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Headache

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Headache

  1. 1. Approach to a patient with headache Dr. Abdul Mottalib Sarker Medicine unit 2 RMCH
  2. 2. , <ul><li>A headache or cephalagia is pain anywhere in the region of head or neck. It can be a symptom of a number of different conditions of head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of pain sensitive structures around the head and neck. </li></ul>
  3. 3. Pain Sensitivity of Cranial Structures <ul><li>Cranial venous sinuses with afferent veins </li></ul><ul><li>Arteries at base of brain and their major branches </li></ul><ul><li>Arteries of the dura </li></ul><ul><li>Dura near base of brain and large arteries </li></ul><ul><li>Dural, Cranial and extracranial nerves </li></ul><ul><li>All extracranial structures </li></ul><ul><li>Brain parenchyma </li></ul><ul><li>Ependyma </li></ul><ul><li>Choroid </li></ul><ul><li>Pia </li></ul><ul><li>Arachnoid </li></ul><ul><li>Dura over convexity </li></ul><ul><li>Skull </li></ul>Pain-Sensitive Pain-Insensitive
  4. 4. Overall Approach Chief Complaint: Headache Headache Alarms Evidence of serious headache disorder by history or physical exam Diagnosis of Primary Headache Disorder Work-up to identify/exclude secondary headache etiology Treat Primary Headache NO YES YES NO Consider work-up for secondary headache
  5. 5. General Mechanisms of Headache <ul><li>Traction on major intracranial vessels </li></ul><ul><li>Distention, dilation of intracranial arteries </li></ul><ul><li>Inflammation near pain sensitive structures </li></ul><ul><li>Direct pressure on cranial or cervical nerves </li></ul><ul><li>Sustained contraction of scalp or neck muscles </li></ul><ul><li>Stimulation from disease of eye, ear, nose and sinuses (referred pain) </li></ul>
  6. 6. Epidemiology <ul><li>60-75% of adults have at least one headache/year </li></ul><ul><li>5-10% will seek physician evaluation </li></ul><ul><li>Less than 10% of ED patients with chief complaint of headache will have emergent secondary cause </li></ul>
  7. 7. Epidemiology <ul><ul><li>Tension </li></ul></ul><ul><ul><li>Migraine </li></ul></ul><ul><ul><li>Cold Stimulus Headache </li></ul></ul><ul><ul><li>Cluster </li></ul></ul><ul><ul><li>69% </li></ul></ul><ul><ul><li>15% </li></ul></ul><ul><ul><li>15% </li></ul></ul><ul><ul><li>0.1% </li></ul></ul>Primary Headache Lifetime Prevalence <ul><ul><li>Hangover </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Metabolic disorder </li></ul></ul><ul><ul><li>Disorders of nose/sinuses </li></ul></ul><ul><ul><li>Head trauma </li></ul></ul><ul><ul><li>Disorders of eyes </li></ul></ul><ul><ul><li>Vascular disorders </li></ul></ul><ul><ul><li>72% </li></ul></ul><ul><ul><li>63% </li></ul></ul><ul><ul><li>22% </li></ul></ul><ul><ul><li>15% </li></ul></ul><ul><ul><li>4% </li></ul></ul><ul><ul><li>3% </li></ul></ul><ul><ul><li>1% </li></ul></ul>Secondary Headache
