The Essentials 4th Edition

Section 1

Background (Headache)

Epidemiology 

• In Saudi Arabia, a comprehensive cross sectional study reported an adjusted one year prevalence of 65.8% for all headache types. Specifically, the prevalence rates were 34.1% for tension type headache, 25% for migraine, and 2% for medication overuse headache. 
• Although cluster headache remains an uncommon with a prevalence of <1 % → It typically leads to significant disability and requires medical attention. 

ICHD-3 criteria for primary headache types

ICHD-3 criteria for primary headache types

Clinicians can quickly become familiar with the most common primary headache disorders and how to distinguish them (Table 3). The diagnostic criteria for primary headache types by ICHD-3 criteria (Migraine, tension-type headache (TTH) or cluster headaches) are as follows:

Migraine without aura 

1. At least 5 attacks fulfilling criteria 2 and 3
2. Headache attacks lasting 4–72 hours (when left untreated or unsuccessfully treated)  
3. Headache has ≥  2/4 of the following:    - Unilateral in location - Pulsating in quality - Moderate or severe pain in intensity - Aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)

1. During the headache, at least 1 of the following symptoms:  - Nausea and/or vomiting - Photophobia and phonophobia 
2. No other explanation for this pain 

Migraine with aura 

1. At least 2 attacks fulfilling criteria 2 and 3

2. One or more of the following fully reversible aura symptoms: -Visual (flickering lights, spots, lines) or loss of vision - Sensory (pins and needles, or numbness) - Speech and/or language (fully reversible dysphasic speech disturbance) - Motor (but not weakness) - Brainstem - Retinal 
3. At least ≥ 3/6 of the following: -At least one aura symptom that spreads gradually over ≥5 minutes  - ≥ 2 aura symptoms occur in succession - Each aura symptom lasts 5–60 minutes - At least one aura symptom is unilateral - At least one aura symptom is positive - The aura is accompanied, or followed by headache within 60 minutes
4. No other explanation for this pain 

POUND mnemonic for migraine headache: 

          Pulsatile 

          One-day duration 

          Unilateral 

          Nausea or vomiting 

          Disabling 

Features of migraine in children and adolescents

• Attacks may last 2 to 72 hours
• Headache is more often bilateral than in adults; an adult pattern of unilateral pain usually emerges in late adolescence or early adulthood
• Photophobia and phonophobia may be inferred by behavior in young children

Tension-type headache (TTH) 

1. At least 10 episodes of headache occurring on < 1 day/month on average (<12 days/year) and fulfilling criteria 2 and 3
2. Lasting from 30 minutes to 7 days
3. At least ≥ 2/4 of the following: - Bilateral location - Pressing or tightening (non-pulsating) quality - Mild or moderate intensity - Not aggravated by routine physical activity such as walking or climbing stairs
4. Both of the following: - No nausea or vomiting - No more than one of photophobia or phonophobia
5. No other explanation for this pain  

Trigeminal autonomic cephalalgias (Cluster Headache)

1. At least 5 attacks fulfilling criteria 2 and 4
2. Severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15-180 minutes (when untreated)
3. At least one of the following symptoms or signs, ipsilateral to the headache: - Conjunctival injection and/or lacrimation - Nasal congestion and/or rhinorrhea - Eyelid edema - Forehead and facial sweating - Miosis and/or ptosis - A sense of restlessness or agitation 
4. Occurring with a frequency between one every other day and 8 per day

5. No other explanation for this pain 

References: 

1. Al Jumah M, Al Khathaami AM, Kojan S, Hussain M, Thomas H, Steiner TJ. The prevalence of primary headache disorders in Saudi Arabia: a cross-sectional population-based study. The Journal of Headache and Pain. 2020 Feb 7;21(1).  DOI: 10.1186/s10194-020-1081-1

2. Benamer HT, Deleu D, Grosset D. Epidemiology of headache in Arab countries. J Headache Pain. 2010;11(1):1-3. doi:10.1007/s10194-009-0173-8
3. 1. Chawla J. Migraine Headache: Practice Essentials, Background, Pathophysiology [Internet]. Medscape.com. 2019. Available from: https://emedicine.medscape.com/article/1142556-overview 
4. 1. Migraine Headache: Practice Essentials, Background, Pathophysiology. eMedicine [Internet]. 2021 Oct 16 [cited 2022 Sep 10]; Available from: https://emedicine.medscape.com/article/1142556-overview?src=mbl_msp_iphone#a4.  
5. Gaul C, Meßlinger K, Holle-Lee D, Neeb L. Pathophysiologie von Kopfschmerzerkrankungen [Pathophysiology of Headaches]. Dtsch Med Wochenschr. 2017;142(6):402-408. doi:10.1055/s-0042-111694
6. 1. Stephens G, Derry S, Moore RA. Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache in adults. Cochrane Database of Systematic Reviews. 2016 Jun 16;
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8. Ihsclassification. Classification - ICHD-3 The International Classification of Headache Disorders 3rd edition [Internet]. ICHD-3 The International Classification of Headache Disorders 3rd edition. 2016. Available from: https://ichd-3.org/classification-outline/
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10. Ha H, Gonzalez A. Migraine Headache Prophylaxis. Am Fam Physician. 2019;99(1):17-24.
11. Ford B, Dore M, Harris E. Outpatient Primary Care Management of Headaches: Guidelines from the VA/DoD. Am Fam Physician. 2021;104(3):316-320.
12. https://www.uptodate.com/contents/pathophysiology-clinical-manifestations-and-diagnosis-of-migraine-in-adults 
13. https://www.uptodate.com/contents/medication-overuse-headache-etiology-clinical-features-and-diagnosis
14. https://www.uptodate.com/contents/post-dural-puncture-headache?search=post%20puncture%20headache&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1010412474
15. https://www.uptodate.com/contents/evaluation-of-headache-in-adults#H574564343
16. https://www.aafp.org/pubs/afp/issues/1998/1115/p1785.html
17. https://www.aafp.org/pubs/afp/issues/2012/0301/p447.html
18.  https://www.uptodate.com/contents/post-dural-puncture-headache? search=post%20dural%20puncture%20headache&source=search_result&selected Title=1~61&usage_type=default&display_rank=1
19. https://www.uptodate.com/contents/headache-during-pregnancy-and-postpartum#H3
20. https://www.aafp.org/pubs/afp/issues/2011/0201/p271.html
21. https://www.uptodate.com/contents/headache-during-pregnancy-and-postpartum#:~:text=For%20patients%20with%20new%20onset,of%20gestation%20with%20a%20headache.
22. https://www.aafp.org/pubs/afp/issues/2023/0700/practice-guidelines-headache-pregnancy-breastfeeding.html