Headache

1. Background/Cultural Points:

   Headache is a common presenting complaint in Cambodia, often as part of a list of other complaints. Common causes seen at MMC include tension- type (often related to one or a combination of the following: stress/poverty, depression, dehydration, sleep-deprivation), migraine (possibly precipitated by MSG/“bee-jeng” in the diet), elevated blood pressure, and anemia. Rarer causes include infections (sinusitis, meningitis) neurocysticercosis and other IC masses. When patients with headache have complaints regarding multiple organ systems, somatization disorder and depression/anxiety should be considered.

2. Work-Up/Diagnosis & Lab:

   1. Thorough history is critical for a clear diagnosis. The patient’s social situation (stress, poverty, occupation), diet (MSG, water intake), drug use, level of function and enjoyment of life, and sleep hygiene should all be ascertained. Screening for anxiety/depression is important. Family history of migraines, etc, is helpful. Review patients medication history to rule-out Rebound HA.
   2. Physical exam should evaluate for high blood pressure, infectious causes, anemia, features of hyperthyroid state, and focal neurologic findings.
   3. Unless there is a strong suspicion of IC mass based on H&P, head imaging is not indicated. If needed, a Head CT with Contrast (order pre-test Creatinine) or MRI may be ordered from Calmette Hospital.
   4. Consider: HCT (in-house), FBG (in-house), TSH (if suspected/hi-risk), CBC/ESR (if concern of malignancy, infection). Infectious etiologies should also be evaluated if indicated: HIV (in-house) (if risks), CSF (sent to Pasteur Institute; consider pre-procedure Head CT if risk of high ICP), etc.
   5. Refer to International Headache Classification (IHS) criteria.

3. Management/Education/Treatment:

   1. Treat the underlying cause.
   2. If Tension Headache suspected:
      1. Review with patient: 1) chronic illness and goals of management (not necessarily “curative”); 2) stress management; 3) sleep hygiene; 4) importance of adequate hydration (2L/day minimum!)
      2. Consider Paracetamol (Acetaminophen) as first line, ibuprofen as second line
   3. If Migraine Headache suspected:
      1. Review with patient: causes, ways to prevent (avoidance of triggers – eg, MSG)
      2. Consider Ibuprofen high-dose as first line (“Triptans” not available). Consider GI prophylaxis if frequent use anticipated and/or GI risks.
      3. Consider caffeine as adjunct.
      4. Consider B-Blocker (Propranolol) for prevention if frequent Migraine HA and no contraindication
   4. If mild Anxiety/Depression, Somatization Disorder, and/or Decreased Sleep are a significant contributing factor or cause, consider Amytriptyline 25-50mg qHS for pain management (low dose TCA). R/O suicidality if prescribing. SE: dry mouth, constipation, orthostasis – all minimal at low dose.
   5. If Dehydration a concern, counsel regarding increased water intake (Goal 2 L/day minimum) and recommend purchase of water filter.

4. Follow-Up:

   If no neurologic “red flags”, patients may follow up at 3-6 month intervals or less frequently.