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
HEADACHE in PrimaryCare
Ayşe Arzu Akalın MD
is sensitive to pain)
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
1.1 Migraine without aura
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
3. Cluster headache and other trigeminal autonomic cephalalgias, including:
3.1 Cluster headache
3.2 Other primary headaches
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)
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
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
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
10.7. Headache attributed to other disorder of homoeostasis
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
Recognizing headaches related to an underlying condition or disease is critical:
13. Trigeminal neuralgia
14. Other headache, cranial neuralgia, central or primary facial pain
Headache in Primary Care
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"
Estimated prevalence of subarachnoidhemorrhagein the setting of thunderclap headache is 43%
Aurais a subjective sensation or motor phenomenon that precedes and marks the onset of a neurological condition, particularly an epileptic seizureor migraine
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
How many different headache types does the patient have?
Aseparate history is needed for each.
Any change in character or intensity?
How did it start (gradually, suddenly, other)?
(episodic or daily and/or unremitting)?
Do youhaveheadaches on a regularbasis?
How bad is yourpain on a scale of 1 to 10?
Whatkind of pain do youhave (throbbing, stubbing, dull, other)?
Where is yourpain? Doesthepainseemto spread toanyotherarea? Ifso, where?
Whatsymptoms do youhavebeforetheheadachestarts?
Whatsymptoms do youhaveduringtheheadache?
Whatsymptoms do youhaverightnow?
(MSG, aspartame, tyramine (found in aged cheeses, some red wines, smoked fish, etc.),sodium nitrite (found in processed meats).
(Chocolate, fruits, dairy, onions, beans, nuts)
(Light, odors (perfume, paint, etc.), travel, abruptchanges in weather or altitude)
(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)
(Timing of headache with menses or change/ addition of hormones)
what manner and with what effect?
Do youtakeanymedicines? Ifso, what?
State of health
attacks and/or their cause?
Do youhaveothermedicalproblems? Ifso, what?
Haveyourecently hurt yourheador had a medicalordentalprocedure?
Physical examination is mandatory when the historyis suggestive of secondary headache.
Investigations, including neuroimaging, are indicated whenthe history or examination suggest headache may be secondaryto another condition.
The most common primary headaches in primary care are:
5 attacks of
• 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.
Aura consisting of at least one of the following, but no motor weakness:
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
Infrequent episodic tension-typeheadache
Frequentepisodic tension-typeheadache Chronictension-type headache
occurs in two subtypes,
- red and watering eye
- running or blocked nostril
(the patient, unable to stay in bed,paces the room, even going outdoors)
migraine or tension-type headache) by chronic overuse ofmedication taken to treat headache or other pain.
is associated with:
Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache: Annals of Emerg Med 2002 (1):39.