  8. 8. Headache in the ED <ul><ul><li>Tension </li></ul></ul><ul><ul><li>Migraine </li></ul></ul><ul><ul><li>Cluster </li></ul></ul><ul><ul><li>32 % </li></ul></ul><ul><ul><li>22 % </li></ul></ul><ul><ul><li>< 1 % </li></ul></ul>Primary Headache <ul><ul><li>Subarachnoid Hemorrhage </li></ul></ul><ul><ul><li>Meningitis </li></ul></ul><ul><ul><li>Temporal Arteritis </li></ul></ul><ul><ul><li>Subdural Hematoma </li></ul></ul><ul><ul><li>CNS tumor </li></ul></ul><ul><ul><li>Miscellaneous illness </li></ul></ul><ul><ul><li>No specific diagnosis </li></ul></ul><ul><ul><li>< 1 % </li></ul></ul><ul><ul><li>< 1 % </li></ul></ul><ul><ul><li>< 1 % </li></ul></ul><ul><ul><li>< 1 % </li></ul></ul><ul><ul><li>3 % </li></ul></ul><ul><ul><li>33 % </li></ul></ul><ul><ul><li>7 % </li></ul></ul><ul><ul><li>3% </li></ul></ul>Secondary Headache Leicht M, Ann Emerg Med 1980;9:404
  9. 9. Primary Headache Migraine Tension Cluster
  10. 10. Tension Headache <ul><ul><li>Duration </li></ul></ul><ul><ul><ul><li>30 min to 7 days </li></ul></ul></ul><ul><ul><li>Pain characteristics (at least 2) </li></ul></ul><ul><ul><ul><li>Pressing/tightening quality </li></ul></ul></ul><ul><ul><ul><li>Mild to moderate severity </li></ul></ul></ul><ul><ul><ul><li>Bilateral location </li></ul></ul></ul><ul><ul><ul><li>No aggravation by routine physical activity </li></ul></ul></ul><ul><ul><li>Associate symptoms (Must have both) </li></ul></ul><ul><ul><ul><li>No vomiting </li></ul></ul></ul><ul><ul><ul><li>No more than one of: nausea, photophobia, phonophobia </li></ul></ul></ul><ul><ul><li>H&P and diagnostic tests do not suggest underlying organic disease </li></ul></ul>International Headache Society Diagnostic Criteria
  11. 11. Migraine Without Aura <ul><ul><li>At least 6 or more periodic attacks </li></ul></ul><ul><ul><li>Duration </li></ul></ul><ul><ul><ul><li>4-72 h if untreated or unsuccessfully treated </li></ul></ul></ul><ul><ul><li>Pain characteristics (at least 2) </li></ul></ul><ul><ul><ul><li>Unilateral location </li></ul></ul></ul><ul><ul><ul><li>Pulsating quality </li></ul></ul></ul><ul><ul><ul><li>Moderate to severe intensity </li></ul></ul></ul><ul><ul><ul><li>Aggravation by walking stairs or similar physical activity </li></ul></ul></ul><ul><ul><li>Associated symptoms (at least 1) </li></ul></ul><ul><ul><ul><li>Nausea, vomiting, or both </li></ul></ul></ul><ul><ul><ul><li>Photophobia or phonophobia </li></ul></ul></ul><ul><ul><li>H&P and diagnostic tests do not suggest underlying organic disease </li></ul></ul>International Headache Society Diagnostic Criteria
  12. 12. Migraine With Aura <ul><ul><li>At least 3 periodic attacks </li></ul></ul><ul><ul><li>Aura characertistics (At least 3 ) </li></ul></ul><ul><ul><ul><li>One or more fully reversible aura symptoms indicating focal cerebral cortical or brain-stem dysfunction </li></ul></ul></ul><ul><ul><ul><li>At least 1 aura symptom develops gradually over >4 minutes or 2 or more symptoms occur in succession </li></ul></ul></ul><ul><ul><ul><li>No single aura symptom lasts > 60 minutes </li></ul></ul></ul><ul><ul><ul><li>Headache begins within 60 minutes of aura onset </li></ul></ul></ul><ul><ul><li>History, physical, and diagnostic tests do not suggest underlying organic disease </li></ul></ul>International Headache Society Diagnostic Criteria
