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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 78-88

Headache in daily practice: What a physician needs to know


Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Submission14-Oct-2020
Date of Decision13-Nov-2020
Date of Acceptance14-Nov-2020
Date of Web Publication21-Apr-2021

Correspondence Address:
Prof. Girish Baburao Kulkarni
Department of Neurology, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_77_20

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  Abstract 


Headache is a common presenting complaint encountered in the outpatient as well as inpatient settings. Appropriate diagnosis and treatment of the commonly encountered primary headaches, timely evaluation for secondary causes, and patient education are the management's cornerstones. Our review aims to summarize the key diagnostic features and treatment of primary headaches and discuss the red flags that aid in the diagnosis of secondary headaches. For this, we searched the PubMed database using the keywords “Primary headache,” “Primary headache AND Diagnosis,” “Primary headache AND Treatment,” “Red flags AND Headache,” “Secondary Headaches.” Those articles written in English and were available in full text were reviewed. In this review, in addition to the clinical and management aspects, we have also elucidated the diagnosis and management of headache in special situations such as pregnancy and menstruation, headache in the emergency room, status migrainosus, and newer developments in the therapeutic armamentarium of headache. We have also tried to simplify the approach to headaches seen in routine outpatient clinics and emergency settings and develop a structured approach for diagnosis and management.

Keywords: Analgesics, headache, migraine, tension-type headache, triptans


How to cite this article:
Mailankody P, Reddy Taallapalli AV, Kulkarni GB. Headache in daily practice: What a physician needs to know. APIK J Int Med 2021;9:78-88

How to cite this URL:
Mailankody P, Reddy Taallapalli AV, Kulkarni GB. Headache in daily practice: What a physician needs to know. APIK J Int Med [serial online] 2021 [cited 2021 May 14];9:78-88. Available from: https://www.ajim.in/text.asp?2021/9/2/78/314201




  Introduction Top


Headache is a common complaint encountered by the physicians in both outpatient and emergency settings. Accurate diagnosis is key to the management. Among the patients, who seek health-care services for headache, more than 80% go to the primary healthcare providers.[1] Due to various barriers related to the care of headache disorders, the diagnosis and treatment are suboptimal. Even in a developed country like the United States, more than half of the patients never received a formal diagnosis.[2] Headache may commonly be a disease itself and may recur (primary) or may be a symptom of an underlying disorder that may occasionally be life-threatening (secondary). Identifying the red flags and appropriate management of the secondary cause is important. Empowering the physicians in proper management will help the patients and the health care system immensely in tackling this burden.


  Definition and Classification Top


The term headache is used to describe pain or discomfort in the head or neck above the orbitomeatal line.[3] The crude 1-year prevalence of headache is 63.9% in Karnataka.[4] Headache is considered primary when there is no other causative disorder. When another disease causes a headache, it is considered secondary. Migraine, tension-type headache (TTH), and trigeminal autonomic cephalalgia (TAC) are the major primary headache disorders. Over 15% of the population is affected by migraine attacks, and 10% of them suffer from weekly attacks.[5] According to the Global burden of Disease Study 2010, the global prevalence of migraine is 14.7%. TTH and migraine were the second and third most prevalent disorders worldwide.[6] Secondary headache occurs in close temporal relation to another disorder that is known to cause a headache. It usually resolves within 3 months after successful treatment or spontaneous remission of the causative disorder.[3]


  Why Do We Need A “Classification”? Top


Headache is a common presenting complaint encountered in various clinical settings. Uniformity of diagnosis across the globe helps better understanding of the burden and development of better ways of addressing the burden. A uniform classification is required for the proper diagnosis, correct treatment, and research.

