HEADACHES IN EMERGENCY

DEPARTEMENT
Troeboes Poerwadi
Departement Neurology
Dr Soetomo General Hospital
Airlangga Medical School
1

Introduction
Headache

is a nearly universal
experience
Top complaints in PHC
Some is serious health concern
Life time prevalence of headache: 93%
Severe headache impacting :20%
population
2% of all visits in ED
2

Differential Diagnosis of
Headache
I.
a.
b.
c.
d.
II.
a.
b.
c.
d.

Primary Headaches
Migraine
Cluster
Tension type
Other benign headache
Secondary Headaches
Head/neck trauma
CVD
Intracranial tumor
Intracranial infection

Differential Diagnosis of
Headache
II.
e.
f.
g.
h.
i.

Secondary Headaches (Cont)

CSF abnormalities
Substance abuse or withdrawal
Systemic disease
Disease of extracranial structures
Cranial neuralgia

Headache Danger Signals

History
Sudden onset of new severe headache
Progressive worsening headache
Onset with exertion, coughing, straining, and/or sexual activity
Associated symptoms such as:
Drowsiness, confusion, memory loss
Chronic malaise, myalgia, antralgia
Fever
Progressive visual disturbances
Weakness, clumsiness, loss of balance
Onset of first headache after the age of 50 years

Headache Danger Signals

On examination:
Abnormal vital sign especially fever or hypertension
Altered consciousness or cognition
Meningeal irritation (stiff neck)
Papiloedema or fundal haemorrhage
Pupils unequal and/or poorly reactive
Weakness of sensory loss in face or limbs
Reflex asymetry or abnormal plantar response
Clumsiness or loss of balance
Tender, poorly-pulsatile cranial arteries

Headache Danger Signals

1.
2.
3.
4.
5.
6.

Sudden onset of new, severe headache

Progressively worsening headache
Onset headache after exertion, straining,
coughing or sexual activity
Presence of associated symptoms
Onset of first headache after the age of 50
years
Any abnormality on neurological or general
physical examination
Edmeads J, 1991

Headache Danger Signals

The Washington Manual Neurology Survival Guide, 2004

Headaches that awaken the patient from sleep

Headaches witj particularly sudden onset and explosive

character

New-onset headache in patients > 50 yrs

Headaches associated with focal neurologic deficits,

papilledema or seizures

Any significant change in headache pattern:

Increased intensity

Increased frequency

Change in quality
6.
Headaches that worsen with the Valsava maneuver or
changes in posture

Headache Danger Signals

The Washington Manual Neurology Survival Guide, 2004
7.
Headaches that in context of recent trauma or cervical
manipulation,
8.
Headaches occuring in immunocompromised patient ( eg.
HIV, cancer)
9.
Meningeal signs or symptoms
10.
Symptoms of increased ICP: nausea, vomiting, blurry
vision, decreased sensorium
11.
Headaches that are particulary worse in the morning or
with prolonged recumbency
12.
Any mental status changes
13.
Headaches with sudden onset during sexual activities or
exertion (although benign varieties exist for both)

Indications for the Dx

Evaluation
Nasty Nine
1. First/worst severe headaches
2. Abrupt-onset headache
3. Progressive headache pattern
4. Headache with neurologic symptoms
> 1 hour
5. Abnormal examination finding
10

Indications for the Dx

Evaluation
Nasty Nine
6. Headaches with syncope or seizures
7. New headaches in children < 5 years of
age, adults > 50 years of age
8. New headache in patient with cancer,
immunosuppresion, or preganancy
9. Headaches worsening with exertion, sex,
valsava
Kanlecki R, AAN 2003

11

ED Evaluation - History

1.
2.

Patient with headache of presents to ED:

The headaches is new
Different from former headache in intensity,
quality or refractory to standard treatment
We must separate benign disorders from
the serious secondary headache
Complete & detailed history, thorough
analysis, careful review or prior headaches,
outline past medical history must be done

12

ED Evaluation - History

1.
2.
3.
4.
5.

