Headache in Primary Care

Done by:
Vinod Singh, Anah Shageer, Shivan Toolsie,
Firas Ali
Annisha Samuel, Corrado Figaro, Aliyah Khan,
Belinda Taklal

Introduction
Headache, or cephalalgia, is defined as diffuse pain in various parts of
the head, with the pain not confined to the area of distribution of a
nerve.
Approximately one-half of the adult population worldwide is affected
by a headache disorder.
A thorough history and physical examination, and an understanding of
the typical features of primary headaches, can reduce the need for
neuroimaging, lumbar puncture, or other studies.

International Classification Of Headache

Disorders
Primary Headaches:
Tension- type (40%)
Migraine (10%)
Cluster

(1%)

Other e.g., cold stimulus headache

Secondary Headaches:
Headache attributed to any of the following: head or neck trauma, cranial or cervical
vascular disorder, nonvascular intracranial disorder, substance use or withdrawal,
infection, disturbance of homeostasis, psychiatric disorder
Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose,
sinuses, teeth, mouth, or other facial or cranial structures

Headache diagnosis
There are no diagnostic tests for any of the primary headache disorders, or for medicationoveruse headache. The history is all-important. A headache history requires time to elicit,
and not finding the time to take it fully is the probable cause of most misdiagnosis.
Headache ought to be a public-health concern. Yet there is good evidence that very large
numbers of people troubled by headache do not receive effective care.
Barriers to effective care:
Clinical barriers - Lack of knowledge among health-care providers
Social barriers - Poor awareness extends to the general public
Political/economic barriers - Many governments, seeking to constrain health-care
costs, do not acknowledge the substantial burden of headache on society.

An approach to the headache history

1. How many
different
headaches types
does the patient
experience?

Separate histories
are necessary for
each. It is
reasonable to
concentrate on the
most bothersome to
the patient but
others should
always attract some
enquiry in case they
are clinically
important.

2. Time questions-

a) Why consulting
now?
b) How recent in
onset?
c) How frequent,
and what temporal
pattern (especially
distinguishing
between episodic

5.
Response
questions

a) What does the

patient do during the
headache?
b) How much is
activity (function)
limited or
prevented?
c) What medication
has been and is
used, and in what
manner?
Physical examination- The primary purpose of the physical examination is to identify
6. Stateof
ofsecondary
a) Completely
well, Should include vital signs, funduscopic and cardiovascular
causes
headaches..
health
or residual
or of the head and face A.complete neurologic examination is
assessment,
and
palpation
between
persisting
essential.
attacks
symptoms?
Investigations,
including neuroimaging, rarely contribute to the diagnosis of headache when
b)
Concerns,
the history and examination
have not suggested an underlying cause.
anxieties, fears
about recurrent
attacks, and/or their
cause

Low Risk Headaches

Patients at low risk of serious headache do not require neuroimaging.
Criteria for Low Risk Headaches are as follows:
Age <30
Features typical of Primary headaches
History of similar headache
No abnormal neurologic findings
No concerning change in usual headache pattern
No high-risk comorbid conditions
No new, concerning historical or physical examination findings.

Primary Headaches

Tension Type headaches

Tension Type Headaches

It is the most common form of headache and affects more than 40% of the adult
population worldwide; females are slightly more affected than males.
Pain is mild to moderate, bilateral, constant and frontal/ nuchal-occipital. It is typically
described as pressure or tightness, like a vice or tight band around the head, and
commonly spreads into or arises from the neck. Whilst it can be disabling for a few
hours, it lacks the specific features and associated symptom complex of migraine.
Stressful events trigger this type of headache e.g. depression, anxiety, noise, sleep
deprivation and is not aggravated by physical activity.
Episodic tension-type headache also occurs in attack-like episodes, with variable and often
very low frequency and mostly short-lasting no more than several hours. Chronic
tension-type headache occurs by definition on >15 days a month, and may be daily.
This condition is disabling.

