Headache Management

1. Classification - Red Flags First

• "Thunderclap" - sudden, worst-ever headache (subarachnoid hemorrhage until proven otherwise)
• New headache in age >50 (giant cell arteritis, mass lesion)
• Fever + neck stiffness (meningitis)
• Headache with focal neurologic signs or papilloedema
• Progressive worsening over days/weeks
• Headache in a cancer or immunocompromised patient

90% of patients presenting to primary care with headache have migraine. - Harrison's Principles of Internal Medicine 22E, 2025

2. Primary Headache Types & Their Management

A. Migraine

• Aspirin, acetaminophen, or NSAIDs (ibuprofen, naproxen)
• Combination: acetaminophen + aspirin + caffeine (FDA-approved)
• Add a dopamine antagonist (metoclopramide 10 mg, prochlorperazine 10 mg) if nausea is present - also enhances GI absorption

• IV prochlorperazine 5-10 mg (superior to opioids in RCTs)
• IV metoclopramide 10 mg
• IV ketorolac 15-30 mg
• IV mixture: prochlorperazine 5 mg + DHE 0.5 mg over 2 min (common protocol)
• Dexamethasone 6-10 mg IV as adjunct to reduce recurrence
• Magnesium sulfate 2 g IV over 30 min (nonvalidated)
• Opioids: Only for severe infrequent headache unresponsive to other therapies; avoid routine use as they worsen long-term outcomes and decrease future triptan responsiveness

• Single-pulse transcranial magnetic stimulation (sTMS) - FDA cleared
• Noninvasive vagus nerve stimulator (nVNS) - FDA cleared
• Remote electrical neuromodulation (arm device)
• Transcutaneous supraorbital nerve stimulation

B. Tension-Type Headache (TTH)

• Simple analgesics: aspirin, acetaminophen, NSAIDs (first-line for episodic TTH)
• More severe headaches may require prescription analgesics, but no specific preparation has proven superior
• Avoid opioids and barbiturate-containing combinations due to dependence and medication overuse risk

• Amitriptyline (single bedtime dose) - treatment of choice when anxiety/depression comorbid
• Some evidence for calcium channel blockers, phenelzine, cyproheptadine
• Propranolol and ergotamine are ineffective unless migraine features co-exist
• Biofeedback, relaxation techniques, massage for anxious/stressed patients
• Medication overuse is a key concern - gradual analgesic withdrawal is essential in chronic daily headache

C. Cluster Headache

• 100% oxygen via mask for 10-15 min at attack onset (highly effective, no side effects)
• Sumatriptan 6 mg SC or zolmitriptan 5 mg nasal spray
• Intranasal lidocaine (adjunct)
• Ergotamine 2 mg orally at bedtime (for predictable nocturnal attacks)

• Verapamil (up to 480 mg/d) - first-line; requires ECG monitoring in older patients
• Prednisone 75 mg/d tapering over ~3 weeks (short-term bridge)
• Lithium 600-900 mg/d (chronic cluster; monitor for toxicity)
• Galcanezumab (anti-CGRP monoclonal antibody) - halved weekly cluster frequency in clinical trials
• Topiramate, melatonin as alternatives

D. Trigeminal Autonomic Cephalalgias (TACs) Comparison

E. Medication Overuse Headache (MOH)

• Occurs when acute medications are used >10-15 days/month
• Highest risk: opioids and barbiturates > triptans > NSAIDs
• Treatment: gradual withdrawal of the offending medication (can be done abruptly for triptans/NSAIDs; slower for opioids/barbiturates)
• Preventive therapy should be started during withdrawal
• Multidisciplinary support improves outcomes

3. When to Refer

• No clear diagnosis
• Primary headache other than migraine or TTH
• Unresponsive to two or more standard therapies for the diagnosed type
• Any suspected secondary headache requiring specialist workup

Recent Evidence Note

Abdominal Tuberculosis (Koch's) - Pain Abdomen Management

Overview

Forms of Abdominal TB

Clinical Presentation - Pain Abdomen in Abdominal TB

Chronic/Subacute:

• Abdominal pain - nonspecific, chronic; most common complaint (80-90% of patients)
• Weight loss, evening fever, malaise, night sweats
• Alternating diarrhoea and constipation
• Palpable RIF mass in 25-50% (ileocaecal involvement)
• Ascites and abdominal distension (peritoneal TB)
• "Doughy feel" of abdomen on palpation - a classical sign

Acute (Emergency presentation):

• Features of acute distal small bowel obstruction - colicky pain, abdominal distension, bilious/faeculent vomiting, absolute constipation
• Rarely: peritonitis from perforation of a tuberculous ulcer
• Acute-on-chronic: superimposed obstruction on longstanding disease

These patients are often extremely ill - dehydrated, malnourished, anaemic, often with active pulmonary TB. - Bailey & Love

Investigations

• FBC - mild anaemia, normal or mildly elevated WBC
• Raised ESR/CRP
• LFTs (especially with hepatic involvement)
• Urea and electrolytes (dehydration in obstruction)

