case discussion : headache

“headache”

CC: ปวดศรีษะขา้งซา้ย มา 1 วนั กอ่นมาโรงพยาบาล

PI: 1 วนักอ่นมา รพ. ขณะน่ังดูทวี ี มอีาการปวดศรีษะขา้งซา้ย บริเวณขมบัซา้ยไลม่าตามเบา้ตา ปวดตุบ๊ๆ ไมม่ปีวดรา้วไปไหน

ร่วมกบัมคีล่ืนไส ้ แตไ่มม่อีาเจยีน ปวดพอทนได ้ปวดเทา่ๆเดิม

ตลอด เป็นอยู ่2-3 ชัว่โมง ไมม่ไีข ้ไมม่นี ้ามูกน ้าตาไหล ไมม่เีหน็

แสงวูบวาบ,ภาพบดิเบี้ยว,ภาพซอ้น กอ่นปวด ไมม่ชีา ไมอ่อ่นแรง

ไมเ่คยปวดเชน่น้ีมากอ่น กนิยาพาราแลว้ไมด่ข้ึีน นอนพกั 1 ชัว่โมง

แลว้ดข้ึีนเลก็นอ้ย กนิยาแกป้วดไมเกรนของภรรยาแลว้ดข้ึีน คดิวา่

ตวัเองเป็นไมเกรนจึงมา รพ.

PH:

No U/D

No food and drug allergy

No smoking, social drinking

FH:

No FH of migraine

PE:

V/S : BP 118/70 mmHg, PR 75/min, RR 15/min,

BT 36.9 *C

HEENT : not pale , anicteric sclera

Heart & Lungs & Abdomen : WNL

Neurological examination

Eye ground : cannot be evaluated (no

ophthalmoscope)

Cranial nerve :

CN II : pupils 3 mm BRTL

CN III,IV,VI : full ROM

CN V : normal sensation , no weakness of

masseter and pterygoid muscle

CN VII : no facial palsy

CN VIII : normal hearing by speaking

CN IX,X : normal gag reflex

CN XI :no weakness of Trapezius and SCM

CN XII : no tongue deviation

Sensory : grossly intact

Motor power grade : V all extremities

DTR 2+ all

Babinski sign : planter respond both sides

Clonus : negative

Meningeal irritate sign : no stiffness of neck

Cerebellar sign : Finger to nose, Tandem gait, Heal to knee to chin : normal

Problem : Unilateral pulsating headache

No red flag signs & symptomso Age > 50

o Progressive course

o Sudden & severe onset

o Pattern changeo Abnormal physical examination

1. Migraine

2. Tension

3. Cluster

4. Other primary headaches 4.1. Primary stabbing headache

4.2. Primary cough headache

4.3. Primary exertional headache

4.4. Primary headache associated with sexual activity

4.5. Hypnic headache

4.6. Primary thunderclap headache

4.7. Hemicrania continua

4.8. New daily-persistent headache (NDPH)

A. At least five headache attacks lasting 4 - 72 hours (untreated or unsuccessfully treated), which has at least two of the four following characteristics:

1. Unilateral location

2. Pulsating quality

3. Moderate or severe intensity (inhibits or prohibits daily activities)

4. Aggravated by walking stairs or similar routine physical activity

B. During headache at least one of the two following symptoms occur:

1. Phonophobia and photophobia

2. Nausea and/or vomiting

A. At least five headache attacks lasting 4 - 72 hours (untreated or unsuccessfully treated), which has at least two of the four following characteristics:

1. Unilateral location

2. Pulsating quality

3. Moderate or severe intensity (inhibits or prohibits daily activities)

4. Aggravated by walking stairs or similar routine physical activity

B. During headache at least one of the two following symptoms occur:

1. Phonophobia and photophobia

2. Nausea and/or vomiting

A. At least five headache attacks lasting 4 - 72 hours (untreated or unsuccessfully treated), which has at least two of the four following characteristics:

1. Unilateral location

2. Pulsating quality

3. Moderate or severe intensity (inhibits or prohibits daily activities)

4. Aggravated by walking stairs or similar routine physical activity

B. During headache at least one of the two following symptoms occur:

1. Phonophobia and photophobia

2. Nausea and/or vomiting

A. At least two attacks fulfilling with at least three of the following: 1. One or more fully reversible aura symptoms indicating focal

cerebral cortical and/or brain stem functions

2. At least one aura symptom develops gradually over more than four minutes, or two or more symptoms occur in succession

3. No aura symptom lasts more than 60 minutes; if more than one aura symptom is present, accepted duration is proportionally increased

4. Headache follows aura with free interval of at least 60 minutes (it may also simultaneously begin with the aura

B. At least one of the following aura features establishes a diagnosis of migraine with typical aura: 1. Homonymous visual disturbance

2. Unilateral paresthesias and/or numbness

3. Unilateral weakness

4. Aphasia or unclassifiable speech difficulty

A. Headache lasting from 30 minutes to

seven days

B. At least two of the following criteria:

1. Pressing/tightening (non-pulsatile) quality

2. Mild or moderate intensity (may inhibit, but

does not prohibit activity

3. Bilateral location

4. No aggravation by walking, stairs or similar

routine physical activity

C . Both of the following:

1. No nausea or vomiting (anorexia may occur)

2. Photophobia and phonophobia are absent, or

one but not both are present

A. Headache lasting from 30 minutes to

seven days

B. At least two of the following criteria:

1. Pressing/tightening (non-pulsatile) quality

2. Mild or moderate intensity (may inhibit, but

does not prohibit activity

3. Bilateral location

4. No aggravation by walking, stairs or similar

routine physical activity

C . Both of the following:

1. No nausea or vomiting (anorexia may occur)

2. Photophobia and phonophobia are absent, or

one but not both are present

A. At least five attacks of severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes untreated, with one or more of the following signs occurring on the same side as the pain 1. Conjunctival injection

2. Lacrimation

3. Nasal congestion

4. Rhinorrhoea

5. Forehead and facial sweating

6. Miosis

7. Ptosis

8. Eyelid oedema

B . Frequency of attacks from one every other day to eight per day

A. At least five attacks of severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes untreated, with one or more of the following signs occurring on the same side as the pain 1. Conjunctival injection

2. Lacrimation

3. Nasal congestion

4. Rhinorrhoea

5. Forehead and facial sweating

6. Miosis

7. Ptosis

8. Eyelid oedema

B . Frequency of attacks from one every other day to eight per day

Migraine without aura

American Academy of Family Physicians

Ibuprofen (400 mg)

Sig 1 tab T.I.D with meal

Ergotamine (1 mg)

Sig 1 tab PO O.D. prn for pain

Flunarizine (5 mg)

Sig 1 cap PO h.s.

Ibuprofen (400 mg)

Sig 1 tab T.I.D with meal

Non-specific medical used

Migraine-Specific medication

Triptans : selective 5-HT agonist

Ergotamine : partial 5-HT1d agonist

Ergotamine (1 mg)

Sig 1 tab PO O.D. prn for pain

2012 American Headache Society

Flunarizine (5 mg)Sig 1 cap PO h.s.