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Council of Cooperative Health Insurance جامعه المربيه الجميه السعوديه الحربيه المربيه Saudi Society of Family and Community Medicine <table><tr><td>Common</td><td>Occasional</td><td>Rare</td></tr><tr><td>Tension</td><td>Drug Induced</td><td>Cluster</td></tr><tr><td>Migraine</td><td>Fatigue</td><td>Meningitis</td></tr><tr><td>Sinusitis</td><td>Trigeminal Neuralgia</td><td>Intracranial Lesion</td></tr><tr><td>Eye Strain</td><td>Iatrogenic</td><td>Pre Eclampsia</td></tr><tr><td>Cervical</td><td>Temp Arteritis</td><td>Severe Hypertension</td></tr></table> D • Take History • Neurological exam including BP - Palpate Temporal arteries (Particularly if age > 50 years) - Fundoscopy REFER ACUTELY FOR CT IMAGING <table><tr><td></td><td>Clinical Features</td><td>Need to Exclude</td></tr><tr><td>S</td><td>Systemic Symptoms: fever, chills weight loss or Secondary Risk Factors (HIV, Cancer)</td><td>Metastasis, Infection</td></tr><tr><td>N</td><td>Neurological Symptoms and Signs: Weakness, Numbness, Confusion, Seizure, Atypical Aura</td><td>Stroke, Mass lesion, Encephalitis</td></tr><tr><td>O</td><td>Older Age at Onset greater than 50 yrs.</td><td>Temporal arteritis, Mass lesion</td></tr><tr><td>O</td><td>Onset: Sudden Onset ( Thunderclap or during Sex)) or After HEAD Injury ( All Head Injuries on anticoagulants need Imaging)</td><td>Bleed</td></tr><tr><td>P</td><td>Papilledema</td><td>Raised intracranial Pressure</td></tr><tr><td>P</td><td>Positional or Postural</td><td>Intracranial Hypotension</td></tr><tr><td>P</td><td>Precipitated by Valsalva</td><td>Raised Intracranial Pressure</td></tr><tr><td>P</td><td>Maneuver or Exertion</td><td>Any Secondary Cause</td></tr><tr><td>Other</td><td>Progressive or Pattern Change</td><td>Raised Intracranial Pressure</td></tr><tr><td>Other</td><td>Headache that Wakes you Up, Headache associated with early morning Vomiting</td><td>Pressure</td></tr></table> REFER ACUTELY to SPECIALITY Fever and Neck Stiffness: Meningitis; to EMS / Neurology Unilateral Painful Red Eye: Acute Glaucoma; to EMS/ Ophthalmology Temporal Tenderness or Jaw Claudication: Temporal Arteritis (Take ESR, start Steroids Immediately refer to Rheumatology/ Vascular Surgery NO RED FLAGS Exclude Red flags Primary or Non- Serious Secondary Headache SECONDARY HEADACHE - non serious cause When to Image • CT Scan when red flags are present - No role for Xray - Imaging is not recommended for tension headaches, cluster headaches or medication overuse headaches simply to reassure patients Primary headache -Most patients who attend with recurrent / chronic headaches have MIGRAINE, TENSION or CERVICAL HEADACHE -Patients may have more than one type, so can develop tension type headaches on underlying migraine. -If features of both migraine and tension-type headache, class as Migraine. -Keeping a headache diary is useful REFERRAL • Cervicogenic Headache: Posterior headaches, and those that fan across the scalp. • TMJ dysfunction: Pain over the TMJ, radiation across scalp and aggravated by chewing. - Medication Headache – e.g. Caffeine, Nitrates, Calcium Chanel Blockers, combined oral contraceptive pill (OCP). If patient has migraines with aura then OCP is contraindicated. - Trigeminal Neuralgia: Consider facial pain with sensory hypersensitivity as a source of headache. - Sinusitis- Frontal headache or over sinuses, may vary with posture, associated with pressure and congestion Migraine (usual cause of chronic headaches) Migraine with Aura Medication overuse Tension Type headache TTH Cluster headache Other Secondary Headaches TYPE Diagnostic Criteria- at least 5 attacks fulfilling 1-4 1. Lasts 4-72 hours treated or untreated. 