  13. 13. Cluster Headache <ul><ul><li>Duration </li></ul></ul><ul><ul><ul><li>15 to 180 minutes untreated </li></ul></ul></ul><ul><ul><li>Pain characteristics </li></ul></ul><ul><ul><ul><li>Severe unilateral orbital, supraorbital, or temporal pain </li></ul></ul></ul><ul><ul><li>Associated symptoms (at least 1, ipsilateral to pain) </li></ul></ul><ul><ul><ul><li>Conjunctival injection, Lacrimation </li></ul></ul></ul><ul><ul><ul><li>Nasal congestion, Rhinorrhea </li></ul></ul></ul><ul><ul><ul><li>Forehead and facial swelling </li></ul></ul></ul><ul><ul><ul><li>Miosis, Ptosis </li></ul></ul></ul><ul><ul><ul><li>Eyelid Edema </li></ul></ul></ul><ul><ul><li>Frequency : </li></ul></ul><ul><ul><ul><li>between 1 every other day to 8/day </li></ul></ul></ul>International Headache Society Diagnostic Criteria
  14. 14. Secondary Headache <ul><ul><li>Intracranial hemorrhage </li></ul></ul><ul><ul><ul><li>Subarachnoid Hemorrhage </li></ul></ul></ul><ul><ul><ul><li>Intracerebral hemorrhage </li></ul></ul></ul><ul><ul><ul><li>Subdural/epidural hematoma </li></ul></ul></ul><ul><ul><li>Meningitis/encephalitis </li></ul></ul><ul><ul><li>Hypertensive encephalopathy </li></ul></ul><ul><ul><li>Ischemic stroke </li></ul></ul><ul><ul><li>Venous sinus thrombosis </li></ul></ul><ul><ul><li>Hypoxia, hypercarbia, carbon monoxide </li></ul></ul>
  15. 15. Secondary Headache <ul><ul><li>Temporal arteritis </li></ul></ul><ul><ul><li>Mass lesions </li></ul></ul><ul><ul><ul><li>Tumor, abscess, arteriovenous malformation </li></ul></ul></ul><ul><ul><li>Altitude sickness </li></ul></ul><ul><ul><li>Metabolic </li></ul></ul><ul><ul><ul><li>Hypoglycemia, fever, hypothyroid, anemia </li></ul></ul></ul><ul><ul><li>Glaucoma </li></ul></ul><ul><ul><li>Pseudotumor cerebri (benign intracranial hypertension) </li></ul></ul>
  16. 16. Secondary Headache <ul><ul><li>Trigeminal Neuralgia </li></ul></ul><ul><ul><li>Post-concussion syndrome </li></ul></ul><ul><ul><li>Sinusitis without complication </li></ul></ul><ul><ul><li>Post-lumbar puncture </li></ul></ul><ul><ul><li>Diet </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Fatigue, postexertion, postcoital </li></ul></ul>
  17. 17. Overall Approach Chief Complaint: Headache Headache Alarms Evidence of serious headache disorder by history or physical exam Diagnosis of Primary Headache Disorder Work-up to identify/exclude secondary headache etiology Treat Primary Headache NO YES YES NO Consider work-up for secondary headache
  18. 18. History <ul><li>Why did this headache bring you to the Emergency Department? </li></ul><ul><ul><li>First or Worst </li></ul></ul><ul><ul><li>Accompanied by new or frightening features </li></ul></ul><ul><ul><li>Last straw </li></ul></ul><ul><li>How did this headache start? </li></ul><ul><li>Have you had previous similar headaches; if so when did this headache type start? </li></ul>
  19. 19. History <ul><li>Where does it hurt? </li></ul><ul><ul><li>Unilateral/bilateral </li></ul></ul><ul><ul><li>Frontal/occipital/facial </li></ul></ul><ul><li>What is the character of the pain? </li></ul><ul><ul><li>Pulsatile, steady, shocklike, tightness </li></ul></ul><ul><li>What other symptoms do you experience? </li></ul><ul><ul><li>Nausea, vomiting, LOC, flushing, lacrimation, drop attack, neck stiffness, photophobia, dizziness </li></ul></ul>
