Acute Headache An Overview M. Wallin, MD, MPH

Most of the time he seemed to see something shining before him like a light, usually in part of the right eye; at the end of a moment, a violent pain supervened in the right temple, then all of the head and neck, where the head is attached to the spine…vomiting, when it became possible, was able to divert the pain and render it more moderate. Hippocrates

The Burden of Headache > 13,000 tons of aspirin consumed annually worldwide Headaches account for 1-2% of ER visits and up to 4% of visits to physicians Lifetime prevalence for any type of headache > 90% for men & 95% for women 23 million Americans with migraine: 18% women, 6% men

> 13,000 tons of aspirin consumed annually worldwide

Headaches account for 1-2% of ER visits and up to 4% of visits to physicians

Lifetime prevalence for any type of headache > 90% for men & 95% for women

23 million Americans with migraine: 18% women, 6% men

Acute Headache Topical Outline Primary vs. Secondary Headache Pathophysiology History Physical Exam Laboratory studies & Imaging Differential Diagnosis Case Studies

Primary vs. Secondary Headache

Pathophysiology

History

Physical Exam

Laboratory studies & Imaging

Differential Diagnosis

Case Studies

Primary vs. Secondary Headache Definitions headache the primary manifestation headache a secondary manifestation of an underlying disease process External Stimulus Goals of the clinician make an accurate headache diagnosis provide emergency therapy provide patient with means of long-term care

Definitions

headache the primary manifestation

headache a secondary manifestation of an underlying disease process

External Stimulus

Goals of the clinician

make an accurate headache diagnosis

provide emergency therapy

provide patient with means of long-term care

Primary Headache Classification International Headache Society, 1988 Migraine Tension-type headache Cluster headache & chronic paroxysmal hemicrania Headache associated with head trauma Headache associated with vascular disorders Headache associated with nonvascular intracranial disorders Headache associated with substances and their withdrawal Headache associated with noncephalic infection Headache associated with metabolic abnormality Headache or facial pain associated with disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures Cranial neuralgias, nerve trunk pain, & deafferentation pain Other types of headache or facial pain Headache not classifiable

Migraine

Tension-type headache

Cluster headache & chronic paroxysmal hemicrania

Headache associated with head trauma

Headache associated with vascular disorders

Headache associated with nonvascular intracranial disorders

Headache associated with substances and their withdrawal

Headache associated with noncephalic infection

Headache associated with metabolic abnormality

Headache or facial pain associated with disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures

Cranial neuralgias, nerve trunk pain, & deafferentation pain

Other types of headache or facial pain

Headache not classifiable

Pathophysiology of Headache Specific mechanism of headache is incomplete Genetics (Familial Hemiplegic Migraine) Migraine Generator Final common pathway

Specific mechanism of headache is incomplete

Genetics (Familial Hemiplegic Migraine)

Migraine Generator

Final common pathway

History Past history of headaches “ first, worst, different, progressive, persistent” Age of onset > 50 years Headache characteristics P alliative Q uality R egion S everity (0-10) T iming

Past history of headaches

“ first, worst, different, progressive, persistent”

Age of onset

> 50 years

Headache characteristics

P alliative

Q uality

R egion

S everity (0-10)

T iming

History Associated Symptoms Fever/Chills/Nightsweats Nausea/Vomiting Photophobia & Phonophobia Neck pain or stiffness Alterations in level of consciousness Focal neurologic symptoms Family History

Associated Symptoms

Fever/Chills/Nightsweats

Nausea/Vomiting

Photophobia & Phonophobia

Neck pain or stiffness

Alterations in level of consciousness

Focal neurologic symptoms

Family History

Physical Examination General Exam Vital Signs General Appearance HEENT (Trauma, dentition, sinus/temples) Neck (ROM, Kernig’s and Brudzinski’s sign) Skin (Rash, bruising, hemorrhages) Lymph Nodes

General Exam

Vital Signs

General Appearance

HEENT (Trauma, dentition, sinus/temples)

Neck (ROM, Kernig’s and Brudzinski’s sign)

Skin (Rash, bruising, hemorrhages)

Lymph Nodes

Physical Examination Neurologic Exam Mental Status: LOC, Orientation, Language, mood/thoughts Cranial Nerves I: Not tested unless history suggestive II: Reading VA each eye, VF by confrontation with double simultaneous stimulation, fundoscopy III, IV, VI: Lateral and vertical eye mvts, pupillary light response V: Pinprick and touch sensation on face VII: Close eyes, show teeth VIII: Whispered voice each ear IX, X: Palate lifts in midline, gag present XI: Shrug shoulders XII: Protrude tongue

Neurologic Exam

Mental Status: LOC, Orientation, Language, mood/thoughts

Cranial Nerves

I: Not tested unless history suggestive

II: Reading VA each eye, VF by confrontation with double simultaneous stimulation, fundoscopy

III, IV, VI: Lateral and vertical eye mvts, pupillary light response

V: Pinprick and touch sensation on face

VII: Close eyes, show teeth

VIII: Whispered voice each ear

IX, X: Palate lifts in midline, gag present

XI: Shrug shoulders

XII: Protrude tongue

Physical Examination Neurologic Exam (cont.) Limbs: Each limb tested separately Tone Power of main muscle groups (0-5 MRC Scale) Coordination: finger-to-nose, heel-to-shin Tendon reflexes Plantar response Pinprick and light touch on hands and feet Double simultaneous stimulation on hands and feet Joint position sense in hallux and index finger Vibration sense at ankle and index finger Gait Romberg’s test

Neurologic Exam (cont.)

