What should be included in a 30-slide PowerPoint presentation on headache for medical students?

Comprehensive 30-Slide PowerPoint Presentation on Headache for Medical Students

Slide Structure and Content

Section 1: Introduction and Epidemiology (Slides 1-3)

Slide 1: Title Slide

• Title: "Headache: Diagnosis and Management"
• Subtitle: "A Comprehensive Guide for Medical Students"

Slide 2: Epidemiology and Burden

• Approximately 50% of the adult population worldwide is affected by headache disorders 1
• Patients lose an average of 4-6 work days annually due to migraines, with nationwide loss of 64-150 million work days 2
• Direct and indirect costs approach $17 billion in the United States 2
• Headache disorders are among the most common reasons to seek medical care 3

Slide 3: Why This Matters

• About 50% of patients stop seeking medical care for migraines due to dissatisfaction with therapy 2
• Headache disorders are often misdiagnosed and undertreated 3
• The number of headache fellowship-trained physicians cannot meet patient demand 3

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Section 2: Red Flags and Emergency Evaluation (Slides 4-7)

Slide 4: Critical Red Flags - History

• Thunderclap headache (sudden onset peaking within 1 second to 1 minute) suggests subarachnoid hemorrhage and requires urgent evaluation 4
• New headache after age 50 requires urgent assessment for temporal arteritis, mass lesions, or other serious pathology 4, 5
• Progressive headache worsening over days to weeks suggests evolving pathology 2, 4
• Head trauma raises concern for subdural hematoma 2
• Atypical aura may indicate transient ischemic attack, stroke, epilepsy, or arteriovenous malformations 2

Slide 5: Critical Red Flags - Physical Examination

• Abnormal neurological examination findings mandate immediate imaging and specialist evaluation 4
• Focal neurological deficits or motor weakness necessitate neurological evaluation to exclude serious secondary causes 4
• Unexplained fever suggests meningitis 2
• Neck stiffness indicates meningitis or subarachnoid hemorrhage 2
• Impaired memory, altered consciousness, or personality changes suggest secondary headache 2

Slide 6: Additional Warning Signs

• Headache worsened by Valsalva maneuver (coughing, straining, bending) suggests increased intracranial pressure 2, 4, 5
• Headache awakening patient from sleep may indicate increased intracranial pressure or serious secondary cause 4, 5
• Headache brought on by sneezing, coughing, or exercise suggests intracranial space-occupying lesion 2
• Weight loss and/or change in memory or personality associated with headache suggests secondary headache 2

Slide 7: Neuroimaging Guidelines

• Use neuroimaging ONLY when a secondary headache disorder is suspected based on red flags 2
• MRI brain is the preferred imaging modality when indicated, offering higher resolution without ionizing radiation 2, 4
• Neuroimaging is NOT indicated for patients with normal neurologic examination, features consistent with primary headache disorders, or long history of similar headaches without change in pattern 5
• CT brain without contrast is recommended if intracranial hemorrhage is suspected 1

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Section 3: Primary Headache Disorders - Migraine (Slides 8-14)

Slide 8: When to Suspect Migraine

• Recurrent headache of moderate to severe intensity 2
• Visual aura 2
• Family history of migraine 2
• Onset of symptoms at or around puberty 2

Slide 9: Migraine Without Aura - Diagnostic Criteria

• Recurrent headache attacks lasting 4-72 hours 2
• At least two of the following features: unilateral location, pulsating quality, moderate to severe intensity, worsening with routine physical activity 2
• Bilateral pain occurs in approximately 40% of individuals with migraine 2
• At least one of the following: nausea/vomiting OR photophobia and phonophobia 2

Slide 10: Migraine With Aura

• Approximately one-third of individuals with migraine experience aura 2
• Aura consists of transient focal neurological symptoms that usually precede but sometimes accompany the headache phase 2
• Visual aura occurs in >90% of affected individuals, classically as fortification spectra 2
• Sensory symptoms occur in approximately 31% of affected individuals, typically as predominantly unilateral paresthesia spreading gradually in face or arm 2
• Less common aura symptoms include aphasic speech disturbance, brainstem symptoms (dysarthria, vertigo), motor weakness (hemiplegic migraine), and retinal symptoms 2

Slide 11: Chronic Migraine

• Chronic migraine is diagnosed when a patient experiences 15 or more headaches per month, each at least 4 hours in duration, with migraine features on 8 or more days per month 4, 5
• This must occur for more than 3 months 5
• Specialist referral is indicated for patients with chronic migraine 2, 4