Specific details which may be helpful:

Lenght of headache history, and
subsequent course
Provocative or palliative factors
Warning symptoms as prodromes or aura
Headache duration,both treated and
untreated
Headache location, quality, intensity, onset,
develompment
13

ED Evaluation - History

6.

7.
8.
9.
10.

Specific details which may be helpful:

Associated symptoms: nausea, sensitivity to
sensory exposures, visual changes, neck
stiffness, tearing or rhinorrhea
Medication or toxin exposure
Postdrome or hangover symptoms
Prior response to medication
Prior testing and results
14

ED Evaluation Physical
Examination
Quick Look Test
Does the patient look well (comfortable),
sick (uncomfortable), or critical (about to
die ?)
Airway and Vital Signs
What is the temperature?
What is the blood pressure?
What is the pulse rate?
15

ED Evaluation Physical
Examination
Selective History and Chart Review
1. What is quality of pain?
2. Where is the located?
3. What time of day do the headaches
occurs?
4. Do warning symptoms occurs before
the headaches begin?
16

ED Evaluation Physical
Examination
Selective History and Chart Review
5.
Do any factors precipate the headaches and what
makes better?
6.
Are any symptoms or associated condition or risk
factor associated with headache?
7.
Is there a history of chronic or recurring
headaches?
8.
Are other any other associated symptoms with
these headaches? ( detailed under Primary
Headache Disiorders)
9.
Do headaches run in family?

17

ED Evaluation Physical
Examination
1.

2.

Head, Eyes, Ears, Nose, Throat (HEENT)

Sinus tenderness (sinusitis)
Temporal artery tenderness ( temporal
arteritis)
Conjunctival injection (cluster headaches)
Neck
Neck muscles spasm (tension headaches)
Meningeal sign (meningitis, SAH)
18

ED Evaluation Physical
Examination
3.

Neurologic Examination
Level of consciousness
Confussion or disorientation
Pupil symmetry
Papil edema and spontaneus venous pulsations)
Retinal hemorhages (flame or subhyloid)
Pronator drifts
Deep tendon and plantar reflexes
Gait

19

Diagnostic Testing
CT scan:
Acute, extremely severe headache (thunderclap
headache)

Headache with progressive onset over days to

weeks that is not similar to previous headaches

Altered mental status (even if intoxicated)

Focal neurologic signs

Papil edema
CT scan: useful in presentations involving trauma or
abrupt headache, acute fracture & hematoma are
best visualized by CT
1.

20

Diagostic Evaluation
2.

3.

MRI scanning
Greater sensitivity&capability of
visualization of the sinuses, posterior fossa,
skull base and preferable for all subacute or
chronic presenta-tions of headache
MRa
May be added in cases where vascular
dissection, malformation, occlusion, or
aneu-rysm is suspected

21

Diagnostic Evaluation
4.

Lumbar puncture
Mandatory in cases possible SAH (whwn
neuroimaging alone is only 90%)
Infectious
Neoplastic meningoencephalitis
Pseudotumor cerebri
CSF should be sent for:cell count, protein,
glucosa, cultures, cytology or special
studies
22

Diagnostic Evaluation
4.

Lumbar puncture
Ct scanning prior to LP is mandatory in
patients with depressed level of consciousness, neurologic focality, papil-ledema
or AIDS, because of the high likelihood of
detecting mass lesion in these patients.
Empirical Rx of suspected meningitis:
ceftriaxone 1 g IV every 12 hours and ampicillin IV 2 g every 6 hours
23

Diagnostic Evaluation
5.

Serum studies
Complete blood count: indicated on patients
with fever, meningismus, or suspected anemia
Erythrocyte sedimentation rate(ESR) should be
check in all individual > age 50 with or different
headache
Carboxyhemoglobin level CO exposure
Arterial blood gases (ABGs) should be
performed in cases hypoxia, hypercapnia or
acidosis
24

Diagnostic Evaluation
EKG and EEG are indicated in cases
headache with any loss of consciousness
7. In cases suspected ocular etiology:
consult to opthalmologist
6.

