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H

EADACHE
DISORDERS:
Approach to
Non-Migraine
The Foundation Types
for Medical Headaches are associated with a significant decrease
in quality of life. Most headache consultations (80%)
Practice occur in primary care. Since two common headache
types, tension-type headache (TTH) and migraine,
Education often share common presentations, this complicates
a definitive diagnosis. In addition, a small percentage
of headaches which are associated with neurologic
emergencies, raises the issue of suitable investigation.
Experience A systematic approach to the specific diagnosis of
headache can assist the clinician in solving these
Expérience clinical dilemmas and provide direction for selecting
appropriate and effective treatment.

Practice Learning PRACTICE CHALLENGES


Integration Objectives • Detection of potentially serious headaches relies
on detailed history and physical examination,
Intégration dans Objectifs which may be difficult to accomplish in a busy
la pratique d’apprentissage primary care practice.
• Presentations of non-specific headache may
New be complex, thereby complicating an accurate
Knowledge diagnosis and appropriate management.
• Chronic daily headache (diagnosis and, especially,
management) continues to be a challenge in the
Nouvelles primary care environment.
connaissances
This module provides the primary healthcare practitioner
with:
• Warning signs of potentially serious secondary
La Fondation headaches
• A practical approach to the diagnosis of non-
pour l’éducation specific headache presentations
• An overview of diagnosis and management of
médicale continue chronic daily headache.

Note: This module focuses on non-migraine headache


disorders. Insofar as tension-type headache is defined
to a large extent by its differences from migraine,
Practice Based Learning Programs (PBLP) migraine is also briefly discussed in comparison.
Programmes d’apprentissage
basé sur la pratique (PABP)
McMaster University
1280 Main Street West  DTC Basement
Hamilton  Ontario  Canada L8S 4L8
EDUCATIONAL MODULE Vol. 18(10), August 2010
Tel: 905-525-9140 ext./poste 22219  1-800-661-3249
© The Foundation for Medical Practice Education
Fax: 905-540-4988
Email: fmpe@mcmaster.ca
Electronic Copy - Resident Use Only
Website: www.fmpe.org
Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010

How would you manage Katie?


CASES

Case 1: Daciana, 27 years old, female

Daciana presents for the third time this year with “sinus”
headache. She had previously been given antibiotics,
resulting in gradual headache relief over a week or two.
Daciana is expecting the same prescription and results Case 3: John, 52 years old, male
again. She has no nasal discharge or fever, and she
didn’t have a cold before this headache started. The John, a teacher, presents with a history of a post-coital
headache is behind her eyes and in her forehead and headache that he describes as a “thunderclap” headache,
has been fairly constant for the last 10 days or so. There which occurred the day before this appointment. He says
is no nausea, vomiting, aura or neurological symptoms, this was the worst headache he’s ever had and rates it
with the exception of slight photophobia. as an intensity of 9 on a scale of 1 to 10. It lasted the
entire day, but has now completely gone. He could not
Blood pressure is normal. Fundi are normal. There is get an appointment yesterday, so he took ibuprofen, 800
tenderness over the forehead and on the orbital rims mg, every six hours. The medication had no appreciable
but not specifically over the sinuses. You notice marked effect on the headache, which “seemed to resolve on
tenderness at the occipital insertion of the paraspinal its own.”
muscles of the neck. The flexion/rotation test reveals
only about 30 degree rotation bilaterally with end range His vital signs are stable, he has no neck stiffness, and
discomfort. You ask Daciana about her neck posture his neurological examination is normal. John has a history
at work and at home. She mentions she often watches of tension headaches, hypertension, and a 20-pack-year
television in bed before going to sleep, with two pillows smoking history. He has never been imaged in the past.
rolled up behind her head. He has no family history of migraine or aneurysm.

What would be your diagnosis? What additional information would you seek?

How would you treat Daciana? How would you handle this case at this juncture?