Limbs: Each limb tested separately

Tone

Power of main muscle groups (0-5 MRC Scale)

Coordination: finger-to-nose, heel-to-shin

Tendon reflexes

Plantar response

Pinprick and light touch on hands and feet

Double simultaneous stimulation on hands and feet

Joint position sense in hallux and index finger

Vibration sense at ankle and index finger

Gait

Romberg’s test

Laboratory Studies Blood CBC Chemistry panel ESR PT/PTT (Consider hypercoagulable profile) TSH ABG (if clinically indicated) Drug screen Urinalysis

Blood

CBC

Chemistry panel

ESR

PT/PTT (Consider hypercoagulable profile)

TSH

ABG (if clinically indicated)

Drug screen

Urinalysis

Imaging X-rays CXR Cervical Spine X-ray Cranial computed tomography (CT) preferred initial imaging study for acute headache Cranial magnetic resonance imaging (MRI) Magnetic resonance angiography (MRA) Cerebral angiography

X-rays

CXR

Cervical Spine X-ray

Cranial computed tomography (CT)

preferred initial imaging study for acute headache

Cranial magnetic resonance imaging (MRI)

Magnetic resonance angiography (MRA)

Cerebral angiography

Other Studies Lumbar puncture (LP) indicated if acute or chronic meningitis, SAH, pseudotumor cerebri (IIT) or low CSF pressure headache suspected preferable to perform CT before LP Electroencephalogram (EEG) indicated if seizures are suspect

Lumbar puncture (LP)

indicated if acute or chronic meningitis, SAH, pseudotumor cerebri (IIT) or low CSF pressure headache suspected

preferable to perform CT before LP

Electroencephalogram (EEG)

indicated if seizures are suspect

Differential Diagnosis Primary headache Migraine Tension-type headache Cluster headache Indomethacin-responsive headache syndromes Secondary headache

Primary headache

Migraine

Tension-type headache

Cluster headache

Indomethacin-responsive headache syndromes

Secondary headache

Migraine Headache IHS Classification Migraine without aura (common migraine) Migraine with aura (classic migraine) Migraine with typical aura Migraine with prolonged aura Familial hemiplegic migraine Basilar migraine Migraine aura w/o headache Migraine with acute onset aura Opthalmoplegic migraine Retinal migraine

Migraine without aura (common migraine)

Migraine with aura (classic migraine)

Migraine with typical aura

Migraine with prolonged aura

Familial hemiplegic migraine

Basilar migraine

Migraine aura w/o headache

Migraine with acute onset aura

Opthalmoplegic migraine

Retinal migraine

Tension-type headache IHS Classification Episodic Tension-type headache Chronic (Daily) Tension-type headache

Episodic Tension-type headache

Chronic (Daily) Tension-type headache

Cluster Headache IHS Classification 5 or more attacks with the following: Severe unilateral supraorbital or temporal pain lasting 15-180 minutes, pain has boring quality One of the following ipsilateral autonomic signs conjunctival injection eyelid edema tearing nasal congestion/rhinorrhea forehead/facial sweating miosis or ptosis Frequency of attacks qod to 8x/day, occur at similar time of day and often awaken pt from sleep

5 or more attacks with the following:

Severe unilateral supraorbital or temporal pain lasting 15-180 minutes, pain has boring quality

One of the following ipsilateral autonomic signs

conjunctival injection

eyelid edema

tearing

nasal congestion/rhinorrhea

forehead/facial sweating

miosis or ptosis

Frequency of attacks qod to 8x/day, occur at similar time of day and often awaken pt from sleep

Indomethacin-Responsive Headache Syndromes Paroxymal Hemicrania Onset second-third decade Females > males (3:1) Unilateral orbit or occipital pain 20 minute attacks, 5 attacks/day on average Hemicrania Continua Prolonged unilateral headache lasting days-weeks

Paroxymal Hemicrania

Onset second-third decade

Females > males (3:1)

Unilateral orbit or occipital pain

20 minute attacks, 5 attacks/day on average

Hemicrania Continua

Prolonged unilateral headache lasting days-weeks

Secondary Headache DDx Subarachnoid Hemorrhage (SAH) “first or worst headache” physicians consistently misdiagnose SAH pts with the greatest potential tx benefits are most often misdiagnosed early complications develop in patients with an incorrect dx Meningitis associated with fever, neck stiffness, confusion

