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Scenario

Doctor : Hi Ms Malika, what can I do for you..

Ms Malika : Headache!

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Introduction

Headache is one of the most common reasons patients seek help from primary care clinic.
The most frequent diagnoses for headache are migraine and tension-type headache (TTH), with the majority of headaches being benign in nature
It can be a symptom of many underlying disorders.
Prevalence can vary with age and is at the highest for population under the age of 50 globally.
The prevalence for migraine and TTH is 14.4% and 26.1% respectively (YLDs -years lived with disability) in 2016 )

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Chronic headache

frequency - ≥15 days per month
duration - ≥4 hours per headache day

- over the period of 3 months²

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CLASSIFICATION OF HEADACHE

Primary headache (not associated with underlying pathology)	Secondary headache (attributed to underlying pathological condition)
Migraine Tension-type headache (TTH) Chronic cluster headache	Post-traumatic, head injury Post infection Inflammatory Tumour Vascular in Origin Psychological Cervicogenic headache Myofacial pain syndrome headache

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DIAGNOSIS

Diagnosis is based on history
It’s important to distinguish between primary and secondary headache, because secondary headache requires further investigation in order to identify the cause and determine the appropriate treatment
Organic pathology must be ruled out if there are RED FLAGS

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Details History and Examinations

Screen For Red Flag

Clusters Headache

Tension Type Headache (TTH)

Migraine

Diagnose Primary Headache

Assess For Secondary Headache

Yes

HEADACHE Diagnosis …

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What are the RED FLAGS

S	Systemic Signs systemic symptoms eg fever, night sweats - systemic illness or medical condition eg immunocompromised with headache
N	Neurological Symptoms -weakness in one arm or leg, numbness that is new or not typical or any visual changes.
O	Onset is Sudden -thunderclap headache, which comes on suddenly at a maximum 10-out-of-10 intensity—can point to a vascular issue like an aneurism and should be evaluated right away.
O	Older Age at Onset – after 50
P4	Progression - becoming more severe or more frequent Papilledema - indication of increased pressure in and around the brain Positional or Precipitated by Valsalva - pressure issue or SOL/mass Pregnancy - during or after pregnancy- pituitary or vascular abnormalities

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Primary Headaches

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Migraine	Tension Type Headache (TTH)	Clusters Headache
Throbbing pain on one side or both sides of head, blurred vison, sensitive to light	Pain like tight band squeezing head	Pain around in or around one eye
Moderate-to-severe intensity / pulsating	Mild / moderate intensity / pressing-tightening	Severe intensity
Unilateral	Bilateral	Unilateral, around / behind the eye / temple
4–72 hours	30 mins to 1 week	15–180 mins
Variable frequency	Variable frequency	1–8 times daily during clusters
Nausea, vomiting, phonophobia, photophobia, pain aggravated by activity	±Pericranial tenderness, may be associated with no more than one phonophobia, photophobia or mild nausea, not worsen with activity	Restlessness, ptosis, conjunctival tearing / injection, rhinorrhoea and/or nasal congestion, facial sweating
Affects 2–3 times more women than men	More common in women than men	Affects 3 times more men than women

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Secondary Headache

Headache features suggest secondary causes:
Recent onset of headaches
Headaches of uncertain pattern
Presence of progressive neurological signs or systemic disturbance (including papilloedema, alteration of conscious level, etc)
Presence of fever
Presence of associated epileptic seizures
A change in an existing headache pattern
Unusual age of onset for a particular diagnosis

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Red Flags (Urgent investigation and referral within hours to days)

Headache exacerbated by coughing, sneezing or straining (concerns of raised intracranial pressure)
Headache provoked by postural change (stooping or bending)
Headache associated with eye movement and blurred vision
Headaches of sudden, severe acute onset – worse than previous headache (may herald subarachnoid haemorrhage or intracranial haemorrhage, vertebral artery dissection, cerebral venous thrombosis or reversible cerebral vasoconstriction syndrome)

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Red Flags…

Headaches with new-onset neurological signs (sensory changes, weakness, diplopia, Horner’s Syndrome, visual field defects)
Headaches associated with fever, stiff neck, generalised aches/pains, rash, malaise, altered consciousness or confusion (concerns of infection)
Headaches that have changed dramatically in quality, nature or site
Headaches failing to respond to appropriate therapy

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Malika, is a 31-year-old lady, Para 3, teacher. Presented with severe headaches, which she says cause her the worst pain she’s ever felt. Explained as pain on 1 side of her head, around her eye and along the side of her face. She also experiences drooping or swelling of the eyelid, watery eye and nasal congestion, on the same side as the headache.