• Sputum AFB smear and culture (even without pulmonary symptoms, CXR is essential)
• IGRA (Interferon-Gamma Release Assay) - Quantiferon or T-SPOT
• Ascitic fluid analysis: straw-coloured exudate, protein >25-30 g/L, WBC >500/mL with lymphocytes >40%, AFB smear often negative, culture takes 4-8 weeks
• Adenosine deaminase (ADA) in ascitic fluid - high sensitivity and specificity for peritoneal TB
• Xpert MTB/RIF assay (on tissue, stool, or fluid) - more sensitive than AFB smear (~65%)
• Tissue biopsy: granulomas with caseation on histology (seen in 50-80% of cases)

• Plain AXR in obstruction: dilated small bowel loops, valvulae conniventes (concertina effect), fluid levels, featureless ileum
• CXR: pulmonary infiltrates/TB lesions (may be normal)
• USS abdomen: ascites (may be loculated), lymphadenopathy, bowel wall thickening
• CT abdomen: ileocaecal valve thickening, asymmetric bowel wall thickening, massive lymphadenopathy with central necrosis (characteristic), cecal contraction, Stierlin sign
• Barium meal/small bowel follow-through: multiple ileal strictures, subhepatic caecum (caecum pulled up by fibrosis - pathognomonic), ileum entering caecum in a straight line from below (Figure 6.38)

• Colonoscopy with biopsy from ileocaecal region - most useful diagnostic procedure
• AFB staining, PCR, and culture on biopsy tissue (with drug sensitivity testing)
• Wear isolation masks when performing

Management

A. General Supportive Measures (All Patients)

1. Nutrition - correct malnutrition; nasogastric or parenteral nutrition if required
2. Hydration/fluid resuscitation - IV fluids for dehydration, especially in obstruction
3. NGT decompression - in obstruction/ileus
4. Anaemia correction - transfusion if Hb critically low pre-operatively
5. Notify public health authorities - TB is a reportable disease; contact tracing

B. Medical Management - Anti-TB Therapy (MAINSTAY)

For extrapulmonary TB including abdominal TB, a total duration of 12-18 months may be preferred in some guidelines/settings due to the depth of tissue penetration and risk of relapse. - Bailey & Love

• Send drug sensitivity testing (DST) from cultures - MDR-TB may be more prevalent in abdominal than pulmonary TB
• Add pyridoxine (Vitamin B6) 10-25 mg/day with isoniazid (prevents peripheral neuropathy)
• In HIV co-infection, ART should be initiated; standard TB regimens are used but with close monitoring for drug interactions (rifampicin and antiretrovirals)
• Adjunctive corticosteroids (prednisolone) may be considered in peritoneal TB with ascites to reduce inflammation and adhesion formation (though evidence is limited)
• Engage a TB specialist for management guidance

C. Surgical Management

Indications for Surgery:

Key principle: Many cases of intestinal obstruction from TB will respond to anti-TB treatment without surgery. Always give adequate medical therapy before deciding on surgical intervention. - Bailey & Love, Summary Box 65.6

Surgical Options (Elective / Post-Medical Treatment):

Surgical principles are similar to Crohn's disease - resections should be kept as conservative as possible to prevent short bowel syndrome. - Bailey & Love, 28th Ed.

Emergency Surgery (Acute Obstruction/Perforation):

• IV fluids - vigorous fluid resuscitation
• NGT decompression
• Correct electrolytes
• Blood transfusion if severely anaemic
• Broad-spectrum antibiotics (for perforation/secondary peritonitis)

• Resection of the diseased segment + proximal ileostomy + distal ileal or colonic mucus fistula (preferred)
• This avoids primary anastomosis, which has a high leak rate in the presence of active infection and poor general condition
• One-stage resection and anastomosis is only performed if the patient's general condition permits (rare in the emergency setting)

Peritoneal TB - Specific Management

• Primarily medical (anti-TB chemotherapy as above)
• Therapeutic paracentesis for tense ascites causing respiratory compromise
• Laparoscopy + peritoneal biopsy if diagnosis in doubt
• Distinguish from peritoneal metastases (CT-guided biopsy or laparoscopy)
• Intestinal obstruction in peritoneal TB (fibrous "dry" type - matted loops) may respond to anti-TB therapy + corticosteroids alone before considering surgery

TB vs Crohn's Disease - Differential Diagnosis Points

Summary Algorithm

Suspected Abdominal Koch's (Pain abdomen)
        ↓
Red flags? (Obstruction / Perforation / Haemorrhage)
        ↓                        ↓
      YES                       NO
        ↓                        ↓
Emergency resuscitation    Confirm diagnosis
  + surgery if required    (Colonoscopy + biopsy, CT, ADA)
                                  ↓
                        START ANTI-TB THERAPY
                        (2HRZE → 4HR, 6-18 months)
                                  ↓
                     Clinical response within 2 weeks?
                        ↓                    ↓
                       YES                  NO
                        ↓                    ↓
                  Continue ATT          Re-evaluate diagnosis
                        ↓             Consider MDR-TB / biopsy
              Post-treatment imaging
                        ↓
              Residual stricture/obstruction?
                        ↓
              ELECTIVE SURGERY
              (Strictureplasty / Limited resection)