Prof Eiad Al Faris

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 Outline
• Headache and its types
• Misconceptions
• Diagnostic approach
• Differential diagnosis
• Urgency considerations

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Background:
Headache……
-is among the most common medical complaints.
-is one of the most common neurological problems presented to Family
physicians and neurologists.

Almost half (50%) of the adult population have had a headache at least
once within the last year. (http://www.who.int/mediacentre/factsheets/fs277/en/)

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What are the 2 categories of headache
classification?

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Types of headaches?

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 Types of headaches

PRIMARY SECONDARY
• Migraine • Space-occupying mass
• Tension type • Vascular lesion
• Medication overuse headache • Infection
• Benign exertional headache • Metabolic disturbance
• Cluster • Systemic problem.
• Other trigeminal autonomic
cephalalgias

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What are the most common and the 2 nd most
common types of primary headaches?

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Guideline for primary care management of
headache in adults. Canadian Family Physician
• Headache on 15 or more days every month affects 1.7–4% of
the world’s adult population

• The lifetime prevalence is 66%:

• Tension-type headache 46% to 78%
• Migraine 14% to 16%
• Cluster headache 0.1% to 0.3%

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Learning objectives
• The best approach to diagnose patients with headache.
• Best practice for migraine prophylaxis.
• Treating tension / cluster headaches.
• Patient education

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 Misconceptions uptodate
• Acute or chronic sinusitis appears to be an uncommon cause of
recurrent headaches, and many pts turn out to have migraine.

• Patients frequently attribute headaches to eye strain. A study

suggested that headaches are only rarely due to refractive error
alone.
• Nevertheless, correcting vision may improve headache
symptoms in some of these patients.

• Hypertension can cause headaches in case of HTN emergencies

but not true for typical migraine or tension headaches.
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Case scenario 1

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Ahmed is a 14-year-old boy. He attends your clinic
accompanied by his mother. He presents with a two months
history of headaches that he describes as “banging” and that
make his head “very sore”.
He says that in the past two months, he has had 6 of these
headaches. He also says that light hurts his eyes when he has
the headaches. He does not feel nauseous or vomit during
the headaches.

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Mother tells you that when Ahmed has the headaches, he is
unable to go to school and that the headaches last from 2 to
4 hours. She gives Ahmed paracetamol and if that doesn’t
work she also gives him ibuprofen. This combination of
medication helps.

What is the most likely diagnosis?

With or without

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14
MIDAS SCALE FOR MIGRAINE
DISABILITY

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 16
Oxford handbook of general practice
 How would you manage this pt?
• Reassure: a serious underlying cause is unlikely
• Migraines are a well-recognised problem
• what causes them is not known for certain

• Explain the risk of medication overuse headache

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For acute management of migraine
Pt preference, comorbidities and risk of adverse events.
First line: Simple analgesics ( Ibuprofen 400 mg, ASA 1000 mg,
naproxen sodium 500-550 mg, acetaminophen 1000 mg )
Second line: Triptans

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 uptodate
Mild to moderate attacks — not associated with vomiting - simple
analgesics (NSAIDs, acetaminophen) or combination analgesics

• Moderate to severe attacks — not associated with vomiting -oral

migraine-specific agents are first-line, including oral triptans and the
combination of sumatriptan-naproxen.
• When complicated by vomiting , non oral migraine-specific
medications including subcutaneous sumatriptan OR nasal
sumatriptan, non oral antiemetic agents

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 Migraine lifestyle and triggers to avoid:
• Irregular or skipped meals
• Irregular or too little sleep
• A stressful lifestyle
• Excessive caffeine consumption
• Lack of exercise
• Obesity

“Guideline for primary care management of headache in adults. Canadian Family Physician”

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Managing patients with migraine cont….