You have been asked to evaluate Malika.

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How will you manage her?

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APPROACH TO PAIN

R-A-T model (approach)

Recognise
Assess
Treat

P5VS: Doctors’ training module

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APPROACH TO PAIN

Recognise

Does the patient have headache?
Do other people know patient has headache?

P5VS: Doctors’ training module

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HOW TO ASSESS PAIN:

Important to

Listen and believe the patient

Take a pain history

“Tell me about your pain…….”

P5VS: Primary Care training module

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APPROACH TO PAIN

Assess:

How severe is the pain
What type of pain is it?
Are there other factors?

P5VS: Doctors’ training module

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HOW TO ASSESS PAIN

P: Place or site of pain

“where does it hurt?”

Record on a body chart

A: Aggravating factors

“what makes your pain worse?”

I: Intensity

“How bad is the pain?”

“What is the pain score?”

N: Nature and neutralising factors

“what does it feel like?”

“What makes the pain better?”

P5VS: Primary Care training module

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Assessment : clinical history

Age of onset – migraine (childhood, adolescence, or young adulthood)/ TTH ( any age)
Frequency & patterns – to determine degree of severity ( similar – benign progressive / worsening – organic)
Duration - How long does each attack last?
Location – unilateral / bilateral /generalised
Intensity - How severe is the headache?
Nature of pain - throbbing and pulsating/ dull, nagging, tight, constricting/ sharp, burning or piercing sensation

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Assessment : clinical history

Any associated symptoms

Visual aura/ Dizziness and vertigo/ nausea / vomitting
Worsening headache with fever
Any neurological deficit – numbness / weakness / diplopia / neck pain & stiffness
Cognitive dysfunction
Change in personality – mood / behaviour
Impaired level of consciousness
Any recent (typically within the past 3 months) head trauma

Predisposing, triggering, aggravating, relieving factors
Eg Triggering factors : cough, Valsalva, sneeze, exercise, stress, food

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Assessment : clinical history

Family history - Does anyone in the family have similar or recurrent headaches?
How does the pain affect your daily activities?
Medications used - Have you responded to any previous treatments? How often have you needed to take these medications?
Concerns, anxieties and fears about attacks - How do you feel between attacks? Do you have any ideas about your headaches, or any worries? Why have you come now?

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Physical Examination

Observe the patient -note any features that can point to diagnosis eg facial asymmetry, red one eyes,
Neurological examination, especially fundoscopy should always be done. Assessment of all four limbs / Assessment of gait
Blood pressure measurement is recommended
Neck examination: neck posture and range of motion, and palpation for muscle tender points.
a focused neurological examination, if indicated; and
an examination for temporomandibular disorders, if indicated.

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*Bagi kegunaan pesakit berumur 4-7 tahun dan pesakit yang tidak dapat menyatakan tahap kesakitan

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Physical Signs

Vital signs
BP : 140/90 mmHg
PR : 100/min
T : 36.5^oC
RR : 16/min
Pain score : 6/10

No neck stiffness
No papilloedema
No facial asymmetry
Power / tone UL /LL - normal

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Diagnosis …

? Primary
? Secondary
? Acute
? Chronic

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Differential Diagnosis

Migraine (with or without aura)
Tension‑type headache
Cluster headache

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General Principles of Treatment of Primary Headache Disorders

Patient education - to ensure compliance to treatment.
Discuss predisposing factors, trigger identification (dietary sensitivities, skipping meals, bright lights) and avoidance, with help of a headache diary (physical or digital). Lifestyle adjustments and medications can modify and control headaches.
All acute drug therapy should be combined with nonpharmacological treatments. A drug should be optimized as long as it is tolerable
Preventive/ prophylaxis treatment should be started at the lowest possible dose and increased gradually, bearing in mind that most drugs in this category need about 4 weeks to take effect and should be reviewed for tapering or discontinuation after 3 to 6 months

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MANAGEMENT

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Acute treatment

The goals for acute treatment are as follows:

∙ Treat attacks effectively, rapidly, and consistently.

∙ Minimize adverse events.

∙ Restore the patient’s ability to function

to reverse, or at least stop the progression of, a headache.
It is most effective when given within 15 minutes of pain onset and when pain is mild.

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Acute Tension Type Headache (TTH)

Medication	Daily dose	Comments
Paracetamol	500 – 4000 mg PO
NSAIDs	●Diclofenac sodium 50 – 225 mg PO ● Ibuprofen 400 mg PO ● Naproxen sodium 275 – 550 mg PO	Avoid excessive and frequent use to reduce risk of developing medication overuse headache There are no clinical trials supporting the use of COX2 inhibitors at present.

