PAIN
Yudiyanta Pain Sub-Department of Neurology Department
Kasus 1 • 38 th • 1HSMRS LBP + kedua bokong • Limitasi ROM terutama pada gerakan fleksi dan rotasi. • NPS 6. • Neuro Exam: dbn • Suhu tubuh 37.8 C. • Nyeri tekan diatas vertebra lumbal 4-5 dan dibokong (+).
Diagnosis yang paling mungkin? A. B. C. D. E.
Fraktur vertebra lumbal 4-5 Spondilolistesis vertebra lumbal 4-5 Hernia Nukleus Pulposus Lumbal 4-5 Sprain Muskuler Referred Pain organ internal
Pemeriksaan Penunjang yang dianjurkan: A. Lumbal X-Ray B. Lumbal CT Scan C. Lumbal MRI D. ENMG E. Belum perlu
Manakah terapi yang paling rasional? A. Acetaminofen 3-4 x 1000 mg B. K-diclofenac 2x 50 mg C. Diazepam 3 x 2 mg D. Codein 3 x 20 mg E. Metilpredisolon 8 mg-8mg-0mg
Lumbar “strain” or “sprain”
Causes of Low Back Pain • • • • • • • • • • • • •
Lumbar “strain” or “sprain” Degenerative changes Herniated disk Osteoporosis compression fractures Spinal stenosis Spondylolisthesis Spondylolysis, diskogenic LBP or other instability Traumatic fracture Congenital disease Cancer Inflammatory arthritis Infections “Psychological”
: 70% : 10% : 4% : 4% : 3% : 2% : 2% : < 1% : < 1% : 0.7% : 0.3% : 0.01% : ? (Stoltz, 2003)
Pemeriksaan Penunjang yang dianjurkan: A. Lumbal X-Ray B. Lumbal CT Scan C. Lumbal MRI D. ENMG E. Belum perlu
Role of X-rays (Radiology) • Usually unnecessary and not helpful • Plain X-ray: – Age > 50 years – No improvement after 6 weeks – Significant Trauma • MRI : – After 6 weeks if have sciatica
Red Flags • • • •
Significant trauma history, or minor in older adults Nocturnal pain in supine position with history of cancer Bladder or bowel incontinence or dysfunction Constitutional symptoms: • Fever / chills • Weight loss • Lymph node enlargement
• Risk factors for spinal infection • Recent infection • IV drug use • Immunosuppression
• Major motor weakness
Compression fracture
Multiple-level degenerative lumbar spondylosis and spinal stenosis
Spondylolisthesis
Manakah terapi yang paling rasional? A. Acetaminofen 3-4 x 1000 mg B. K-diclofenac 2x 50 mg C. Diazepam 3 x 2 mg D. Codein 3 x 20 mg E. Metilpredisolon 8 mg-8mg-0mg
Summary of Evidence on Medications for Acute Low Back Pain (Chou & Huffman, 2007) Drug
Net Benefit
Effective vs. Placebo?
Inconsistency ?
Overall Quality of Evidence
Comments
Acetaminophen
Moderate
Unclear
Some inconsistency
Good
Few data on serious adverse events
Antidepressants
No evidence
No evidence
No evidence
No evidence
-
Antiepileptic drugs
No evidence
No evidence
No evidence
No evidence
Evaluated only in patients with radicular LBP
Benzodiazepines
Moderate
Unable to determine
Some inconsistency
Fair
No reliable data on risks of abuse or addiction.
NSAIDs
Moderate
Yes
No
Good
May cause serious gastrointestinal and cardiovascular adverse event. Insufficient evidence to judge benefits and harms of aspirin and celecoxib for LBP
Opioids
Moderate
No evidence
Not applicable
Fair
No reliable data on risks of abuse or addiction
Skeletal Muscle Relaxant
Moderate
Yes
No
Good
Little evidence of antispasticity skeletal muscle relaxants baclofen and dantrolene for LBP
Systemic Corticosteroids
Not Effective
No
No
Fair
Mostly evauated in patients with radicular LBP
Tramadol
Unable to estimate
No evidence
Not applicable
Poor
The only trial compared tramadol with an NSAID not available in US
• Jika pada pemeriksaan ditemukan: – TD : 110/80 – Ureum: 28 – Creatinin : 1,1 – SGOT: 30 – SGPT: 28 – Nyeri tekan epigastrium (+).