Case 2: Katie, 43 years old, female


INFORMATION SECTION
Katie is a writer with one book published and one in the
works. For the past five years, she has been suffering CLASSIFICATION
from chronic headaches on most days of the week. The
headaches tend to start in the middle of the day and last 1. The second edition of the International Classification
4 to 10 hours. They are non-pulsating and bilateral, with of Headache Disorders (ICHD-II) broadly classifies
a band-like pattern. She rates them at 5 on a scale of 1 headaches into primary, secondary, and other
to 10, and the intensity has increased over time. Katie headache categories,1 which are further divided into
currently takes about 120 acetaminophen (Tylenol®) several headache types (Appendix 1).
tablets per month. Although she has tried anti-migraine
medications, including several triptans, beta blockers, 2. Specific headache diagnosis is critical because
and calcium channel blockers, all were ineffective for her. effective treatment differs according to headache

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Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010

type.2 Primary headache, which includes migraine, • Chronic TTH: ≥ 15 days/month


tension-type headache (TTH), and cluster headache, • Probable TTH.
is not associated with underlying disease and is It is important that episodic TTH be differentiated
treated symptomatically.2 Secondary headache is from migraine, probable migraine, cervicogenic
caused by an underlying disease process to which headache (headache arising from the upper cervical
treatment is directed. Symptomatic treatment, spine), and “sinus headache” (headache due to
however, may also be necessary. rhinosinusitis).3 Chronic TTH must be differentiated
from other causes of chronic daily headache.
3. The clinical presentation of TTH varies, and no
mandatory diagnostic criteria exist.3 As TTH is often 5. Episodic Tension-type Headache (ETTH) versus
defined by how it differs from migraine, the criteria for Migraine
diagnosis of migraine without aura are included here.1 • Several precipitating and aggravating factors are
Diagnosis of TTH or migraine requires fulfillment common to both ETTH and migraine, including
of the ICHD-II criteria (Table 1).1 It is important to stress, fatigue, lack of sleep, and missed
note that a patient may simultaneously have both meals.4
TTH and migraine.3 Probable migraine is defined • Other suggested factors have involved weather,
as a headache subtype lacking one criterion for a odours, smoke, light, and bending over. 4
migraine diagnosis. This headache type is especially • When there is disability with episodic headache,
easy to confuse with TTH. Disabling primary episodic the diagnosis is more likely to be migraine than
headache is more likely to be migraine than TTH. TTH.3 Because of the similarities in symptoms,
however, these headache types must be
DIAGNOSTIC CHALLENGES differentiated by pain characteristics.

4. Although TTH is the most prevalent headache type, 6. Cervicogenic Headache


only a small proportion of patients consulting with a The IHS has identified cervicogenic headache as a
physician have this headache type.3 TTH is classified distinct subgroup caused by disease or dysfunction
into: of structures in the neck. It is thought to represent
• Episodic TTH: infrequent episodic (< 1 day 14-18% of headaches.5
month) and frequent episodic (1–14 days/
month)
Table 1. International Classification of Headache Disorders II: Criteria for Diagnosis of Tension-type
Headache and Migraine1
Criteria Tension-type Headache Migraine
Number of At least 10 episodes At least 5 previous attacks
Episodes
Duration 40 minutes to 7 days 4 to 72 hours (may be shorter in children)
Pain At least two of the following: At least two of the following pain characteristics:
Characteristics Pressing or tightening, non-pulsating Pulsating
quality Moderate-to-severe intensity
Mild-to-moderate intensity, but does
not preclude activity Unilateral (may be bilateral in children)
Bilateral Aggravated by routine physical activity, or causing
Not aggravated by routine physical avoidance of routine physical activity
activity
Associated Both of the following: At least one of the following:
Features No nausea or vomiting Nausea and/or vomiting (often more prominent in
children)
No photophobia or phonophobia Photophobia and phonophobia
or only one of photophobia or
phonophobia
Underlying Not caused by another disorder. Not caused by another disorder
Conditions

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Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010

