Headache in primary care
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HEADACHE in Primary Care. Ayşe Arzu Akalın MD Family Medicine. In the end of this lecture the students will be able to;. d ifferentiate primary and secondary headache list the characteristics of most common headache types in primary care

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Headache in primary care

HEADACHE in PrimaryCare

Ayşe Arzu Akalın MD


In the end of this lecture the students will be able to

In the end of thislecturethe students will be able to;

  • differentiate primary and secondary headache

  • list the characteristics of most common headache types in primary care

  • explain the warning features in history and physical exam

  • list the common headache triggers



  • Headache or cephalalgia is pain or discomfort perceived in the head, neck or both.

  • Primary headache disorders are recurrent benign headaches.

  • Secondary headaches result from an underlying pathology caused by a distinct condition. (eg., aneurysm, infection, inflammation, or neoplasm)



  • Annual prevalence may be as high as 90%, with a minority of those sufferers pursuing medical evaluation.

  • Headache is the second most common pain syndrome in primary care ambulatory practice.

E pidemiology


  • Inchildrenthe rate of thepatientswhoseekcareforheadache has a negativecorrelationwiththe age.

  • Theprevalanceincreaseswithagesignificantlyandthepain is less in severityanddurationcomparedwithadults.

  • Incidence is between 20%-54% in the pre-adolescence period based to the epidemiologic studies.

Pain insensitive s tructures in brain

Pain InsensitiveStructures in Brain

  • Brainparenchyma

  • Dura over convexity of skull(Dura around vascular sinuses and vessels

    is sensitive to pain)

  • Ependyma

  • Choroid plexus

  • Arachnoid

  • Piamatter

Pain sensitive s tructures in head intracranial

Pain Sensitive Structures in Head INTRACRANIAL

  • Cranial venous sinuses with afferent veins

  • Arteries at base of brain and arteries of dura including middle meningeal artery

  • Dura around venous sinuses and vessels

  • Falxcerebri

Pain s ensitive s tructures in h ead extracran i a l nerves

Pain Sensitive Structures in Head EXTRACRANIAL & NERVES

  • Skin

  • Scalp appendages

  • Periosteum

  • Muscles

  • Arteries

  • Mucosa

  • Trigeminal (V. CN)

  • Facial (VII. CN)

  • Vagal (X. CN)

  • Glossopharyngeal(IX. CN)

  • OpticandoculomotorCNs (II & III: CN)

Causes of h eadaches

Causes of Headaches.

1. Traction or dilatation of intracranial or extracranialarteries.

2. Traction of large extracranialveins

3. Compression, traction or inflammation of painsensitiveintracranial structures

4. Spasm and trauma to cranial and cervical muscles.

5. Meningeal irritation and raised intracranial pressure

6. Eye, ear, noseandthroatpathologies

Classification of international headache society a primary headaches 90

Classification of International HeadacheSocietyA- PrimaryHeadaches(90%)

1. Migraineincluding:

1.1 Migraine without aura

1.2 Migrainewithaura

2. Tension-type headache, including:

2.1 Infrequent episodic tension-type headache

2.2 Frequent episodic tension-type headache

2.3 Chronic tension-type headache

2.4 Probabletension-typeheadache

3. Cluster headache and other trigeminal autonomic cephalalgias, including:

3.1 Cluster headache

3.2 Other primary headaches

Classification of international headache society a primary headaches 901

Classification of International HeadacheSocietyA- PrimaryHeadaches(90%)

4. Other primary headaches

4.1. Primary stabbing headache

4.2. Primary cough headache

4.3. Primary exertional headache

4.4. Primary headache associated with sexual activity

4.4.1. Preorgasmic headache

4.4.2. Orgasmic headache

4.5. Hypnic headache

4.6. Primary thunderclap headache

4.7. Hemicrania continua

4.8. New daily persistent headache (NDPH)

Primary h eadache definition


  • None of theprimary headaches is associated with demonstrable

    • organic disease or

    • structural neurologic abnormality.

  • Laboratory and imaging test results are generally normal.