The most recent classification, the ICHD3 is available in a user-friendly online version (www.ichd-3.org) [Table 1]. This resource enables easy and quick diagnosis of headaches in the outpatient setting, facilitating the patient's appropriate and tailored treatment. Primary headache needs to be distinguished from secondary headache. Even among primary headaches, the treatment depends on the type of headache.
Table 1: The international classification of headache disorders 3 classification of headache disorders

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  Pathophysiology of Headache Top


Cranial nerves carry the pain fibers. Part of the dura at the brain's base, proximal segment cerebral arteries and venous sinuses, middle meningeal arteries and superficial temporal arteries, external periosteum of the skull, skin, subcutaneous tissues, and extracranial arteries are the pain-sensitive structures around the brain.[7] Traction on major intracranial vessels, dilation or distension of the intracranial or extracranial arteries, inflammation adjacent to the pain-sensitive structures, and structural involvement of the cranial or cervical nerves are some of the mechanisms of headache.[7]

Migraine has a neurovascular basis. It is an abnormal state of the brain with secondary vascular effects.[8] Aura corresponds to the cortical spreading depression (CSD). The CSD is a slowly propagating wave (2–6 mm/min) of depolarization of neurons and glia, and this wave is followed by a prolonged cessation (15–30 min) of cortical activity. It is believed to originate from the cerebral cortex, hippocampus, and cerebellum.[9]

Neuropeptides such as calcitonin gene-related peptide (CGRP), vasoactive intestinal peptide, and substance P are discharged from the trigeminal afferents, possibly in response to CSD, and this leads to the dilation of blood vessels and extravasation of plasma proteins leading to “sterile” neurogenic inflammation. The activation of the trigeminal nucleus in the brainstem leads to migraine features as the nucleus has connections with other parts of the brain like the thalamus, which has projections to the somatosensory cortex and limbic system. The trigeminal nucleus also has connections with the hypothalamus and superior salivatory nucleus, which probably explains the autonomic features in migraine.[10]

A strong family history suggests a genetic component to migraine risk. To summarize, both genetic and environmental factors contribute to the pathogenesis of migraine.[11]


  Common Primary Headache Disorders Top


Migraine

In a door-to-door survey, Kulkarni et al. found that the crude 1-year prevalence of definite migraine was 25.6% in Karnataka's urban and rural populations. The prevalence of migraine was more among females (32.4%) compared to males (18.6%) and more among those from rural areas (29.7%) compared to those from urban areas (21.9%).[1]

Migraine is a recurrent disabling neurovascular disorder characterized by a unilateral, pulsating headache of moderate to severe intensity, which worsens on exertion and is accompanied by nausea and/or vomiting, photophobia, and phonophobia [Table 2]. Each attack's duration may range from 4 to 72 h, and five such attacks are required to diagnose episodic migraine. The most common type of migraine is common migraine or migraine without aura. Migraine with aura or classic migraine is characterized by headache preceded by a disruption of nervous function (mostly visual). The ratio of classic to common migraine is 1:5.[7] Nevertheless, it is less prevalent in the Indian context. Aura is seen in <5% of migraine patients in India (unpublished observation).
Table 2: Primary headache disorders: An overview

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The most common aura of migraine is visual and is characterized by positive moving visual symptoms with scintillating, shimmering, jagged edges, and lasts for typically 20–30 min.[7] Characteristically, the aura symptoms gradually build up over 5–10 min and usually last up to 1 h and followed or preceded by the characteristic migraine headaches, and aura symptoms are recurrent. When a patient has the first episode of aura, it must be distinguished from a seizure and a stroke. Positive visual symptoms also characterize occipital seizures. Nevertheless, they last only for a few seconds.[12] In an occipital transient ischemic attack (TIA), hemianopia or blindness are the visual symptoms. They appear and disappear suddenly and last for a few minutes.[3] Other seizure phenomena may accompany the visual symptoms in case of an occipital seizure and other vertebrobasilar symptoms in an occipital TIA case.[3],[12]

Prodromal symptoms like yawning, blurred vision, sensitivity to light, and or sound, nausea may occur a few hours before the onset of headache in a patient with migraine. Mood changes and fatigue may occur after the headache improves, and may last for up to 48 h.[7] Emotional stress, changes in sleep pattern, travel, skipping a meal, odors, menstrual cycle, bright light, weather, exercise, or overactivity, some food items were the triggers identified by Kulkarni et al. during their study (unpublished observation). Certain features of migraine are peculiar to the Indian population, such as migraine triggered by a head bath.[13] Migraine is called chronic when it occurs on more than 15 days per month for at least 3 months.[3] The diagnosis of migraine remains clinical; based on the criteria. No investigation can confirm the diagnosis.

