HEADACHE

1. HEADACHE UKM FAMILY MEDICINE TELECONFERENCE 11TH FEB 2014 BY DR NAZIHAH MOHD KHALID SUPERVISOR: DR IRENE LOOI, CONSULTANT NEUROLOGIST HOSPITAL SEBERANG JAYA

2. GENERAL OBJECTIVE • At the end of this session, the postgraduate trainees in Family Medicine should be able to discuss the differential diagnosis of headache including providing appropriate treatment and advice to the patient.

3. Specific Objectives • Formulate a differential diagnosis of headache-either primary and secondary • Recognize warning signs of symptomatic (secondary) headaches • Differentiate the common causes of headache • Understand the current theories about the pathophysiology of migraine • Initiate acute and long term treatment of migraine

4. Introduction • Headaches are one of the most common neurological problems presented to primary care and neurologists. • They are painful and debilitating for individuals, an important cause of absence from work or school and a substantial burden on the society.

5. Epidemiology • Almost everyone experience headache at some point of their life • Headache affects 95% of people in their life-time • Headache affects 75% of any people in one year • One in 10 people have migraine • One in 30 people have headache more often than not, for 6 months or more • At least 90% of patients seen in neurology clinic with headache will have migraine, tension type headache or chronic daily headache syndrome • Sinister cause of headache are rare, perhaps 0.1% of all headache in primary care

6. Classification • Headache disorders are classified into primary and secondary based on the International Classification of Headache Disorders, 2nd Edition (ICHD-2). • Primary headache • Etiology not well understood. • Classified according to their clinical pattern. • Most common are tension type headache, migraine and cluster headache. • Medication overuse headache is common in those taking medication for a primary headache disorder.

7. 2. Secondary headache • Organized by the underlying cause. • Search for red flags, both in the history and on general and neurologic examination. • Recommend confirmatory testing

9. Diagnosis • The accurate diagnosis of headache relies heavily on a careful history, supplemented by detailed general and neurological examinations. • Elements of the history and physical examination enable the clinician to diagnose primary headache disorders, and to elicit suspicion of secondary headache disorders (warning flags) that require prompt investigations.

13. Do not refer patients diagnosed with tension type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance. • Include the following in the discussion with the patients: • A positive diagnosis, including an explanation of the diagnosis and reassurance that other pathology has been excluded • Options of management • Recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers

14. Headache Diary • Aid the diagnosis of primary headaches • Record the following for a minimum of 8 weeks • Frequency, duration and severity of headaches • Any associated symptoms • All prescribed and over the counter medications taken to relieve the headaches • Possible precipitants • Relationship of headache to menstruation

19. Consider further investigations or referral for patients who present with new onset of headache and any of the following: • Compromised immunity, for example, HIV or immunosuppresive drugs • Age under 20 years old and history of malignancy • A history of malignancy known to metastasize to the brain • Vomiting without other obvious cause

21. Migraine • Migraine headache is one of the most common, yet potentially debilitating disorders encountered in primary care. • Thorough history and physical examination can help confirm the diagnosis of migraine and rule out emergent condition. • Evidence based aid for migraine diagnosis POUND • Pulsatile quality of headache • One day duration (four to 72 hours) • Unilateral location • Nausea or vomiting • Disabling intensity

22. Prodrome • Affects 1 in 10 patients at most • Usually 24-48 hours before headache • E.g. mood change, behavioral change, yawning, hunger, cravings, fatique (or the opposite) • Aura • Affects up to 30% • Typically precedes the headache, evolving and subsiding over 5-60 minutes • There is often “no man’s land” period between resolution of the aura and headache emergence, usually less than 60 minutes

23. Aura • May sometimes intrude upon, or occur only during the headache phase. • Typically visual, although almost any neurological symptoms may occur. • The aura may occur in isolation, termed typical aura without headache. Here focal epilepsy or transient ischaemic attacks (TIA) enter the differential. The length and evolution of attacks are helpful discriminators, focal seizures usually lasting seconds to minutes, TIAs do not evolve.

24. The nature of aura may change over time and, when it does, it often alarms the patients. However this remains entirely consistent with migraine and does not indicate the need for urgent investigations. • People with aura who lose the associated headache as they get older, rarely complain; those who acquire aura in isolation, often in middle age, present typically to the TIA or eye clinic.

26. Migraine headache is typically severe, throbbing and unilateral. Typically, it lasts for 24 hours or less but can continue for 72 hours, and occasionally longer (hours to days). • It often improves after vomiting and/or sleep, and generally improves with analgesia. • Associated features; most migraine patients complain of at least one of nausea/vomiting and dislike of noise/light/movement, and often all of these. • Patients with migraine feel (and look) unwell, and may complain of more global features such as mood change or lethargy. Rarely, more dramatic features including acute confusional states and even coma.

27. Frequency: median is about 1.5 attacks per month, but at least 1 in 10 have weekly attacks. • Triggers: hunger, sleep deprivation and “stress” are all recognized, and certainly an assessment of the patient’s lifestyle is warranted. • Hormones: migraines during periods, migraine emerging in pregnancy or with exogenous estrogens are all well recognised. The difficulty is that the relationship is often inconsistent, with paradoxical effects. Patients who think that there is hormonal link must keep a daily dairy of headache and menstruation.