Pilihan NSAIDs yang paling rasional? A. Ibuprofen 2-3 x 400 mg B. K-Diclofenac 2x50 mg C. Asam Mefenamat 3x500 mg D. Paracetamol 3x500 mg E. Celecoxib 2x200 mg
Analgesic efficacy, compared with placebo, of treatments for acute and chronic non-specific low back pain.
Machado L A C et al. Rheumatology 2009;48:520-527, SMT: spinal manipulatif therapy
Berapa lama saya bedrest? A. 1-2 hari B. 5 hari C. 1 minggu D. 10 hari E. Tidak perlu bedrest, langsung aktifitas
Apakah boleh pijat? A. Boleh B. Tidak boleh
Exercise & Bed Rest • Advice to stay active: – There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica • 1-2 days of bed rest if necessary • Light activity, avoiding heavy lifting, bending or twisting
Analgesic efficacy of treatments for NSLBP of any duration.
© The Author 2008. Published by Oxford University Press on behalf of the British Society for Machado L A et al. Rheumatology 2009;48:520-527 Rheumatology. All C rights reserved. For Permissions, please email:
[email protected]
KASUS 2 • Wanita 52 th dg keluhan nyeri punggung bawah menjalar ke tungkai kanan. Riwayat angkat junjung (+), riwayat trauma (-). Pada pemeriksaan nyeri terutama dirasakan saat gerakan ekstensi badan dan miring ke kiri, dan dirasakan lebih nyaman dengan posisi badan fleksi dan menekuk ke kanan. Nyeri sudah dirasakan selama 2 bulan.
Diagnosis yang paling mungkin? A. B. C. D. E.
Fraktur vertebra lumbal Spondilolistesis vertebra lumbal Hernia Nukleus Pulposus Lumbal Sprain Muskuler Referred Pain organ internal
Pemeriksaan fisik yang paling sensitif mendukung diagnosis kerja anda: A. Patrick sign B. Kontra-Patrick Sign C. Lasegue sign D. Lasegue silang sign E. Babinski sign
Pemeriksaan Penunjang yang dianjurkan: A. Lumbal X-Ray B. Lumbal CT Scan C. Lumbal MRI D. ENMG E. Belum perlu
Role of X-rays (Radiology) Diagnosis
Test
Disc
CT
0.90
0.70
MRI
0.90
0.70
CT Myelo
0.90
0.70
CT
0.90
0.80-0.95
MRI
0.90
0.75-0.95
Myelogram
0.77
0.70
“Herniation”
Spinal Stenosis
Sensitivity
Specificity
• Pada evaluasi lebih lanjut, OS mengeluh nyeri dengan rasa kemeng dan pegal, tidak berdenyut, disertai rasa terbakar, kadang-kadang jika salah posisi nyeri seperti tersetrum sampai ujung kaki. Kesemutan dan tebal2 juga dirasakan. NPS 6.
Terapi Farmakologi yang paling rasional? A. Paracetamol 325 mg-tramadol 37,5 mg, gabapentin 100 mg, metikobalamin 500 mcg B. Paracetamol 650 mg, amitriptilin 25 mg, gabapentin 100 mg C. Tramadol 50 mg, amitriptilin 25 mg, codein 10 mg D. Paracetamol 650 mg, tramadol 50 mg, carbamazepin 200 mg E. Celecoxib 200 mg, amitriptilin 25 mg, metilprednisolon 8 mg po
NE
5-HT
(Kanzler et al., 2002)
STT Spinal Cord DORSAL HORN
Periphery
PAF
NE 5-HT NE
STT
5-HT
5-HT3 α2
α2
mu Glu
NMDA AMPA
PAF
SP NKA
NK1
mu 5-HT1A GABA A/B
Dorsal Horn Neuron Other Dorsal Horn Neurons
GABA InterNeuron
Anterior Horn Neurons
Action of AED
Stafstrom C, 1998
Summary of Evidence on Medications for Sub Acute or Chronic Low Back Pain (Chou & Huffman, 2007) Drug
Net Benefit
Effective vs. Placebo?
Inconsistency ?