The headache is typically localized to the neck or Note: Info Points 6 and 7 have a foundation in
occipital regions but may project to the head and/or physiotherapy literature which, unfortunately, is not
face.1 The most important/sensitive signs indicating supported by large randomized control trials but
cervical headache were: based more on expert opinion.
• unilateral headache with side consistency. For
example, if the patient reported that one day the 8. Episodic Tension-type Headache (ETTH) versus
headache was on the left and the other day on Headache Due to Rhinosinusitis
the right, then it was less likely cervical in origin It has been reported that “sinus headache” is
(although it may be bilateral). overdiagnosed. One study (N = 2991) investigating
• headache precipitated or aggravated by certain patients with a supposed history of “sinus
postures such as prolonged reading, keyboarding, headache” reported that 88% of these individuals
turning to look back, neck hyperextension, etc. were subsequently diagnosed with either migraine
• restricted range of motion of the neck especially or migrainous headache, based on headache history
with rotation.6 and symptom description [Level II-2 evidence].10
• evidence of impaired cervical function most Signs such as headache triggers, pain location and
commonly at C1-2.7 The flexion/rotation test autonomic symptoms associated with the sinuses
(method follows) has been shown to accurately (i.e., nasal congestion) often contributed to the
identify dysfunction at this level. With the patient resulting misdiagnoses.11
lying supine, first the neck is flexed bringing the
chin to the manubrium, and then the neck is In the absence of fever or purulent discharge
passively rotated to the right and left (normal (rhinosinusitis), recurrent headaches with “sinus”
rotation is 45 degrees). A decrease in rotation symptoms, should prompt a systematic headache
on one or both sides indicates dysfunction at evaluation.
the level of C1-2.8 Nerve block can relieve
cervicogenic headache3 (but is seldom used in Chronic Headache and Headache Comparisons
general practice).
9. Chronic Daily Headache is actually considered to be
The presence of painful segmental dysfunction a category of headache, not a diagnosis.
occurring in C1-3 most clearly identified patients with • This category includes headache that is present
cervicogenic headaches from those with migraine or > 15 days/month for > 3 months and involves
tension-type headaches.5 a variety of primary and secondary headache
types.12
7. Mechanism of Cervicogenic Headache • Risk factors for chronic daily headache include
Flexing the neck to bring the chin to the manubrium obesity, history of > 1 headache/week, caffeine,
tests the entire cervical spine. In cervicogenic and overuse of acute headache treatments (>
headache, however, the concern is with the upper 10 days/month).12
three segments of the cervical spine (occipito-axial • Other risk factors implicated in chronic daily
region). In order to test and limit flexion to the headache include stressful life events, neck
upper three segments, have the patient lie supine injury, and snoring (which appears to be a
and retract the chin as if making a “double chin.” common factor).13;14
Similarly, to extend only the upper three segments,
have the patient, still while lying supine, thrust 10. Chronic Tension-type Headache (TTH) versus
the chin forward. Chin retraction (flexion) or chin Hemicrania Continua
protrusion (extension) is held for a few minutes at • Unlike chronic TTH which is often bilateral,
a time. If either of these postures results in the hemicrania continua has a unilateral
headache increasing, decreasing, or terminating, the presentation.3
pain is coming from the upper cervical spine. The • Although this rare, continuous, moderately
pain usually results from static loading in the end severe headache may vary in intensity, it never
range (which creates static postural distortion) not completely disappears.15
necessarily from dynamic movement of the spine. • Cranial autonomic disturbances, such as
The flexion/rotation test (see Info Point 6) may help miosis and eye-tearing, accompany hemicrania
to confirm if the dysfunction is at the level of C1- continua.12
2.8;9 (Information summarised from pp. 189-199 in
McKenzie, 1990)

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Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010

11. Chronic Tension-type Headache (TTH) versus Chronic 15. Subarachnoid Hemorrhage
Migraine3 • Fewer than half of patients present with a
• Chronic TTH: All days with a headache which characteristic sudden, violent headache.19
meets chronic TTH criteria • Sentinel headache, which may be confused with
• Chronic migraine: > 15 days/month for > 3 migraine, sinusitis, or neck problems, may occur
months1 6 – 20 days before the actual hemorrhage.20
• Chronic TTH with episodic migraine: < 50% of Sentinel bleed is thought to represent a small
days with a headache which meets migraine or “leak” of an aneurysm which subsequently
probable migraine criteria seals itself. Presenting signs depend on the
• Chronic migraine: ≥ 50% of days with a headache aneurysm location. This headache may also
which meets migraine or probable migraine resemble thunderclap headache. Nonsteroidal
criteria. anti-inflammatory drugs (NSAIDs) may relieve
pain temporarily.
12. Medication overuse headache
• This type of headache can be associated with
triptans, ergots, or analgesics (Appendix 1),12 APPROACH TO THE PATIENT WITH HEADACHE
and can complicate a diagnosis of chronic daily
headache.13 16. History
• The risk of medication overuse headache For each patient with headache, a medical and social
increases with both the frequency of use and history (including history of head and/or neck trauma,
the number of medications used for acute use of alcohol and medication) should be done. For
headache.16 each headache type (a patient may have more than
• Since medication overuse headache is refractory one type of headache), a thorough headache history
to treatment, termination of acute medications is critical to an accurate diagnosis.2;21-23
is essential for accurate diagnosis and
effective management.12 “Withdrawal symptoms • Headache: Age of onset, duration, frequency,
usually last for 2 – 10 days (average 3.5 days) progression, family history of headache
and include withdrawal headache, nausea, • Pain: Severity, characteristics, location, radiation,
vomiting, arterial hypotension, tachycardia, activity limitation
sleep disturbances,restlessness, anxiety, and • Associated symptoms: Aura, systemic signs
nervousness. The withdrawal phase is much (such as rash), focal neurologic symptoms,
shorter when patients are overusing only nausea, vomiting, phonophobia, photophobia
triptans.”16 • Precipitating or aggravating factors: Including
• If discontinuation does not reduce headache lifestyle changes (diet, sleep, travel), strenuous
frequency, then chronic daily headache could be unaccustomed physical activity, positional
considered as a diagnosis.3 changes
• Treatment: Type, amount, effectiveness and
13. The Contribution of Caffeine duration of relief, frequency of use.
• Headaches associated with consumption of
caffeine result more from withdrawal of caffeine Requesting that the patient keep a headache diary
than from its use or overuse.1 for a few weeks can provide valuable information.