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Acute Migraine

Drug Class	Medication & Dose	Comments
Triptans	Sumatriptan 50 mg to 100 mg	For use in moderate to severe migraine. Triptans are vasoconstrictors and should be avoided in patients with cardiovascular disease If headache reduced after first dose but symptoms recur, a second dose can be given within 24 hours but not exceeding 300mg/day.
Paracetamol	500 – 4000 mg PO
NSAIDs	● Diclofenac sodium 50 – 75 mg PO or 75 mg IM ● Diclofenac potassium 50 – 100 mg daily PO ● Ibuprofen 400 – 2400 mg PO ● Mefenamic Acid 500 – 1000 mg PO ● Naproxen sodium 550 – 1100 mg PO	Avoid excessive and frequent use to reduce risk of developing medication overuse headache

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Acute Migraine

Drug Class	Medication & Dose	Comments
Triptan and NSAID	sumatriptan + naproxen sodium 500 to 550 mg	Combinations should be considered for patients with severe migraine Antiemetics - recommended to treat nausea and potential emesis in migraine
Alkaloid	Ergotamine –(cafergot) Adults—2mg (1 tablet) placed under the tongue at the first sign of a migraine attack, followed by 2 mg every 30 minutes. Do not use more than 3 tablets in a day or 5 tablets in a week.	selective arterial vasoconstriction on certain cranial vessel beds For selected patients where triptans are not an option, a vasoconstrictor, it should not be used in patients with cerebrovascular or cardiovascular disease
COX – 2 inhibitors	Etoricoxib 120 mg stat PO	Concerns regarding possible cardiovascular or renal complications, warrant careful consideration, especially with frequent use and if vascular risk factors are present

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Acute Migraine

Antiemetics
Recommended to treat nausea and potential emesis in migraine

Oral Metoclopramide (10 mg up to 4 times per day)
Oral Domperidone (10 mg up to 3 times per day)
Intravenous metoclopramide (10 mg) - in the acute treatment of patients with migraine. Side effects include akathisia and dystonia.

Drug to be avoided
Opioids - Opioid analgesics and combination analgesics containing opioids (e.g., codeine, Morphine, pethidine, oxycodone, and buprenorphine ) are not recommended for routine use for the treatment of migraine owing to their potential for causing medication overuse headache, may be necessary when other medications are contraindicated or ineffective, or as a rescue medication when the patient's usual medication has failed.

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Acute Clusters Headache

Drug Class	Medication & Dose	Comments
Triptans	Sumatriptan 50 mg to 100 mg PO	do not exceed 100 mg/dose
High flow (100%) oxygen	● 12 L/min through a non rebreathing mask (for 15 minutes)	Higher flow (up to 15 L/min) may be tried if no response initially. Beware of risk of respiratory suppression in patients with chronic obstructive airways disease

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Progress Case

She was given ibuprofen 400mg tds
TCA 2 weeks to review symptoms
Headache diary

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Headache diary

to record the frequency, duration and severity of headaches
to monitor the effectiveness of headache interventions
as a basis for discussion with the person about their headache disorder and its impact

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HEADACHE DIARY

Malika tells you that, since her first severe headache 2 weeks ago, she has experienced 6 more headaches. She says that on average her headaches last from 30 to 90 minutes.

eg:

4 brufen

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Malika also experienced very severe headache for the first time, worse on changing posture , associated with nausea and vomiting and blurring of vision, for which she went to accident and emergency, where she was given a CT scan.
The CT scan was normal.
Been informed that the blood investigations were also normal.
She was refer back to KK with possible diagnosis of Migraine

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What about DIAGNOSTIC STUDIES?

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Neuroimaging and Diagnosis in Chronic Headache

Neuroimaging is not indicated in patients with recurrent headaches with the clinical features of migraine, a normal neurological examination, and no red flags for potential causes of secondary headache.
Sinus x-rays and cervical spine x-rays are not recommended for the routine evaluation of the patient with migraine.
Electroencephalography (EEG) is not recommended for the routine evaluation of patients with headache.

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Neuroimaging and Diagnosis in Chronic Headache

Brain magnetic resonance imaging (MRI) or non-contrast brain CT necessary WHEN there is :
unexplained focal neurological signs and recurrent headache

to exclude a space-occupying central nervous system lesion.

headache clearly precipitated by exertion, cough, or Valsalva

to exclude a Chiari malformation or a posterior fossa lesion

postural change has a major effect on headache intensity,

to look for indirect evidence of a CSF leak (dural enhancement) or a space-occupying lesion.