Subarachnoid Hemorrhage (SAH)

“first or worst headache”

physicians consistently misdiagnose SAH

pts with the greatest potential tx benefits are most often misdiagnosed

early complications develop in patients with an incorrect dx

Meningitis

associated with fever, neck stiffness, confusion

Secondary Headache DDx Subdural hematoma recent trauma (+/-) Stroke (Ischemic or Hemorrhagic) occurs with focal neurologic sx Cervicocephalic arterial dissection trauma hx (+/-), neck pain, ipsilateral Horner’s Giant cell arteritis > 50 yrs, visual loss, temporal pain,  ESR

Subdural hematoma

recent trauma (+/-)

Stroke (Ischemic or Hemorrhagic)

occurs with focal neurologic sx

Cervicocephalic arterial dissection

trauma hx (+/-), neck pain, ipsilateral Horner’s

Giant cell arteritis

> 50 yrs, visual loss, temporal pain,  ESR

Secondary Headache DDx Cerebral venous thrombosis diffuse headache from increased ICP, may see sz or focal neurologic symptoms Idiopathic intracranial hypertension young obese women, blindness may develop Unruptured vascular malformation (AVM) can result in migraine like headaches Cerebral tumors/abscesses progressive headache over weeks to months

Cerebral venous thrombosis

diffuse headache from increased ICP, may see sz or focal neurologic symptoms

Idiopathic intracranial hypertension

young obese women, blindness may develop

Unruptured vascular malformation (AVM)

can result in migraine like headaches

Cerebral tumors/abscesses

progressive headache over weeks to months

Secondary Headache DDx Dental: abscesses/TMJ oral or jaw pain initially Sinusitis overdiagnosed, dx more likely with fever/purulent nasal discharge Trigeminal neuralgia sharp unilateral pain usually over maxillary distribution Low CSF pressure headache sx resolve in supine position and recur when upright Acute Glaucoma periorbital pain, conjuntival injection, lens clouding

Dental: abscesses/TMJ

oral or jaw pain initially

Sinusitis

overdiagnosed, dx more likely with fever/purulent nasal discharge

Trigeminal neuralgia

sharp unilateral pain usually over maxillary distribution

Low CSF pressure headache

sx resolve in supine position and recur when upright

Acute Glaucoma

periorbital pain, conjuntival injection, lens clouding

Case Study #1 72 year-old man awoke with complete blindness in his right eye. For the past month he complained of a new frontal headache that started on the right but has since become bilateral. The patient also complained of fatigue and joint aches for two months. Yesterday, he noted a 15-20 minute episode of darkening of vision in his right eye. On examination, the right pupil reacted consensually but not to direct light. There was no movement or light perception in the right eye. The right optic nerve head was swollen and pale; several small linear hemorrhages were present. The remainder of the neurologic exam was normal.

72 year-old man awoke with complete blindness in his right eye. For the past month he complained of a new frontal headache that started on the right but has since become bilateral. The patient also complained of fatigue and joint aches for two months. Yesterday, he noted a 15-20 minute episode of darkening of vision in his right eye. On examination, the right pupil reacted consensually but not to direct light. There was no movement or light perception in the right eye. The right optic nerve head was swollen and pale; several small linear hemorrhages were present. The remainder of the neurologic exam was normal.

Case Study #2 18 year-old female presents for an evaluation of episodic headaches that occur four to five times a month. The headaches started five years ago but have since increased in severity. Nausea and lightening waves of light are perceived 30 minutes before the onset of the headache. The headache itself in usually on the left side, throbbing in nature and severe. It lasts 4-6 hours. Light and sound make the headache worse. Her mother and sister have a history of headaches as well. While Excedrin and Ibuprofen worked well in the past, they have become less effective in relieving the pain.

18 year-old female presents for an evaluation of episodic headaches that occur four to five times a month. The headaches started five years ago but have since increased in severity. Nausea and lightening waves of light are perceived 30 minutes before the onset of the headache. The headache itself in usually on the left side, throbbing in nature and severe. It lasts 4-6 hours. Light and sound make the headache worse. Her mother and sister have a history of headaches as well. While Excedrin and Ibuprofen worked well in the past, they have become less effective in relieving the pain.

Case Study #3 48 year-old male with a history of migraine headaches and squamous cell skin cancer presented with recurrent right frontal-occipital headaches associated with coughing and straining. The headaches have been present for one month. He also describes brief spells of flickering lights in his left visual field associated with nausea. The spells occur once or twice a day. His physical exam is normal.

48 year-old male with a history of migraine headaches and squamous cell skin cancer presented with recurrent right frontal-occipital headaches associated with coughing and straining. The headaches have been present for one month. He also describes brief spells of flickering lights in his left visual field associated with nausea. The spells occur once or twice a day. His physical exam is normal.