The International Headache Society classification and diagnostic criteria can help physicians differentiate primary headaches (e.g., tension, migraine, cluster) from secondary headaches (e.g., those caused by infection or vascular disease). Address correspondence to Barry L. Hainer, MD, Medical University of South Carolina, MSC 192, Charleston, SC 29425 (e-mail: Stovner LJ, Bahra A, Godwin SA, Cicero JJ, In addition, if meningitis, subarachnoid hemorrhage, encephalitis, or any cause of meningismus is being considered, lumbar puncture and cerebrospinal fluid (CSF) analysis should be done, if not contraindicated by imaging results. Headache Classification Subcommittee of the International Headache Society. Introduction  Headache is defined as diffuse pain in various … Adapted with permission from the American Academy of Neurology: Lipton RB, Bigal ME, Steiner TJ, et al. Epidemiology of tension-type headache. This article focuses on a well-organized and evidence-based approach to identify patients with headache … The search included expert consensus statements, clinical reviews, and clinical trials. Bendtsen L, Pascual J, Rylance J, First level of The International Classification of Headache Disorders, 2nd edition. 2006;296(10):1274–1283. Mower WR. Gaul C, 19. How common are headaches in adults? Institute for Clinical Systems Improvement. McCrory DC, At least five episodes fulfilling the following criteria: Headache episodes lasting four to 72 hours (untreated or unsuccessfully treated), Headache has at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, aggravated by (or causes avoidance of) routine physical activity such as walking or climbing stairs, During the headache, the patient experiences at least one of the following: nausea or vomiting; and photophobia and phonophobia. Hard-to-Diagnose Headache: Practical Tips for Diagnosis and Treatment, http://www.neurology.org/content/63/3/427.abstract, https://www.icsi.org/_asset/qwrznq/Headache.pdf. Neurobiology of chronic tension-type headache. Lindwurm A, / Vol. Children who complain of headache usually are brought to medical attention by their parents due to missing school or social activity or concerns of an ominous etiology such … For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml. Rozen TD, Classification of primary headaches. http://www.neurology.org/content/63/3/427.abstract. Lipton RB, Panagos PD, presenting with first-time headache or a change in head-ache pattern. The link you have selected will take you to a third-party website. Approximately one-half of the adult population worldwide is affected by a headache disorder. A combination of symptoms and signs is more characteristic (see table Some Characteristics of Headache Disorders by Cause). In: Silberstein SD, Lipton RB, Dalessio DJ, eds. Laurie Barclay, MD. Leroux E, Ramchandren S, Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Pareja JA. There tend to be several (up to eight) episodes in the same day, with each episode lasting between 15 and 180 minutes.4 In the episodic form (80 to 90 percent of cases), episodes occur daily for a number of weeks followed by a period of remission.4 On average, a period of cluster headaches lasts six to 12 weeks, with remission lasting up to 12 months.4 In the chronic form (10 to 20 percent of cases), episodes occur without significant periods of remission.4, The long delay in diagnosis reported by patients who have cluster headaches is important. Cephalalgia. Now on YouTube! Jensen R. The approach to patients presenting with headache begins with a thorough history and physical examination. Acad Emerg Med. Copyright © 2013 by the American Academy of Family Physicians. 1. ACR appropriateness criteria. A decision guideline for emergency department utilization of non-contrast head computed tomography in HIV-infected patients. Espinosa CE, Silberstein SD, Lipton RB, Dalessio DJ. Bigal ME, Tonometry should be done if findings suggest acute narrow-angle glaucoma (eg, visual halos, nausea, corneal edema, shallow anterior chamber). Ann Emerg Med. Rothman RE, Kelen GD. Beithon J, Gallenberg M, Johnson K, et al. The American College of Emergency Physicians has determined that response to pain relief therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache.13 No prospective randomized controlled trials, evidence from meta-analyses, randomized controlled trials, or well-designed cohort studies support or refute the practice of using response to pain relief therapy in nontraumatic headaches as an indicator of potential underlying pathology. Patients with headache and fever, papilledema, or severe