  20. 20. History <ul><li>Precipitating/aggravating factors </li></ul><ul><ul><li>Trauma, exertion, noise, position, foods, drugs, weather, anxiety, menstration </li></ul></ul><ul><li>Relieving factors </li></ul><ul><ul><li>Darkroom, position, pressing on scalp, medication </li></ul></ul><ul><li>Medical history </li></ul><ul><ul><li>HIV, Cancer, HTN </li></ul></ul><ul><ul><li>Recent procedure (LP) </li></ul></ul><ul><ul><li>Change in medications </li></ul></ul>
  21. 21. History <ul><li>Family History </li></ul><ul><ul><li>Migraine headaches, subarachnoid hemorrhage </li></ul></ul><ul><li>Environment </li></ul><ul><ul><li>Carbon monoxide </li></ul></ul>
  22. 22. Physical Exam <ul><li>Vital signs </li></ul><ul><ul><li>fever, hypertension, hypoxia </li></ul></ul><ul><li>Head/face </li></ul><ul><ul><li>trauma, bruits, tenderness </li></ul></ul><ul><li>Eyes </li></ul><ul><ul><li>conjunctiva, cornea, pupils, fundi:papilledema </li></ul></ul><ul><li>Ears </li></ul><ul><ul><li>OM or hemotympanum </li></ul></ul><ul><li>Mouth </li></ul><ul><ul><li>Teeth, TMJ </li></ul></ul><ul><li>Neck </li></ul><ul><ul><li>pain/stiffness/tenderness </li></ul></ul><ul><ul><li>Carotid and/or vertebral bruits </li></ul></ul><ul><li>Skin </li></ul><ul><ul><li>rash </li></ul></ul><ul><li>Neurologic </li></ul><ul><ul><li>Mental status </li></ul></ul><ul><ul><li>Pupils, EOM, Visual fields </li></ul></ul><ul><ul><li>Focal deficits </li></ul></ul><ul><ul><li>Horner's syndrome </li></ul></ul><ul><ul><li>Ataxia </li></ul></ul>
  23. 23. investigation <ul><li>1.cbc esr </li></ul><ul><li>Urine r/e </li></ul><ul><li>S.creatinine </li></ul><ul><li>Rbs </li></ul><ul><li>Csf </li></ul><ul><li>X-ray skull. </li></ul><ul><li>X-ray pns. </li></ul><ul><li>Ct </li></ul><ul><li>Mri </li></ul>
  24. 24. Diagnostic Alarms <ul><li>Onset after age 50 </li></ul><ul><li>Sudden onset </li></ul><ul><li>Increased frequency and severity </li></ul><ul><li>New onset with risk factors for HIV or cancer </li></ul><ul><li>Associated with systemic illness (HT,DM,fever, meningismus, rash) </li></ul><ul><li>Altered consciousness or focal neurologic deficits </li></ul><ul><li>Papilledema </li></ul><ul><li>Significant trauma </li></ul>
  25. 25. Overall Approach Chief Complaint: Headache Headache Alarms Evidence of serious headache disorder by history or physical exam Diagnosis of Primary Headache Disorder Work-up to identify/exclude secondary headache etiology Treat Primary Headache NO YES YES NO Consider work-up for secondary headache
  26. 26. ED Treatment of Primary Headache <ul><ul><li>Tension </li></ul></ul><ul><ul><ul><li>Oral Analgesics (NSAIDS, Acetaminophen) </li></ul></ul></ul><ul><ul><li>Migraine </li></ul></ul><ul><ul><ul><li>Serotonin agonists </li></ul></ul></ul><ul><ul><ul><ul><li>ie, Sumitriptan 50 mg PO or 6.0 mg SQ </li></ul></ul></ul></ul><ul><ul><ul><li>Narcotics IV or IM </li></ul></ul></ul><ul><ul><li>Cluster </li></ul></ul><ul><ul><ul><li>100% oxygen </li></ul></ul></ul><ul><ul><ul><li>Intranasal lidocaine ? </li></ul></ul></ul><ul><ul><ul><li>NSAIDS </li></ul></ul></ul><ul><ul><ul><li>Migraine specific therapies </li></ul></ul></ul>