2. At least 2 of the following -Unilateral location -Pulsating quality -Moderate/severe pain -Aggravation by routine Physical Activity (Walking/ Climbing Stairs) 3. During the headache at least 1 of: -Nausea / vomiting -Photophobia/phonophobia 4. No other cause identified Usually episodic Can be chronic (15% of cases). Chronic Migraine is > 15 days /month for more than 3 months. Episodic is < 15 days per month Occurs in 1/3 of migraine patients At least 2 attacks fulfilling A-B A. More than of the following fully reversible aura symptoms: 1. Visual 2. Sensory 3. Sensory and / or language 4. Motor 5. Brainstem 6. Retinal (Typical symptoms include flickering lights, spots, partial loss of vision, numbness, pins and needles or Speech disturbance) B. More than 2 of the following 4 Characteristics: i. 1 aura symptom spreads gradually over >5 mins, and/or >2 symptoms occur in succession. ii. Each individual aura symptom lasts 5-60 minutes iii. 1 aura symptoms are unilateral iv. Aura accompanied or followed in <60 minutes by headache Full recovery after attacks -Medication history is crucial especially use of over the counter analgesia -Triptans / opioids > 10 days a month for >3 months -Simple analgesics > 15 days a month for >3 months -Usually underlying migraine Usually episodic; can be chronic -Bilateral -Pressing / Tightening (Non pulsatile) feels like a tight band -Mild to Moderate NOT SEVERE) -Not aggravated by routine activities -Duration 30 mins-continuous -Deemed chronic if >15days per month -Can occur in combination with migraine -Severe/Very severe UNILATERAL- Orbital, Suborbital and /or temporal pain lasting 15-180 minutes - Either or both of the following: 1. At least one of the following symptoms or signs, ipsilateral to the headache: - A. Conjunctival injection and or lacrimation - B. Nasal Congestion and or Rhinorrhea - C. Eyelid Oedema - D. Forehead and Facial Sweating - E. Forehead and Facial Flushing - F: Sensation of fullness in the ear - G: Miosis and or Ptosis 2. A sense of restlessness or agitation. Patients typically walk up and down or rock to and for, unlike migraineurs who are motion sensitive Affects M:F (4:1 ratio) -Usually aged 20+ years: Peak age 20-40 -Bouts last 6-12 weeks. -Usually occur 1-2x year -Rarely chronic throughout year. Acutely - Nasal or sc triptan prn • 100% Oxygen 15L/min (consult neurology; not if patient is a smoker / uses E cigarettes) Termination of cluster - Prednisolone 60mg daily – reduce by 10mg every 3 days • Verapamil 20-40mg tds increased if needed • Refer all cluster cases for specialist review + MRI Other Secondary Headaches TYPE Neck Most Common form of Secondary Causes. • Prolonged flexion from Mobile phone use. - Originates in neck/ back of head and fans across scalp Trigeminal neuralgia - Triggered unilateral facial pain - Sudden paroxysmal - Not continuous - Carbamazepine 100-200mg daily; gradually increased to effect; Ice pick / stabbing - Sudden Severe brief fleeting head pains - Various locations - Seek opinion or further review Chronic Paroxysmal Hemicrania (CPH) or Hemicrania Continua (HC) -Unilateral Severe -Paroxysmal or Constant respectively - +/- Autonomic features -15-30 mins -Seek opinion or further review References: 1. Steiner, T.J., Jensen, R., Katsarava, Z. et al. Aids to management of headache disorders in primary care (2nd edition). J Headache Pain 20, 57 (2019). 2. Headaches in over 12s: diagnosis and management NICE Clinical guideline [CG150] Published date: September 2012 Last updated: November 3. The British Association for the Study of Headache (BASH) National headache management system for adults 2019 4. Dodick, DW. Clinical clues and clinical rules: primary vs secondary headache. Adv Stud Med 2003; 3(6c): S550–S555. TYPE MANAGEMENT MANAGEMENT