Slide 12: Migraine Phases

• Prodromal symptoms (before pain onset): depressed mood, yawning, fatigue, cravings for specific foods 2
• Aura phase (if present): typically visual or sensory symptoms 2
• Headache phase: 4-72 hours of characteristic pain 2
• Postdromal symptoms (after headache resolution): can last up to 48 hours, often include tiredness, concentration difficulties, neck stiffness 2

Slide 13: Acute Treatment of Migraine - First and Second Line

• First-line medication: NSAIDs (acetylsalicylic acid, ibuprofen, or diclofenac potassium) 2
• Second-line medication: Triptans 2
• When triptans provide insufficient pain relief, combine with fast-acting NSAIDs 2
• Advise use of acute medications early in the headache phase, as effectiveness depends on timely use with correct dose 2
• Use prokinetic antiemetics (domperidone or metoclopramide) as adjunct oral medications for nausea/vomiting 2

Slide 14: Acute Treatment - Medications to Avoid

• Avoid oral ergot alkaloids (poorly effective and potentially toxic) 2
• Avoid opioids and barbiturates (questionable efficacy, considerable adverse effects, risk of dependency) 2, 5
• Frequent, repeated use of acute medication risks development of medication-overuse headache (MOH) 2, 5

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Section 4: Migraine Prevention and Special Populations (Slides 15-17)

Slide 15: Preventive Treatment Indications

• Consider preventive therapy when migraine continues to impair quality of life despite optimized acute therapy 2
• Patients considered for preventive treatment remain adversely affected on at least 2 days per month 2
• Consider severity of attacks, duration of attacks (menstruation-related attacks tend to last longer), and migraine-related disability 2
• Further indication: overuse of acute medication 2

Slide 16: Preventive Treatment Options

• Topiramate is the only agent with proven efficacy in randomized controlled trials for chronic migraine 4
• OnabotulinumtoxinA is the only FDA-approved therapy for chronic migraine prophylaxis 4
• Evidence-based prophylaxis options include topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and valproate 5
• Efficacy of preventive therapy is rarely observed immediately; assess after 2-3 months for oral medications, 3-6 months for CGRP monoclonal antibodies, 6-9 months for onabotulinumtoxinA 2

Slide 17: Special Populations

• Children and adolescents: Presentation can differ from adults; bed rest alone can be sufficient; use ibuprofen for acute treatment and propranolol, amitriptyline, or topiramate for prevention 2
• Women who are pregnant or breastfeeding: Use paracetamol for acute treatment; avoid preventive treatment if possible 2
• Older people: Secondary headache, comorbidities, and adverse events are all more likely; poor evidence base for all drugs in this age group 2

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Section 5: Other Primary Headache Disorders (Slides 18-20)

Slide 18: Tension-Type Headache

• Characterized by bilateral, pressing/tightening quality, mild to moderate intensity 4, 6
• At least two of the following: pressing/tightening (nonpulsatile) character, mild to moderate intensity, bilateral location, no aggravation with routine activity 2
• Both of the following: no nausea or vomiting (may have anorexia), no photophobia and phonophobia (but may have one or the other) 2
• Lacks autonomic features 4, 6

Slide 19: Cluster Headache - Diagnostic Criteria

• Five attacks with frequency of 1-8 attacks on any given day 2, 6
• Severe unilateral, supraorbital, or temporal pain lasting 15-180 minutes (untreated) 2, 6
• At least one of the following ipsilateral autonomic symptoms: lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, ptosis, miosis, eyelid edema 2
• Referral to neurology is recommended for all cluster headaches 4

Slide 20: Cluster Headache - Treatment

• First-line acute therapies: Subcutaneous sumatriptan 6 mg and 100% oxygen inhalation at 12 L/min (both with Level 1 evidence) 6
• 70% of patients achieve relief within 10 minutes with sumatriptan; equal efficacy with oxygen therapy 6
• Screen for CAD risk factors before prescribing sumatriptan: hypertension, hypercholesterolemia, smoking, obesity, diabetes, family history 6
• Verapamil is the prophylactic drug of choice, starting at 360 mg/day, with ECG monitoring for PR interval prolongation at higher doses 6

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Section 6: Medication-Overuse Headache (Slides 21-22)

Slide 21: Medication-Overuse Headache (MOH)

• MOH is a secondary headache disorder that is an important differential diagnosis for chronic migraine 2
• MOH commonly develops from overuse of acute medication to treat migraine attacks 2
• Discourage medication overuse and recognize and stop established medication overuse to prevent MOH 2