ICHD-2 Diagnostic Criteria for Episodic TTH

Infrequent:
At least 10 episodes occurring on average <12 per year (<1 day per month)
Lasts 30min-7 days
Headache has 2 of the following: Bilateral location,Tightening (nonpulsatile),
mild/moderate intensity, not aggravated by routine physical activity
Not associated with: N+V,Photophobia/Phonophobia, or any other disorder
Frequent:
At least 10 episodes occurring 1> but <15 days / month for 3 months
Fulfills all other criteria as with Infrequent Episodic TTH

Treatment:
Regular exercise is of general and potentially considerable benefit and always worth
recommending. Physical modalities such as heat and massage could also be
recommended.
Episodic TTH is self-limiting, non-disabling, and rarely raises anxieties about its causation
or prognosis. Reassurance, if needed, and symptomatic treatment are often quite
sufficient. Over-the-counter analgesics (aspirin, ibuprofen) are usually sufficient; other
NSAIDs (ketoprofen, naproxen) are sometimes indicated.
These treatments are inappropriate in chronic TTH. Amitriptyline is otherwise the drug
treatment of choice for frequently recurring episodic TTH or for chronic TTH.
If all else fails then the patient can be referred to a pain management clinic.

Migraine headaches

Etiology
The exact cause of migraines are unknown
Hormonal Changes: Some women experience migraines at the time of their period possibly because of the
changes in hormones such as oestrogen levels .These type of migraines usually occur between

two days before the start of the period to three days after. Some women only experience
migraines around this time, which is known as pure menstrual migraine. However, most
women experience them at other times too and this is referred to as a menstrual related
migraine.
Emotional Triggers: Stress, anxiety, tension, shock, depression and excitement
Physical Triggers: Tiredness, Poor quality of sleep, Poor posture, Shoulder and neck tension,
Hypoglycaemia, Strenuous exercise (if not used to it)
Dietary Triggers: Missed, delayed and/or irregular meals, dehydration, alcohol, caffeine products such as
tea and coffee, chocolate, citrus food, cheese
Environment:Bright lights, flickering screens such as computer screens and tv, smoking or smoky rooms,
loud noises, changes in climate ( humidity or very cold temperatures), strong scents, stuffy
atmosphere

Diagnosis (Adults)(Without Aura)

The diagnosis of migraine is based on the history. According to diagnostic criteria established by the
International Headache Society (IHS), patients must have had at least 5 headache attacks that lasted 4-72
hours (untreated or unsuccessfully treated) and the headache must have satisfied the characteristics seen
below without being attributed to any other disorder:

POUND- Pulsatile quality of duration 4-72 hours, Unilateral location, Nausea /vomitting and
Disabling intensity.

Diagnosis (ADults)(With Aura)

The IHS defines aura as reversible focal neurologic symptoms that usually develop gradually over 520 minutes and last for less than 60 minutes. Headache with the features of migraine without aura
usually follows the aura symptoms. Less commonly, the headache lacks migrainous features or is
completely absent.
ICHD-2 Diagnostic Criteria for migraines with typical aura (at least 2 episodes fulfilling
the following):
Aura consists of at least one of the following: Fully reversible visual symptoms (+ve- Flickering
lights,spots,lines/ -ve- loss of vision.) Fully reversible sensory symptoms (+ve- Pins&needles/ve- numbness)
Aura consists of at least two of the following: homonymous visual symptoms and/or unilateral
symptoms; at least one aura symptom develops gradually over five or more minutes and/or
different aura symptoms occur in succession over five or more minutes; each symptom lasts at
least five minutes, but no longer than 60 minutes.
A headache that fulfills the criteria for migraine without aura, and begins during the aura or follows
the aura within 60 minutes.

Diagnosis - (Children)
Migraine manifestations by patient age:

Infants - episodic "head banging."

Preschoolers - migraine with ill appearance, abdominal pain, vomiting, and need to sleep. They may exhibit pain by irritability, crying,
rocking, or seeking a dark room in which to sleep.

In children aged 5-10 years, migraine typically has the following features:

Bifrontal, bitemporal, or retro-orbital headache

Nausea/Vomiting

Abdominal cramping

Photophobia/Phonophobia

A need to sleep

Children of this age usually fall asleep within 1 hour of attack onset. The most common accompanying symptoms include the following:

Pallor with dark circles under the eyes (migraine facies)/Tearing

Swollen nasal passages/Thirst

Edema/Excessive sweating

Increased urination/Diarrhea

Older children may present with a unilateral temporal headache. They should describe the quality, timing, severity, precipitating factors,
duration.