25

Differential Diagnosis and

Management
A.
1.
2.
3.
4.
5.
6.
7.
8.

Secondary Headache Syndrome

Subarachnoid hemorrahage
Meningoencephalitis
Intracranial mass lesion
Posttraumatic headache
Disorders of CSF volume or flow
Cerebrovascular disease
Inflammatory disorders
Other secondary headache syndrome
26

Differential Diagnosis and

Management
A.
1.

Secondary Headache Syndrome

Subarachnoid hemorrhage [SAH]
Symptom : the worst headache of my life, the abrupt
nature is actually more characteristic than its severity
The abrupt onset of severe occipital or generalized
headache (thunderclap headache) in patient with no
previous history of headache
Syncope or seizure, confussion, neck stiffness, focal
deficits, or coma may be present
Signs of localizing neurologic dysfunction may be absent
Ocular hemorrhage (Subhyaloid hemorrhage)

27

Differential Diagnosis and

Management
A.

Secondary Headache Syndrome

Subarachnoid hemorrhage [SAH]
Approximately half patients have warning
symptoms within a month of rupture,
including generalized headache, cranial
nerve palsies, and setinel bleeding
50% patients with aneurysms have warning
symptoms, usually 6-20 days before SAH

28

Differential Diagnosis and

Management
A.

Secondary Headache Syndrome

Subarachnoid hemorrhage [SAH]
Emergency CT is procedure of choice, but
unremarkable (10% of cases), a lumbar
puncture is mandatoryCSF xanthochromic
Treatment : 60 mg nimodipine po every 4
hours
Neurosurgical consultations will be necessary

29

Differential Diagnosis and

Management
A.

Secondary Headache Syndrome

Subarachnoid hemorrhage [SAH]
Risk factors: hypertension, cigarette smoking, oral
contraceptive, alcohol (debatable), diurnal
variations in blood pressure, pregancy, cocaine
abuse
10-20% patients die before reaching medical care
Mortality is 10% within first few days
Overall mortality 50-60% in the first 30 days after
hemorrhage

30

Differential Diagnosis and

Management
A.
2.

Secondary Headache Syndrome

Meningoencephalitis
Symptoms aside from headache, fever,
neck stiffness, photophobia, nausea, while
the presence of Kernigs and Brudzinskis
sign may help establish meningeal irritation
If suspected CNS infection demands
emergent CT followed by LP

31

Differential Diagnosis and

Management
A.

Secondary Headache Syndrome

Meningoencephalitis
There is a subacute or an acute onset of contant,
increasingly severe pain
The headache is ussualy generalized but may be
worse in the occipital area
It increased with physical activity
Altered conciousness may be present
Photophobia, strasbismus, ptosis, or pupilary
inequality may be present
LP is mandatory

32

Differential Diagnosis and

Management
A.
3.

Secondary Headache Syndrome

Intracranial mass lesions
Cause: epidural &subdural hematoma, brain
abscesses, brain tumors
History of trauma:epidural or subdural
History of infection, and present sub-acutely
Brain tumors may present more chronic
picture
33

Differential Diagnosis and

Management
A.

Secondary Headache Syndrome

Intracranial mass lesions
Complaints of nausea, visual blurring or
obscurations, dizziness, unsteadiness, and
exacerbations of pain activity or valsava
may be noted
Impairment in the level of consciousness,
particularly when accompanied by focal
neurologic findings or papilledema

34

Differential Diagnosis and

Management
A.

Secondary Headache Syndrome

Intracranial mass lesion
The most important diagnostic clue is a
bilateral, nonthrobbing headache that is
worse in the morning
The headache is an initially mild and
intermittent, increasing in severity to steady,
nonthrobbing pain.
It may awaken the patient at night

35

Differential Diagnosis and

Management
A.