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Chronic Headache Management

3 approaches to treat chronic headache

acute treatments (i.e. those taken during attacks or exacerbations of chronic pain), and
preventive treatments / prophylaxis (medication or other interventions designed to reduce the tendency to have attacks)
lifestyle and trigger management

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Prophylaxis in Chronic Migraine : Indications

Attacks significantly interfere with a patient’s daily routines despite acute treatment.
Frequent attacks (≥ 4 monthly headache days).
Contraindication to, failure of, or overuse of acute treatments, with overuse defined as:

10 or more days per month for ergot derivatives, triptans, opioids, combination analgesics, and a combination of drugs from different classes that are not individually overused
15 or more days per month for non-opioid analgesics, paracetamol, and NSAIDs.

Side effects with acute treatment.
Patient preference

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Chronic Migraine Prophylaxis

Drug Class	Medication & Dose	Comments
Beta Blockers	Propranolol 40 – 120 mg PO Atenolol 25 – 50 mg PO Metoprolol 50 – 100 mg PO	Should not be used in patients with co-existent asthma, severe cardiac insufficiency or Raynaud's phenomenon. - Treatment option in hypertensive patients with migraine
Angiotensin II-receptor blockers (ARB)	● Candesartan 4 –16 mg PO	- Treatment option in hypertensive patients with migraine
Cyclic Antidepressants (TCA)	● Amitriptyline 10 – 50 mg PO	- Sedating effect of TCA may be beneficial for patients with comorbid insomnia. Common side effects are dry mouth, sedation, blurred vision and constipation.
Calcium Channel Blockers	● Flunarizine 5 – 10 mg PO – (Sibelium)	- CI : History of depression, pre-existing symptoms of Parkinson’s disease, other extrapyramidal disorders

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Chronic Migraine Prophylaxis

Drug Class	Medication & Dose	Comments
Anticonvulsants	Sodium Valproate (immediate release) 200 – 400 mg PO Topiramate 25 –100 mg PO	May cause neural tube defects and teratogenic potential. Do not use in pregnant woman. Not recommended in patients with liver disease. Inform patients of side effects of topiramate (tingling of hands, visual blurring, panic attack and depression).
5-HT antagonists	● Pizotifen 0.5 – 2 mg PO	- Avoid abrupt withdrawal.

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Non – pharmacological

Relaxation Therapy
Acupuncture – one to two sessions per week for several (2 or more) months, with each treatment lasting approximately 30 minutes.
Hyperbaric Oxygen – insufficient evidence

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Importance of Education about migraine

Reduce medication overuse; treat rebound
Stop smoking
Regular sleep
Regular eating
Avoid caffeine and other offenders
Exercise
Stress management

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Tension Type Headache (TTH) Prophylaxis

PHARMACOLOGICAL
Drug Class	Medication & Dose	Comments
TCA	Amitriptyline 10–50 mg PO	- Maintain for up to 6 months until remission is achieved, then withdraw. Mechanism of action is independent of its antidepressant actions
Muscle relaxants & migraine-specific drugs		- have limited effectiveness and cannot be recommended
NON – PHARMACOLOGICAL
Avoid / Treat / Eliminate triggers: inadequate sleep, sinus disease, shift work, improvement of posture, irregular meals and dental pathology Stress management in stress-related illness / psychological trigger / depressive disorder Lifestyle changes to reduce stress, and relaxation or cognitive therapy to develop strategies for coping with stress Physical therapy for musculoskeletal symptoms - hot and cold packs, ultrasound and electrical stimulation, the improvement of posture, relaxation and exercise programmes

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Follow up

What advice and support can you offer Malika about her diagnosis and her pain?
As a minimum, explain to her about the diagnosis
Reassure her that :

Other pathology has been excluded.
This type of headache is a well-recognised problem

You understand that it is having a big impact on her life, prophylaxis will be helpful.

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Take-home message

Involve patients in their care to improve adherence
Consider comorbidities and, when possible, choose a single medication to treat multiple comorbid disorders
When the patient is a woman of childbearing age, discuss contraception and the potential risk of medication use during pregnancy. Do not routinely offer combined hormonal contraceptives for contraception to women and girls who have migraine with aura
Give each preventive medication at an adequate dose and for an adequate time (6–8 months)
Avoid overused medications
Re-evaluate the therapy; functional outcome and follow-up is important.

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