  • Thephysical and neurologic examinations are also usually normal

  • Primary h eadache definition1


    • Should an abnormality be found on testing, by definition, it most likely is not the cause of the headache.

    • During the headache attack however, patients might have some abnormal clinical findings

    B secondary headaches 10

    B- SecondaryHeadaches(10%)

    5. Headache attributed to head and/or neck trauma, including:

    5.2 Chronic post-traumatic headache

    6. Headache attributed to cranial or cervical vascular disorder, including:

    6.2.2 Headache attributed to subarachnoid hemorrhage

    6.4.1 Headache attributed to giant cell arteritis

    7. Headache attributed to non-vascular intracranial disorder, including:

    7.1.1 Headache attributed to idiopathic intracranial hypertension

    7.4 Headache attributed to intracranial neoplasm

    B secondary headaches

    B- SecondaryHeadaches

    8. Headache attributed to a substance or its withdrawal, including:

    8.1.3 Carbon monoxide-induced headache

    8.1.4 Alcohol-induced headache

    8.2 Medication-overuse headache

    8.2.1 Ergotamine-overuse headache

    8.2.2 Triptan-overuse headache

    8.2.3 Analgesic-overuse headache

    9. Headache attributed to infection, including:

    9.1 Headache attributed to intracranial infection

    B secondary headaches1

    B- SecondaryHeadaches

    10. Headache attributed to disorder of homoeostasis

    10.1. Headache attributed to hypoxia and/or hypercapnia

    10.2. Dialysis headache

    10.3. Headache attributed to arterial hypertension

    10.4. Headache attributed to hypothyroidism

    10.5. Headache attributed to fasting

    10.6. Cardiaccephalalgia

    10.7. Headache attributed to other disorder of homoeostasis

    B secondary headaches2

    B- SecondaryHeadaches

    11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures, including:

    11.2.1 Cervicogenic headache

    11.3.1 Headache attributed to acute glaucoma

    12. Headache attributed to psychiatric disorder

    Secondary h eadache definition

    Secondary Headache Definition

    • Secondary headaches are usually of

      • recent onset and

      • associated with abnormalities found on clinical examination.

  • Laboratory testing or imaging studies confirm the diagnosis.

  • Secondary headache definition

    Secondary Headache Definition

    Recognizing headaches related to an underlying condition or disease is critical:

    • because treatment of the underlying problem usually eliminates the headache

    • the condition causing the headache may be life-threatening.

    C cranial neuralgias central and primary facial pain and other headaches

    C- Cranial Neuralgias, Central and Primary Facial Pain and Other Headaches

    13. Trigeminal neuralgia

    14. Other headache, cranial neuralgia, central or primary facial pain

    Headache in primary care1

    Headache in Primary Care

    Taking a diagnostic history

    Taking a Diagnostic History

    • The history is all-important in the diagnosis of the primaryheadache disorders and of medication-overuse headache

    • There are no useful diagnostic tests.

    • The historyshould elicit any warning features of a serious secondaryheadache disorder.

    Warning f eatures in h istory

    Warning Features in History

    Any new headache in an individual patient, or a significantchange in headache characteristics, should be treated withcaution.

    "I havenever had a headachelikethisbefore"

    "This is theworstheadache I have ever had"

    Specific w arning f eatures in history 1 5

    Specific WarningFeaturesin History (1/5)

    • Thunderclap headache (intense headache with “explosive”or abrupt onset) ͢→subarachnoid hemorrhage)

      Estimated prevalence of subarachnoidhemorrhagein the setting of thunderclap headache is 43%

    Specific w arning f eatures in history 2 5

    Specific WarningFeaturesin History (2/5)

    • Headache with atypical aura (duration >1 hour, or includingmotor weakness) ͢→ symptoms of transient ischemic attack (TIA) or stroke

    • Aura without headache in the absence of a prior history ofmigraine with aura ͢→ symptoms of TIA or stroke

    • Aura occurring for the first time in a patient during use ofcombined oral contraceptives ͢→ risk of stroke

    Headache in primary care

    Aurais a subjective sensation or motor phenomenon that precedes and marks the onset of a neurological condition, particularly an epileptic seizureor migraine