Treatment of migraine

Migraine can be managed with pharmacological as well as nonpharmacological methods. Acute management is for immediate pain relief, and prophylaxis decreases the frequency, duration, and severity of episodes.

Nonpharmacological

Avoidance of triggers, 150 min of exercise per week, and sleep hygiene are essential in managing migraine episodes.[14],[15] Relaxation techniques and yoga are also important nonpharmacological tools in treating migraine.[14],[16] Maintaining a headache diary helps detect a pattern and assess response to treatment.


  Pharmacological Measures Top


Acute treatment

The objective of acute treatment is to restore full function within 2 h of onset and ensuring no recurrence for the next 24 h.[17] Optimum acute treatment is also important to prevent the conversion of episodic to chronic migraine.[16] Specific agents used for migraine treatment are triptans. They act on 5-hydroxytryptamine receptor 1D and prevent the release of CGRP. Nonsteroidal anti-inflammatory drugs (NSAIDs) and antiemetics are the nonspecific drugs used for acute control. Drugs can be administered through oral, subcutaneous, intravenous, and intramuscular routes. Intranasal, sublingual routes and skin patches are some of the newer delivery routes for certain drugs [Table 3].[18] If the time to peak is <30 min or the headache is accompanied by severe nausea and vomiting, nonoral routes are preferred.[17]
Table 3: Treatment of migraine

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Prevention

The goal is to reduce headache frequency, severity, and duration. Institution of timely and appropriate acute and prophylactic medication is important to prevent the development of chronic migraine and medication overuse headache (MOH) [Table 3] and [Table 4].[14],[19] In the case of a middle-aged woman with migraine and depression, amitriptyline may the drug of choice and not propranolol or flunarizine. On the contrary, for a young migraineur who is a driver by occupation, propranolol is the drug of choice.
Table 4: Indications and tips for migraine prophylaxis

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Future directions

Understanding the role of CGRP in migraine has led to the development of molecules targeting both CGRP and its receptor. Some of these drugs which are being currently used on a trial basis will soon become available for the management of both acute and preventive treatment of migraine [Table 5] and [Table 6].[14],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30]
Table 5: Newer drug formulations for migraine

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Table 6: Newer devices/techniques for migraine management

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Migraine and menstruation

Menstrual migraine could be pure menstrual migraine wherein headache occurs only during the menstruation (−2 to +3 days) and at no other time during the cycle. More common is the menstrually related migraine in which the attacks occur throughout the cycle but increase in the frequency or intensity during the menstruation.[3] NSAIDs are used for acute and prophylactic treatment for both types of menstrual migraines. For pure menstrual migraine, hormonal treatment may help in prophylaxis.[31]

Migraine in pregnancy

More than 80% of the patients with migraine have an improvement in their headache during pregnancy.[32] The use of medications must be minimized as much as possible. Rest, relaxation therapy, and biofeedback may be tried for mild attacks. Paracetamol can be used for abortive treatment. In general, prophylaxis is discontinued before pregnancy or after diagnosis of pregnancy as most of them improve during pregnancy. However, if the attacks are frequent, severe, or prolonged and do not respond to abortive therapy, beta-blockers like propranolol and tricyclic antidepressant, like amitriptyline are considered first, and second-line agents, respectively. An attempt should be made to avoid them during the first trimester and explain the possibility of an effect on developing fetus before starting them.[33] Greater occipital nerve block has been successfully tried for the management of migraine during pregnancy.[34] There is scarce data regarding the use of non-invasive stimulation devices in pregnancy. Nevertheless, anecdotal reports suggest that single-pulse transcranial magnetic stimulation is safe for acute migraine in pregnancy.[35]