Treatment - (Adults)
Migraine treatment involves acute (abortive) and preventive (prophylactic) therapy. Patients with frequent attacks usually require
both.
Abortive medications ( within 15 minutes of pain onset)include the following:
Selective serotonin receptor agonists (triptans - frovatriptan)
Ergot alkaloids (eg, ergotamine, dihydroergotamine [DHE])
Analgesics (acetaminophen, oxycodone)
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Combination products (a triptan and an NSAID, Treximet)
Antiemetics (chlorperazine, promethazine)
Prophylactic medications include the following:
Antiepileptic drugs (Valproic acid)
Beta blockers (Propranolol)
Tricyclic antidepressants (amitriptyline)
Calcium channel blockers
Selective serotonin reuptake inhibitors (SSRIs)
NSAIDs (naproxen sodium)
Serotonin antagonists (Methysergide)
Botulinum toxin
Treatment of migraine may also include the following:
Reduction of migraine triggers (eg, lack of sleep, fatigue, stress, certain foods, use of vasodilators/oral contraceptives)
Nonpharmacologic therapy (eg, biofeedback, cognitive-behavioral therapy, relaxation therapy)

Treatment - (Children)
Management of pediatric migraine has 3 facets - education, plan of treatment & prophylaxis.

Acute attacks
During the attack, advise the child to lie down in a cool, dark, quiet room and go to sleep at the time of the attack. Children should be
given simple analgesics such as acetaminophen or ibuprofen. Stronger analgesic medication, such as butalbital, may be necessary.
Promethazine (rescue) diminishes nausea, causes drowsiness, and seems to decrease pain. Intravenous (IV) dihydroergotamine (DHE)
is an effective abortive agent when used early in an attack in children over 12 years of age. Serotonin 5-HT-receptor agonists (ie, triptans)
are approved by the FDA for treatment of acute migraine attacks in adolescents (ie,almotriptan [Axert], zolmitriptan [Zomig Nasal Spray],
naproxen/sumatriptan[Treximet]) and in children (ie, rizatriptan [Maxalt]).
Nonpharmacologic treatment modalities such as self-relaxation, biofeedback, and self-hypnosis may be reasonable alternatives to
pharmacologic treatment in managing childhood migraine, particularly in adolescents.

Prophylaxis

Amitriptyline
Propranolol
Selective serotonin reuptake inhibitors (SSRIs)
Anticonvulsants - Eg, gabapentin, valproate, divalproex, topiramate
Riboflavin
Tricyclic antidepressants (TCAs)
The agents that seem to be the most effective/well tolerated prophylactic medication in children are those that block the 5-HT2
serotonin receptor;i.e. beta blockers, cyproheptadine, and methysergide (Sansert). The FDA has approved topiramate (Topamax) for
prevention of migraine headache in adolescents aged 12-17 years. Initially administer drugs at very low dosages and slowly titrate to
therapeutic efficacy, for a duration of 3 - 6 months then withdraw slowly to prevent relapse.

Cluster Type Headaches

Cluster type headaches

There is another group of disorders, the trigeminal autonomic cephalalgias, where daily
occurrence of headache is usual. The most common is cluster headache.
CH affects mostly men (male to female ratio about 6:1) in their 20s or older (very rarely
children) and very often smokers. The condition has its name because, typically,
headaches occur in bouts for 6-12 weeks, once a year or two years, often at the same
time each year.
The pain of CH is intense and strictly unilateral. Although most often focused in one or the
other eye, it can spread over a larger area of the head. There may, also, be a
continuous background headache. The associated autonomic features of ipsilateral
conjunctival injection and lacrimation, rhinorrhoea or nasal blockage, eyelid edema,
forehead and facial sweating, and ptosis as the most obvious feature of a partial
Horners syndrome, may not all be present.
Typically CH occurs daily, at a similar time each day, and usually but far from always at
night, 1-2 hours after falling asleep.

ICHD-2 Diagnostic Criteria for CH

At least five episodes of the following:
Severe unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 minutes if
untreated.
Previously mentioned autonomic symptoms.
Headache episodes occur from one every other day to eight per day.
Episodic Cluster Headaches: At least two cluster periods lasting seven to 365 days and
separated by pain-free remissions of more than one month.
Chronic Cluster Headaches: Episodes recur for more than one year without remission
periods or with remission periods lasting less than one month.

Treatment
It is the one primary headache that may not be best managed in primary care, but the
primary-care physician has an important role in recognizing it. Analgesics have no place in
the management of cluster headaches.
Acute drug intervention
Sumatriptan 6 mg subcutaneously is the treatment of choice, unless contra-indicated. It is
the only proven highly-effective acute treatment. In a high proportion of cases it aborts
the attack in 5-10 min. Sumatriptan is contra-indicated in uncontrolled hypertension or
the presence of risk factors for coronary heart disease or cerebrovascular disease.
Oxygen 100% at 10-15 l/min for 10-20 min helps some people. Its advantage, when it
works, is its safety, allowing multiple daily uses. The high flow-rate requires a special
regulator and non-rebreathing mask.