    Specific w arning f eatures in h istory 3 5

    Specific WarningFeatures in History (3/5)

    • New headache;

      in a patient older than 50 years →symptom ͢of temporal arteritis or intracranial tumour,

      in apre-pubertal child ͢→ requires specialist referral and diagnosis

      in a patient with a history of cancer, HIVinfection or immunodeficiency ͢→ secondaryheadache

    Specific w arning f eatures in history 4 5

    Specific WarningFeatures in History (4/5)

    • Progressive headache, worsening over weeks or longer͢→ intracranial space-occupying lesion

    • Headache aggravated by postures or maneuvers that raiseintracranial pressure ͢→ intracranial tumour, CNS infection

    Specific w arning f eatures in h istory 5 5

    Specific WarningFeatures in History (5/5)

    • Headache first occuring with exercise ͢→ ruptured aneurysm

    • Headache hours to weeks after a history of trauma, especially in an older person ͢→ subdural hematoma

    • Similar new onset of headaches in an acquaintance or family member ͢→ environment exposure such as carbon monoxide

    Questions to a sk in the h istory 1 7

    Questions to Ask in the History(1/7)

    How many different headache types does the patient have?

    Aseparate history is needed for each.

    Any change in character or intensity?

    Is thisyourfirstorworstheadache?

    Is thisheadacheliketheonesyouusuallyhave?

    Questions to a sk in the h istory 2 7

    Questions to Ask in the History(2/7)

    Time questions

    • Why consulting now?

    • How recent in onset?


      How did it start (gradually, suddenly, other)?

    • How frequent, and what temporal pattern

      (episodic or daily and/or unremitting)?

      Do youhaveheadaches on a regularbasis?

    • How long lasting?

    Questions to a sk in the h istory 3 7

    Questions to Ask in the History(3/7)

    Character questions

    • Intensity of pain?

      How bad is yourpain on a scale of 1 to 10?

    • Natureand quality of pain?

      Whatkind of pain do youhave (throbbing, stubbing, dull, other)?

    • Site and spread of pain?

      Where is yourpain? Doesthepainseemto spread toanyotherarea? Ifso, where?

    Questions to a sk in the h istory 4 7

    Questions to Ask in the History(4/7)

    Character questions

    • Associated symptoms?

      Whatsymptoms do youhavebeforetheheadachestarts?

      Whatsymptoms do youhaveduringtheheadache?

      Whatsymptoms do youhaverightnow?

    Questions to a sk in the h istory 5 7

    Questions to Ask in the History(5/7)

    Cause questions

    • Predisposing and/or trigger factors?

    • Aggravating and/or relieving factors?

    • Family history of similar headache?

    Common headache triggers


    • Alcohol

    • Caffeine

    • Food additives

      (MSG, aspartame, tyramine (found in aged cheeses, some red wines, smoked fish, etc.),sodium nitrite (found in processed meats).

    Common headache triggers1


    • Foods

      (Chocolate, fruits, dairy, onions, beans, nuts)

    • Environmental changes

      (Light, odors (perfume, paint, etc.), travel, abruptchanges in weather or altitude)

    Common headache triggers2


    • Lifestyle factors

      (Insufficient, excessive, disrupted, or irregular sleep; tobacco or alcohol use; fasting; physical activity; head injury; schedule changes; stress or release from stress; anger; or exhilaration)

    • Hormone changes, or addition of estrogen- containingmedication

      (Timing of headache with menses or change/ addition of hormones)

    Questions to a sk in the h istory 6 7

    Questions to Ask in the History(6/7)

    Response questions

    • What does the patient do during theheadache?

    • How much is activity (function) limited or


    • What medication has been and is used, in

      what manner and with what effect?

      Do youtakeanymedicines? Ifso, what?

    Questions to a sk in the h istory 7 7

    Questions to Ask in the History(7/7)

    State of health

    • Completely well, or residual or persisting

      between attackssymptoms?

    • Concerns, anxieties, fears of recurrent

      attacks and/or their cause?

      Do youhaveothermedicalproblems? Ifso, what?

      Haveyourecently hurt yourheador had a medicalordentalprocedure?