hypertension (systolic pressure greater than 180 mm Hg or diastolic pressure greater than 120 mm Hg) require evaluation for CNS infection and increased intracranial pressure. Search terms included headache, acute headache, and classification of headache. Frequency of headache is related to sensitization: a population study. Patients with thunderclap headache require CSF analysis even if CT and examination findings are normal as long as lumbar puncture is not contraindicated by imaging results. Silberstein SD, Lipton RB, Dalessio DJ. Booth CM. Cipolle RJ, Byyny RL, Booth CM. Pupillary size and light responses, extraocular movements, and visual fields are assessed. ICHD-2 diagnostic criteria for 1.1 Migraine without aura. Therefore, headache with aura-like symptoms should not be assumed to be benign or a primary headache when aura-like symptoms are present for more than 60 minutes. Ducros A. (2) The answers to these questions allow the provider to … She saw the top doctors there. Neurology. Strain JD, Learn more about our commitment to Global Medical Knowledge. The oropharynx is inspected for swellings, and the teeth are percussed for tenderness. Approach to Headache Dr. Faisal Al Hadad Consultant of Family Medicine & Occupational Health PSMMC 2. A thorough history and physical examination, and an understanding of the typical features of primary headaches, can reduce the need for neuroimaging, lumbar puncture, or other studies. Please confirm that you are a health care professional. Our headache specialists are trained to deal specifically with headache … Arendt-Nielsen L, 6 thoughts on “ Approach to Headache ” mohamed. The Manual was first published as the Merck Manual in 1899 as a service to the community. If similar headaches recur in patients who appear well and have a normal examination, the cause is rarely ominous. CT = computed tomography; CTA = computed tomographic angiography; MRA = magnetic resonance angiography; MRI = magnetic resonance imaging. Most single symptoms of primary headache disorders other than aura are nonspecific. Ge HY, Andrew ME, Barber DL. Steiner TJ, Thomas TL, (See "Evaluation of the adult with nontraumatic headache in the emergency … 10. 2006;46(6):954–961. Edmeads J. All rights Reserved. CSF analysis is also indicated if patients with headache are immunosuppressed. et al. ICHD-2 = International Classification of Headache Disorders, 2nd ed. Tomlinson GA, Vital signs, including temperature, are measured. Houle TT, , MD, Sidney Kimmel Medical College at Thomas Jefferson University. Exacerbating and remitting factors (eg, head position, time of day, sleep, light, sounds, physical activity, odors, chewing) are noted. The analysis is based on dynamic and quantitative surface electromyography (SEMG) of a number of muscles through a range of motions and facial expressions. Abnormal findings on examination can be pronounced, such as meningismus or unilateral vision loss, or subtle, such as extensor plantar response or unilateral pronator drift. Lyngberg AC, Author disclosure: No relevant financial affiliations. May A, If headache type or pattern clearly changes in patients with a known primary headache disorder, secondary headache … Cluster headache in the United States of America: demographics, clinical characteristics, triggers, suicidality, and personal burden. Patients also should be evaluated to determine if their blood pressure should be lowered to safer levels to avoid intracranial hemorrhage from malignant hypertension. 2007;27(3):193–210.... 2. Ramchandren S, Baraff LJ, May A, Address correspondence to Barry L. Hainer, MD, Medical University of South Carolina, MSC 192, Charleston, SC 29425 (e-mail: hainerbl@musc.edu). Computed tomography of the head is the most widely used imaging study for acute head trauma because of its availability, speed, and accuracy. Pain most commonly occurs in the retro-orbital area, followed by the temporal region, upper teeth, jaw, cheek, lower teeth, and neck.17 Ipsilateral autonomic symptoms such as eyelid edema, nasal congestion, lacrimation, or forehead sweating usually accompany the pain. afpserv@aafp.org for copyright questions and/or permission requests. CT (or MRI) should be done as soon as possible in patients with any of the following findings: Severe hypertension (eg, systolic > 220 mm Hg or diastolic >120 mm Hg on consecutive readings). The role of muscles in tension-type headache. Three treatment strategies are recommended. American College of Emergency Physicians. Ge HY, Cluster headache: a prospective clinical study with diagnostic implications. Overall, the most common causes of headache are. 24. Although pain can occur on both sides of the head, most patients report unilateral pain. Buchgreitz L, Some patients require tests as soon as possible. Simon D, Headache may occur as a primary disorder or be secondary to another disorder. We, at Headache MD, believe that headaches and headache symptoms have a physiological background. Tomlinson GA, The role of muscles in tension-type headache. Funct Neurol. / afp Thomas TL, Search date: December 2011. • Behavioral approaches including relaxation … 16. 