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1. Headache
Jaber Amin AL-Manasia
5th year medical student
Presented to:
Dr. Amaal Al Nemry

2. :Objectives
.defenition-1
.epidemiology-2
.primary causes-3
.secondary causes- 4
.evaluation and diagnosis- 5
.mangment-6

3. Headache is pain in any part of the head,
including the scalp, face (including the
orbitotemporal area), and interior of the head.
Headache is one of the most common reasons
patients seek medical attention.

4. Headache is common, with a lifetime prevalence of about 90% of
the general population. It accounts for 4.4% of consultations in
primary care and 30% neurology outpatient consultations.
The 8th most common outpatient diagnosis for family physicians
and the 13th for general internists.
As many as 4.5 million americans will experience recurrent
headaches.

5. Identify patients w/ treatable headache disorders,
Diagnose the likely cause of the headaches,
Prescribe appropriate interventions,
Help patients changes in their lifestyle or
environment to reduce the severity of headaches.
5

6. DIFFERENTIAL DIAGNOSIS
Primary Headache (90%)
Secondary Headache (10%)
result from processes that
manifest themselves primarily as
head pain.
manifestations of another
process.
No Organic Pathology:
• Migraine
• Cluster headache
• Tension headache
Sinusitis
caffeine withdrawal
neck arthritis
viral infections
meningitis
Temporal artritis
Pseudotumer cerebri
Trigeminal neuralgia
Subarachnoid hemorrhage

7. Migraine
Chronic, genetically linked primary headache
Affects > 10% of adults (most common headache seen in
primary care)
usually begin in late childhood or early adulthood (but the
diagnosis may be delayed several years)
Women>>>men among adults ( ratio is equal in children ).

8. ,,,cont
. The presentation of migraine is variable
Because neurologic symptoms may either precede
(“aura”) or accompany the headache, migraine can
sometimes be confused with serious causes of headache,
such as a transient ischemic stroke. (TIA).
Because patients with migraine often report pain in the
face or around (or behind) one eye, they are sometimes
misdiagnosed as having sinus headaches.

9. :Diagnostic criteria for migraine
International Headache Society ( IHS )Criteria for the Diagnosis of Migraine

10. The frequency, severity, and associated symptoms of
frequency severity
migraine can vary between patients and within a given
lifetime. Fluctuations in serum estrogen concentration in
women (e.g., phase of the menstrual cycle, pregnancy) are
often associated with onset, remission, or change in
.severity of migraine-related symptoms
Other known “triggers” include certain foods, caffeine,
sleep deprivation, psychosocial stressors,or changes in
. weather or barometric pressure
.Daily pain diaries can help identify such triggers

17. Tension–type headache
 Tension-type headache is the most common cause of headache
overall with a prevelance of ( 30 – 80 % ) in the general community
 Tension-type headaches are usually mild or moderate in severity
and are often self-treat
 They are commonly episodic but can develop into daily or near-daily
headaches.
 Many patients with tension-type headaches describe bilateral
symptoms or a “headband-like” pain.
 Tension-type headache and migraine can occur concomitantly in the
same patient

18. IHS diagnostic criteria for tension-type headaches states that 2 of the
: following characteristics must be present
)Pressing or tightening (nonpulsatile quality
Frontal-occipital location
Bilateral - Mild/moderate intensity
Not aggravated by physical activity

19. :Tension-type headache history is
Duration of 30 minutes to 7 days
*
*insomia
No nausea or vomiting (anorexia may occur)
*
*difficulty concentrating
Photophobia or phonophobia
*
*no prodrome
Minimum of 10 previous headache episodes; fewer than 180 days per*
" year with headache to be considered "infrequent
May occur acutely under emotional distress or intense worry*
Often present upon rising or shortly thereafter
Muscular tightness or stiffness in neck, occipital, and frontal regions*
Duration of more than 5 years in 75% of patients with chronic*
headaches
New headache onset in elderly patients should suggest etiologies*
other than tension headache

20. M N G EM T
A A
EN
• Careful assessment followed by discussion of likely
precipitants and explanation of the fact that the
symptoms are not due to any sinister underlying
pathology is more likely to be beneficial than analgesics.
• Excessive use of analgesics, particularly of codeine, may
actually worsen the headache (analgesic headache).
• Physiotherapy (with muscle relaxation and stress
management) is usually beneficial, and low-dose
amitriptyline (10 mg nocte increased gradually to 30-50
mg) sometimes helps.