Red Flag Headaches 17. Physical Examination


The physical examination should include the
14. In red flag headaches, specific characteristics of following: 2;23
the headache occurring in the history, or signs in • Neurologic examination, including examination
the physical examination, suggest the presence of of the optic fundi
a secondary headache that would warrant urgent • Blood pressure
investigation by an appropriate specialist (Appendix • Palpation of the head and neck for muscle
2).17;18 New-onset headache, or headache differing tenderness, range of movement, and crepitus.
from the patient’s normal pattern, requires clinical
examination including blood pressure measurement 18. Investigation and referral
and neurological examination with fundoscopy.18 Investigations are indicated if the history or physical
Headache accompanied by unexplained abnormal examination point to the presence of secondary
neurologic signs warrants neuroimaging. headache23 and/or red flags.18 The most common

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Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010

initial investigations would include neuroimging (CT • As part of the acute medication withdrawal,
or magnetic resonance imaging, depending on the a tricyclic antidepressant may be initiated to
presentation). If the CT is negative, lumbar puncture reduce headache frequency.12
is a consideration. Urgent neurologist referral might • Prednisone taken for several days may reduce
also be considered.19 the duration of severe withdrawal headache:12
o 60 mg for five days.12
o A tapered prednisone regimen (60 mg
MANAGEMENT STRATEGIES for two days, 40 mg for two days, 20 mg
for two days plus ranitidine 300 mg/day)
19. Tension-type Headache (TTH) has been associated with significantly
• Patients typically treat episodic TTH with NSAIDs reduced headache symptoms and a lack of
or acetaminophen.2 Unfortunately, no evidence withdrawal symptoms.25
guides specific selection of medications for • Discontinuation of medication as an inpatient
individual patients. may be needed for patients who:12
• Limiting analgesic use to a maximum of twice o Are unsuccessful in attempting termination
weekly can prevent development of medication as outpatients
overuse headache. o Are consuming a barbiturate or opioid dosage
• Prophylactic agents, such as amitriptyline that makes outpatient discontinuation
(Elavil®), can reduce both headache frequency unsafe
and acute use of medications in patients with o Have medical or psychiatric conditions that
chronic TTH. makes outpatient termination inadvisable.
• It is also appropriate to identify, and attempt
to modify, factors (such as smoking) that may 21. Cervicogenic Headache
be triggering or exacerbating these headaches. • When successful management is applied to the
Results from the HEAD-hunt study24 (N=51,383 cause of the problem, pain should resolve within
completed questionnaires) indicated that three months.1 Physical and manual therapy is
“[p]revalence rates for headache were higher the basis of treatment.
amongst smokers compared with never • Appropriate use of analgesics or anaesthetic
smokers, most evident for those under 40 years injected into trigger points allows patients to
smoking more than 10 cigarettes per day (OR participate in physical therapy.26 A controlled
1.5, 95% CI 1.3–1.6)” trial found the effectiveness of physiotherapy
o The possibility of reversed causality is was not dependent on age, gender or headache
worth consideration, i.e., the fact that the chronicity.27
headache itself may contribute to smoking,
because stressful situations could increase 22. Hemicrania Continua
the urge to smoke. This rare headache responds completely to
o In addition, the addictive nature of nicotine, indomethacin.3
particularly when used daily, may increase
the likelihood of experiencing a headache Non-pharmacologic Approaches
in a way similar to medication overuse
headache.24 23. Behavioural interventions can reduce symptoms of
TTH.28 Therapies include biofeedback, meditation,
20. Medication Withdrawal in Medication Overuse relaxation training, hypnosis, and cognitive
Headache behavioural therapy.
• Although there is a lack of well-conducted
trials to assess the effectiveness of solely 24. A recent review of RCTs (N = 2317 patients) involving
discontinuing medication,12 termination of acupuncture in patients with frequent episodic and
medications for acute headache remains the chronic TTH, concluded that acupuncture could be
treatment of choice, since patients seem to valuable in patients with frequent TTH [Level I-1
improve after medication is discontinued. On Evidence].29
average, withdrawal symptoms last 3.5 days
(range 2-10 days).16
• Although simple analgesics can be terminated
abruptly, opioids and barbiturates should be tapered
off over a period of approximately one month.12