Secondary Headache Syndrome

Intracranial mass lesion
It is worse with the Valsava maneuver
When severe, it is associated with vomiting
Papil edema is present earlier
It is often associated with focal neurologic
signs ( asymetric reflexes, palsy of
extraocular muscles, pupilary asymmetry)
36

Differential Diagnosis and

Management
A.
4.

Secondary Headache Syndrome

Posttraumatic headache
Occur after significant head trauma (loss of
conciousness) and have both organic and psychologic
components.
It may be indistinguisable from chronic, recurring tension
headache
The duration is usually no longer than 6 months
May be associated with a sensation of dizziness
It may be part of postconcussionsyndrome, which
characteristic by anxiety, fatique, irritability, and inability to
concentrate

37

Differential Diagnosis and

Management
A.
5.

Secondary Headache Syndrome

Disorders of CSF volume or flow
Hydrocephalus & pseudotumor cerebri may
be present with symptoms and signs of
increased intracranial pressure
Acute obstructive hydrocephalus may be present as: a sudden increased in intracranial
pressure with headache, gait and visual disturbance, incontinence and syncope

38

Differential Diagnosis and

Management
A.

Secondary Headache Syndrome

Disorders of CSF volume or flow
Chronic hydrocephalus andpseudotumor cerebri
present with more subacute pictures
Pseudotumors, or benign intracranial hypertension, often presents as an idiopathic con-dition
in young, overweight women, although it may
associated with pregnancy or the use of vitamin A,
tetracycline, or steroids; papillede-ma, signs of
meningismus and focal neurologic signs such as
sixth nerve palsies may be present

39

Differential Diagnosis and

Management
A.

Secondary Headache Syndrome

Disorders of CSF volume or flow
Acute hydrocephalus is diagnosed by ventriculomegaly on CT and neurosurgical consulta-tion
Pseudotumor is generally diagnosed by an elevated CSF opening pressure following a normal CT, LP is temporarily therapeutic, while a
diuretic as acetolamide should be instituted

40

Differential Diagnosis and

Management
A.

Secondary Headache Syndrome

Disorders of CSF volume or flow
Headache of intracranial hypotension is
characterized by its postural nature. It is
aggravated in the upright position and often
accompanied by nausea, dizziness, visual change,
or neck stiffness
Post LP headache: precipitated by sitting or
standing and relieved promptly by lying down; it
isoften frontal or occipital, may be generalized; it is
occurs within 1 to 2 days of LP cause by leakage of
CSF

41

Differential Diagnosis and

Management
A.
6.

Secondary Headache Syndrome

Cerebrovascular disease:
Either arterial (stroke) or venous (cerebral
vein/sinus thrombosis) may result in acute
headache and neurologic symptoms
The headache rapid develompment, isolation to a
single vascular territory, presence of negative
phenomena without positive component (numbness
without paresthesias, visual loss without
scintlillation), and duration greater than 60 minutes

42

Differential Diagnosis and

Management
A.
6.

Secondary Headache Syndrome

Cerebrovascular disease:
Arterial dissection may be spontaneous or
traumatic in nature, and is more common
among migraineus.
Carotid dissection is severe, periorbital, and
accompanied by anterior neck pain, transient
or persistent neurologic complaints,
ipsilateral carotid bruit or Horners syndrome

43

Differential Diagnosis and

Management
Secondary Headache Syndrome
6. Cerebrovascular disease:

Vertebral dissection often involves posterior

headache that may be unilateral, accompanied
by neck pain and transient or persistent neurologic complaints.
Neuroimaging studies and vascular investigation (angiography, MRA, MRV or ultrasound)
are warranted, and anticoagulation or
thrombo-lytic therapy may be necessary
A.