Headache occurring during the puerperal stage could be due to other causes such as cerebral venous thrombosis, preeclampsia/eclampsia, posterior reversible encephalopathy syndrome, postdural puncture headache, pituitary apoplexy, subarachnoid hemorrhage, and other stroke syndromes.[36] Hence, imaging must be done to rule out secondary causes of headache. If imaging is normal, migraine has to be considered when the attacks are recurrent and satisfy the diagnosis criteria. The safety of abortive and prophylactic drugs during breastfeeding should be ascertained before prescribing.


  Status Migrainosus Top


Status migrainosus is defined as a debilitating migraine that lasts for more than 72 h in a known patient of migraine.[3] The differential diagnosis for status migrainosus are idiopathic intracranial hypertension, subdural hematoma, brain tumor, brain abscess, cervical artery dissection, meningitis, sphenoid sinusitis, and acute glaucoma. History and a normal neurological examination help in the diagnosis.[37] Subcutaneous sumatriptan is the treatment of choice.[38] Intravenous fluids, NSAIDs, antiemetics, corticosteroids, nerve blocks especially greater occipital nerve block, are other treatment options for status migrainosus in emergency settings. If the patient has severe dehydration, intractable headache or vomiting, poor response to emergency treatment, very high headache-related disability, inpatient care may be considered.[37]


  Tension-type Headache Top


TTH, the most common type of headache, is characterized by a nonpulsating headache, bilateral and mild to moderate in intensity [Table 2]. At least ten episodes are required to make a diagnosis. The duration can range from 30 min to 7 days. There will be no nausea or vomiting, as seen in migraine. The lifetime prevalence of TTH can be as high as 78%.[39] A door to door survey by Kulkarni et al. found that the 1-year crude prevalence of TTH was 34.8%.[1] Based on the frequency of occurrence, TTH can be classified as infrequent episodic, frequent episodic, and chronic TTH.

The TTH can begin at any age, and the peak prevalence is between the age of 40 and 49 years.[40] Pathophysiology of TTH remains unclear, though it is generally agreed that pericranial muscles and fascia contribute to the genesis of the headache.[41] The pain threshold is lower in patients with chronic TTH.[42] A large number of patients with chronic TTH have tenderness of the cervical and the pericranial muscles. Migraine may also be holocranial and hence may be misdiagnosed as TTH.[43] Hence, the differentiation should be made between the two by carefully enquiring about the migrainous features.

The management includes nonpharmacological as well as pharmacological measures.[44] Avoidance of triggers, if any, stress management, including relaxation techniques and biofeedback, are helpful. Analgesics especially NSAIDs, are used in the treatment of acute attacks.[45] If the patient has a headache on at least 2–3 days per month, a preventive treatment can be given, and amitriptyline is the drug of choice.[41]


  Other Types of Primary Headaches Top


Sharp pain occurring on one side and accompanied by autonomic symptoms on the same side constitute TAC.[3] The TACs differ from each other in terms of duration of the attack, frequency of occurrence, and treatment [Table 2].

Chronic headache

Headache occurring on 15 or more days per month for at least 3 months is a chronic headache.[3] Chronic headaches are a severely disabling long-term condition with higher symptom frequency and severity than episodic headaches.[46] Chronic headache includes both primary and secondary headache disorder.[47] The primary headache could be chronic migraine, chronic TTH, hemicrania continua, or new daily persistent headache (NDPH). NDPH is characterized by distinct and clearly remembered onset, with pain becoming continuous and unremitting within 24 h.[3] The pain is usually bilateral and characterized by a tight or squeezing quality of mild-to-moderate intensity.[48] Secondary causes should be ruled out by identifying the red flags and appropriate investigations. Identification and treatment of medical and psychiatric comorbidities are important in the management of chronic headaches. Treatment details of primary headaches are given in [Table 2] and [Table 3].