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Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010

THE BOTTOM LINE CASE COMMENTARIES


• Red flags alert the clinician to potentially serious
causes of secondary headache. Case 1: Daciana, 27 years old, female
• A specific headache diagnosis is crucial to
effectively managing headaches. What would be your diagnosis?
• Since chronic daily headache is a headache
category, not a diagnosis, a specific diagnosis of Cervicogenic headache may be mistaken for sinus
this type of headache is critical for adequately headache, as pain originating from the neck may be
managing pain. referred to the forehead and face. Daciana has no
  signs indicating sinus headache (nasal discharge, fever,
respiratory infection) (Info Point 8). Sinus radiographs
are of dubious value, as both false negatives and false
positives can occur. Cervicogenic headache can be due to
posture or neck position, neck strain, or cervical arthritis
(Appendix 1). Pressure on trigger points in the neck, such
as the occipital or paraspinal muscle insertion points, can
provoke pain. Her flexion/rotation test is abnormal for
someone her age indicating C1-2 dysfunction. Although
photophobia is most common with migraine, it may also
occur with non-migraine headaches (Table 1). One could
also have her lying supine and gradually raise the head
on towels one at a time (Info Point 7). In this case, the
headache moved from the sinus area of the forehead to
the occiput with a decrease in the intensity of the pain.

How would you treat Daciana?

Management of cervicogenic headache is primarily non-


pharmacologic (Info Point 21). It is important for the
patient to understand that posture can affect muscles
in the neck causing areas to produce referred pain in
the head (Info Point 6). Gradual stretching and neck
retraction exercises help reduce tightness in the back
of the neck. A physiotherapist can provide the necessary
education and treatment (Info Point 21). Trigger point
injection with an anaesthetic agent may help manage
the pain until the neck muscles have a chance to relax
(Info Point 21). Complementary medicine approaches
(such as biofeedback, meditation, relaxation training,
hypnosis, and cognitive behavioural therapy) may also be
useful (Info Points 23, 24). Although ibuprofen (Advil®)
or acetaminophen (Tylenol®) can be used sparingly, it
is important to avoid regular use, which can promote
medication overuse headache (Info Point 12). It is
important to follow up to ensure the headaches have
resolved.

Case 2: Katie, 43 years old, female

How would you manage Katie?

Her history clearly indicates chronic daily headache, likely


associated with medication overuse (Info Points 9, 12). In
most cases like this one, an underlying chronic headache

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Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010

type exists. This, however, cannot be diagnosed until use cranial computed tomography (CT) (Info Point 18). If the
of acute headache medication has been discontinued CT scan is negative, a lumbar puncture is indicated to
and characteristics of the underlying headache have assess for blood in the cerebrospinal fluid (CSF) and
been observed (Info Points 9, 12). It is important to must be done within 10 days of onset of subarachnoid
explain to Katie the cause of her daily headaches and hemorrhage to detect xanthachromia.
the need for her to discontinue acetaminophen. She
needs to pick a time when she can devote several days to Case evolution: John was not imaged at the first
this process (Info Point 20). Some patients may require presentation, but sent home with reassurance. He went
hospitalization for detoxification. Starting a tricyclic on to have a subarachnoid hemorrhage a week later (Info
antidepressant upon medication discontinuation may Point 15). His symptoms were similar to the headache
reduce headache frequency after withdrawal of acute he experienced with the sentinel bleed. However, the
medications (Info Point 20). Prednisone has also been symptoms persisted and he developed unilateral
used to facilitate withdrawal (Info Point 20). weakness and facial droop.