• Encourage patients to participate actively in their treatment:

-self-monitoring to identify factors influencing migraine

-maintaining a lifestyle that does not worsen migraine

-practicing relaxation techniques
-maintaining good sleep hygiene
-using cognitive behavioral therapy (CBT)to avoid negative thinking
-improving communication skills to talk effectively about pain with family and others
-using acute and prophylactic medication appropriately

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Case scenario 2

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• Aliya is a 28-year-old woman who was diagnosed with migraine with
aura 6 months ago. She has, on average, 1 migraine attack per week,
for which she takes an NSAID and an anti-emetic.
• Because Aliya has migraine about 4 times per month, she is unlikely to
develop medication overuse headache. You are therefore happy with
her current treatment plan.
• However, during an attack, she is unable to work or continue her
normal daily activities. She also worries a lot about when the next
attack is going to happen and their frequency causes her to take
a lot of time off work.

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• You want to confirm that she is not a taking combined hormonal
contraceptive for contraception purposes.
Why?
• The Centers for Disease Control and Prevention (CDC), 2017 (medical
eligibility criteria) recommends that the combined hormonal
contraception should not be used in women with migraine with aura
at any age.

• There is an increased risk of ischaemic stroke in people with migraine

with aura. This risk is increased in women using combined hormonal
contraception.

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You suggest propranolol for migraine prophylaxis.

a) How would you assess the effectiveness of the propranolol?

Headache diary

b) When would you review the need to continue this prophylaxis?

-It might take 4-8 wk for substantial benefit to occur
-If the prophylactic drug provides substantial benefit in the first 2 mo of therapy, this
benefit might increase further over several additional months of therapy
6-12 months after the start of prophylactic treatment.

Headaches in over 12s: diagnosis and management (2012 updated 2015) 25

She wants to become pregnant in the future, but still
needs migraine prophylaxis, what should you do?

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She wants to become pregnant in the future, but still
needs migraine prophylaxis, what should you do?
• Migraine without aura often improves during pregnancy. However,
migraine with aura is more likely to continue throughout pregnancy.

•Seek specialist advice if prophylactic treatment for migraine is needed

during pregnancy.

•Offer pregnant women paracetamol for the acute treatment of

migraine.

Headaches in over 12s: diagnosis and management (2012 updated 2015)

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Case scenario 3

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Abdullah is a 31-year-old man. He has a history of severe headaches,
which are the worst pain he has ever felt. When he gets these
headaches, he has pain on one side of his head, around his eye and
along the side of his face. He also experiences watery eye and nasal
congestion, on the same side as the headache.

He experienced the headache for the first time two weeks ago. The CT
scan done was normal and you have been asked to evaluate him.

He tells you that, since his first severe headache 2 weeks ago, he has
experienced 6 more headaches. He says that on average his severe
headaches last from 30 to 90 minutes.

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 What advice and support can you offer
about his diagnosis?
• Management primarily pharmacologic
• Offer O2 or a subcutaneous or nasal triptan for the acute treatment.

• What prophylaxis for cluster headache could you offer him?

• Prophylactic medication: consider offering him verapamil.

• Seek specialist advice before starting verapamil
• Early specialist referral recommended
Guideline for primary care management of headache in adults, Canadian Family Physician

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 What medications would you not offer for the acute
management of his cluster headache attacks?

• You would not offer paracetamol, NSAIDS, or opioids as there is no

evidence to suggest that they would have any clinical benefit in the
treatment of cluster headache.

NICE: https://www.nice.org.uk/donotdo/do-not-offer-paracetamol-nsaids-opioids-ergots-or-oral-triptans-for-the-acutetreatment-of-cluster-headache
https://www.uptodate.com/contents/cluster-headache-treatment-and-prognosis?search=cluster%20headache
%20prophylaxis&source=search_result&selectedTitle=1~65&usage_type=default&display_rank=1#H5

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 Practice points for primary headache
• Rule out secondary headache (Space-occupying mass, heamorrhage,
Infection).

• Imaging is not recommended for the routine assessment of patients with

headache with normal neurologic examination findings, and no red flags.

• History and physical examination findings are usually sufficient to make a

diagnosis

• Migraine should be considered in patients with recurrent moderate or

severe headaches and normal neurologic examination findings

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Guideline for primary care management of headache in adults, Canadian Family Physician
General practice points cont….

• Consider a diagnosis of migraine in patients with a previous diagnosis

of recurring “sinus” headache.

