This document provides an overview of headaches for optometrists. It discusses the prevalence and burden of common headaches like migraines and tension-type headaches. Migraines affect 12-15% of the population, especially women during their working lives, and cause significant disability. Tension-type headaches are also very common. The document reviews potential visual or ocular symptoms associated with different headache types and lists red flags that could indicate more serious underlying causes. It provides guidance on evaluating headaches, making a diagnosis, explaining the condition to the patient, and discussing appropriate management and treatment goals.
3. Headache for Optometrists
1. Over-view of Headache
2. Common benign headaches
3. Serious headaches
(with some ocular/visual emphasis)
4. Headache in the UK
• Affects nearly everyone occasionally
• Is a problem for around 40% of people
• Is one of the most frequent causes of
consultation in both general practice (4%
of all adults/year) and neurological
clinics (25% of all new referrals)
• Represents an immense socio-economic
burden
5. Migraine in the UK
• Affects 12-15% of the population
• Affects 3X more women than men
• Most troublesome late teens to early 50s
(working lives)
• Also occurs in children and the elderly
7. Primary Headache
“Headache is an integral part of the
syndrome…diagnosis is symptom based.”
Secondary Headache
“A de novo headache occurring with
another disorder recognised to be
capable of causing it….diagnosis is
aetiological”
8. Headache Classification
Part 1: The Primary Headaches
Migraine
Tension-type headache
Cluster headache and other TACs
Part 2: The Secondary Headaches
Headaches attributed to:Head and/or neck trauma
Cranial or vascular disorder
Non-vascular intracranial disorder
A substance or its withdrawal
Infection
Disorders of homeostasis
Disorders of
cranium/neck/eyes/ears/nose/sinuses
Teeth/mouth
Psychiatric disorder
Part 3: Cranial Neuralgias
9. Life-time Prevalence of Symptomatic and Nonsymptomatic Headaches in a General Population
Disorder
%
Migraine without aura
Episodic TTH
Idiopathic stabbing
External compression
Cold stimulus
Benign Cough Headache
Headache associated with sexual activity
Hangover
Fever Headache
Head Trauma
Metabolic (fasting)
Disorders of the neck, eyes, ears
Disorders of the nose/sinuses
9
66
2
4
15
1
1
72
63
4
19
1, 3, 0.5
15
Ref: Rasmussen and Olesen Neurology 1992;42:1225-1231
10. Differential diagnosis of 906 patients who presented to a
general neurology clinic with headache or facial pain as
the major or only symptom
Diagnosis
Number
%
Tension headache
Migraine
Headache ? Cause
Post-traumatic
Facial pain ?cause
Depression
Trigeminal neuralgia
Cluster headache
Malignant IC Tumour
Benign IC Tumour
Temporal arteritis
Post-herpetic neuralgia
Benign IC hypertension
Cough headache
Subdural haematoma
Sinus infection
296
241
139
71
38
29
29
19
14
9
6
5
4
3
2
1
32
27
15
8
4
3
3
2
1.5
11. Primary Headaches
1. Migraine
2. Tension-type headache
3. Cluster headache and other trigeminal autonomic
cephalalgias
4. Other primary headaches
– Primary stabbing/cough/exertional/sexual
activity/thunderclap
– Hypnic
– Hemicrania continua
– New daily-persistent headache
22. The burden of migraine
Prevalence
• Migraine is most common during the productive years
20
18
16
14
12
10
8
6
4
2
0
18.3%
14.3%
7.6%
Age-related prevalence
of migraine
Migraine prevalence (%)
% of UK population
Gender-related
prevalence of migraine
30
Females
25
Males
20
15
10
5
0
Overall Females
Steiner TJ et al. Cephalalgia 2003; 23:519-527
Males
20
30
40
50
Age (years)
60
23. The burden of migraine
Disability due to migraine
Normal function
Severe
impairment/
bed rest
9%
53%
38%
Some impairment
• 91% of migraine patients report disability
Lipton RB et al. Headache 2001; 41:646-657
24. Trigger Factors for Migraine
1. Stress – relaxing
2. Hormonal changes in women
3. Sleep deprivation/lying in
4. Dietary changes
5. Environmental stimuli
6. Combinations
There may not be any!
35. Cluster Headache
(Migrainous Neuralgia)
• Fairly rare disorder - prevalence 0.1 %
• Male:Female ratio approx. 5:1
• Usually a primary headache disorder;
occasional post-traumatic cases, or rarely
secondary to pituitary tumour or aneurysm
• Occasional familial cases (4-7%)
• Majority of sufferers enthusiastic smokers
36. Episodic Cluster Headache
•
•
•
•
•
•
Onset typically 20-30, occasionally older
Bouts of attacks lasting 1week to 4 months
Bouts 1-2/year, often seasonal (spring, autumn)
Sometimes long remissions lasting years
Sensitive to triggers only in bouts
10-20 % go on to chronic CH
37. Headache/Pain with Visual/Occular
Symptoms or Signs
Primary Headache Syndromes
Migraine
Cluster headache and other Trigeminal
Autonomic Cephalalgias (TACs)
SUNCT (short-lasting, unilateral, neuralgiform
headache with conjunctival injection and
tearing)
Cranial Neuralgia
Trigeminal Neurlagia
38. Headache/Pain with Visual/Occular
Symptoms or Signs
•
•
•
•
•
•
•
Corneal ulcer
Sceritis/Episcleritis
Glaucoma
?Retinal Migraine
?Opthalmoplegic Migraine
Optic Neuritis
Pituitary Tumours
Are all Secondary Headaches
40. Red Flags in Headache History
•
•
•
•
•
Sudden onset severe headache
New headache in old people
Headache with coughing/straining
Persistent morning headache with nausea
Steadily worsening headache
Note: Serious causes of headache may have no
abnormal signs
41.
42.
43.
44.
45. Dealing with Headache
1. Is it serious?
The patient’s view
2. If not, what is it due to?
Diagnosis?
Explanation?
3. Management and treatment
Goals. Realism