21. Cluster headache
not common (0.3% to 0.4% )
are more prevalent in males
classic presentation is described as a series of headaches
occurring close together over 6 to 12 weeks and so named
cluster
severe, intense, unilateral pain lasting from several seconds to
many minutes.
Concurrent symptoms include ipsilateral lacrimation,
rhinorrhea, and ptosis.
The headache is also always on the same side,
no matter how many months lapse between episodes.

22. Cluster headache

23. A. At least 20 attacks fulfilling criteria B – D
B. Severe or very severe unilateral orbital, supraorbital and/or
Temporal pain lasting 15 – 180 min if untreated
: C. Headache is accompanied by at least one of the following
Ipisilateral conjunctival injection and/or lacrimation . 1
Ipsilateral nasal congestion and/or rhinorrhoea. 2
Ipsilateral eyelid oedema. 3
Ipsilateral forehead and facial sweating. 4
Ipsilateral miosis and/or ptosis. 5
Sense of restlessness or agitation. 6
D. Attacks have a frequency from one every other day to eight
Per day
E. Not attributed to another disorder

24. M N G EM T
A A
EN
• Acute attacks can usually be halted by subcutaneous injections
of sumatriptan or by inhalation of 100% oxygen.
• Preventative therapy with the agents used for migraine is
often ineffective but attacks can be prevented in some patients
by verapamil (80-120 mg 8-hourly), methysergide (4-10 mg
daily, for a maximum of 3 months only) or short courses of
oral corticosteroids.
• Patients with severe and debilitating clusters can be helped
with lithium therapy, although the usual precautions
concerning the use of this drug should be observed.

25. Comparison of key features distinguishing migraine , tension , and cluster headaches
Migraine
Tension
Cluster
Laterali
ty
Unilateral
)(60%
Bilateral
)Unilateral (exclusive
Intensit
y
Moderate or
severe
Mild or moderate
Severe
Pain
descriptor
) (variable
Pulsating
)(50%
Pressing or
tightening
Boring, piercing
Physica
l
activity
Aggravation
by physical
activity
Does not worsen with
physical activity
Restlessness or agitation during attack
Associated
Nausea and/or
/ photophobia
phonophobia
No nausea, but may
rarely have
photophobia or
phonophobia
Ipsilateral symptoms; conjunctival injection,
lacrimation, nasal congestion, rhinorrhea, forehead
and facial sweating, miosis, ptosis, eyelid edema
Duratio
n
hr 72–4
Minutes to days
to 180-min cluster periods- 15
symptom
s

28. Sinusitis & “sinus headache
Symptoms suggesting a nasal or sinus
:etiology (rhinosinusitis) include
purulence in the nasal cavity
nasal obstruction
altered smell (hyposmia or anosmia)
and/or fever.

29. ,…Cont
Patients who self-treat presumed sinus headaches with
decongestants often report incomplete resolution of
and present in the primary care office seeking
. antibiotics
One their pain estimate is that 70% to 80% of patients
presenting with “sinusitis causing a headache” may
actually have migraine or could be classified as having
probable migraine based on the presence of most but
.not all of the IHS criteria

30. Chronic daily headache
3% and 5% of adults worldwide experience headaches daily or
nearly daily.
Paradoxically, the very medications commonly used to treat
episodic headaches (including over-the-counter analgesics, especially
acetaminophen, and migraine-specific medications such as triptans)
are implicated in the transformation of episodic to chronic
headaches, especially if consumed more often than 2 days per week
over several months.
Family physicians should be aware that this is a common condition
associated with a significant burden of suffering, and that effective
treatment of migraine and tension-type headache without the
overuse of medication may help prevent the development of this
difficult to- treat condition.

31.  Raised intracranial pressure may be caused by mass
lesions (especially tumours), cerebral oedema, obstruction to CSF
circulation (causing hydrocephalus) or impaired CSF absorption,
as in idiopathic intracranial hypertension and cerebral venous
obstruction, Characterized by : (secondary)Headache,
Impairment of conscious level, Papilloedema, Vomiting,
bradycardia, arterial hypertension.
:Headache
• Worse in morning, improves through the day
•
•
•
•
•
Associated with morning vomiting
Worse bending forward
Worse with cough and straining
Relieved by analgesia
Dull ache, often mild

32. Pseudotumor cerebri

33.  Pseudotumor cerebri occurs when the pressure inside your
skull (intracranial pressure) increases for no obvious reason.
 When no underlying cause for the increased intracranial
pressure can be discovered, pseudotumor cerebri may also be
called idiopathic intracranial hypertension.
 Symptoms mimic those of a brain tumor, but no tumor is
present.
 Pseudotumor cerebri can occur in children and adults, but it's
most common in obese women of childbearing age.

