HEADACHE. UKM FAMILY MEDICINE TELECONFERENCE 11 TH FEB 2014 BY DR NAZIHAH MOHD KHALID SUPERVISOR: DR IRENE LOOI, CONSULTANT NEUROLOGIST HOSPITAL SEBERANG JAYA. GENERAL OBJECTIVE.
UKM FAMILY MEDICINE TELECONFERENCE 11TH FEB 2014
BY DR NAZIHAH MOHD KHALID
SUPERVISOR: DR IRENE LOOI, CONSULTANT NEUROLOGIST HOSPITAL SEBERANG JAYA
Do not refer patients diagnosed with tension type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.
Consider further investigations or referral for patients who present with new onset of headache and any of the following:
The nature of aura may change over time and, when it does, it often alarms the patients. However this remains entirely consistent with migraine and does not indicate the need for urgent investigations.
Migraine headache is typically severe, throbbing and unilateral. Typically, it lasts for 24 hours or less but can continue for 72 hours, and occasionally longer (hours to days).
Frequency: median is about 1.5 attacks per month, but at least 1 in 10 have weekly attacks.
Symptomatic treatment is only effective for the headache/nausea elements; there is no symptomatic treatment for the aura.
Most episodes develop during waking hours and progression over the course of the day is common.
It is crucial to elicit the temporal pattern of the headache disorder during clinical assessment because the extensive symptoms overlap between primary and secondary headaches.
Although attacks of TTH are generally less disabling than those of migraine, work absence are common, and the total societal burden appears to exceed that of migraine because of the high prevalence of TTH.
TTH is mainly managed through administration of medication during acute episodes.
Preventive pharmacologic therapy is generally advised for those patients experiencing at least 2 to 3 headache days each week.
Indications for the institution of daily pharmacologic preventive therapy:
Once an effective dose is reached, treatment is typically continued for 6 to 12 months, at which point daily medication may be tapered and the patient followed clinically.
The prognosis of TTH is generally favorable, with limited disability during headache occurrences and age related improvement or resolution of episodes later in life.
This condition has a heritable tendency in some families and first degree relatives of affected people have an estimated 14-48 fold increased risk of developing it.
The pain of cluster headache is unilateral(97%) of patients with episodic disease and mainly focused behind the eye (88-92%), over the temple (69-70%) or over the maxilla (50-53%).
The attacks should last between 15 and 180 minutes, although on rare occasions they can last longer.
Between 70% to 93% of patients describe a sense of restlessness and agitation during an attack and will often pace, rock back and forth, and bang their heads.
Triptans: parenteraltriptans have been shown to be an effective treatment for individual attacks, whereas orally administered triptans are not.
Aims to suppress the attacks for the duration of the bout, or over longer periods in those with chronic cluster headache, with the fewer possible side effects.
Verapamil can be slowly withdrawn and stopped once the bout is assumed to have ended and lower doses do not allow breakthrough attacks.
General population:1% adults 0.5% adolescents (aged 13-18 years)
It is the frequency of doses rather than the absolute quantity of drug consumed that is important; lower daily doses carry a greater risk of causing MOH than larger weekly doses.
British Associations for the Study of Headache state that patients with MOH fare better if they are motivated and understand that their “treatment” is likely to be causing their frequent headache.
The withdrawal headache and associated symptoms varies depending on the types of medications that have been overused.
The mean success rate for withdrawal therapy (defined as at least a 50% reduction in headache days) over 1-6 months is around 72%.
Patients with MOH should be referred to neurologist if attempted withdrawal fails in primary care. Patients who have psychiatric comorbid or drug dependence behavior should have these conditions treated additionally.
ICHD-11 defined secondary headaches as follows:
During history, symptoms suggestive of secondary cause should become obvious.
Evaluation of patients with headache and any of the following features, and consider for further investigations and/or referral:
Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze
Symptoms and signs of acute narrow angle glaucoma (an uncommon eye condition that results from blockage of the drainage of fluids from the eye. Symptoms of acute glaucoma may include headache with a painful red eye and misty vision or haloes, and in some cases nausea. Acute glaucoma may be differentiated from cluster headache by the presence of semi dilated pupil compared with the presence of a constricted pupil in cluster headache)
Depression: headache is not uncommon symptom of depression, although there may also be overlap with other disorder as well.
-confidently reassure patient and caregivers
-identify and removing headache triggers (disrupted sleep, skipped meals, stress), regulating lifestyle and instituting behavioral therapies (relaxation techniques, stress management)
-caffeine-abuse or withdrawal can precipitate headache in adolescents
-intermittent use of analgesics
-successful use of analgesics includes:
1)taking enough medication
2)taking medication early in the course of the headache
3)making medication available to the child (especially at school)
Some headache syndromes are amenable to medical treatment (e.g. migraine) but others are much less so (chronic daily headache) and an honest explanation is usually appreciated.