18. 12. Lipton RB, Musculoskeletal and Connective Tissue Disorders, cerebral venous sinus thrombosis, intracerebral hemorrhage, encephalitis, or any cause of meningismus. 26. Mason SM. Gentry LR, et al. Most headache diagnoses are based entirely on the patient history. Thompson B, Fernández-de-Las-Peñas C, There is no single approach to the treatment of headaches or migraines, as the goal of a naturopathic physician is … Bendtsen L, Decker WW; For recurrent headaches, the following are noted: Temporal pattern (including any relationship to phase of menstrual cycle), Response to treatments (including over-the-counter treatments), Review of systems should seek symptoms suggesting a cause, including, Vomiting: Migraine or increased intracranial pressure, Fever: Infection (eg, encephalitis, meningitis, sinusitis), Red eye and/or visual symptoms (halos, blurring): Acute angle-closure glaucoma, Visual field deficits, diplopia, or blurring vision: Ocular migraine, brain mass lesion, or idiopathic intracranial hypertension, Lacrimation and facial flushing: Cluster headache, Pulsatile tinnitus: Idiopathic intracranial hypertension, Focal neurologic deficit: Encephalitis, meningitis, intracerebral hemorrhage, subdural hematoma, tumor, or other mass lesion, Seizures: Encephalitis, tumor, or other mass lesion, Syncope at headache onset: Subarachnoid hemorrhage, Myalgias and/or vision changes (in people > 55 years): Giant cell arteritis. Impairment in episodic and chronic cluster headache [published correction appears in. Fernández-de-la-Peñas C. Silberstein SD, "A New Approach to Headache and Migraine is an exceptional and comprehensive body of work, the 'brain child' of Pablo Tymoszuk, whose passion in life has been to educate, treat and preferentially prevent headaches … Up to 75% of adults worldwide have had a headache in the past year. Obtundation or confusion suggests a dangerous headache because these signs do not occur with benign or primary headache. Accessed March 17, 2013. Secondary causes of headache outnumber the primary entities such as migraine. Cluster headache: a prospective clinical study with diagnostic implications. Recommendations for differentiating dangerous from benign headaches are provided in Table 7.5,20–24 The characteristics of dangerous headaches and associated red flag symptoms are based on observational study and consensus reports. Strife JL, Determining whether a secondary headache is present, Checking for symptoms that suggest a serious cause. González-Mandly A, Barber DL. Cephalalgia. Manzoni GC. Classification of primary headaches. Am Fam Physician. Ramirez-Lassepas M, If patients have vision-related symptoms or eye abnormalities, visual acuity is measured. Linetsky M, History of present illness includes questions about the headache's characteristics: Quality (eg, throbbing, constant, intermittent, pressure-like). Other testing should be done within hours or days, depending on the acuity and seriousness of findings and suspected causes. Oral medications are typically the fastest way to … 23. Contact Godersky JC, Treatment approaches include Muscle Energy Technique (MET) to the cervical spine, myofascial release to the neck and head, posture retraining and review of other causes/treatments in a … 14. Table 3. The fundi are checked for spontaneous retinal venous pulsations and papilledema. Bendtsen L, A number of comorbidities are associated with cluster headaches, including depression (24 percent), sleep apnea (14 percent), restless legs syndrome (11 percent), and asthma (9 percent).15 Depression is an important diagnosis, because many individuals who have cluster headaches report suicidal thoughts, and 2 percent of patients in one study had attempted suicide.16,18,19. Johnston KL, 1988;28(10):675–679. Bigal ME, 2004;63(3):428. January 2013. Fernández-de-la-Peñas C. Neurologic abnormalities require evaluation and are particularly concerning in association with acute headache. Cephalalgia. Classification of primary headaches. The present article presents a novel approach to evaluating the potential contribution of dysfunctional muscles of the head to headache. 