28. Migraine (management) • Always assess whether any treatment at all is required-an explanation and reassurance may be sufficient. • Avoidance of triggering factors. • Simple housekeeping tips such as not skipping meals, adequate sleep etc and providing more information is often appreciated. • Explain that drug treatment is one avenue. • Before starting/adding drugs, look at the patient’s current medications and consider whether drug withdrawal is appropriate (e.g. COCP) • Explain how treatment should be used, symptomatic versus preventative treatment, so often confused by patients.

29. Symptomatic treatment is only effective for the headache/nausea elements; there is no symptomatic treatment for the aura. • Early nausea and vomiting are likely to reduce the absorption of oral medication, and the parenteral route might be better. • A stepped approach using simple analgesia first, is appropriate, as this is highly effective for many patients.

31. Preventive therapy may be appropriate for selected patients. • The US Headache Consortium’s recommended the following indications for preventive therapy: • Contraindications or intolerance to symptomatic therapy • Headache symptoms occurring more than two days per week • Headache severely limit quality of life despite symptomatic therapy • Presence of uncommon migraine condition, including hemiplegic migraine, basilar migraine, migraine with prolonged aura or migrainous infarction

33. Other treatments for migraine • Acupuncture: the only alternative treatment for migraine for which there is any evidence, it should be considered as a non-drug option, although limited availability. • Psychological intervention: no specific evidence to support its use, but a “pain management” approach may be helpful in patients with severe, drug resistant migraine provided medication overuse headache is kept in mind.

34. Tension Type Headache (TTH) • TTH is an ill-defined and likely heterogeneous syndrome. • Diagnostic criteria are based on more on what it is not rather than what it is. • By definition, TTH involve pain that is NOT localized, NOT throbbing, NOT aggravated by activity and NOT severe, associated neurologic, autonomic or migrainous features are NOT components of TTH. • NO significant nausea, NO vomiting, photophobia and phonophobia CANNOT both be present. • Finally, must exclude secondary causes of headache possibilities.

36. Most episodes develop during waking hours and progression over the course of the day is common. • The most frequently reported triggers for TTH are mental or physical stressors, which explains why the term “tension-type” headache. Used to be known as “stress” and “muscle contraction” headache. • Other commonly described triggers are hunger, dehydration, overexertion, alterations in sleep patterns, caffeine withdrawal and female hormonal fluctuations.

37. It is crucial to elicit the temporal pattern of the headache disorder during clinical assessment because the extensive symptoms overlap between primary and secondary headaches. • General and neurological examinations are key component to clinical evaluation and can provide clues to the potential presence of organic disease. • The difficulty in distinguishing ETTH from migraine headache, two of the most common episodic headache types, is widely acknowledged.

39. Slight female preponderance; female to male ratio 5:4 • Most develop prior to age 30, with peak prevalence between the ages of 40 and 49 and a subsequent decrease with age in both sexes. • There is also a correlation between prevalence of ETTH and higher educational level. • Link exists between TTH and emotional distress of life tension. Environmental influences appear to carry greater importance than genetic factors in the development of TTH.

40. Although attacks of TTH are generally less disabling than those of migraine, work absence are common, and the total societal burden appears to exceed that of migraine because of the high prevalence of TTH.

41. TTH (Management) • Approach of management involves a combination of lifestyle, physical and pharmacologic measures. • Nonpharmacologic management should always be considered, although the scientific evidence is limited. • Recommendations for regulation of sleep, meals, and exercise are generally quite valuable. • Stress management and behavioral therapies are useful in the management of TTH

42. TTH is mainly managed through administration of medication during acute episodes. • Simple analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) and combination agents are most commonly recommended. • Their use should be strictly limited to an average of 2 to 3 days per week to avoid medication overuse headache and potential contribution toward transformation into CTTH.

43. NSAIDs are generally considered the drugs of choice for acute TTH. • Ibuprofen and naproxen sodium are listed as first line agents in the NSAIDs category because of the better gastrointestinal tolerability. • Opioid analgesics are not recommended for the management of TTH.

45. Preventive pharmacologic therapy is generally advised for those patients experiencing at least 2 to 3 headache days each week. • Although analgesic may be continue to be beneficial when taken at such levels, the issues of medication overuse headache and transformation into more refractory cases of CTTH must be considered.

46. Indications for the institution of daily pharmacologic preventive therapy: • Progression in frequency or severity of attacks • Development of adverse events with acute medications • Decline in efficacy of acute medications • These medications should be started at low doses and gradually increased based on efficacy and tolerability

47. Once an effective dose is reached, treatment is typically continued for 6 to 12 months, at which point daily medication may be tapered and the patient followed clinically.

48. The prognosis of TTH is generally favorable, with limited disability during headache occurrences and age related improvement or resolution of episodes later in life.

49. Cluster headache • Cluster headache is a primary headache disorder classified with similar conditions known as trigeminal autonomic cephalalgias. • Typified by recurrent attacks of unilateral pain, which are very severe and usually involve the orbital or periorbital region innervated by the first (ophthalmic) division of the trigeminal nerve. • Characteristic signs and symptoms of activation of the cranial autonomic pathways accompany the pain on the same side.