Overall Quality of Evidence
Comments
Acetaminophen
Moderate
No trial in patients LBP
No
Good
Asymptomatic elevation of liver function test at therapeutic doses
Antidepressants
Small To moderate
Yes
No
God
Only TCA have been shown effective for LBP. No evidence for Duloxetine or venlafaxine
Antiepileptic drugs
Small to moderate
Yes
Not applicable
Poor
1 trial evaluated topiramate for back pain with or w/out radiculopathy
Benzodiazepines
Moderate
Mixed result
Some inconsistency
Fair
No reliable data on risks for abuse or addiction
NSAIDs
Moderate
Yes
No
Fair
May cause serious GI and CV adverse event. Insufficient evidence to judge benefits and harms of aspirin or celecoxib for LBP
Opioids
Moderate
Yes
No
Fair
No reliable data on risks for abuse or addiction
Skeletal Muscle Relaxant
Unable to estimate
unclear
Not applicable
Poor
-
Systemic Corticosteroids
No evidence
No evidence
No evidence
No evidence
Mostly evaluated in patients with radicular LBP
Tramadol
Moderate
Yes
No
Fair
-
• Hasil lab menunjukkan: – Hb 12 g% – Al 7.000 – SGOT: 100 – SGPT : 189 – Ureum: 63 – Creatinin 2,7
Berdasarkan Klinis dan Hasil Lab diatas, analgetik apa yang paling anda rekomendasikan?
A. Paracetamol 650 mg B. Paracetamol 500 mg + Celecoxib 100 mg C. Paracetamol 325 mg + tramadol 37,5 mg D. Celexocib 200 mg+ meloksikam 7,5 mg E. Piroxicam 20 mg + Paracetamol 300 mg F. Asam mefenamat 500 mg + paracetamol 500 mg
Stephan A. Schug Combination analgesia in 2005—a rational approach: focus on paracetamol–tramadol Published online: 2 June 2006, Clinical Rheumatology 2006
Cont’ • safety concerns about long-term use: – has demonstrated efficacy in the control of a variety of chronic pain states. – long-term treatment up to 2 years’ duration. – well-tolerated and has reduction in adverse events – a useful add-on analgesic treatment if existing therapy is insufficiently effective
Pemeriksaan MRI menunjukkan hasil seperti ini:
Anda merekomendasikan tindakan operatif jika: A. B. C. D. E.
Bacaan imaging HNP Sindrome cauda equina Progressive Motor Loss Intractable Pain Klinis canalis stenosis spinalis
Pemeriksaan MRI menunjukkan hasil seperti ini:
Buldging discus - Compression Fracture
Herniated Disc
1. Kompresi mekanik langsung 2. Inflamasi biologis 3. Iskemia lokal (Simon, 2003; Kidd dan Richardson, 2002)
BULGING
EXTRUDED
PROLAPSED
SEQUESTRATION
Spondilolisteis
SURGICAL • Indications: – – – –
Cauda Equina PROGRESSIVE Motor Loss Intractable Pain Spinal Canal Stenosis
Surgical Outcome (Weber et al) • At 1 year: – 90% good outcome with Surgery as compared to 60% with NonSurgery • At 4 years: – Surgery is slightly better (not statistical) • At 10 years: – Same for both groups
Jika MRI seperti berikut:
Edukasi pada pasien ini yang paling tepat: A. 62% herniasi diskus akan mengalami resorpsi spontan B. Respons baik dengan operasi C. Prognosis jangka panjang > 10 tahun lebih baik pada pasien yang dioperasi D. Harus minum obat seumur hidup E. Tidak akan bisa sembuh
PROGNOSIS on NON-SURGICAL • Treated the patient, not the diagnostic test • Recovery: – 80 % Æ 3 days to 3 weeks, with or without treatment – Up to 90 % resolved in 6-12 weeks
– 86-90% satisfactory outcome in one year
Saals et al, Bush et a
– 62% Disc Herniation Resorb Over Time
• Large Compressive DiscsÆ symptomatic : – Respond well to surgery – high rate of clinical improvement with non-operative treatment (Saals et al)
Other Modalities • • • • • •
Back Brace/Corset/Lumbar Support Traction Injections: Inconclusive evidence TENS Hot/Cold Ultrasound
Prevention • Exercise: – Aerobic, back/leg strengthening
• Back braces and education about proper lifting techniques • Weight loss and smoking cessation
Exercises • •
Improves pain and function Many programs available, but difficult to make any scientific recommendations for one type versus another
Injections •
• •
Epidural injections: – Insufficient and conflicting evidence Facet joint injections: – No improvement Local/Trigger point injections: – Possibly some benefit
Symptom Magnification Examination: • Waddell signs: signs suggesting symptom magnification and psychological distress – Superficial or non-anatomic distribution of tenderness – Non-anatomic or regional disturbance of motor or sensory impairment – Inconsistency on positional SLR – Inappropriate/excessive verbalization of pain or gesturing – Pain with axial loading or rotation of spine
Kasus 3 • Anda bekerja di klinik panti jompo • 65 th dg nyeri terbakar dan rasa tersetrum di dahi sebelah kiri dan di sekitar mata kiri. • 3 bl timbul plenting-plenting yang nyeri pada daerah tsb namun sudah sembuh. • Saat ini nyeri NPS 8, • Nyeri memberat bila tersentuh, terkena sentuhan rambut atau angin.
