Headaches B. Wayne Blount, MD, MPH

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Headaches B. Wayne Blount, MD, MPH

  1. 1. Headaches B. Wayne Blount, MD, MPH
  2. 2. OBJECTIVES  Know the APPROACH to the HA Pt.  Know how to distinguish primary from secondary HAs  List the 3 most common types of primary HAs  Distinguish among those 3  Name common, evidence-based RX for those 3
  3. 3. How to APPROACH the patient with a headache  NEED to distinguish primary from secondary headache disorders  Done by an accurate history and a focused physical exam
  4. 4. Questions in a Headache History  Is this your FIRST or WORST headache?  Severity on a scale of 1 to 10?  Do you have headaches on a regular basis?  Is this headache similar to prior headaches?  When did this headache begin?  How did it start (gradually, suddenly, other)?
  5. 5. Questions in a Headache History  How long does the headache usually last?  What symptoms do you have before the headache starts?  What symptoms do you have during the headache?  What symptoms do you have right now?  How often do you have these headaches?
  6. 6. Questions in a Headache History  Where is your pain?  Does the pain spread to any other area? If so, where?  Pain quality?(throbbing, stabbing, dull, pressure from inside, pressure from outside, other)?
  7. 7. Questions in a Headache History  Do you have other medical problems? If so, what?  Do you take any medicines? If so, what?  Do any of your family members have headaches?
  8. 8. The physical exam  Purpose of the physical examination is to identify causes of secondary headaches  Only a minority of headaches are secondary, but this category contains the most life-threatening conditions
  9. 9. The physical exam  Include vital signs, a complete neurologic exam (including funduscopic exam), CV, head, and neck exam  A complete neurologic examination is essential
  10. 10. The neuro exam  mental status  level of consciousness  cranial nerve testing  pupillary responses  funduscopic exam  motor strength testing  deep tendon reflexes  sensation  pathologic reflexes (e.g. Babinski's sign)  cerebellar function and gait testing  signs of meningeal irritation (Kernig's and Brudzinski's signs).
  11. 11. Funduscopic exam  Papilledema
  12. 12. Secondary Headaches
  13. 13. Secondary Headaches  Minority of headaches  Can be life threatening  Usually treatable
  14. 14. Secondary headaches  Occur as a consequence of an underlying condition  Trauma  Structural lesion  Vascular disorder  Infection
  15. 15. Secondary Headaches  Certain features of the history will make you suspect secondary headache  Physical exam will be abnormal  Focal neurologic findings  Signs of infection  Evidence of head trauma
  16. 16. Secondary Headaches  Findings on history  First or worst HA ever  Sudden-onset headache  Incr. frequency & severity of usual HA  Age > 40 years old  Incr. in pain with coughing, sneezing, straining  Wakes pt. from sleep or disturbs sleep
  17. 17. Secondary Headaches  Findings on history  HIV +  History of cancer  History of head trauma  Symptoms of infection  Fever, nausea, and vomiting  Photophobia  Stiff neck
  18. 18. Secondary Headaches Findings on PE  unilateral loss of sensation  unilateral weakness  unilateral hyperreflexia  signs of infection
  19. 19. Secondary Headaches Findings on PE  Head trauma  Papilledema  Changes in mental status  Ataxia
  20. 20. Secondary Headaches  Signs of infection  Fever  Nuchal rigidity  + Brudzinski sign  + Kernig sign  Petechial rash  Confusion/delirium  CSF abnormalities
  21. 21. Red Flags on history  Onset after age 40  Temporal arteritis  Mass lesion  Incr. frequency and severity  Subdural hematoma  Mass lesion  Medication overuse
  22. 22. Red Flags on history  Sudden onset of headache  Subarachnoid hemorrhage  Vascular malformation  Mass lesion or hemorrhage into mass lesion
  23. 23. Red Flags on history  History of head trauma  Intracranial hemorrhage  Subdural hematoma  Epidural hematoma  Post-traumatic headache