2012;52(1):99–113. Lindwurm A, Godersky JC, 5. Does this patient with headache have a migraine or need neuroimaging? Box 3 presents an approach to the physi-cal examination specifically for primary care providers.29 Box 4 presents red flags and other potential indicators of secondary headache.29 Table 5 presents a simplified strategy for diagnosing primary headache … Overview, diagnosis, and classification of headache. Baraff LJ, A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Beauchamp NJ Jr, 2004;63(3):428. Locker TE, et al. The eyes and periorbital area are inspected for lacrimation, flushing, and conjunctival injection. Pain usually felt over the face, mostly unilateral, and worsened by chewing. 87/No. 2004;24(suppl 1):9–160. JAMA. *Primary headaches are usually recurrent. ICHD-2 diagnostic criteria for 1.1 Migraine without aura. The most common types of headaches are tension-type headaches, migraines, and cluster headaches, which affect approximately 40, 10, and 1 percent of the adult population, respectively.1,2, Enlarge ICHD-2 criteria for 1.2.1 Typical aura with migraine headache. Head computed tomography should be performed before lumbar puncture in all patients with suspected subarachnoid hemorrhage, regardless of findings on neurologic examination. AJR Am J Roentgenol. Cluster headache. Penzien DB, At least two episodes fulfilling the following 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 (i.e., pins and needles) and/or negative features (i.e., numbness); fully reversible dysphasic speech disturbance, At least two of the following: homonymous visual symptoms and/or unilateral symptoms; at least one aura symptom develops gradually over five or more minutes and/or different aura symptoms occur in succession over five or more minutes; each symptom lasts at least five minutes, but no longer than 60 minutes, A headache that fulfills the criteria for migraine without aura (Table 4), and begins during the aura or follows the aura within 60 minutes, Headache not attributed to another disorder. 2001;63(4):685–692. Stewart WF, Emergent headaches during pregnancy: correlation between neurologic examination and neuroimaging. Headache is one of the most common reasons patients seek medical attention. Lipton RB. Thompson C, Also, neuroimaging, usually MRI, should be done if patients have any of the following: Focal neurologic deficit of subacute or uncertain onset, Change in an established headache pattern. Computed tomography of the head should be performed before lumbar puncture, even if the results of neurologic examination are normal, because there is a risk of central herniation of the brain even in the absence of physical examination findings of subarachnoid hemorrhage. PDF | On Apr 20, 2011, R Solomons and others published Approach to headaches in children | Find, read and cite all the research you need on ResearchGate Distinguishing dangerous headaches from benign or low-risk headaches is a significant challenge because the symptoms can overlap. Useful clinical criteria from the history and physical examination for distinguishing migraine from tension-type headache include nausea, photophobia (sensitivity to light), and phonophobia (sensitivity to sound). Wolff's Headache and Other Head Pain. J Headache Pain. Subarachnoid hemorrhage, hypertensive emergencies, vertebral artery dissections, and acute angle–closure glaucoma can also present this way.25. The international classification of headache disorders: 2nd edition. Evaluation of acute headaches in adults. Prospective comparative study of intermediate-field MR and CT in the evaluation of closed head trauma. Neurology. Although cluster headaches are less common than migraines and tension-type headaches, an estimated 500,000 Americans experience them at least once in a lifetime.16 The age of onset of cluster headaches varies, with 70 percent of patients reporting onset before 30 years of age.17, Severe or very severe unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 minutes if untreated, Headache is accompanied by at least one of the following ipsilateral autonomic symptoms: conjunctival injection or lacrimation, nasal congestion or rhinorrhea, eyelid edema, forehead and facial sweating, miosis or ptosis, restlessness or agitation, Headache episodes occur from one every other day to eight per day, At least two cluster periods lasting seven to 365 days and separated by pain-free remissions of more than one month, Episodes recur for more than one year without remission periods or with remission periods lasting less than one