After resolving the medication overuse headache,


additional information needs to be gathered about the
underlying headache. As anti-migraine medications were
ineffective, Katie is more likely to have chronic TTH than
chronic migraine. However, having Katie keep a detailed
headache diary (Info Point 16) can help characterize her
headaches and identify both aggravating and relieving
factors (Table 1, Info Point 5). A detailed history may
be helpful in identifying the original headache type
(Info Point 18). Chronic headaches are often difficult to
manage, and eventual referral to a neurologist or pain
clinic may be necessary (Info Point 18).

Case 3: John, 52 years old, male

What additional information would you seek?

Additional information about this headache and any other


headaches would be useful (Info Point 16). The first
episode of severe headache would provide insufficient
information to classify it as either migraine or TTH. In
fact, a number of episodes is the criteria required to
make a diagnosis (Table 1). John’s presentation can,
however, be considered a “red flag” for a potentially
serious underlying cause of headache (Info Point 14,
Appendix 2). Age > 50 years, smoking, hypertension
and headache associated with exertion, are factors that
increase the risk of a serious underlying cause for John’s
headache (Appendix 2).

How would you handle this case at this juncture?

Specific investigations are indicated to rule out


potentially serious causes of headache (Info Point 18).
Sentinel bleeds can precede subarachnoid hemorrhage
by as many as six to 20 days. They are frequently
misdiagnosed, ignored, or completely missed by both
patient and physician (Info Point 15). If a sentinel bleed is
suspected, however, it is appropriate to make an urgent © The Foundation for Medical Practice Education
consultation with a neurologist or internist and perform Vol. 18(10), August 2010

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Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010

Authors: Christine Thornton, MD, CCFP LEVELS OF EVIDENCE


Family Physician  
Categorization of evidence and recommendations
Barrie, Ontario
 
I-1 Evidence from meta-analyses, systematic reviews or
Reviewers: Linda Gagnon, MD, CCFP, FCFP large randomized controlled trials.
Family Physician  
Dartmouth, Nova Scotia I-2 Evidence from at least one properly randomized
controlled trial.
Sian Spacey, MD, FRPCP  
Clinical Neurologist II-1 Evidence from well-designed controlled trials without
Vancouver, British Columbia randomization.
 

II-2 Evidence from well-designed cohort or case-control
Medical Editor: Richard Russek, MD, CCFP analytic studies, preferably from more than one centre
Family Physician or research group.
Cambridge, Ontario  
II-3 Evidence from comparisons between times or places
Medical Writer: Joanna Gorski, BSc(Hon),BEd,DVM with or without the intervention. Dramatic results in
Niagara-on-the-Lake, Ontario uncontrolled experiments could also be included here.
 
Researcher: Dawnelle Hawes, BA, BKin, MEd III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
Hamilton, Ontario
committees.

Strength of Recommendations
The Foundation’s module team would like to acknowledge  
the assistance of Roger Butler, Carol Geller, and Liz Shaw A Good evidence to recommend the clinical action.
for their participation in the initial roundtable discussion.  
We also wish to thank the Practice Based Small Groups B Fair evidence to recommend the clinical action.
facilitated by Murray Awde (London, Ontario) and Ruth  
Simkin (Winnipeg, Manitoba) who pilot tested this C Existing evidence is conflicting and does not allow
making a recommendation for or against the use
educational module and provided suggestions for
of the clinical action. However, other factors may
improvement. influence decision making.
 
Disclosures of competing interests: D Fair evidence to recommend against the clinical action.
 
No competing interests were declared for Christine E Good evidence to recommend against the clinical
Thornton, Linda Gagnon, Sian Spacey, Richard Russek, action.
or Joanna Gorski.  
I Insufficient evidence (in quantity and/or quality) to
make a recommendation. However, other factors may
influence decision making.
While every care has been taken in compiling the information contained
in this module, the Program cannot guarantee its applicability in specific   
clinical situations or with individual patients. Physicians and others Adapted from: The Canadian Task Force on the Periodic Health
should exercise their own independent judgement concerning patient Examination. www.ctfphc.org/ctfphc&methods.htm Accessed
care and treatment, based on the special circumstances of each case. December 15, 2008.

Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM,
Anyone using the information does so at their own risk and releases et al. Current methods of the US Preventive Services Task Force: a
and agrees to indemnify The Foundation for Medical Practice Education review of the process. Am J Prev Med 2001;20(3S):21-35. PMID:
and the Practice Based Small Group Learning Program from any and all 11306229 2007 update available at www.ahrq.gov/clinic/uspstf/
grades.htm Accessed December 15, 2008.
injury or damage arising from such use.