44

Differential Diagnosis and

Management
A.
7.
a)

Secondary Headache Syndrome

Inflammatory disorders
Giant cell arteritis, or temporal arteritis
The onset of severe, continous unilateral head pain
in an elderly people over age 50-55 and female
Tender swollen nonpulsatile temporal arteries are
often, but not always, present
Approximately half will present with symptoms of
polymyalgia rheumatica: antralgias,myalgias, fever,
night sweats, and weight loss
Elevated ESR often in the range of 50-100
Diagnostic temporal arteritis biopsy

45

Differential Diagnosis and

Management
A.
7.
b)

Secondary Headache Syndrome

Inflammatory disorders
Temporomandibular neuralgia(TM synd)
Unilateral,severe.constant,aching fascial pain
around temporomandibular joint, radiating to the
jaws associated with tenderness over mandibular joints
Pain is exacerbated by movement of the lower
jaws
Associated clicking or grating sound
46

Differential Diagnosis and

Management
A.
7.
b)

Secondary Headache Syndrome

Inflammatory disorders
Temporomandibular neuralgia(TM synd)
May be associated with bruxism during sleep,
depression or insomnia
Commonly in young women or in elderly patients
with severe overbite resulting from the loss of back
teeth
Palpation of the temporalis muscles or direct
pressure on temporomadibular jointspain
X-ray degenerative changes in the cartilage

47

Differential Diagnosis and

Management
A.
7.
c)

Secondary Headache Syndrome

Inflammatory disorders
Acute bacterial sinusitis sinus headache
Frontal, nonthrobbing headache, with fascial tenderness and
pain, purulent or colored nasal discharge with congestion and
often fever
They may uni or bilateral, the location depends on the sinus
involved
Maxillary pain is often in the cheek or upper jaw, ethmoid pain
between the eyes, frontal pain in the forehead, spenoid pain
at the vertex or any cranial location
CT scan more sensitive than plains film

48

Differential Diagnosis and

Management
A.
8.
a)

Secondary Headache Syndrome

Other secondary headache syndrome
Ocular headache: glaucoma, diplopia, orbital tumor or
retroocular inflamation
Feeling heaviness in the eyes, gradually more severe
Its absent on awakening, appears in afternoon and
gradually worsens
Pain may be dull, bursting,sharp,throbbing and its
often due to persistent muscle contraction
The pain is bifrontal or periorbital in location
May be associated with prolonged reading

49

Differential Diagnosis and

Management
A.
8.
b)

Secondary Headache Syndrome

Other secondary headache syndrome
Trigeminal neuralgia (tic douloureux)
Recurrent pain in the distribution of one or more
branches of N.V
Pain radiate to the jaws or teeth and present as a dental
problem
Precipitated by minimal sensory stimuli to the affected
side of the face
It occurs after 40 years of age; suspect MS when the
onset is earlier
There is no sensory loss in the trigeminal distribution; if
there is sensory loss or decreased corneal reflex
maybe tumors or vascular abnormalities
50

Differential Diagnosis and

Management
A.
8.
c)

Secondary Headache Syndrome

Other secondary headache syndrome
Toxic headache
Toxic headache has characteristic as vascular
headache
Cause by drugs: phenacetin, amyl nitrite, reserpine,
lithium, dextroamphetamine, ephedrine, disulfiram,
digitalis, imipramine
May result after excessive intake of alcohol or coffe
May after discontinuation of corticosteroid,
barbiturate, ergot or narcotics
Occupational hazard: insecticides, CO ect
51

Differential Diagnosis and

Management
B.
1.
2.
3.
4.
5.

Primary Headache Syndrome

Tension-type headache
Cluster headache
Migraine headache
Chronic Paroxysmal Hemicrania
Drug Rebound Headache

52

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Tension Type Headache

HIS Diagnostic Criteria
2 of the following pain characteristics:

Pressing / tightening (nonpulsating) quality

Mild or moderate intensity-may inhibit but does not prohibit

activities

Bilateral

Not aggravated by physical activity (eg walking stairs)

Both of the following:

No nausea or vomiting

Photophobia and phonophobia are absent, or one but not the other
is present

53

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Clinical Features of Tension Type Headache

54

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Cluster headaches
IHS Diagnostic Criteria

A> 5 attack B-D

B. Severe unilateral orbital, supraorbital, and /or temporal

pain listing 15-180 mins when untreated

C . Headache is associated with>1 of the following ipsilateral

signs: conjuctival injection, lacrimation, nasal congestion,
rhinorrhea, forehead and facial sweating, miosis, ptosis,
eyelid edema