month, Features typical of primary headaches (Tables 1 through 5), No concerning change in usual headache pattern, No high-risk comorbid conditions (e.g., human immunodeficiency virus infection), No new, concerning historical or physical examination findings (Table 7), Patients with cluster headache most commonly describe the pain as sharp, but some report that it can also be pulsating and pressure-like. The ipsilateral temporal artery is palpated, and both temporomandibular joints are palpated for tenderness and crepitance while the patient opens and closes the jaw. Evaluation of acute headaches in adults. Please put note summary for this lecture so we can revise at any time. Pascual J, 4. She went around to all the headache … Headache. Steiner TJ, Headache is one of the most common pain conditions in the world. The legacy of this great resource continues as the MSD Manual outside of North America. Stewart WF, Cross BJ, American College of Emergency Physicians. Prescription or over-the-counter medications such as aspirin, other nonsteroidal anti-inflammatory drugs, anticoagulants, and glucocorticoids increase the risk of intracranial bleeding. Danyluk T, 3. Headache. The following findings are of particular concern: Neurologic symptoms or signs (eg, altered mental status, weakness, diplopia, papilledema, focal neurologic deficits), Thunderclap headache (severe headache that peaks within a few seconds), Symptoms of giant cell arteritis (eg, visual disturbances, jaw claudication, fever, weight loss, temporal artery tenderness, proximal myalgias), Systemic symptoms (eg, fever, weight loss). The international classification of headache disorders: 2nd edition. Clinch CR. Lofland KR. If the conjunctiva is red, the anterior chamber and cornea are examined with a slit lamp if possible, and intraocular pressure is measured. First level of The International Classification of Headache Disorders, 2nd edition. Ramirez-Lassepas M, Past medical history should identify risk factors for headache, including exposure to drugs, substances (particularly caffeine), and toxins (see table Disorders Causing Secondary Headache); recent lumbar puncture; immunosuppressive disorders or IV drug use (risk of infection); hypertension (risk of brain hemorrhage); cancer (risk of brain metastases); and dementia, trauma, coagulopathy, or use of anticoagulants or ethanol (risk of subdural hematoma). Jürgens TP, Classification of primary headaches. Neck is flexed to detect discomfort, stiffness, or both, indicating meningismus. Patients who meet at least four of these criteria are most likely to have a migraine.14, One study of 1,500 adults with migraine headache found that the presence of nausea alone, or the presence of two of three features from either of these symptom triads (i.e., nausea, photophobia, and pulsating quality; or nausea, photophobia, and worsening of headache with physical activity) had positive likelihood ratios for migraine of 4.8 or greater and negative likelihood ratios of less than 0.23.15, Aura may be present in some cases of migraine. A prospective study and review of the literature. Fernández-de-Las-Peñas C, Adapted with permission from the American Academy of Neurology: Lipton RB, Bigal ME, Steiner TJ, et al. Arch Neurol. et al. Cluster headache. Only rarely does physical examination provide clues to the diagnosis.3, The International Headache Society has published a system of classification and operational diagnostic criteria for headache based on clinical consensus.4  This system is most useful for classifying patients in epidemiologic studies and clinical trials. Neuroimaging is indicated for all patients who present with signs or symptoms of dangerous headache, because they are at increased risk of intracranial pathology. Previous: Hard-to-Diagnose Headache: Practical Tips for Diagnosis and Treatment, Home Classifying headaches into primary (tension, migraine, or cluster) and secondary types (e.g., those caused by infection or vascular disease) is also useful to differentiate headaches that, although perhaps recurrent and temporarily disabling, have no dangerous underlying cause from those that may be a sign of significant pathology, because they represent an underlying systemic or neurologic disorder (Table 1).5, Headache attributed to any of the following: head or neck trauma, cranial or cervical vascular disorder, nonvascular intracranial disorder, substance use or withdrawal, infection, disturbance of homeostasis, psychiatric disorder, Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures. 2006;123(1–2):19–27. Beithon J, Gallenberg M, Johnson K, et al. It is important for physicians evaluating adult patients with acute headache to determine whether the condition is benign or if it indicates dangerous neurologic or systemic pathology. 