Pain Management for Headache

Ranjan Kumar Pain Clinic, Persahabatan Hospital

Jakarta

Headaches

• Headache is one among the most commonreasons patients seek medical attention.

• The gold standard for diagnosis and management of headache is a carefulinterview supported by neurological andgeneral medical examinations

(De Luca and Bartleson, 2010).(International HeadacheSociety Classification Subcommittee, 2004).

Common causes of headache

Primary headache• Tension –type 69%• Migraine 16%• Idiopathic• Stabbing 2%• Exertional 1%• Cluster 0,1%

Secondary headache• Systemic infection 63%• Head injury 4%• Vascular disorders 1%• Subarachnoid hemorrhage

< 1%• Brain tumor 0,1%

Evaluation of headache. Bhavna Rote.Clinical methods in Pain Medicine. 2nd edition.Gautam Das, 2017. hal :23-37

Various structures, which can bethe pain generators or source of pain for headache.

Evaluation of headache. Bhavna Rote.Clinical methods in Pain Medicine. 2nd edition.GautamDas, 2017. hal :23-37

Classification of headaches

Primary(those not associated

with an underlying pathology)

Migraine

Tension Type

Cluster headaches

Secondary(those attributed to an underlying pathologic

condition)

infectious

neoplastic

Vascular, drug induced,

idiopathic.

Painful cranial neuropathies, other facial pains n other headaches

• By 1988, recognizing the need for improvement in headache classification, the International Headache Society (IHS) published a new system, the second edition of the International Headache Classification (ICHD-2)

• Recently International Headache Societyhad published ICHD, 3rd edition (beta version)

Primary headache

Migraine headache

Chronic neurologic disorder

Episodic attacks of head pain

And associated symptoms

Prevalence in US Women 18%

Men 6%

Estimated to be approximately 50%

Never seek medical advices

Treat themselves

Diagnostic criteria for 1.2 migrain with auraDiagnostic criteria for 1.1 migrain without aura

Headache. A pocket guide of pain management. Copyright 2010. Inflexxion.Hal 65-77

Tension-type headache

Most common type

Prevalence of episodic type vary widely

(30-80%)

Studies shown-25% of TTH

have migraine-62% of

migraineurs have TTH

The headache classification (modified) ICHD-3 code

Diagnostic criteria for tension-type headache (TTH)

Headache. A pocket guide of pain management. Copyright 2010. Inflexxion.Hal 65-77

Cluster headache

Strictly unilateral headache

Usually occuring once or few times a day at

characteristic timeLasting for 15-180

minutes

Occuring in a series which last from several weeks to several months

Third major type of primary headache

More frequent in men than women ( 5x )

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Diagnostic criteria for cluster headache

Diagnostic criteria for Episodic and Chronic cluster headache

Autonomic characteristics of cluster headache

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(IHS criteria)

Secondary Headache• attributed to an underlying pathologic

condition :---Head and/or neck trauma.---Cranial or cervical vascular disorder ---Cranial nonvascular disorder---Infection.---Disorder of the cranium, neck, eyes, ears, nose, sinuses,

teeth, mouth, or other facial or cranial structure .---Psychiatric disorder

Painful cranial neuropathies and other facial pains

• Trigeminal neuralgia• Glossopharyngeal neuralgia• Nervus intermedius (facial nerve) neuralgia• Occipital neuralgia• Optic neuritis• Headache attributed to ischemic ocular motor

nerve palsy

• Tolosa hunt syndrome• Paratrigeminal oculosympathetic (Raeder’s)

syndrome.• Recurrent painful opthalmoplegic neuropathy.• Burning mouth syndrome (BMS).• Persistent Idiopathic facial pain (PIFP)• Central neuropathic pain

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Unilateral severe painFelt in the distribution of the glossopharyngeal nerve, auricular n pharyngeal branches of the vagus

nerve.Occurs in the ear, posterior third of the tongue n tonsillar fossa.

Rare, 1/100 as common TN.Most frequently in middle aged men n women.

Majority idiopathic or related to neurovascular compression of cranial nerves.Tx, carbamazepine/gabapentin, intervention or surgical.

Glossopharyngeal neuralgia

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Characterized by sharp pain originating in the back of the head.Pain radiating into the distribution pof GON n LON n sometimes into the eye.Most cases are unilateral.Causes : idiopathic, trauma/compression to involved nerves.Tx : antiepileptic agents (1st line), intervention or surgical.

Occipital neuralgia

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Diagnosis is the most important part in any branch of clinical practice for management of patient’s complains.

To reach the diagnosis1. Proper history2. Clinical examination3. Investigations

special subheading under investigation part, called diagnostic interventions or diagnostic nerve blocks which help us in finding pain generators.

Patient’S history•Age of onset,location,pain intensity,progression, character, duration,frequency,aggravating n relieving factors, associated features, aura symptoms, impact of daily activity.

Headache history

•Familial hemiplegic migraine•Secondary headaches

Family history

•Investigations•Medications•Any changes of character or pattern.

Past history of headache

Medicinal history

Comorbidities

Some medicines itself can cause headache: oral contraseptives, hormone replacement therapy, antihistamin,nitrate, etc. Medication overuse.,

History of Cancer, head trauma, asthma,high blood pressure,depression, Insomnia,Infection of dental, nose, ears.

Physical Examination

• General examination• Systemic examination : --CNSàhigher function

àInspectionàpalpation of head, face and neckàpercussionàauscultationàcranial nerve examination (N I-N XII)

-body habitus-blood pressure-fever-skin changes

Memory,Concentration,Speech,Orientation

Investigation

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References• 1. Evaluation of headache. Bhavna Rote.Clinical methods in Pain Medicine. 2nd

edition.Gautam Das, 2017. hal :23-37• 2.Painful Disease States: Headaches. Brinder Vij and Stewart J.Tepper.

Fundamentals of Pain medicine. Springer International Publishing AG 2018. hal 281-290

• 3.Specific Clinical Situations. Acute Pain Management: Scientific Evidence. Australian and New Zealand College of Anesthetics and Pain Medicine. 4th edition.Acute Pain Management: Scientific Evidence.2015. hal 317-327.

• 4.Evaluation of headache. Zachary McCormick and Rajiv Reddy. Treatment of chronic pain conditions. Springer science and Bussiness media LLC 2017. Hal 25-28

• 5.Pain Management Secrets. 4th edition. Elsevier 2018.• 6.Headache. A pocket guide of pain management. Copyright 2010. Inflexxion.Hal

65-77