In most cases, prophylactic drugs are the mainstay of treatment as symptomatic treatment alone is
rarely sufficient to achieve adequate control. Prophylactic drugs should be commenced as early as
possible after the start of a new cluster period.
Verapamil is a reasonable first-line choice for both episodic and chronic CH. it is usually well
tolerated: constipation and flushing are common side-effects.ECG should be checked for
atrioventricular block before commencing treatment and whenever the dosage is increased.
Beta-blockers should not be given concomitantly
Prednisolone may be preferred because, unlike all other treatments, it is commenced in high
dosage. A starting dose of 60-100 mg, once daily for 2-5 days, will most often produce
marked, almost immediate relief. Because of the potential otherwise for serious side-effects,
treatment is limited to a very short and intensive course.
Lithium carbonate should be considered in episodic or chronic CH if verapamil is not
effective.Serum concentrations must be frequently monitored. Symptoms of early toxicity
(nausea, diarrhoea, polyuria, polydipsia) without benefit mandate abandonment of this
therapy. Serious long-term side-effects include tremor, oedema, electrolyte disturbance,
muscle weakness, central nervous system disturbance, ECG abnormality and hypo- or
hyperthyroidism. Renal, cardiac and thyroid functions should be monitored. NSAIDS should not
be taken concomitantly.
Methysergide 1-2mg tds may be effective in up to 70% of patients with episodic and is worth
trying when other treatments fail. Tolerance may develop after two or three treatment

With the exception of steroids, effective prophylaxis should be continued in episodic cluster
headaches until the patient has been headache-free for at least 14 days. This
minimizes the risk of relapse.
Drugs should be withdrawn by progressive dosage reduction rather than ceased abruptly. If
relapse does occur, treatment must be resumed.
Prophylaxis sometimes converts chronic cluster headaches into the episodic form, and
then can be withdrawn after 14 days symptom-free. Otherwise, chronic cluster
headache may require medication to be continued indefinitely.

Red Flag Signs and Symptoms

It is important to have knowledge of red flag signs and symptoms as well, as those identified
in the history or physical exam can indicate serious underlying pathology.
Red flag signs and symptoms include:
focal neurologic signs
Papilledema
neck stiffness
an immunocompromised state
sudden onset of the worst headache of the patient's life
personality changes
headache after trauma

With the exception of steroids, effective prophylaxis should be

continued in episodic cluster headache until the patient has been
headache-free for at least 14 days. This minimizes the risk of relapse.
Drugs should be withdrawn by progressive dosage reduction rather than
ceased abruptly. If relapse does occur, treatment must be resumed.
Prophylaxis sometimes converts chronic cluster headache into the
episodic form, and then can be withdrawn after 14 days symptom-free.
Otherwise, chronic cluster headache may require medication to be
continued indefinitely.

Secondary Headaches

Some headaches signal serious underlying disorders. These may demand immediate
intervention. Although relatively uncommon, they worry non-specialists because they are in
the differential diagnosis of primary headache disorders.
More commonly encountered in the tropics are the acute infections, viral encephalitis,
malaria and dengue fever, all of which can present with sudden severe headache with or
without a neurological deficit.

Suggestive Findings
Sinusitis

Positional face or tooth

pain, fever, purulent
rhinorrhea

Subarac
hnoid
Hemorrh
age

Peak intensity a few

seconds of headache
onset (thunderclap
headache), vomiting,
syncope, altered level
of consciousness

Intracere
bral
Hemorrh
age

Sudden onset,
vomiting, focal
neurological deficits,
altered mental status

Tumor/M
ass

Seizure, diplopia,
altered mental status,
vomiting, papilledema,
focal neurological
deficits,

References
http://emedicine.medscape.com/article/1142556
http://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guid
elines-update-2_v5-1-indd.pdf
http://www.l-t-b.org/assets/11/911ED67B-AE9E-5D3A-5285F94A99BF5
1DC_document/Headache_for_primary_care.pdf
http://www.allcountries.org/health/headache_disorders.html
http://www.who.int/mediacentre/factsheets/fs277/en/

Thank you!!!