Page 226 Guide to Pain Management in Low-Resource Settings

214 Arnaud Fumal and Jan Schoenen

• Is the pain on one or both sides?
Table 1
Tension-type headache (episodic form): • Is it aggravated by physical activity?
general diagnostic criteria (ICHD-2) • Th e presence of trigger zones and lancinating
General Diagnostic Criteria
quality suggest a neuralgia.
A. Headache lasting from 30 minutes to 7 days • Is a migraine aura present?
B. At least 2 of the following pain characteristics: • Very importantly, are there accompanying symp-
Bilateral location
Pressing/tightening (non-pulsating) quality toms such as nausea, hypersensitivity to light and
Mild or moderate intensity sound, or autonomic symptoms such as tearing,
Not aggravated by routine physical activity such as walking or stuff y nose, sweating, ptosis, or miosis?
climbing stairs
Th e next question is whether the patient has one
C. Both of the following:
1. No nausea or vomiting (anorexia may occur) or more diff erent kinds of headache. Th is must be eluci-
2. No more than one of photophobia or phonophobia dated skillfully. Th e reason for the consultation must be
D. Not attributed to another disorder made clear. Is it because the usual headache is getting
worse, or is it because of a new kind of headache? We
tention and may need quick complimentary investiga- have to keep in mind that if headache is the fi fth most
tions, while those with a longer headache history gen- common complaint seen in United States emergency de-
erally require time and patience rather than speed and partment, the minority of these patients have a second-
imaging. Patients with a headache history of more than ary cause for headache, and an even smaller number have
2 years defi nitely have a primary headache disorder. Red a grave and potentially catastrophic cause for headache,
fl ags (see Table 2) that should alert to the possibility of a such as meningitidis or subarachnoid hemorrhage.
secondary headache include pain of sudden onset, fever, In clinical practice, it is known that patients
marked change in pain character or timing, neck stiff - may not easily identify and recall certain features of
ness, pain associated with neurological disturbances, their headaches, such as the presence and type of aura
such as cognitive dysfunction or weakness, and pain symptoms, specifi c associated symptoms, and the coex-
associated with local tenderness, for example of the su- istence of several types of headache. Th erefore, the use
perfi cial temporal artery. of monitoring instruments becomes crucial in the di-
agnosis of these disorders. Using headache diaries and
Table 2 calendars, the characteristics of every attack can be re-
Migraine with aura diagnostic criteria (ICHD-2) corded prospectively, increasing the accuracy of the de-
Diagnostic Criteria for Migraine without Aura scription and making it possible to distinguish between
A. At least 5 attacks fulfi lling criteria B–D coexisting headache types.
B. Headache attacks lasting 4–72 hours (untreated or unsuccess- Moreover, headache diaries provide the phy-
fully treated)
sician with information concerning other important
C. At least 2 of the following pain characteristics:
Unilateral location features, such as the frequency and temporal pattern
Pulsating quality of attacks, drug intake, and the presence of trigger fac-
Moderate or severe intensity tors. Use of acute drugs can be checked for optimal dos-
Aggravation by or causing avoidance of routine physical activity ing. Frequent use (10 days or more per month) of acute
(e.g., walking or climbing stairs)
medication is an alert for medication overuse headache.
D. During headache at least one of the following:
1. Nausea and/or vomiting Th e diary could even be sent to headache patients before
2. Photophobia and phonophobia their fi rst consultation at the headache center as it can
E. Not attributed to another disorder improve the clinical diagnosis from the fi rst interview.

Patients with recent onset headache or with What is essential to know
neurological signs require at the least brain imaging
about migraine?
with computed tomography (CT) or magnetic reso-
nance imaging (MRI). To classify primary headaches, Migraine is the commonest cause of severe episodic re-
the following questions are crucial: current headache. Migraine aff ects approximately 12%
• Frequency and duration of attacks. of Western populations, and prevalence is higher in fe-
• Headache severity. males (18%) than males (6%). Migraine is a recurrent