• Medication overuse is considered when patients with migraine or

tension-type headache use combination analgesics,
• Opioids, or triptans on ≥10 d/mo
or
• Acetaminophen or NSAIDs on ≥15 d/mo

• Comprehensive migraine therapy includes management of lifestyle

factors and triggers, acute and prophylactic medications, and
migraine self-management strategies
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 SNOOP( red flag signs)
Systemic symptoms fever, weight loss, cancer, pregnancy,
immunocompromised state
Neurologic symptoms confusion, impaired alertness, papilledema, neurologic
signs, meningismus, or seizures

Onset Age >40 years, or sudden "thunderclap“

Other associated conditions Head trauma, headache awakens from sleep, worse
with Valsalva maneuvers.

Progression or change in attack frequency, severity

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 Characteristics of migraine, tension-type, and cluster headache
syndromes
Symptom Migraine Tension-type Cluster

Adults: Unilateral in 60 to 70 percent, Always unilateral, usually

Location Children and adolescents: Bilateral in Bilateral begins around the eye or
majority temple

Pain begins quickly, reaches

Gradual in onset, crescendo pattern; a crescendo within minutes;
Characteristics pulsating; moderate or severe Pressure or tightness which pain is deep, continuous,
intensity; aggravated by routine waxes and wanes excruciating, and explosive
physical activity in quality
Patient Patient prefers to rest in a dark, quiet Patient may remain active Patient remains active
appearance room or may need to rest
Duration 4 to 72 hours 30 minutes to 7 days 15 minutes to 3 hours

Ipsilateral lacrimation,
Associated Nausea, vomiting, photophobia, redness of the eye; stuffy
symptoms phonophobia; may have aura None nose; rhinorrhea; pallor;
sweating; Horner syndrome
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Important elements in history : headache for the first time
or those with a change in headache pattern

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 Important elements in history : headache for the first time
or those with a change in headache pattern

Explore the following important elements :

• Headache onset (thunderclap, head or neck trauma)
• previous attacks (progression of symptoms)
• duration of attacks (4 hours, continuous)
• days per month with headache
• Pain location
• associated symptoms
• Relationship to precipitating factors (stress, posture etc)
• Effect on work and family activities
• Response to acute and preventive medications
• Presence of coexistent conditions (depression, asthma, etc) 38
Approach to the physical examination

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 Approach to the physical examination

• Blood pressure & temp measurement

• Screening neurologic examination
• Neck examination
• If indicated, a focused neurologic examination
• If indicated by associated jaw complaints, an examination for
temporo-mandibular disorders

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Red flags and other potential indicators of
secondary headache

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Red flags Emergent (address immediately)
• Thunderclap onset
• Fever and meningismus
• Papilledema with focal signs or reduced LOC
Guideline for primary care management
• Acute glaucoma
of headache in adults, Canadian Family
Physician
Urgent (address within hours to days)
• Temporal arteritis
• Papilledema (WITHOUT focal signs or reduced LOC)
• Relevant systemic illness
• Elderly patient: new headache with cognitive change

yes Refer and

Possible indicators of secondary headache investigate
• Unexplained focal signs
• Atypical headaches
• Unusual aura symptoms
• Onset after age 50 y

Aggravation by neck movement

• Abnormal neck examination findings (cervicogenic headache)
• Jaw symptoms (consider temporomandibular joint disorder)
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 Headache with ≥2 of
• Nausea
• Light sensitivity migraine
• Interference with activities

NO

Tension
Headache with no nausea but ≥2 of type
• Bilateral headache headache
• Non pulsating pain
• Mild to moderate pain
• Not worsened by activity

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 Medication overuse
Assess
• Ergots, triptans, combination analgesics, or codeine ≥10 d/mo
OR
• Acetaminophen or NSAIDs ≥15 d/mo
Manage
• Educate patient
• Consider prophylactic medication
• Provide an effective acute medication for severe attacks
• Gradual withdrawal of opioids if used
• Abrupt (or gradual) withdrawal of acetaminophen, NSAIDs, or triptans

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Diagnosing primary headache syndromes