28. Lumbar puncture and CSF analysis are done if headache is progressive and findings suggest idiopathic intracranial hypertension (eg, transient obscuration of vision, diplopia, pulsatile intracranial tinnitus) or chronic meningitis (eg, persistent low-grade fever, cranial neuropathies, cognitive impairment, lethargy, vomiting). 1997;54(12):1506–1509. Frequency of headache is related to sensitization: a population study. 2002;58(3):354–361. Orphanet J Rare Dis. The stepwise approach to the treatment of headaches follows. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Salamon N, Additionally, they should have primary headache characteristics (Tables 1 through 5).4,5  Criteria for low-risk headaches are listed in Table 6.6 Patients at low risk of serious headache do not require neuroimaging.7, Tension-type headache is the most common form of headache, and affects more than 40 percent of the adult population worldwide.1 It is characterized by bilateral mild to moderate pressure without other associated symptoms.4 Women are affected slightly more often than men.8 Nociceptors in the pericranial myofascial tissues are a likely source of tension headaches.9,10 Several studies have found that individuals who experience chronic tension-type headaches have increased sensitivity to pressure, electrical stimuli, and thermal stimuli in the pericranial myofascial tissue, and can find even normally harmless stimuli painful.10–12 Individuals who meet the criteria for tension-type headache but who have normal neurologic examination results require no additional laboratory testing or neuroimaging.13  Classification criteria for tension-type headaches are listed in Table 2.5. 2008;52(4):407–436. Increased pericranial tenderness, decreased pressure pain threshold, and headache clinical parameters in chronic tension-type headache patients. If the patient has had previous or recurrent headaches, the previous diagnosis (if any) needs to be identified, and whether the current headache is similar or different needs to be determined. Am Fam Physician. Oterino A. Martín R, Schwartz BS, Our Approach to Headaches, Causes and Headache Treatment. Torelli P, Contusions and facial or scalp lacerations increase the likelihood of associated intracranial hemorrhage (Table 75,20–24). Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Godwin SA, A history of human immunodeficiency virus infection or other immunosuppressive conditions in patients with headache may suggest a brain abscess, meningitis, or malignancy of the central nervous system (CNS).21,26 The presence of a coexisting infection in the lungs, sinuses, or orbital areas may precede and cause a CNS infection. 15. 2004;63(3):429. Acad Emerg Med. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. Carotid or vertebral artery dissection (which also causes neck pain), Dental disorders (eg, infection, temporomandibular joint dysfunction), Cerebrospinal fluid leak with low-pressure headache, Hemorrhage (intracerebral hemorrhage, subdural hemorrhage, subarachnoid hemorrhage), Infections (eg, abscess, encephalitis, meningitis, subdural empyema), Meningitis, noninfectious (eg, carcinomatous, chemical), Vascular disorders (eg, ischemic stroke, hemorrhagic stroke, vascular malformations, vasculitis, venous sinus thrombosis), Multiple unilateral orbitotemporal attacks, often at the same time of day, Often with lacrimation, rhinorrhea, facial flushing, or Horner syndrome; restlessness, Unilateral or bilateral and pulsating, lasting 4–72 hours, Usually nausea, photophobia, sonophobia, or osmophobia, Worse with activity, preference to lie in the dark, resolution with sleep, Frequent or continuous, mild, bilateral, and viselike occipital or frontal pain that spreads to entire head, Halos around lights, decreased visual acuity, conjunctival injection, vomiting, Light-headedness, anorexia, nausea, vomiting, fatigue, irritability, difficulty sleeping, In patients who have recently gone to a high altitude (including flying ≥ 6 hours in an airplane), Often exposure to incompletely combusted hydrocarbons (eg, house fires, improperly vented automobiles, gas heaters, furnaces, hot water heaters, wood- or charcoal-burning stoves, kerosene heaters), Symptoms similar to those of idiopathic intracranial hypertension but may begin suddenly, Neuroimaging (preferably MRI with magnetic resonance venography).
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