  24. 24. Red Flags on history  History of HIV or cancer  Meningitis  Brain abscess  Metastasis  Opportunistic infection
  25. 25. Red Flags on PE  Papilledema  Meningitis  Mass lesion  Psuedotumor cerebri
  26. 26. Red Flags on PE  Signs of systemic illness or infection  Meningitis  Encephalitis  Lyme disease  Systemic infection  Collagen vascular disease
  27. 27. Primary headaches
  28. 28. Primary headaches  Most common type  Have no organic cause  Usually recurrent  Normal neurologic exam  Key to correct diagnosis is the history
  29. 29. Primary headaches  Many different types  Most common  Migraine  Tension  Cluster  Differentiated by  Duration  Frequency  Location  Severity  Quality of pain
  30. 30. Primary Headaches  Migraine  Tension-type  Cluster
  31. 31. IHS diagnostic criteria for migraine without aura A. At least 5 attacks fulfilling B-D in the absence of another alternative disorder (eg metabolic, vascular, substance abuse) B. Headache lasts 4-72 h (untreated or unsuccessfully treated) C. Headache with at least 2 of following :unilateral, pulsating, moderate or severe intensity (inhibits daily activities) or aggravation by walking stairs or similar activity) D. During headache at least one of (i) nausea and/or vomiting, or (ii) photophobia and phonophobia
  32. 32. Migraine epidemiology  Approximately 5% of men and 10-15% of women.  First attack occurs in majority during adolescence and early 20s. Uncommon to occur for first time after age 40 years. Remission common after menopause or in fifth and sixth decades.  50-70% report a family history
  33. 33. Migraine –other symptoms  Prodromal symptoms occur in 25-40% in the 24 h prior to a headache and include mood changes eg elation, food cravings, thirst and excessive yawning. Presumably of hypothalamic origin.  Hypersensitivity of scalp, hypersensitivity to smell  Auras – blurring of vision or ‘spots’ most common. Paraesthesia is next most common. Dysphasia and hemiparesis less common. Auras usually occur 1 hour prior to a migraine and last less than 1 hour.
  34. 34. IHS diagnostic criteria for migraine with aura A. At lease 2 attacks fulfilling B B. At least 3 of the following characteristics: ♦ One or more fully reversible aura symptoms indicating focal cerebral, cortical and/or brainstem dysfunction. ♦ At least one aura symptom develops gradually over more than 4 minutes, or 2 or more symptoms occur in succession. ♦ No aura symptom lasts more than 60 minutes. If more than one aura symptom is present, accepted duration is proportionally increased. ♦ Headache follows aura with a free interval of less than 60 minutes (but it may also begin before or simultaneously with aura).
  35. 35. Factors associated with an attack  Increased incidence on weekends and holidays  Menstrual pattern  Reduced frequency in first trimester of pregnancy  Stress (often as crisis is resolving)  Fasting or missing a meal  Certain foods eg chocolate, alcohol, cheese  Extreme changes in weather
  36. 36. Drug therapy  Acute attacks – analgesics, NSAIDS, dopamine antagonists, ergotamines and triptans  Preventive therapy – propranolol, tricyclic antidepressants, methysergide, valproate, natural therapies eg feverfew, high dose riboflavin; ? Newer – gabapentin and topiramate  ? Role of acupuncture etc
  37. 37. Unusual migraine manifestations  Migraine with prolonged aura – aura lasts > 60 minutes and < 7 days with normal neuroimaging.  Migrainous infarction (prev called complicated migraine) – auras not fully reversible within 7 days and/or neuroimaging confirmation of ischaemic infarction.  Status migrainosus – attack lasts > 72 h whether treated or not.  Childhood periodic syndromes – abdominal migraine and cyclical vomiting, benign paroxysmal vertigo of childhood, alternating hemiplegia of childhood (typical age onset < 18 months).  Familial hemiplegic migraine – migraine with aura including hemiparesis with at least one affected first degree relative.