OS hanya bersedia minum satu jenis obat. Obat mana yang paling anda rekomendasikan?
A. Meloksikam 1x15 mg B. Asam mefenamat 3x500 mg C. Metikobalamin 3x500 mcg D. Parasetamol 3x650 mg E. Amitriptilin 1x12,5 mg
Hasil EKG menunjukkan VES jarang, HHD, dan iskemik anterior. Obat mana yang anda rekomendasikan ? A. Gabapentin 2x75 mg B. Tramadol 2x50 mg C. Metikobalamin 3x500 mcg D. Parasetamol 3x650 mg E. Amitriptilin 1x12,5 mg
EFNS GUIDELINES FOR THE TREATMENT OF PHN
Recommendations: First line therapy
TCAs, gabapentin, pregabalin, and topical lidocaine (evidence level A)
Second line therapy
Strong opioids, tramadol and capsaicin (evidence level B)
Lack of or weak efficacy
Mexiletine and NMDA antagonists (evidence level A)
EFNS: European Federation of Neurological Societies
What is Neuropathic pain? Definition: Pain arising as a direct consequence of a lesion or disease affecting the somatosensory NERVE system
Characterized by: Pain often described as shooting, electric shock-like or burning. The painful region may not necessarily be the same as the site of injury. Almost always a chronic condition (e.g. post herpetic neuralgia, post stroke pain) Responds poorly to conventional analgesics
Perceived pain
Nerve lesion
Descending modulation
Ascending input
Nociceptive afferent fiber Spinal cord Ectopic discharges
The Inter-Relationship Between Pain, Sleep, and Anxiety / Depression Pain
Functional impairment Anxiety & Depression
Nicholson and Verma. Pain Med. 2004;5 (suppl. 1):S9-S27
Sleep disturbances
What is the Correlation Between Causes, Muscular pain, Neuro-endocrine (HPA Axis) disorders and Psychological distress Emotional, Environmental and Genetic Predisposition Cortex-Limbic System- Hypocampus
Perception
Thalamus & Hypothalamus
CRH, TRH, GhRH, PRF, GnRH
Pituitary
ACTH, TSH, GH, Prolactine, FCH-LH
Adrenal, Thyroid
Cortisone, Thyroid, Prolactine, Estrogen, Progesterone
Neuro-hormonal Disfunction Sympathetic
Metabolic
Dorsal Horn
Muscle Trauma
PAIN
Karakteristik
Post Herpetic Neuralgia
Trigeminal Neuralgia
Tipe Nyeri
Dominan terbakar, nyeri tajam
Dominan seperti kesetrum listrik
Perjalanan
Kronik
Akut, intermitten/ paroksismal
Gangguan sensibilitas
+
+/-
Lokasi
Unilateral
Unilateral
Pain free interval
Jarang ada
Selalu ada
Faktor presipitasi
-
Mengunyah, menelan, berbicara
Kasus 4 • Laki-laki, 60 tahun penderita Ca prostat, mengeluhkan nyeri sangat hebat di tulang belakang, dirasakan seperti ditusuk-tusuk, dan kadang seperti terbakar. NPS 9. Nyeri ini muncul sejak sekitar 1 tahun yang lalu saat pasien pertama kali didiagnosis menderita keganasan prostat. Nyeri ini dirasakan hilang timbul namun semakin lama semakin berat dan konstan. Pemeriksaan neurologis didapatkan gangguan BAB dan BAK, dengan anestesi dermatom L5S1. Pemeriksaan lab menunjukkan kadar PSA 125 mg/dl dengan Ro terlampir.
