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Czech headache
guidelines for
general
practitioners
Jolana Marková
Thomayer University Hospital
Prague
Guideline concept
Guideline goal:
 Improve headache management by first-line physicians
Improvement diagnosis using appropriate tools
 Improve treatment
 Increase awareness and interest of general practitioners in
headache
 Initiative of Czech GP society

Guideline preparation
 GP addressed CHS
 Identification of major issues to be covered
(based on GPs’ needs)
 Creation of joint team (GPs and neurologists) to
work on guidelines
 Guideline draft
 Assessment by neurologists
 Assessment by GPs (not team members)
 Final version of guidelines
Guideline implementation
First draft and
public discussion
Establishment
of guideline
team
Introduction of
guidelines at the
congress of GP
society
Final version
of guideline
Management
audit and
feedback to GPs
Implementation
of guideline
Implementation
of findings and
guideline
up-date
Expectations of
specialists
 Neurologists' expectations:
Higher awareness among first-line
physicians
 Improved diagnosis
 Improved management
 Patients visit the specialist better diagnosed,
in a shorter time after the appearance of
headache

Headache
Classification and Diagnostic Criteria for Headache
Disorders (IHS)
Primary headache disorders
1–4
Secondary headache disorders
5–12
Cranial Neuralgias
13-14
Headache
 Important features in headache history:
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Attack onset
Pain location
Attack duration
Attack frequency and timing
Pain severity
Pain quality
Associated features
Headache
alarms
Headache alarms
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Sudden-onset severe headache
Accelerating pattern of headache
Headache begins after the age of 50
Severe headache with fever and vomiting
Headache with focal neurological symptoms
Headache in patient with cancer or HIV
Primary Headaches
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Migraine
Tension-type headache
Cluster headache
Trigeminal autonom. cephalalgias
Secondary Headaches
• Headache attributed to head and/or neck
trauma
• Headache attributed to vascular disorder
• Headache attributed to non-vascular
intracranial disorder
• Headache attributed to a substance or its
withdrawal
• Headache attributed to infection
Secondary Headaches
• Headache attributed to homeostasis
disorder
• Headache or facial pain attributed to
disorder of cranium, neck, eyes, ears, nose,
sinuses, teeth, mouth or other cranial
structure
• Headache attributed to psychiatric disorder
• Cranial neuralgias
Migraine
Focus on practical applicability in first-line.
• Diagnosis of migraine
• Treatment
• Acute migraine attack
• Prophylactic treatment
• Follow up
Migraine-phases
Not only headache – combination of
neurological, gastrointestinal and autonomic
changes
Prodrome phase
Aura
Headache and asssociated symptoms
Headache resolution phase
Migraine- Aura
Complex of focal neurological
symptoms- positive or negative
phenomena
Precedes or accompanies an attack
Last less than 60 minutes
Visual ( scotoma,color shapes,migration)
Sensory
Motor
Language disturbances
Migraine - headache
Unilateral – hemicrania
Severe intensity
Throbbing, pulsating character
Aggravated by physical activity
Accompanied with nausea, vomiting
Photophobia, phonophobia
Depression,fatigue, anxiety, irritabily are
common in migraine patients
Migraine – therapy
ACUTE ATTACK TREATMENT:
• Mild forms: NSAID, ASA, Paracetamol and/or
combinations with prokinetics
• Moderate forms: Triptans
• Severe forms: Triptans (incl. nasal spray, inj.)
and prophylaxis
Migraine – therapy
Since generic sumatriptan entered the Czech
market it has been used widely by the majority
of migraine patients.
Generic entry has also enabled GPs to
prescribe effective medication at a lower price
level.
Migraine – therapy
PROPHYLACTIC TREATMENT:
• Anticonvulsants (valproic acid, topiramat)
• Beta-blockers
• Calcium channel blockers
• Antidepressants (tricyclics, SSRI)
Prophylactic treatment remains fully under the neurologist's
competence.
Indication is consistent with IHS criteria.
Migraine – diagnosis
Introduction of adapted, simple questionnaire
for use in first-line.
Own development as:
• MIDAS perceived as rather complicated for
patients and physicians
• Interpretation often imprecise
Diagnostic scheme – migraine
Impact of migraine questionnaire
to assess disability level
“How much does headache negatively influence
your daily activities (work, school, social activities,
housework)”