D.Frequency: Attack occur 1 every other day up to 8 per day

55

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Cluster headaches
1.
Episodic cluster headache:occurs in periods
lasting 7 days to 1 yr, separated by pain-free
periods lasting >14 days
2.
Chronic cluster headache: occurs for > 1 yr
without remission or with remissions lasting < 14
days

56

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Cluster headaches
Additional Features

One unique is a male predominance (9:1)

Typical onset is 20-40 yrs

As detailed above, the classic cluster headache is periorbital

and unilateral, with relatively rapid onset and associated with
sharp and excruciating pain

Cluster refers to distinguishing time course of these

headaches

May be identified in the waiting room

Alcohol is an especially common trigger

57

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Clinical Features of Cluster Headaches

58

Differential Diagnosis and

Management
Primary Headache Syndrome

B.

Migraine Headaches
IHS Diagnostic Criteria
Migraine without Aura
. A.>5 attacks fulfilling criteria B-D
.B.Untreated or unsuccessfully treated headache that last 4-72
hrs
.C.Headache with .2 of the following characteristic:

Unilateral
Pulsating quality
Moderate or severe intensity (interference with daily activities)
Aggravated by routine physical activity (eg.walking up stairs)

59

Differential Diagnosis and

Management
Primary Headache Syndrome

B.

Migraine Headaches
IHS Diagnostic Criteria
Migraine without Aura
. D.During headache,>2 of the following:

Nausea and/for vomiting

Photophobia and phonophobia

.E. >1 of the following:

History and physical exam do not suggest headache

secondary to organic or systemic metabolic disease
History and/or physical exam suggest a secondary disorder
that has been ruled out by appropriate investigations
A secondary disorder is present, but migraine attacks do not
occur for the first time in close temporal relation to the
disorder

60

Differential Diagnosis and

Management
Primary Headache Syndrome

B.

Migraine Headaches
IHS Diagnostic Criteria
Migraine Aura
. A.> 2 attacks fulfilling criterion B
. B.> 3 of the following four characteristics:

> 1 fully reversible aura symptom indicating focal cerebral

cortical and/or brainstem dysfunction
> 1 aura symptom that develops gradually over > 4 mins or
> 2 symptoms occuring in succession
No single aura symptom lasting > 60 secs
Headache follows aura with free interval of < 60 mins. It may
also begin before or stimulataneously with aura

61

Differential Diagnosis and

Management
Primary Headache Syndrome

B.

Migraine Headaches
IHS Diagnostic Criteria
Migraine Aura
. C. > 1 of the following:

History and physical exam do not suggest headaches

secondary to organic or systemic metabolic disease
History and/or physical exam suggest such a disorders, but
it is ruled out by appropriate investigations
Such disorder is present, but migraine attacks do not occur
for the first time in close temporal relation to the disorder

62

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Migraine Headaches
IHS Diagnostic Criteria
Less Common Variants

Opthalmologic migraines: which present with third

nerve palsies, but can affect cranial nerve III-IV

Retinal migraines: rare potentially serious spasms

of retinal artery with corresponding visual loss or
obscuration

63

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Migraine Headaches
Migraine Phases
Prodorme

Occurs in 30-40% of the patients

Lenght may vary in patients from minutes to hours, or

even days

Stereotypical symptoms in patients include vaque

sensations of discomfort, drowsiness, depression,
photophobia, impaired concentration and changes in
bowel or bladder functions

64

Differential Diagnosis and

Management
Primary Headache Syndrome

B.

Migraine Headaches
Migraine Phases
Aura

Visual:
o
o
o
o

Fortification spectra:zigzag lines across the visual field

Scintillating scotoma
Phosphenes: bright flashes of lines
Metamorphopsia: alteration in the size or shape of objects
in the visual field

65

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Migraine Headaches
Migraine Phases
Other common symptoms:

Paresthesia: Cheiro-oral paresthesia refers to the most

common phenomenon of numbness, which begins in
the hand but travels proximally until it reaches the
corner of the mouth

Aphasia

Motor weakness (unilateral)

Dysarthria

66

Differential Diagnosis and

Management

Primary Headache Syndrome

B.