  27. 27. Prophylaxis Treatment of Primary Headache <ul><ul><li>Tension </li></ul></ul><ul><ul><ul><li>Reassurance </li></ul></ul></ul><ul><ul><ul><li>Antidepressant &/or Anxiolytic drugs </li></ul></ul></ul><ul><ul><ul><li>(Tricyclic antidepressant or/& SSRI) </li></ul></ul></ul><ul><ul><li>Migraine </li></ul></ul><ul><ul><ul><li>Betablockers: Proponolol </li></ul></ul></ul><ul><ul><ul><li>Ca channel blocker: Verapamile </li></ul></ul></ul><ul><ul><ul><li>Antidepressant: ( Tricyclic antidepressant or/& SSRI) </li></ul></ul></ul><ul><ul><ul><li>Anticonvulsant: Na valproate, topiramate, </li></ul></ul></ul><ul><ul><ul><li>Methysergid. </li></ul></ul></ul><ul><ul><ul><li>Pizotifine. </li></ul></ul></ul><ul><ul><li>Cluster </li></ul></ul><ul><ul><ul><li>Steroid </li></ul></ul></ul><ul><ul><ul><li>Lithium carbonate </li></ul></ul></ul><ul><ul><ul><li>Verapamile </li></ul></ul></ul>
  28. 28. Overall Approach Chief Complaint: Headache Headache Alarms Evidence of serious headache disorder by history or physical exam Diagnosis of Primary Headache Disorder Work-up to identify/exclude secondary headache etiology Treat Primary Headache NO YES YES NO Consider work-up for secondary headache
  29. 29. Diagnostic Studies <ul><li>Computerized tomography </li></ul><ul><ul><li>Hemorrhage, tumor, abscess, AVM </li></ul></ul><ul><li>Lumbar puncture </li></ul><ul><ul><li>Hemorrhage, infection, increased CSF pressure </li></ul></ul><ul><li>Limited indications for MRI, MRA, or Angiography </li></ul><ul><li>Laboratory studies based on suspected etiologies </li></ul><ul><ul><li>ESR: Temporal arteritis </li></ul></ul><ul><ul><li>Carboxyhemoglobin: Carbon monoxide </li></ul></ul>
  30. 30. Subarachnoid Hemorrhage <ul><li>Approximately 50% of have &quot;sentinal bleed&quot; </li></ul><ul><li>50% with &quot;sentinal bleed&quot; will rebleed within 2-6 wks </li></ul><ul><li>Rebleed </li></ul><ul><ul><li>50% mortality </li></ul></ul><ul><ul><li>> 50% of survivors have significant neurologic deficits </li></ul></ul><ul><li>Head CT negative in 1-10% of cases </li></ul><ul><ul><li>Sensitivity decreases with time from onset of sx </li></ul></ul><ul><li>LP if head CT negative (RBC's 3 hrs, xanthochromia 12 hrs) </li></ul><ul><li>Angiography if postive CT or LP </li></ul>
  31. 31. Temporal Arteritis <ul><li>Rare before age 50 </li></ul><ul><li>Temporal artery tenderness, swelling, redness, nodularity </li></ul><ul><li>Visual disturbance </li></ul><ul><ul><li>Visual loss in 7-60% if untreated </li></ul></ul><ul><li>Jaw claudication </li></ul><ul><li>Systemic symptoms </li></ul><ul><ul><li>fever, wt loss, anorexia, malaise </li></ul></ul><ul><li>Polymyalgia rheumatica (prox muscle pain/tend./stiffness) </li></ul><ul><li>ESR usually > 50 (mm/hr) </li></ul><ul><li>Temporal artery biopsy </li></ul><ul><ul><li>multinucleated giant cells / inflammation </li></ul></ul><ul><li>Therapy: High dose steroids </li></ul>
  32. 32. Overall Approach Chief Complaint: Headache Headache Alarms Evidence of serious headache disorder by history or physical exam Diagnosis of Primary Headache Disorder Work-up to identify/exclude secondary headache etiology Treat Primary Headache NO YES YES NO Consider work-up for secondary headache

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