    Diagnostic d iary

    Diagnostic Diary

    • Once serious causes have been ruled out, a headache diarykept over a few weeks clarifies the pattern of headaches andassociated symptoms as well as medication use or overuse.

    Physical e xamination

    Physical Examination

    Physical examination is mandatory when the historyis suggestive of secondary headache.

    • General appearance, Does s/he look unwell?

    • Vitalsigns, Measure BP

    • Head and neck examincludingpalpation

    • Neurologicalexamincludingfundoscopy

    • ENT exam,

    • Ophtalmologic exam (astigmatism, glocoma)

    Warning f eatures on e xamination

    Warning Features on Examination

    • Pyrexia

    •  Blood Pressure (sist >200 mmHg / diast >120 mm Hg)  hypertensiveencephalopathy,

    • A palpable tender temporalartery  Temporalarteritis

    • Papilledema  increasedintracranialpressure

    Warning f eatures on e xamination1

    Warning Features on Examination

    • Focal neurological signs

    • Stiffneck, rush, fever, photophobia, vomiting and other systemic signs meningitis, encephalitis

    • Headache aggravated by postures or maneuvers raisingintracranial pressure  intracranialtumour, subduralhematoma, epiduralbleeding



    Investigations, including neuroimaging, are indicated whenthe history or examination suggest headache may be secondaryto another condition.

    Primary h eadaches

    Primary Headaches

    The most common primary headaches in primary care are:

    • Migraine (with aura / without aura)

    • Tension-type headache

    • Cluster headache

    • Medicine-associated headache

    M igraine


    • Episodic attacks with specific features of which nausea is the most characteristic.

    • Attack frequency between once a year and once a week (most commonly once a month).

    • In children, attacks tend to be of shorter duration and abdominal symptoms more prominent.

    Migraine without aura ihs criteria

    Migraine without aura: IHS criteria

    5 attacks of

    • Headache lasting 4-72 hours.

    • Must be associated with nausea or vomiting or photophobia and phonophobia

    • Must have 2 of the following

      • Unilateral

      • Pulsating

      • Moderately / severe.

      • Aggravated by physical activity



    • Primary headache disorder with genetic basis.

    • Activation of a mechanism deep in the brain causes release of pain-producing inflammatory substances around the nerves and blood vessels of the head.

    • Why this happens periodically, and what brings the process to an end in spontaneous resolution of attacks, are to a large extent uncertain.

    M igraine1


    • Starting at late childhood or puberty,

    • Affects those aged between 35 and 45 years but also younger people, including children.

    • Prevalence in Europe and America: 6-8% in men and 15-18% in women

    • Prevalence in Turkey: 10% in men and 22% in women.



    In children:

    • attacks may be shorter-lasting

    • headache is more commonly bilateral and less usually pulsating

    • gastrointestinal disturbance is more prominent.

    Migraine with typical aura


    • Migraine with aura affects one third of people with migraineand accounts for 10% of migraine attacks overall.

    • Aura is a subjective sensation or motor phenomenon that precedes and marks the onset of a neurological condition, particularly an epileptic seizureor migraine

    Migraine with typical aura1


    • Characterized by aura preceding headache, one or more neurological symptoms that develop gradually over >5 minutes and resolve within 60 minutes:

      • hemianoptic visual disturbances, or a spreading scintillating scotoma (patients may draw a jagged crescent if asked) and/or unilateral paresthesia of hand, arm and/or face and/or (rarely) dysphasia.

    Migraine with typical aura diagnostic criteria


    Aura consisting of at least one of the following, but no motor weakness:

    • Fully reversible visual symptoms including positive features (e.g., flickering lights, spots, or lines) and/or negative features (i.e., loss of vision)

    • Fully reversible sensory symptoms including positive features (e.g., pins and needles) and/or negative features (i.e., numbness)

    • Fully reversible dysphasic speech disturbance


      Headache begins during the aura or follow the aura within 60 minutes


      Diagnostic Criterion: Must have at least 2 attacks fulfilling the above criteria and no signs of Secondary headache disorder

