 2 of the following • Unilateral • Pulsating • Moderately / severe. • Aggravated by physical activity

  48. Migraine • Primary headache disorder with genetic basis. • Activation of a mechanism deep in the brain causes release of pain-producing inflammatory substances around the nerves and blood vessels of the head. • Why this happens periodically, and what brings the process to an end in spontaneous resolution of attacks, are to a large extent uncertain.

  49. Migraine • Starting at late childhood or puberty, • Affects those aged between 35 and 45 years but also younger people, including children. • Prevalence in Europe and America: 6-8% in men and 15-18% in women • Prevalence in Turkey: 10% in men and 22% in women.

  50. Migraine In children: • attacks may be shorter-lasting • headache is more commonly bilateral and less usually pulsating • gastrointestinal disturbance is more prominent.

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