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 Acute Migraine Medication
First line Ibuprofen 400 mg
ASA 1000 mg
naproxen sodium 500-550 mg
acetaminophen 1000 mg

Second line • Triptans: oral sumatriptan 100 mg

• Subcutaneous sumatriptan 6 mg if the patient is
vomiting early in the attack.
• Nasal spray: sumatriptan 20 mg if patient is
nauseated
Antiemetics: domperidone 10 mg or metoclopramide
10 mg for nausea

Third line Naproxen sodium 500-550 mg in combination with a

triptan
Fourth line Fixed-dose combination analgesics (with codeine if
necessary; not recommended for routine use
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 Prophylactic Medications
Prophylactic MEdications Starting dose Titration,* daily Dose Target dose or
increase therapeutic range

First line propranolol 20 mg twice daily 40 mg/wk 40-120 mg twice daily

metoprolol 50 mg twice daily 50 mg/wk 50-100 mg twice daily

amitriptyline 10 mg at bedtime 10 mg/wk 10-100 mg at bedtime
Second line
Topiramate 25 mg/d 25 mg/wk 50 mg twice daily

candesartan 8 mg/d 8 mg/wk Few side effects; limited

experience in prophylaxis
gabapentin 300mg/d 300 mg every 3-7 d Few drug interactions

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 Medications for tension-type headache
Medication Dose

Acute
Ibuprofen 400 mg
ASA 1000 mg
Naproxen sodium 500-550 mg
Acetaminophen 1000 mg

Prophylactic
First line
amitriptyline 10-100 mg/d
nortriptyline 10-100 mg/d

Second line
• mirtazapine 30 mg/d
• venlafaxine 150 mg/d

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Chronic headache

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• Aliya asks if there is anything that can be done to reduce the
frequency of her migraine attacks.

• Explain that prophylactic treatments prevent, rather than cure, a

condition.

• Depending on the person’s clinical needs and their preferences

• offer prophylaxis with propranolol
• consider treatment with amitriptyline

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Medication overuse headache (MOH)
• Also called analgesic rebound headache
• Consider a diagnosis in patients with
• headache on ≥15 d/mo
• possible medication overuse
• use of triptans, ergots, combination analgesics, or opioid-containing medications on
≥10 d/mo,
or
• use of acetaminophen or NSAIDs on ≥15 d/mo
• Highest with opioids containing combination analgesics, and
aspirin/acetaminophen/caffeine combinations.
• Intermediate with triptans
• Lowest with NSAIDs 53
 Coping strategies for headache
• patients with suspected medication overuse might benefit from self-
management strategies:
• (eg, identification and management of controllable headache triggers,
relaxation exercises, effective stress management skills, and activity
pacing)
• Headache diaries that record acute medication intake are important
in the prevention and treatment of medication-overuse headache

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 Prophylactic medication
• Educate patients on the need to take the medication daily and
according to the prescribed frequency and dosage
• Ensure that patients have realistic expectations, Explain that…
-Headache attacks will likely not be abolished completely
-A reduction in headache frequency of 50% is usually considered worthwhile
and successful
-It might take 4-8 weeks for substantial benefit to occur
-If the prophylactic drug provides a substantial benefit in the first 2 mo
of therapy, this benefit might increase further over several additional
months of therapy
• Evaluate the effectiveness of therapy using patient diaries
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Prescribing prophylactic medication
cont
• For most prophylactic drugs, initiate therapy with a low dose and
increase the dosage gradually to minimize side effects
• Increase the dose until the drug proves effective, until dose limiting
side effects occur, or until a target dose is reached
• Continue the prophylactic drug for at least 6-8 wk after dose titration
is completed
• Because migraine attack tendency fluctuates over time, consider
gradual discontinuation of the drug for many patients after 6 to 12 mo
of successful prophylactic therapy

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Management of MOH- Patient education.

• Acute medication overuse can increase headache frequency

• When medication overuse is stopped, headache might worsen
temporarily and other withdrawal symptoms might occur
• Many patients will experience a long-term reduction in headache
frequency after medication overuse is stopped
• Prophylactic medications might become more effective

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Special thanks to Prof. Eiad AlFaris for
providing the materials for this TBL

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