  Secondary Headaches and Red Flags Top


Secondary headache reduces or resolves within 3 months of successful treatment or spontaneous remission of the underlying cause.[3] A timely diagnosis of secondary headache is often rewarding as many secondary causes are treatable and can prevent life-threatening complications when managed early [Table 7]. “Red flags” help in the identification of secondary causes of headache. The presence of papilledema is a “red flag” that tells us that it is not a migraine. If not diagnosed on time, the patient can develop visual loss. When the headache occurs abruptly, or there is a recent change in the pattern, a secondary cause should be considered. Furthermore, positional headache (worsens when upright) and headache precipitated by coughing or sneezing should alert the physician that it is not a primary headache. Systemic symptoms like fever, weight loss, an immunocompromised state like human immunodeficiency virus, present or past history of malignancy, co-existent neurological deficits, age of onset of headache more than 50 years, and occurrence during pregnancy and puerperium are some of the red flags for diagnosis of secondary headache [Figure 1], [Figure 2], [Figure 3], [Figure 4] and [Table 8].[49]
Table 7: Clinical features, investigations, and treatment of common secondary headaches

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Table 8: Pointers to secondary causes of headache

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Figure 1: Cerebral venous thrombosis. (a) Axial contrast enhanced computed tomography of the brain shows empty delta sign (arrow) due to the enhancement of the dura and nonenhancement of the thrombus. (b) Mixed density lesion in the left frontoparietal region suggestive of hemorrhagic infarct

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Figure 2: Idiopathic intracranial hypertension. (a) T2 axial sections-kinking of the bilateral optic nerves (arrow). (b) Magnetic resonance venogram reveals bilateral sigmoid sinus stenosis in idiopathic intracranial hypertension (arrow). (c) T1 sagittal image shows empty sella (arrow)

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Figure 3: Intracranial hemorrhage. (a) Axial plain computed tomography brain shows hyperdensity in the left cerebellar hemisphere and brainstem obliterating the 4th ventricle suggestive of acute hemorrhage. (b) Axial computed tomography brain plain shows right parietal lobar hemorrhage. (c) Plain computed tomography reveals hyperdensity across bilateral sylvian fissures (arrows) and inter-hemispheric fissure (arrow head) suggestive of disuse subarachnoid hemorrhage

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Figure 4: Headache-an approach. TTH: Tension type headache, TAC: Trigeminal autonomic cephalalgia

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Thunderclap headache (TCH) is a severe headache that reaches maximum intensity in <1 min.[3] Subarachnoid hemorrhage, cerebral venous thrombosis, intracranial hypotension, cervical artery dissection, pituitary apoplexy, brain infections, intake of vasoactive substances like cannabis, cocaine, amphetamines, nasal decongestants reversible cerebral vasoconstriction syndrome are the various causes of TCH.[50]

Medication overuse headache

MOH is a headache that occurs as a result of regular overuse of medications for acute control. Once the overuse is stopped, the headache mostly resolves.[3] The MOH is a secondary headache and develops in patients with preexisting primary headache disorder that occurs on ≥15 days per month for >3 months.[3] The most common primary headache disorder associated with MOH is migraine.[51] The prevalence of MOH in the general population is 1%–2%.[52] MOH can be simple or complex. Short-term overuse with small amounts, minimal psychiatric comorbidity, and no history of relapse after withdrawal suggest simple MOH, whereas significant psychiatric comorbidity history of relapse suggests complex MOH.[53],[54] Combination analgesics, opioids, and triptans are associated with increased risk of developing MOH. More than ten headache days monthly, female gender, comorbid psychiatric disorders or chronic pain conditions, lower socioeconomic status, and dependency behavior are the risk factors for MOH development.[55] Patient education regarding the “too frequent” use of acute medications, risk factors, and consequences of medication overuse is the first step in the management of MOH.[56] Further, detoxification with abrupt cessation of the overused drugs followed by the initiation of prophylaxis with topiramate or botulinum toxin will be required for the treatment of MOH.[56]