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Headache Disorders: Approach to Non-Migraine Types Volume 18(10), August 2010

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validity of the cervical flexion-rotation test in C1/2-related
cervicogenic headache. Man Ther 2007; 12(3):256-262. (23) Steiner TJ, MacGregor EA, Davies PTG. Guidelines for All
PM:17112768 Healthcare Professionals in the Diagnosis and Management
of Migraine, Tension-Type, Cluster and Medication-Overuse
(8) Mulligan BR. Self Treatments for Back, Neck, Limbs. A new Headache. 3:1-52. 2007. Hull, UK, British Association for the
approach. 2nd ed. London, ON: Canzed Seminars (Canadian Study of Headache. Accessed July, 2010.
distributor); 2006.
(24) Aamodt AH, Stovner LJ, Hagen K, Brathen G, Zwart J. Headache
(9) McKenzie RA. The Cervical and Throacic Spine: Mechanical prevalence related to smoking and alcohol use. The Head-HUNT
Diagnosis and Therapy. Waikanae: NZ: Spinal Publications; Study. Eur J Neurol 2006; 13(11):1233-1238. PM:17038038
1990.
(25) Krymchantowski AV, Barbosa JS. Prednisone as initial
(10) Schreiber CP, Hutchinson S, Webster CJ, Ames M, Richardson treatment of analgesic-induced daily headache. Cephalalgia
MS, Powers C. Prevalence of migraine in patients with a history 2000; 20(2):107-113. PM:10961766
of self-reported or physician-diagnosed “sinus” headache. Arch
Intern Med 2004; 164(16):1769-1772. PM:15364670 (26) Biondi DM. Cervicogenic headache: a review of diagnostic
and treatment strategies. J Am Osteopath Assoc 2005; 105(4
(11) Eross E, Dodick D, Eross M. The Sinus, Allergy and Migraine Suppl 2):16S-22S. PM:15928349
Study (SAMS). Headache 2007; 47(2):213-224. PM:17300361
(27) Jull GA, Stanton WR. Predictors of responsiveness to
(12) Dodick DW. Clinical practice. Chronic daily headache. N Engl J physiotherapy management of cervicogenic headache.
Med 2006; 354(2):158-165. PM:16407511 Cephalalgia 2005; 25(2):101-108. PM:15658946

(13) Hutchinson S. Chronic daily headache. Prim Care 2004; (28) Sierpina V, Astin J, Giordano J. Mind-body therapies for
31(2):353-67, vii. PM:15172511 headache. Am Fam Physician 2007; 76(10):1518-1522.
PM:18052018
(14) Scher AI, Lipton RB, Stewart WF. Habitual snoring as a risk
factor for chronic daily headache. Neurology 2003; 60(8):1366- (29) Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White
1368. PM:12707447 AR. Acupuncture for tension-type headache. Cochrane Database
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(16) Katsarava Z, Jensen R. Medication-overuse headache:
where are we now? Curr Opin Neurol 2007; 20(3):326-330.
PM:17495628