Imaging
Terapi yang paling anda pilih: A. Tramadol 50 mg po B. Morfin sulfat 10 mg C. Risedronat sodium 60 mg D. Fentanil patch 25 mcg E. Ketorolac injeksi 1 amp
Primary or Metastatic Carcinoma
SPONDILITIS
Kasus 5 • Wanita 25 tahun, sekretaris, mengeluhkan nyeri kedua tangan, sejak 8 HSMRS. dirasakan panas, tebal-tebal dan kemeng mulai dari sendi siku sampai dengan tangan terutama pada jari telunjuk dan jari tengah. Tidak ada rasa tebal-tebal pada kelingking. NPS ratarata 5. Rasa ini lebih parah pada saat tidur malam hari bahkan menyebabkan pasien terbangun karena nyeri. Pekerjaan mengharuskan leher sering menunduk, dan kadang-kadang merasakan nyeri leher terutama sore hari. Nyeri tekan epigastrium (-). Pemeriksaan fisik dbn.
Diagnosis yang paling mungkin? A. HNP C5-6 B. Polineuropati C. Myelopathy D. Myalgia E. Carpal tunnel syndrome
Nasehat Pertama ? A. Splinting position B. Tidak boleh angkat berat C. Kurangi makanan tinggi glukosa D. Tidak boleh makan tinggi kolesterol E. Minum obat secara teratur
Analgetik pilihan Anda: A. Paracetamol 3x650 mg B. Metampiron 3x500 mg C. Tramadol 2x50 mg D. Paracetamol 325 mg + tramadol 33 mg E. Na-diclofenac 2x25 mg
Kombinasi terapi yang paling rasional? A. Paracetamol+deksamethason B. Na-diclofenac, metilprednisolon+metikobalamin C. K-diclofenac + gabapentin + metikobalamin D. Deksamethason injeksi E. Vit B injeksi, ketorolac injeksi
Terapi non farmakologi yang anda anjurkan: A. Operasi dekompresi B. Fisioterapi exercise C. Ultrasound dan diatermi D. Layar komputer kerja sejajar mata sehingga tidak menunduk saat kerja E. Bedrest
CTS • Normal pressure : 0–5mm HgÆ 30mm Hg at rest in CTS, and is 90mm Hg with wrist flexion or extension in patients with CTS. • • Classic symptoms : – night pain that wakes the patient from sleep, – pain with maximal wrist flexion or extension, – decreased grip strength, and decreased dexterity.
Summary of Tests Test Phalen’s Tinel’s Compression
Sensitivity 75% 64% 87%
Specificity 62% 71% 90%
Non-operative Treatment • Splinting (nocturnal, neutral) • Oral agents – NSAIDs, Vitamin B6 (?) – Neither effective in isolation
• Steroid injection – 80% relief short-term, ~10-20% @ 1.5 years – (+) response predictive of success with surgery – dexamethasone safest
Summary • CTS is a clinical diagnosis – ED are confirmatory
• Non-operative treatment early • Operative treatment – if denervation of APB – failure of non-operative treatment
Kasus 6 • Mahasiswi, 20 tahun datang dengan keluhan nyeri kepala berdenyut, sejak 3 hari yang lalu, terutama di frontal dan temporal. Pemeriksaan fisik dan neurologis tidak ditemukan abnormalitas. Gangguan penglihatan (-). Pada pemeriksaan NPS berkisar 8. Pasien merasakan silau jika melihat sinar. Pasien sedang mengalami faringitis sejak 1 hari , dan ada rasa mual.