Headache in the emergency room

Headache is a common complaint in the emergency room.[57] Primary headache disorders such as migraine, TTH, TACs, and secondary headaches caused by sinusitis, hypertension, subarachnoid hemorrhage, neuro infection, or malignancy can present to the emergency department. Among the primary headaches presenting to the emergency, migraine is the most common cause.[58],[59],[60] Patients with migraine may also present to the emergency when the abortive or the rescue medications fail.[61] A detailed history and examination can help in the diagnosis of secondary headaches, which can be confirmed by appropriate investigations [Table 7] and [Table 8]. The treatment depends on the underlying etiology of the headache [Table 3] and [Table 7].[62],[63],[64]

Approach to headache

History is the cornerstone of the diagnosis. Detailed interview regarding the onset, progression, nature, duration, frequency, and severity of headache can give a clue to the diagnosis. General physical examination, including the vitals and neurological examination, are mandatory for every patient with headache. For example, elevated BP and bradycardia may be due to Cushing's reflex in raised intracranial tension. Horner's syndrome may suggest a diagnosis of cervical artery dissection. Work up for secondary causes will be guided by the key features in history and examination. For primary headaches, both diagnosis and management rely entirely on history [Figure 4] and [Table 8].

Headache diary

Maintaining a diary by the patient helps in objective documentation of the details, which might be forgotten otherwise. The diary will help in determining the pattern and frequency, thereby guiding the physician to choose the most appropriate therapy [Figure 5]. The duration and frequency may help in the diagnosis of certain types of headaches like a menstrual migraine.
Figure 5: Headache diary

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Use of complementary and alternative medicine in headache

The National Institutes of Health defines complementary and alternative medicine (CAM) as a group of diverse medical and health care systems, practices, and products that are not generally considered conventional medicine.[65] A large number of patients (30%–80%) use CAM in addition to the conventional treatment for the management of headaches.[66],[67] Patients who use CAM often report that the CAM is more “useful” than conventional care.[68] Mind-body therapies such as deep breathing exercises, meditation, yoga, relaxation exercise, guided imagery, herbal supplements, chiropractic, massage, homeopathy, Ayurveda, and acupuncture are some of the CAM used by patients.[67] More studies are required to evaluate the benefits of CAM use in migraine.

Barriers to headache care in the country

Various patient-related and physician-related barriers are responsible for the suboptimal headache care in our country in addition to the problems such as poverty, overcrowding, and poor education.[69] Myths and misconceptions like headaches are due to eye or sinus problems, financial constraints, fear of side effects, self-medication, frequent change of doctors lead to poor control of headaches. Physician-related issues like the wrong drug, underdosing, and lack of patient education are also barriers to headache care in our country.[69]


  Conclusion Top


Headache can be the presenting symptom in outpatient as well as emergency settings. Physicians need to be well-versed in diagnosing and treating common primary headache disorders, identifying the red flags, and timely management of secondary headaches. We summarized the characteristics of primary headaches, current and future therapeutic options for managing headaches, secondary causes, and approach to headaches. We also reviewed the common drugs used for acute control and prophylaxis, their dosage side effects, and contraindications, which will help day-to-day practice. Being cautious in special situations like a migraine in pregnancy and puerperium, considering the comorbidities while prescribing medications, and timely referral to the specialist when treatment response is poor will help in the appropriate management of headaches.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Abstract
Introduction
Definition and C...
Why Do We Need A...
Pathophysiology ...
Common Primary H...
Pharmacological ...
Status Migrainosus
Other Types of P...
Secondary Headac...
Conclusion
Tension-type Hea...
References
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