    Scintillating scotoma


    Tension type headache

    Tension-type headache

    • Pericranial tenderness

    • Headache usually generalized most intense about neck or back of the head

    • No focal neurologic symptoms

    • Nonspesific symptoms

    • No family history

    Tension type headache1

    Tension-type headache

    • Mostcommonheadache 25-35%

    • Most misdiagnosed headache

    • Age: ≥ 20

    • Gender: F / M = 3 / 1

    • Mild to moderate in severity, often self-treated

    Tension type headache2


    Triggering factors

    • Physical and / or psychological stress

    • Noise

    • Glare

    • Changes in sleep or nutrition

    • Menstruation

    • Bad posture

    • Oromandibulary disturbances

    Tension type headache3


    Associating symptoms

    • Sensitivity in head and neck muscles

    • Sleep disturbances

    • Balance disturbances

    • Limitation in conjugated eye movements

    • Psychiatric disorders

    Tension type headache4

    Tension-type headache

    Infrequent episodic tension-typeheadache

    Frequentepisodic tension-typeheadache Chronictension-type headache


    Cluster headache

    Cluster headache

    occurs in two subtypes,

    • Episodic cluster headache occurs in bouts (clusters), typically of 6-12 weeks’ duration, once a year or two years, and then remits until the next cluster.

    • Chronic cluster headache, which persists without remissions (>12 months or remission <14 days), is less common. It may develop from and/or revert to episodic cluster headache.

    Cluster headache1

    Cluster headache

    • mostly affects men

    • manifests as strictly unilateral, excruciating pain aroundthe eye

    • recurs frequently, typically once or more daily, commonlyat night

    • is short-lasting, for 15-180 minutes(typically 30-60 minutes)

    Cluster headache2

    Cluster headache

    • has highly characteristic and strictly ipsilateral autonomicfeatures including any of:

      - red and watering eye

      - running or blocked nostril

      - ptosis

    • causes marked agitation

      (the patient, unable to stay in bed,paces the room, even going outdoors)

    Triggering factors


    • Alcohol intake

    • Medication (sublingual nitroglycerine)

    • Hunger

    • Stress

    • Climate change

    • Allergies

    • Hormonal changes

    Medication overuse headache

    Medication-overuse headache

    • a chronic daily headache syndrome,

    • is an aggravation of a prior headache (usually

      migraine or tension-type headache) by chronic overuse ofmedication taken to treat headache or other pain.

    • All acute headache medications may have this effect.

    M edication overuse headache

    Medication-overuse headache

    • Frequency, regularity and duration of intake are importantdeterminants of risk.

    • A history can be elicited of increasingly frequent headacheepisodes, with increasing medication use, over months tomany years.

    Medication overuse headache1

    Medication-overuse headache

    is associated with:

    • regular use of simple analgesics on ≥15 days a monthand/or- regular use of opioids, ergots or triptans, or any combinationof these, on ≥10 days a month

    • occurs daily or near-daily

    • is present – and often at its worst – on awakening in themorning

    M edication overuse headache1

    Medication-overuse headache

    • is initially aggravated by attempts to withdraw the medication.

    • Diagnosis of medication-overuse headache is confirmed ifsymptoms improve within 2 months after overused medicationis withdrawn.

    Acute o nset h eadache

    Acute OnsetHeadache

    • Sufficient evidence from retrospective and prospective studies to support the association of an acute sudden onset headache with a vascular event.

    • Sudden onset headache is a red flag

      Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache: Annals of Emerg Med 2002 (1):39.

    Life threatening c auses of a cute h eadaches

    Life Threatening Causesof Acute Headaches

    • Vascular events

      Intracranial hemorrhage

      • Subdural hemorrhage

      • Subarachnoid hemorrhage

      • Thrombosis,

      • Vasculitis,

      • Malignant hypertension

      • Arterial dissection

      • Aneurysm

    Life threatening c auses of a cute h eadaches1

    Life Threatening Causesof Acute Headaches

    • Infections




    Life threatening c auses of a cute h eadaches2

    Life Threatening Causes of Acute Headaches

    • Intracranial masses

    • Preeclampsia

    • Carbon monoxide poisoning

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