Headache for Canadian Medical Students

Introduction

Headache is a common presenting complaint in Canadian primary care and emergency settings. As a future Canadian physician preparing for the MCCQE1, understanding the various types of headaches, their presentations, and management strategies is crucial. This guide will focus on the most important aspects of headache diagnosis and treatment in the Canadian healthcare context, aligning with MCCQE1 objectives and the CanMEDS framework.

Types of Headaches

Headaches are broadly classified into two categories: primary and secondary. Understanding this classification is essential for MCCQE1 preparation.

Migraine

Migraine is a common primary headache disorder affecting approximately 2.7 million Canadians. Understanding its presentation and management is crucial for MCCQE1 success.

Diagnostic Criteria (ICHD-3)

For MCCQE1 preparation, memorize these criteria:

1. At least 5 attacks fulfilling criteria 2-4
2. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
3. Headache has at least two of the following characteristics:
   • Unilateral location
   • Pulsating quality
   • Moderate or severe pain intensity
   • Aggravation by or causing avoidance of routine physical activity
4. During headache, at least one of the following:
   • Nausea and/or vomiting
   • Photophobia and phonophobia

Management

Tension-Type Headache

Tension-type headache is the most common primary headache disorder. Its recognition and management are important for MCCQE1 preparation.

Diagnostic Criteria (ICHD-3)

1. At least 10 episodes fulfilling criteria 2-4
2. Headache lasting from 30 minutes to 7 days
3. At least two of the following characteristics:
   • Bilateral location
   • Pressing or tightening (non-pulsating) quality
   • Mild or moderate intensity
   • Not aggravated by routine physical activity
4. Both of the following:
   • No nausea or vomiting
   • No more than one of photophobia or phonophobia

Management

• Acute treatment: NSAIDs or acetaminophen
• Preventive treatment: Amitriptyline if chronic
• Non-pharmacological: Stress management, physical therapy

Cluster Headache

Cluster headache is a severe primary headache disorder that's important to recognize for the MCCQE1 exam.

Diagnostic Criteria (ICHD-3)

1. At least 5 attacks fulfilling criteria 2-4
2. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes (when untreated)
3. Either or both of the following:
   • 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
     • Forehead and facial flushing
     • Sensation of fullness in the ear
     • Miosis and/or ptosis
   • A sense of restlessness or agitation
4. Occurring with a frequency between one every other day and 8 per day

Management

• Acute treatment: Oxygen therapy, sumatriptan injection or nasal spray
• Preventive treatment: Verapamil, lithium, or topiramate

Red Flags for Secondary Headaches

For MCCQE1 preparation, memorize these red flags that suggest a secondary headache:

1. Sudden-onset severe headache ("thunderclap")
2. New headache after age 50
3. Progressively worsening headache
4. Headache associated with systemic symptoms (fever, weight loss)
5. Headache with focal neurological signs
6. Headache triggered by position change or Valsalva maneuver
7. Headache in an immunocompromised patient

Canadian Guidelines for Headache Management

The Canadian Headache Society provides guidelines for headache management, which are essential to know for the MCCQE1:

1. Use validated screening tools for migraine diagnosis in primary care
2. Consider prophylaxis for patients with ≥4 migraine days/month
3. Educate patients on medication overuse headache risk
4. Refer to a headache specialist if standard treatments fail or diagnosis is uncertain

Key Points to Remember for MCCQE1

• Know the diagnostic criteria for primary headaches (migraine, tension-type, cluster)
• Understand the red flags suggesting secondary headaches
• Be familiar with Canadian guidelines for headache management
• Recognize the importance of non-pharmacological approaches in headache management
• Understand the role of neuroimaging in headache evaluation
• Be aware of medication overuse headache as a complication of frequent analgesic use

Sample Question

A 35-year-old woman presents to her family physician with a 6-month history of recurrent headaches. She describes the pain as bilateral, pressing, and of moderate intensity, lasting 2-3 hours. The headaches occur 3-4 times per week and are not associated with nausea, vomiting, or sensitivity to light or sound. Physical examination is normal. Which one of the following is the most likely diagnosis?

• A. Migraine without aura
• B. Cluster headache
• C. Tension-type headache
• D. Medication overuse headache
• E. Chronic daily headache

Explanation

The correct answer is:

• C. Tension-type headache

This patient's presentation is classic for tension-type headache:

1. Bilateral location
2. Pressing quality
3. Moderate intensity
4. No associated symptoms like nausea, vomiting, photophobia, or phonophobia
5. Duration within the typical range for tension-type headache (30 minutes to 7 days)

Migraine typically involves unilateral, pulsating pain with associated symptoms. Cluster headache presents with severe unilateral pain and autonomic symptoms. Medication overuse headache requires a history of frequent analgesic use. Chronic daily headache is a descriptive term, not a specific diagnosis.

References

1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.

2. Becker WJ, Findlay T, Moga C, Scott NA, Harstall C, Taenzer P. Guideline for primary care management of headache in adults. Can Fam Physician. 2015;61(8):670-679.

3. Worthington I, Pringsheim T, Gawel MJ, et al. Canadian Headache Society Guideline: acute drug therapy for migraine headache. Can J Neurol Sci. 2013;40(5 Suppl 3):S1-S80.

4. Peng KP, Wang SJ. Epidemiology of headache disorders in the Asia-pacific region. Headache. 2014;54(4):610-618.

5. Katsarava Z, Buse DC, Manack AN, Lipton RB. Defining the differences between episodic migraine and chronic migraine. Curr Pain Headache Rep. 2012;16(1):86-92.