Migraine Headaches
Headache Phases

Pain:
o

Common description include throbbing, dull, boring,

pulsating, and lacinating
More often unilateral, lasting 4-72 hrs in adults

Common associated symptoms include nausea,

vomitting, photophobia, sonophobia, blurry vision,
scalp tenderness, abndominal pain, irratability,
anxiety and depression
The most exacerbating and relieving factors are
physical activity and sleep, respetively

67

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Clinical Features of Migraine Headaches

68

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Chronic Paroxysmal Hemicrania (CPH)

A very rare headache syndrom

CPH resembles cluster headache in that it presents

as multiple, short, severe periorbital headaches that
occurs on a daily basis

The headaches can be associated with autonomic

featuressuch as ipsilateral nasal stuffiness or
rhinorrhoea, ptosis, tearing and/or conjunctival
injection

69

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Chronic Paroxysmal Hemicrania (CPH)

The patient are almost always female

The headache attacks are shorter (average duration 12 minutes) and much more frequent, with attacks
occuring on avarage 14 times per day

The tendency for attacks to cluster is not as

pronouced, and the condition responds completely to
indomethacin, and nothing else

The pathogenisi completely obscure

Referal to a specialist is recommended

70

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Clinical Features of Chronic Paroxysmal Hemicrania

(

71

Differential Diagnosis and

Management
B.
Primary Headache Syndrome
Drug Rebound Headache

Analgesics as being abused by headaches patients and

causing daily headaches if it taken in chronic mannerDRH

Prevalence unknown; analgesic abuse has been estimated at

2 %)

More common in women than in man, probably reflects the

fact that more women suffer from headache than men

Amongst headache patients, it seems about 4% are likely to

be drug absusers (ie taking analgesics or ergotamine every
day)

72

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Drug Rebound Headache

The headache typically persists throughout the whole day, although

it fluctuates in intensity

It is present on waking and described as mild to moderate, dull,

bilateral, frontal-occipital or diffuse.

Headaches are not normally associated with visual disturbances or

autonomic symptoms, but migraine attacks are commonly
superimposed upon the rebound headache with of the usual
symptomatology

Patients self medicate throughout the day, often every 3-4 hrs, since
after that time headache generally worsens as analgesia begins to
wear off

Pain relief, if gained at all, is trasient and rarely complete

73

Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Drug Rebound Headache

Pathogenesis

Dependency on ergotamine or the simple analgesics may have

both a physiological and a psychological component

Ergot has been shown to be active within the CNS, which may
result in a pharmacological dependence

Simple analgesics, frequently formulated in combination with

caffeine and/or opioids which have well documented abuse
potential, are thought, by some, to eventually supress pain control
mechanism after chronic use

DRH should be suspected in all patients who prolonged daily

headaches and especially in those patients who say they have
headache all day, every day

74

Differential Diagnosis and

Management
B.
Primary Headache Syndrome
Drug Rebound Headaches
Management Principles

Prompt and complete withdrawal of the analgesic

If a narcotic analgesics is involved, withdrawal must be gradual and

concomitant use of neuroleptics is common

May require supportive care for some days upon cessation of therapy

May need fluid replacement, use of anti-emetics, hypnotics and sedatives for
up to 14 days

During rebound headache, all analgesics should be avoided

Prevent habituation again

Used a headache diary for the following 2 months

Prognosis

The success rate of withdrawal therapy reported in the literature is between

40-100%, with a mean rate of 70% depending of the time follow up, the drugs
taken and the original type of headache

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Differential Diagnosis and

Management
B.

Primary Headache Syndrome

Clinical Features of Drug Rebound Headache

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Algorithme

77

Algorithme

78

Algorithme

79

Algorithme

80