34. :signs and symptoms
Moderate to severe headaches that may originate behind-1
your eyes, wake you from sleep and worsen with eye
.movement
Ringing in the ears that pulses in time with your heartbeat-2
Nausea, vomiting or dizziness-3
Blurred vision-4
Brief episodes of blindness, lasting only a few seconds and-5
(affecting one or both eyes (visual obscurations
Difficulty seeing to the side-6
(Double vision (diplopia-7
(Seeing light flashes (photopsia-8
Neck, shoulder or back pain-9

35. :RISK FACTORS
Obesity
Obese women under the age of 44 are nearly 20 times more likely to
.develop the disorder
Medications
Growth hormone
Oral contraceptives
Tetracycline
Discontinuation of steroids
Excess vitamin A
:Health problem
Addison's disease Lyme disease
Mononucleosis
Polycystic ovary syndrome
Sleep apnea
Underactive parathyroid glands
Head injury
Kidney disease
Lupus

36. :Tests and diagnosis
Eye exams
If pseudotumor cerebri is suspected, we will look for a distinctive
type of swelling — called papilledema — in the back of the eye.
We will also undergo a visual fields test to see if there are any
blind spots in patient vision besides normal blind spot in each
.eye where the optic nerve enters the retina
Brain imaging
CT or MRI scans can rule out other problems that can cause
.similar symptoms, such as brain tumors and blood clots
Spinal tap (lumbar puncture)
A lumbar puncture — which involves inserting a needle between
two vertebrae in lower back — can determine how high the
.pressure is inside your skull

37. Trigeminal neuralgia

38.  Trigeminal neuralgia is a chronic pain condition that affects
the trigeminal nerve, which carries sensation from your face
to your brain.
 Trigeminal neuralgia affects women more often than men,
and it's more likely to occur in people who are older than 50.
.

39. :Signs and symptoms
Episodes of severe, shooting or jabbing pain that may -1
.feel like an electric shock
Spontaneous attacks of pain or attacks triggered by things such as -2
touching the face, chewing, speaking and brushing teeth
Bouts of pain lasting from a few seconds to several seconds - 3
Pain in areas supplied by the trigeminal nerve, including the -4
.cheek, jaw, teeth, gums, lips, or less often the eye and forehead
Pain affecting one side of your face at a time-5
.Attacks becoming more frequent and intense over time -6

40. Trigeminal neuralgia can occur as a result of aging, or it can be
related to multiple sclerosis or a similar disorder that damages the
. myelin sheath protecting certain nerves
Less commonly, trigeminal neuralgia can be caused by a tumor
. compressing the trigeminal nerve
Some people may experience trigeminal neuralgia due to a brain
lesion or other abnormalities. In other cases, a cause can't be
.found
Triggers
Shaving
Stroking your face
Eating
Drinking
Brushing your teeth
Talking
Putting on makeup
Smiling
Washing your face

41. Tests and diagnosis
Diagnosis of trigeminal neuralgia mainly based on description of the
:pain, including
Type. Pain related to trigeminal neuralgia is sudden, shock-like and*
.brief
Location*
Triggers. Trigeminal neuralgia-related pain usually is brought on by*
light stimulation of your cheeks, such as from eating, talking or even
.encountering a cool breeze
.A neurological examination. Touching examination,reflexes testingMagnetic resonance imaging (MRI). to determine if multiplesclerosis or a tumor is causing trigeminal neuralgia. Sometimes we may
ask for MRA to view the arteries and veins and highlight blood flow
(.(magnetic resonance angiogram

42. Temporal arteritis

43. Giant cell arteritis is an inflammation of the lining of *
. your arteries
:signs and symptoms
Persistent, severe head pain and tenderness,-1
usually in temple area
Vision loss or double vision-2
Scalp tenderness — it may hurt to comb your hair-3
or even to lay your head on a pillow, especially
where the arteries are inflamed
Jaw pain (jaw claudication) when you chew or-4
open your mouth wide
Fever-5
Unexplained weight loss-6

44. Risk factors
.The exact cause of giant cell arteritis isn't known •
:several factors can increase risk •
Age. Giant cell arteritis affects older adults almost exclusively — the
average age at onset of the disease is 70, and it rarely occurs in people
.younger than 50
Sex. Women are about two times more likely to develop giant cell
.arteritis
Northern European — especially Scandinavian — .Although giant
cell arteritis can affect anyone, people born in Northern European
. countries appear to have higher rates of giant cell arteritis
Polymyalgia rheumatica. People with polymyalgia rheumatica have
stiffness and aching in the neck, shoulders and hips. About 15 percent
.of people with polymyalgia rheumatica also have giant cell arteritis