Diagnosis yang paling mungkin A. Migraine headache B. Cluster headache C. Tension type headache D. Nyeri kepala terkait infeksi/inflamasi E. Galucoma
Classification and Diagnostic Criteria 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Migraine (7) Tension-type headache (3) Cluster headache and chronic paroxysmal hemicrania (3) Miscellaneous headaches unassociated with structural lesion (6) Headache associated with head trauma (2) Headache associated with vascular disorders (9) Headache associated with non-vascular intracranial disorder (7) Headache associated with substances or their withdrawal (5) Headache associated with non-cephalic infection (3) Headache associated with metabolic disorder (6) Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures (7) Cranial neuralgias, nerve trunk pain and deafferentation pain (8) Headache not classifiable (1)
TOTAL : 67 (Silberstein & Young, 2005)
BACKGROUND HEADACHE
Primary
Secondary
headache condition itself is the problem, and no underlying or dangerous cause for it can be identified. The classification is based on symptom profiles
headache are related to other conditions, and a 'secondary symptom'. They are classified according to their causes (e.g. vascular, psychiatric, etc.).
Bajwa & Wootton, 209
History and examination • No ‘gold standard’ tests or biologic markers exist • A good history is the key to diagnosis. • Examination is usually normal in patients with primary headache. • A systematic case history Æ single most important Æ diagnosis, future work-up and treatment plan. • Æ focus the physical examination and prevent unnecessary investigation and imaging studies
Consider a diagnosis of migraine • Patients with recurrent severe disabling headaches associated with nausea and sensitivity to light, and with a normal neurological examination (C).
Consider a diagnosis of tension-type headache • in patients with recurrent, non-disabling bilateral headache and a normal neurological examination (C).
Consider the diagnosis of a trigeminal autonomic cephalalgia (cluster headache, paroxysmal hemicrania, short lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT)) • in patients with frequent, brief, unilateral headaches in a trigeminal distribution with ipsilateral cranial autonomic features (D)
New daily persistent headache • Cresendo pattern in daily: exclude secondary causes (such as subarachnoid haemorrhage, meningitis, raised intracranial pressure, low pressure headache, giant cell arteritis) (D).
Investigation • Neuroimaging is not indicated in patients who have a clear history of migraine, no “red flag” features, and a normal neurological examination(D). • In stable migraine only 0.2% have relevant abnormalities on neuroimaging. • Both magnetic resonance imaging and computed tomography can identify incidental abnormalities that may result in patient anxiety as well as dilemmas in practical and ethical management.
For patients with a first presentation of thunderclap headache • Refer immediately to hospital for exclusion of subarachnoid haemorrhage or alternative secondary cause of thunderclap headache (such as intracranial haemorrhage, meningitis, cerebral venous sinus thrombosis) by CT brain scan, and lumbar puncture if CT brain scan is normal (D).
Investigation • The following are warning signs or “red flags” for potential secondary headache, based on observational studies (D): – new headache in a patient aged over 50; – thunderclap onset (that is, abrupt and severe); – focal and non-focal symptoms; – abnormal signs; – headache changing with posture; – valsalva headache (headache triggered by valsalva-type manoeuvres such as coughing, sneezing, bending, heavy lifting, straining); – fever – history of HIV; – cancer
Indications for imaging studies • AAN, AAFP, ASIM: – Patients with danger signs. – Non-acute headache and an unexplained abnormal finding on neurologic examination. – In the remaining patients Æ remain one of clinical judgment • increased severity of symptoms or resistance to appropriate drug therapy; • change in characteristics or pattern of headache • family history of an intracranial structural lesion
Bajwa & Wootton, 209
SUGGESTIVE INFECTION • For patients with headache and features suggestive of infection of the central nervous system (such as fever, rash), refer immediately to hospital (D).
SUGGESTIVE INCREASED of ICP • For patients with headache and features suggestive of raised intracranial pressure (such as worse lying flat, valsalva headache, focal or non-focal symptoms or signs, papillo-oedema), refer urgently for specialist assessment (D).
Consider intracranial hypotension • in all patients with headache developing or worsening after assuming an upright posture (D). • Refer such patients to a neurologist or headache clinic for specialist assessment (D)
Consider giant cell arteritis • in any patient over the age of 50 presenting with a new headache or change in headache, and check erythrocyte sedimentation rate and C reactive protein levels (D).
SUMMARY • The appropriate evaluation of headache complaints includes the following: – Rule out "Danger signs“. – Determine the type of primary headache using the patient history as the primary diagnostic tool. – There may be overlap in symptoms (migraine and tension-type headache; migraine and some secondary causes of headache (such as sinus disease)). – An imaging study is warranted in "Indications for imaging studies“