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APPENDIX 1. ICHD-II CLASSIFICATION OF HEADACHE DISORDERS*

Part I: Primary headaches 7. Non-vascular cranial disorder


a. High cerebrospinal fluid pressure (due to
1. Migraine hydrocephalus, trauma)
a. Without aura b. Low cerebrospinal fluid pressure (due to
b. With aura fistula or lumbar puncture)
c. Childhood precursors to migraine c. Non-infectious inflammatory disease
d. Retinal migraine d. Intracranial neoplasm
e. Complications of migraine e. Intrathecal injection
i. Chronic migraine (previously transformed f. Epileptic seizure
migraine)17 g. Chiari malformation type I
f. Probable migraine h. Other
2. Tension-type headache 8. Substance or its withdrawal
a. Infrequent episodic a. Acute substance use or exposure
b. Frequent episodic b. Medication overuse headache [MOH]
c. Chronic c. Adverse event with chronic medication use
d. Probable d. Substance withdrawal (caffeine)
3. Cluster headache and other trigeminal autonomic 9. Infection
cephalalgias a. Intracranial infection
a. Cluster headache b. Systemic infection
b. Paroxysmal hemicrania c. HIV/AIDS
c. Short-lasting unilateral neuralgiform d. Post-infection headache (viral, bacterial)
headache with conjunctival injection and 10. Disorder of homeostasis
tearing a. Hypoxia
d. Probable trigeminal autonomic cephalalgias b. Dialysis
4. Other primary headaches c. Arterial hypertension
d. Hypothyroidism
Part II: Secondary headaches attributed to: e. Fasting
f. Cardiac cephalalgia
5. Head and/or neck trauma g. Other
a. Acute and chronic post-traumatic 11. Disorder of cranium, or facial or cranial structures
headaches a. Cranial bone
b. Acute and chronic headaches due to b. Neck
whiplash injury i. Cervicogenic headache
c. Traumatic intracranial hematoma c. Eyes
d. Other head and/or neck trauma d. Ears
e. Post-craniotomy headache e. Rhinosinusitis
6. Cranial or cervical vascular disorder f. Teeth, jaws and related structures
a. Ischemic stroke or transient ischemic g. Temporomandibular joint
attack h. Other
b. Non-traumatic intracranial hemorrhage 12. Psychiatric disorder
c. Unruptured vascular malformation a. Somatisation disorder
d. Arteritis b. Psychosis
e. Carotid or vertebral artery pain
f. Cerebral venous thrombosis Part III: Cranial neuralgias, central and primary
g. Other intracranial vascular disorder facial pain and other headaches

13. Cranial neuralgias and central causes of facial pain


14. Other headache, cranial neuralgia, central or
primary facial pain

*Synthesized from information found in The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004; 24 Suppl 1:
9-160.

© The Foundation for Medical Practice Education, www.fmpe.org


August 2010

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APPENDIX 2. RED FLAG HEADACHES AND HEADACHE FEATURES

Some feature of history or examination suggests a secondary headache cause (red flag). The following red flags should
prompt urgent headache investigation.

• Abnormal neurologic examination


o Focal findings
 Cranial nerve defect
 Cerebellar dysfunction
 Papilledema (possibly increased intracranial pressure)
 Absent venous pulsations on fundus examination
 Visual field defect
 Motor or sensory deficit
o Non-focal findings
 Cognitive disturbance
• Change in established headache
o Pattern or profile
o Frequency, characteristics, or associated symptoms
o Progressive headache (possible mass lesion)
• New-onset headache
o Patients > 50 years of age
o Persistent headache
o Sudden onset (may indicate bleeding)
o Associated with rash (may be associated with Lyme disease or meningitis)
o In specific situations:
 HIV (possible opportunistic infection)
 Previous cancer diagnosis (may be a sign of metastases)
 Neck trauma
 Mild head trauma in elderly (subdural hematoma)
o After exertion or valsalva manoeuvre, such as coughing, laughing, straining (may point to mass lesion or
subarachnoid bleed)
• Associated systemic findings
o Fever
o Neck stiffness
o Jaw claudication (temporal arteritis)
o Systemic signs or symptoms
o Increased erythrocyte sedimentation rate (may point to systemic infection, collagen disease or temporal
arteritis)
o Pressing visual disturbances (can be associated with glaucoma or optic neuritis)
o Presence of risk factors for cerebral venous sinus thrombosis, such as pregnancy
• Atypical headache or features
o Headache lacking characteristic migraine features (as found in IHS criteria), such as nausea, photophobia,
phonophobia, and throbbing
o Headache not meeting diagnostic criteria for migraine or TTH (especially if normal therapy is ineffective)
o Thunderclap headache (rapid time to peak intensity)
o Headache awakening patient (although migraine is the most common cause of morning headache)
o Persistent unilateral temple headache in adults (possible cranial arteritis)
o Headache changing with posture (possible low cerebrospinal fluid pressure)
o Headache with primary headache characteristics but unusual features
 Migraine-like presentation with aura lasting > 60 minutes: may indicate a secondary cause

Sources: 1) Millea PJ, Brodie JJ. Tension-type headache. Am Fam Physician 2002; 66(5):797-804; 2) Joubert J. Diagnosing headache. Aust Fam
Physician 2005; 34(8):621-625; 3) Diagnosis and management of headache in adults. Quick Reference Guide. 2008; 107. Edinburg, UK. Scottish
Intercollegiate Guidelines Network (SIGN); 4) Richman E. When a Headache Isn’t Just a Headache. Neurology Reviews com 2000; 8(11); 5) Ryan RE,
Jr., Pearlman SH. Common headache misdiagnoses. Prim Care 2004; 31(2):395-405, viii.

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