Headache+One-Pager

**History:** Age at onset Presence or absence of aura and prodrome Frequency, intensity and duration of attack Number of headache days per month Time and mode of onset Quality, site, and radiation of pain Associated symptoms and abnormalities Family history of migraine Precipitating and relieving factors Effect of activity on pain Relationship with food/alcohol Response to any previous treatment Any recent change in vision Association with recent trauma Any recent changes in sleep, exercise, weight, or diet <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">State of general health <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Change in work or lifestyle (disability) <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Change in method of birth control (women) <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Possible association with environmental factors <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Effects of menstrual cycle and exogenous hormones (women)

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 8px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;"><span style="font-family: Times New Roman; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">**Brief Headache Screen:** //Daily/3-4 days per week/ 1-2 days per week/ 1-3 days per month/ 1x a month to 1x per year/almost never// <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;"> 1. How often do you get severe headaches (ie, without treatment it is difficult to function)? <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">2. How often do you get other (milder) headaches? <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;"> 3. How often do you take headache relievers or pain pills? <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;"> 4. Has there been any recent change in your headaches? <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 8px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">//Presence of episodic disabling headache correctly identified migraine in 93% with episodic migraine and 78% with chronic headache with migraine.//

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">**Physical Exam:** <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">BP/Pulse <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Bruit at neck, evaluate eyes, and head for clinical signs of AVM <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Palpate the head, neck, and shoulder regions <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Check temporal and neck arteries <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Examine the spine and neck muscles <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">A functional neurologic examination including getting up from a seated position without any support, walking on tiptoes and heels, cranial nerve examination, **fundoscopy** and otoscopy, tandem gait and Romberg test, and symmetry on motor, sensory, reflex and cerebellar (coordination) tests, Plantar reflex(to evaluate UMN)

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">**Warning signs on EXAM**: <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Neck stiffness/meningismus <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Papilledema suggests the presence of an intracranial mass lesion, benign intracranial hypertension (pseudotumor cerebri), encephalitis, or meningitis <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Focal neurologic signs suggest an intracranial mass lesion, arteriovenous malformation, or collagen vascular disease

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">**Characteristics of headache with serious underlying pathology:**

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px; text-indent: 36px;"> **History:** <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px; text-indent: 36px;"> **Physical examination:**
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Explosive onset and severe at onset ||
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">No similar headaches in the past ||
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Concomitant infection ||
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Altered mental status ||
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Headache with exertion ||
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Age over 50 ||
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Immunosuppression ||
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Neurologic abnormalities ||
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Decreased level of consciousness ||
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Meningismus ||
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Toxic appearance ||
 * <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Papilledema ||

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">**Imaging Indicated in:** <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Nonacute headache + unexplained abnormal finding on neurologic examination. <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Unclear indication with absence of neurologic symptoms (eg, headache worsened by Valsalva, causing awakening from sleep, new headache in older population, or progressively worsening headache). <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Not warranted for patients with migraine and a normal neurologic examination, unless patient has atypical migraine features <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Recent significant change in the pattern, frequency or severity of headaches <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Progressive worsening of headache despite appropriate therapy <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Focal neurologic signs or symptoms <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Onset of headache with exertion, cough, or sexual activity <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Orbital bruit <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">Onset of headache after age 40 years <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;"> <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 5px 0px;">**Once you have ruled out a Life Threatening Headache move on to Diagnosis and Treatment:**

<span style="font-family: Times; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**Primary** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Tension-type <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Migraine <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Cluster

<span style="font-family: Times; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**Secondary(2% of HA)** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Meningitis <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">SAH <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Tumor <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Stroke/TIA <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Temporal Arteritis

<span style="font-family: Times; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**Recognizing the pattern of primary HA** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">+FH <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">stereotypic headache pattern over time <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Menstrual association <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Prodromes and/or aura <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Resolution with sleep <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Changing location of HA <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Otherwise healthy

<span style="font-family: Times; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**1. Tension-type HA:** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**At least 10 previous episodes from 30 minutes to 7 days characterized by at least 2 of the following pain characteristics:** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Pressing,tightening, non pulsatile quality <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Mild or moderate intensity (may inhibit but does not prohibit activity) <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Bilateral location <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Not aggravated by routine physical activity

<span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**And both of the following:** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">No n/v <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Photophobia or phonophobia may be present but not both

<span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Chronic version 15d/month add nausea

<span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**Risk Factors for tension HA:** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Musculoskeletal condition <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Stress <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Anxiety <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Fatigue <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Anger <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Poor posture/ergonomics

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">**Tension HA Treatment:** <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">__Episodic:__ <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Tylenol, NSAID, caffeine <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Butalbital/narcotics

