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Francisco Machado
13/10/97
Headache Study Group 1986 One year prospective study of one family practice.
265 patients presented with a headache.
A very small proportion of headaches are caused by life threatening conditions.
Two main challenges in general practice:
1. To respond to those cues that distinguish patients with life
threatening conditions from those with a functional headache
2. About 16% of patients with functional headache become chronic
sufferers.
There is good reason to believe that a patient centered approach at the
onset is associated with a good outcome.
Assessment of the patient with Headache
The history is the most important part of the assessment of a patient with a
headache.
Important features in the history include:
how long has the patient being having headaches i.e. acute, chronic or
acute
on chronic
frequency
mode of onset
duration
site
severity
description of pain
precipitating factors
warning symptoms
accompanying symptoms
relieving factors
trauma
family history of headaches
Everything must be taken in context of the patients situation i.e. how does the headache affect the patient
At the end of the history, we should have a good idea if the headache is function or organic.
Examination is determined by the history.
Most would measure BP, look in fundi, cranial nerves neck movements, scalp
tenderness in patients over 50.
Factors that make a headache significant include
1. Present on waking
2. Headache increases with coughing, straining
3 A associated neurological symptoms
4. Any associated neuro signs
5. If the characteristics do not suggest migraine or tension headache
Early morning headache
1. Raised intracranial pressure
2. Depression, the patient does not wake with the headache but it starts whilst
in bed.
3. Cervical spondylosis
4. Tension headache classically starts later on in the day but may be present on
waking especially if the patient has had a restless night.
5. Cluster headaches may wake the patient in the night.
Migraine and the pill
A woman of 20 has increasingly severe migraine. She smokes and takes the COC
pill. She will not contemplate any other form of contraception. Is she at risk?
How would you advise?
Yes at risk
It is very common for migraine to be more frequent and more severe.
If focal symptoms occur most women will stop the pill.
If the migraine is worse, provided no severe focal symptoms, the risks of stoke
are small. Might try a low dose pill or change to POP.
She should also stop smoking.
But if she develops focal symtoms including aura she is at increased risk of a
thrombotic stroke and she should stop COC. Any woman who develops migraine de
novo should stop the COC
Headaches in children
Common presenting feature. In adolescents tends to signify a benign problem,
but in a young child it is less common and is more likely to be caused by a
serious problem
Tension type headaches are uncommon before adolescence
Features that indicate specialist referral include:
1. Any headache that occurs more than twice a week
2. Unilateral headache without other classical migraine features
3. Occipital headache as a constant feature
4. Any headache with abnormal neurological signs (excluding migraine features)
5. Headache consistently present in the early morning
6. Headache that is consistently made worse by change in position or sudden
movement.
Short notes on Migraine
15-18% of females and 6% of males have migraine
Principles of management
Food Chocolate, cheese red wine,
citrus fruits,
monosodium glutamate
Lack of food or fluids
Lack of sleep
Stress or relaxation after a
bad day
Cervical spondylosis,
malocclusion
Exercise and sex
Environmental factors Cold, wind, heat, noise, smells
Hormones mentrual headaches
4. Acute treatment
5. Prohylaxis
Refs
Gruffydd-Jones Effective treatments for migraine. Practioner 241 Sep 1997
McWhinney A Textbook of Family Medicine
Compiled by Francisco Machado
13/10/97