A talk covering epidemiology, diagnosis and management of primary headache disorders, common cases of secondary headache disorders and when to order brain imaging, lumbar puncture in headaches.

1. MANAGEMENT OF
HEADACHE
DR SUDHIR KUMAR MD DM (NEUROLOGY)
CONSULTANT NEUROLOGIST, APOLLO HOSPITALS,
HYDERABAD

2. SCOPE OF MY TALK
 Epidemiology of headaches,
 Diagnosis of primary headache syndromes,
 When to do brain imaging in a case of headache,
 Other investigations in headache evaluation,
 Treatment of headache syndromes.

3. EPIDEMIOLOGY
 Headache is the commonest disorder encountered in
Neurology OP clinics,
 Prevalence varies across studies,
 The median one-year prevalence found in a recent
study were- migraine (9%); tension type headache
(16%) and chronic daily headache (3%). (Headache,
2014)
 Lifetime prevalence- migraine (18%), TTH (52%)
 Migraine is more common in women than men after puberty (2-3:1)

4. PRIMARY HEADACHE
SYNDROMES
 Migraine,
 Tension type headache,
 Cluster headache,
 Medication overuse headache.

5. MIGRAINE (1)
 A. At least five attacks fulfilling criteria B-D
 B. Headache attacks lasting 4-72 hours,
 C. Headache has at least two of the following:
1. Unilateral location, 2. Pulsating quality, 3. Moderate or
severe pain intensity, 4. Aggravation by routine
physical activity.
 D. During headache, at least one of the following:
1. Nausea and/or vomiting, 2. photophobia and
phonophobia.

6. MIGRAINE (2)
 Chronic migraine- headaches occurring 15 or more
days in a month for three months or more.
 Status migranosus- Headache attack lasting for more
than 72 hours.
 Migraine with aura- Aura (for 5-60 min) preceding an
attack of headache.

7. TENSION TYPE HEADACHE
(1)
 Headache lasts for 30 min to 7 days,
 Headache has at least two of the following:
1. Bilateral location, 2. Pressing/tightening (non
pulsatile) quality, 3. Mild or moderate intensity, 4.
Not aggravated by routine physical activity.
 Both of the following:
1. No nausea or vomiting, 2. Either phonophobia or
photophobia (not both)

8. TENSION TYPE HEADACHE
(2)
 Infrequent TTH- <1 headache per month,
 Frequent TTH- 1-15 headaches per month,
 Chronic TTH- >15 headaches per month for three
months or more.

9. CLUSTER HEADACHE (1)
A. At least 5 attacks fulfilling criteria B-D.
B. Severe or very severe orbital/supraorbital/temporal
headache, lasting for 15-180 min,
C. Headache is accompanied by at least one of:
1. Conjunctival injection or lacrimation, 2. Eye lid
oedema, 3. Nasal congestion, 4. forehead or facial
sweating, 5. miosis or ptosis, 6. restlessness or
agitation
D. Attack frequency every other day to 8/day.

10. CLUSTER HEADACHE (2)
 Episodic CH- Headaches occurring during periods of
7-365 days, separated by pain free period of one
month or more,
 Chronic CH- Attacks occur over >1 year, without
remission periods or remission periods of <1 month.

11. OTHER PRIMARY
HEADACHES
 Cough headache,
 Exercise induced headache,
 Headache related to sexual activity,
 Headache related to cold stimulus,
 External pressure induced headache,
 Hypnic headache (occurs during sleep)

12. MEDICATION OVERUSE
HEADACHE
 Headache present on >15 days per month,
 Regular overuse for >3 months of one or more pain
killers for headache,
 Headache has worsened during medication overuse.
(Pain killers may include triptans, ergotamines, opioids,
other analgesics; use >10 days per month)

13. SECONDARY HEADACHE
DISORDERS
 Trauma/head injury,
 Vascular disorder (Ischemia, hemorrhage, CVST)
 Non vascular intracranial disorder (IIH, low pressure,
inflammatory disease, neoplasm),
 Infection (CNS, systemic, others)
 Related to psychiatric disorder

14. WHEN TO ORDER BRAIN
IMAGING?
 Brain scan is expected to be normal in most patients
with headaches; also, fundus examination may be
normal in patients with brain tumors.
 Red flags, where MRI may be needed:
1. New onset headache,
2. Abrupt onset,
3. Progressive symptoms,
4. Abnormal neurological signs,
5. Headache with exertion,
6. Change with head position,
7. Change with valsalva maneuver, such as cough, sneeze,
strain

15. CAN LUMBAR PUNCTURE BE DONE IF
FUNDUS EXAM IS NORMAL?
 Patient with headache and suspected meningitis/IIH
would require lumbar puncture to confirm/exclude the
diagnosis.
 Papilledema may be absent in brain tumors (JNNP,
1975)
 Absence of papilledema does not mean that ICP is
normal in an acute setting. It may take a few days to
develop. (Ophthalmology, 1996)
 So, it is always good to do a brain scan before doing lumbar
puncture in these situations.

16. TREATMENT OF
HEADACHES
 Migraine: Acute attacks- triptans, ergot, NSAIDS
 Migraine: Prevention- propranolol, divalproex,
topiramate, BOTOX
 TTH- Acute attacks- Ibuprofen, diclofenac, aspirin,
paracetamol, naproxen (Level A evidence)
 TTH- prevention: Amitriptyline (Level A); Mirtazapine,
venlafaxine (Level B)

17. CASE 1
 60-year old woman,
 New onset headache of one month duration,
 Throbbing, bilateral,
 Associated generalized aches and pains.
 Diagnosis??

18. CASE 1 (cont’d)
 Jaw claudication noted while chewing,
 Intermittent visual blurring,
 Tenderness in temporal region,
 Elevated ESR/CRP
 Temporal artery biopsy- suggestive of giant cell
arteritis
 Responded to steroids.

19. CASE 2
 25-year old overweight woman,
 Headache of three months duration,
 Headache more in mornings,
 Horizontal diplopia,
 Transient visual obscurations,
 Diagnosis?

20. CASE 2 (cont’d)
 Fundi- bilateral papilloedema,
 Rest of neurological examination normal
 Normal MRI/MRV,
 CSF opening pressure- elevated.
 Diagnosis- Idiopathic intracranial hypertension.
 Treated with acetazolamide and steroids.

21. CASE 3- POST LP
HEADACHE
 Bilateral headaches starting within 7 days of LP,
 Worsens within 15 minutes of assuming upright position,
 Disappears within 30 min of lying down,
 Usually resolves in a few days, but may last for upto 19
months(!)
 Diagnosis is usually clinical; if LP is done-low CSF
pressure, high protein and lymphocyte count
 MRI if done- diffuse enhancement, with descent of brain
and brainstem.

22. CASE 3 (cont’d)
 Factors reducing the incidence of post LP headaches-
small needle diameter, direction of needle, atraumatic
needles, replacement of stylet, fewer LP attempts.
 Factors not influencing the incidence of Post LP
headaches- volume of spinal fluid removed, rest after LP,
hydration after LP, lying down vs sitting position while
performing LP, CSF characteristics (such as pressure,
cell counts, infection, etc).
 Conservative treatment- rest, hydration, analgesics
 Epidural blood patch, if conservative treatment fails.

23. CONCLUSIONS
 The causes of headache are varied.
 Systematic history and examination are the most
valuable tools in the correct diagnosis of underlying
cause.
 Brain imaging and LP are useful in final confirmation
of certain important causes.
 Management depends on the exact cause of
headache identified.

24. THANKS
98661 93953
drsudhirkumar@yahoo.com
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