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">__Chronic:__ <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Amitriptyline, mirtazapine <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Stretching, massage, exercise, ergonomic adjustment <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Mind-body tx <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">-biofeedback <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">-CBT <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">-stress management and relaxation training <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Beware of prolonged use of narcotics b/c can get rebound HA and dependence

<span style="font-family: Times; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**2. Migraine without Aura:** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**At least 5 headache attacks lasting 4-72 hours characterized by at least two of the following characteristics:** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Unilateral pain <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">throbbing/pulsatile <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">moderate to severe in intensity <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">aggravation by routine activity <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**In addition at least 1 of the following:** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">nausea +/- vomiting <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">photophobia and /or phonophobia <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Diagnosis should include at least 5 previous attacks and no evidence of underlying disease

<span style="font-family: Times; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**3. Migraine with aura:** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**Headache follows attacks. Fulfilling at least 3 of the following:** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">1 or more fully reversible visual symptoms with either positive or negative features, and also includes sensory or speech symptoms <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">At least 1 aura symptoms develops gradually over more than 4 minutes or 2 or more symptoms occur in succession <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">No aura symptom lasts more than 60 minute <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Headache follows aura with a free interval of less than 60 minutes (May also begin simultaneously with the aura)

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">**Risk Factors for Migraine HA:** <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Hormonal fluctuations <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Chronobiologic/abrupt changes <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Vasodilator use <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Drugs <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Sensory input <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Emotional stress <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Trauma-emotional/physical

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;"> With Diagnosis of Migraine: <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Depression is 3x more common <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Anxiety and panic dx are 6-8x more common <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">IBS 8x more common <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Stroke 4x more common

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">**Migraine Treatment:** <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">__**Prodrome:**__ Tylenol, high dose NSAID

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">__**Abortive therapy:**__ <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Triptans(Sumatriptan) <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">DHE <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Tylenol <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">NSAID <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Phenothiazines: Metoclopromide IV or IM <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Valproic acid <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Opiods: avoid if possible can develop chronic migraine after receiving parenteral opiods <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Magnesium sulfate: 1 g loading dose <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Olanzapine: 10mg dose <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px; text-indent: 36px;">**Other options:** <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Injection/block: occipital nerve block, trigger point, botox <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Occipital nerve stimulator <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">PT/Mind body <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Alternative: Petadolex( petasites hybridus, butterbur) magnesium, feverfew, riboflavin(B2), coenzyme Q10 <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">NO MELATONIN <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Hormone manipulation: decrease estrogen drop at menopause, DO NOT USE IN MIGRAINE WITH AURA

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">__**Prophylactic:**__ <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Inderal 60-240mg daily <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Depakote 250mg BID <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Amitriptyline/Nortriptyline 10-100mg qhs <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Verapamil 180-240mg Daily <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Naproxen 500mg BID <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Neurontin 100-600mg TID

<span style="font-family: Times; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**4. Cluster HA:** <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">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 <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Conjunctival injection <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Lacrimation <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Nasal congestion <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Rhinorrhoea <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Forehead and facial sweating <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Miosis <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Ptosis <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Eyelid edema

<span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Associated factors: 9:1male to female, may have seasonal variations, usually no n/v, restlessness and agitation

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">**Risk factors Cluster HA:** <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">ETOH <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Cig <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Cold wind exposure <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Heat blown in face <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Seasonal

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 12px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">**Cluster HA treatment:** <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">__**Acute:**__ <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">high flow oxygen 10L/min for 10min or 7L/min for 15min <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">oral medications usually ineffective <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">injectable sumatriptan 6mg SQ <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">DHE 1mg SQ/IM/IV/intranasal <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">intranasal lidocaine- 1ml of 10% via cotton swab

<span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">__**Non acute:**__ <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Verapamil 360-480mg/day <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Lithium 900mg QD <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Depakote 250mg BID <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Prednisone 60mg daily and taper over 2-3 wks for new/recurrent cluster headache <span style="font-family: Times New Roman; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0px;">Anti-seizure medication: topiramate, gabapentin

<span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">**Sinus HA:** <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Not a primary HA <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Frequent migraine misdiagnosis <span style="font-family: Times; font-size-adjust: none; font-size: 10px; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal; margin: 0.1px 0px;">Presents with fever, purulent nasal d/c, acute sinusitis

Links: Headache Progress Note:

Headache diary: http://www.headaches.org/For_ Professionals/Headache_Diary

Excercises For Migraine: http://www. straightenupamerica.org/ Handouts/Handouts.html

AAFP Articles: http://www.aafp.org/afp/ topicModules/viewTopicModule. htm?topicModuleId=10