Slide 22: Managing MOH

• For MOH, withdraw overused medication, preferably abruptly 2
• Advise patients that frequent, repeated use of acute medication risks development of MOH 2, 5
• Patients should be informed about proper medication use to avoid rebound headaches 5

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Section 7: Patient Education and Follow-up (Slides 23-24)

Slide 23: Patient Education Essentials

• Provide appropriate reassurance and agree on realistic objectives 2
• A realistic objective is a return of control from the disease to the patient with treatment that mitigates attack-related disability 2
• Explain that effective treatment does not mean cure of migraine 2
• Identify predisposing and/or trigger factors 2
• Maintain a headache diary to track frequency, severity, triggers, and treatment response 5

Slide 24: Long-Term Management

• Use headache calendars to assess effectiveness and adverse events 2
• When outcomes are suboptimal, review diagnosis, treatment strategy, dosing, and adherence 2
• Manage migraine long-term in primary care; maintain stability of effective treatment and react to change 2
• Identify and avoid personal triggers, establish regular sleep patterns, consider stress management techniques 5

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Section 8: Diagnostic Approach Algorithm (Slides 25-26)

Slide 25: Step-by-Step Diagnostic Approach

1. Take careful medical history, applying ICHD-3 criteria 2
2. Assess for red flags in history and physical examination 4, 5
3. Perform thorough physical and neurological examination 2
4. Use validated diagnostic aids: headache diaries, ID-Migraine questionnaire, Migraine Screen Questionnaire 2
5. Consider differential diagnoses, including other primary and secondary headache disorders 2
6. Use neuroimaging ONLY when secondary headache disorder is suspected 2

Slide 26: Key Diagnostic Questions

• Location, character, intensity, duration of headache 2, 5
• Associated symptoms (nausea, vomiting, photophobia, phonophobia, autonomic symptoms) 2
• Frequency and pattern of attacks 5
• Triggers and aggravating factors 5
• Impact on daily activities and quality of life 5
• Previous treatments and response 5

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Section 9: Drug Safety Considerations (Slides 27-28)

Slide 27: Triptan Safety Warnings

• Serious adverse cardiac events, including acute myocardial infarction, life-threatening cardiac rhythm disturbances, and death have been reported within hours of sumatriptan administration 7
• Triptans can cause coronary vasospasm 7
• Screen for cardiovascular disease or risk factors before prescribing triptans 7
• Contraindicated in patients with uncontrolled hypertension 7
• Risk of serotonin syndrome when combined with SSRIs or SNRIs 7

Slide 28: NSAID Safety Warnings

• NSAIDs increase risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal 7
• Patients with known cardiovascular disease or risk factors may be at greater risk 7
• Use the lowest effective dose for the shortest duration possible 7
• NSAIDs can lead to onset of new hypertension or worsening of preexisting hypertension 7
• Monitor blood pressure closely during NSAID treatment 7

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Section 10: Multiple Choice Questions (Slides 29-30)

Slide 29: MCQ Set 1

Question 1: A 28-year-old woman presents with recurrent unilateral throbbing headaches lasting 8-24 hours, associated with nausea and photophobia. What is the FIRST-LINE acute treatment?

• A) Opioids
• B) NSAIDs (ibuprofen or aspirin)
• C) Triptans
• D) Ergot alkaloids

Answer: B 2

Question 2: Which of the following is a red flag requiring urgent evaluation?

• A) Bilateral headache
• B) Thunderclap headache peaking within 1 minute
• C) Headache lasting 6 hours
• D) Photophobia

Answer: B 4

Question 3: What defines chronic migraine?

• A) 10 or more headache days per month
• B) 15 or more headache days per month with migraine features on 8 or more days
• C) Daily headaches for 1 month
• D) Any headache lasting more than 72 hours

Answer: B 4, 5

Slide 30: MCQ Set 2

Question 4: What is the ONLY FDA-approved therapy for chronic migraine prophylaxis?

• A) Topiramate
• B) Propranolol
• C) OnabotulinumtoxinA
• D) Amitriptyline

Answer: C 4

Question 5: A 45-year-old man presents with severe unilateral orbital pain lasting 60 minutes with ipsilateral lacrimation and nasal congestion, occurring twice daily for the past week. What is the FIRST-LINE acute treatment?

• A) NSAIDs
• B) Subcutaneous sumatriptan 6 mg or 100% oxygen at 12 L/min
• C) Oral ergotamine
• D) Opioids

Answer: B 6

Question 6: When is neuroimaging indicated in headache evaluation?

• A) All new headaches
• B) Only when red flags are present or secondary headache is suspected
• C) All migraines with aura
• D) All chronic headaches

Answer: B 2, 4