Slightly, not much (mild migraine)
Treatment: ASA, Paracetamol, NSAID, combination with
prokinetics
 Moderately (moderate migraine)
Treatment: Triptans
 Significantly (severe migraine)
Treatment: Triptans and prophylactics. Patient indicated for
specialist consultation.
Tension – type headache
Pressing/tightening quality
Mild or moderate intensity
Bilateral location
No aggravation by walking stairs
No nausea or vomiting
Often depression
High lifetime prevalence (70–90%)
Tension – type headache
Acute treatment
analgesics, NSAIDs, muscle relaxants
Prophylactic treatment
antidepressants
– tricyclics, SSRI
non-pharmacological treatment
– relaxation, physical therapy techniques
Subarachnoid hemorrhage
• sudden-onset severe headache
• stiff neck
• nausea, vomiting
• alteration of consciousness
• often beginning during physical activity
Subarachnoid hemorrhage
• urgent admission to hospital
• CT, lumbal puncture
• neurosurgeon – consultation
• angiography
• intervention
• pharmacological treatment to prevent complications
Headache in stroke patients
Various combinations of headache, focal
neurological deficits and alteration of consciousness
• ischemic stroke
• hemorrhagic stroke
Admission to hospital is needed in the shortest
possible time in every stroke patient.
Headache in patients
with brain tumor
• pain quality similar to tension-type headache,
bilateral
• neurological focal symptoms, epileptic seizure as
an initial symptom
• elevated intracranial pressure
• personality changes
CT, MRI, neurosurgery
Medication overuse headache
 Headache often increase in frequency
 Patients develop a pattern of daily or nearly
daily headache with increasing medication use
 Simple analgetics, combined analgetics, NSA,
ergots, triptans, opioids
 High depression comorbidity
 Headache now is caused by medication
overuse
Medication overuse headache
 Headache present on more than 15days/month
 Pain is dull, presssing-tightening quality,
 mild or moderate intensity
 bilateral location
 no aggravation by walking stairs
 Substance intake on (10-15) days /months on a
regular basis for 3 months
 Headache has developed or markedly
worsened during substance overuse
Medication overuse headache
Treatment
 Patient wants to stop with overuse
 stop substance intake completedly
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detoxification
pain control with parenteral therapy
estabilishment of effective prophylactic
treatment
patient education
estabilishment of outpatient methods of pain
control
Cervicogenic headache
 Occipital or suboccipital pain
 Neck tendrness a muscle spasms that may
produce pain
 Limitation of movementr or unusual postures
 Sensory abnormalities in the distribution of the
upper cervical roots
Cervicogenic headache
 Clinical, laboratory or imaging evidence
of a disorder or lesion within the cervical
spine or soft tissues of the neck
 Headache is mostly unilateral
 Mild or moderate intensity
 nausea or vomiting sometimes
 No photo or phonophobia
 Sometimes vertigo or instability
Cervicogenic headache
Treatment
 NSA, myorelaxants, analgetics- only a
short time
 Antidepressants – tricyclics, SSRI
 Physioterapy
 Long term living style improvement
Traumatic and post-traumatic
headache
 Acute posttraumatic headache
 Chronic posttraumatic headache
 Whiplash injury
 Headache attributed to traumatic intracranial
haematoma – epidural, subdural
Traumatic and post-traumatic
headache
Headache accompanied by other symptoms
 Dizziness
 Difficulty in concentration
 Personality changes
 Sleep disturbances
 Anxiety
 Depression
 Vertigo
Traumatic and post-traumatic
headache
Diagnostic methods
 Clinical neurological examination
 Imaging – RTG, CT, MRI
Treatment
 Transport to the hospital
 Neurosurgery
 Intensive care
Thank you for your attention