45. complication
,Blindness. This is the most serious complication of giant cell arteritis
.Sudden painless and perminant
.Aortic aneurysm
.Stroke

46. :Tests and diagnosis
Giant cell arteritis can be difficult to diagnose because its early symptoms
resemble those of many common conditions. For this reason, your will try to
.rule out other possible causes of the problem
:tests
Physical exam. In addition to asking about symptoms and medical history,
paying particular attention to your temporal arteries. Often, one or both of these
arteries are tender with a reduced pulse and a hard, cord-like feel and
.appearance
Blood tests.1- erythrocyte sedimentation rate. This test measures how quickly
red blood cells fall to the bottom of a tube of blood. Red cells that drop rapidly
.may indicate inflammation in the body
(.C-reactive protein (CRP- 2
Biopsy. The best way to confirm a diagnosis of giant cell arteritis is by taking a
.small sample (biopsy( of the temporal artery
If you have giant cell arteritis, the artery will often show inflammation that
includes abnormally large cells, called giant cells, which give the disease its
.name

47. imaging tests may also be used for diagnosing giant*
cell arteritis and for monitoring treatment. Possible
:tests include
.(Magnetic resonance angiography (MRA
.Doppler ultrasound
.(Positron emission tomography (PET

48. worst headache of my life
 sudden and severe headache reaching
maximal intensity within minutes and
lasting an hour or more
 may be accompanied by focal neurologic
signs or other symptoms such as
nausea, vomiting, photophobia, neck
stiffness, seizures, or altered level of
consciousness

49. worst headache of my life
 It’s important not to miss SAH because early
diagnosis and treatment is essential to improving
outcomes.
 Asking about headache severity in the context
of previous headaches helps to ascertain the
severity without suggestion or prompting of the
patient with the words “worst headache of my
life,” which is not very sensitive or specific as a
screening question for SAH.

50. HISTORY
• Age at onset
• Presence or absence of aura and prodrome
• Frequency, intensity and duration of attack
• Number of headache days per month
• Time and mode of onset
• Quality, site, and radiation of pain
• Associated symptoms and abnormalities
• Family history of migraine
• Precipitating and relieving factors
• Effect of activity on pain

51. …CONT
• Relationship with food/alcohol
• Response to any previous treatment
• Any recent change in vision
• Association with recent trauma
• Any recent changes in sleep, exercise, weight, or diet
• State of general health
• Change in work or lifestyle (disability)
• Change in method of birth control (women)
• Possible association with environmental factors
• Effects of menstrual cycle and exogenous hormones
(women)

52. :PHYSICAL EXAMINATION
1. Blood pressure measurement.
2. Neurological examination:
•
Optic neuritis usually present as sudden, severe
unilateral loss of vision suggests
•
•
lesion in optic nerve pathway/ pituitary mass may
present as unilateral field defect.
Glaucoma present as holes around light
3. Fundoscopy: presence of papillodema might be sign
of intracranial mass, psudotumorcerebri,
encephalitis or meningitis
4. Examination of cerebellar system
5. Examine for neck brui/check for temporal and neck
arteries.

53. :RED FLAGS
• SUGGESTING SERIOUS PROGRESSIVE OR LIVE-THREATENING
DISEASE IN PATIENTS WITH HEADACHE
“Red Flags”
Headache that is sudden, explosive, (The worst headache
of my life)
Headache with focal neurological signs or symptoms or
papillodema
Headache of new in onset, that is constant, prevents sleep,
and progressive over age of 50
local tenderness, absence of temporal pulse, or jaw
claudication
Headache in the elderly patient accompanied by focal
neurological symptoms
Headache accompanied by fever, stiff neck, photophobia
or other systemic signs
Headache hours to weeks after trauma especially in elderly
Headache first occurring with exertion
Diagnosis
Intracranial
hemorrhage
Tumor, subdural
hematoma ,epidural
bleeding
Intracranial mass ,
temporal arteritis
Temporal arteritis (TA)
Cerebro- Vascular
Accident(CVA)
Meningitis, encephalitis
Subdural hematoma
Rupture aneurysm

54. attacks

55. References:
1.Essentials of family medicine ( Sloane( 6th edition 2012
2.Clinical medicine (Kumar(7th edition 2009
3.Diagnosis and management of headache in adults; Scottish Intercollegiate
Guidelines Network, 2008
4.Adult health clinical guidelines (HSS( 2006
5.www.migraine.ca