  38. 38. Migraine headaches  Unilateral  Throbbing pain  Moderate to severe  Aggravated by movement  4-72 hours  Nausea +/- vomiting  Photophobia
  39. 39. IHS diagnostic criteria for episodic tension-type headache A. At least 10 previous headache episodes fulfilling B- D. Less than 180 attacks/yr B. Headache lasts 30 minutes to 7 days C. At least 2 of the following: pressing or tightening quality (no-pulsating), mild to moderate intensity (may inhibit but does not prohibit activities), bilateral, no aggravation by walking stairs or similar routine activity D. Both of the following (i) no nausea or vomiting (may have anorexia); (ii) photophobia and phonophobia are both absent (or one but not the other is present). Chronic tension headache has same features but headache is present for at least 15 days a month during at least 6 months.
  40. 40. Tension headaches  Two to three times more common in women  Bilateral in 90%  Dull and pressure-like; some patients experience jabs of pain  10% may also suffer from migraine  In up to 50% of patients, the headache is daily  If associated with regular analgesic usage consider diagnosis of headache induced by chronic substance use or exposure
  41. 41. Tension headaches  Band-like, bilateral  Tightness/pressure/dull ache  Radiates to neck and shoulders  Mild to moderate  Not aggravated by movement  30 min to several days
  42. 42. Cluster headache  Severe, unilateral pain, orbitally, supraorbitally and/or temporally, lasting 15- 180 minutes, occurring from once every other day to 8 times a day.  Bouts may last weeks or months (or so-called cluster periods) and then remit for months or years (average 1/year)  80-90% are episodic (as above), 10-20% are chronic. 85% with episodic cluster headaches are males vs F>M for chronic
  43. 43. IHS diagnostic criteria for episodic cluster headache A. At least 5 attacks fulfilling B-D B. Severe unilateral orbital, supra-orbital and/or temporal pain lasting 15-180 minutes untreated. C. Headache associated with at least one of the following signs: conjunctival injection; lacrimation; nasal congestion; rhinorrhea; forehead and facial sweating; miosis, ptosis, eyelid oedema. D. Frequency once every other day to 8 per day. Chronic refers to similar attacks but occurring for > 1 year without remission or with remission lasting < 14 days.
  44. 44. Cluster headache (continued)  Associated features – Horner’s syndrome, nasal blockage and rhinorrhoea, conjunctival injection  Alcohol and vasodilators may trigger pain during an attack  Treatment – acute: 100% oxygen, ergotamines and triptans; preventive: ergotamines, methysergide, corticosteroids, verapamil, lithium
  45. 45. Cluster headaches  Unilateral  Hot poker/ stabbing pain  Excruciating  Autonomic dysfunction  Restless  15 min to 3 hours
  46. 46. Headache induced by chronic substance use or exposure  Occurs after daily doses of substance for > 3 months. Headache is chronic (15 days or more per month) and headache disappears within 1 month after withdrawal of substance.  Ergotamine induced headache – preceded by daily ergotamine ingestion (oral ≥ 2mg, rectal ≥ 1mg).  Analgesic abuse headache (> 100 tablets a month or aspirin or equivalent of other mild analgesics).  Caffeine withdrawal headache – patient consumes caffeine daily and > 15 g/month. Occurs witin 24 h of last caffeine and is relieved within 1 hour by 100 mg caffeine.
  47. 47. Chronic paroxysmal hemicrania  Attacks with same characteristics of pain and associated symptoms and signs as cluster headache but short lasting (2-45 minutes), more frequent (attack frequency 5 a day or more for more than half of the time), occur mostly in females and there is absolute effectiveness of indomethacin (150 mg or less).
  48. 48. Trigeminal neuralgia  F:M = 2:1  Most commonly after age 40 years  Pain affecting gums, cheek or chin as single or repeated stabs although in less than 5% forehead (CNV division 1) may also be affected  Important characteristics are pain intensity, brevity and tendency to recur in cycles  Pain never crosses to opposite side but may be bilateral in 3-5%.  Majority are idiopathic although compression of trigeminal nerve by blood vessel in brainstem most likely cause (>85%). Tumour or angioma can be seen in up to 6% and <5% of patients may have MS. Hence, MRI is diagnostic test of choice.
  49. 49. Other headaches – “Normal” headaches  Excessive stimulation of scalp nerves eg wearing tight goggles, diving into cold water  Ice-cream headache –holding very cold ice- cream in mouth or swallowing ‘cold’ ice- cream. Increased frequency in migraineurs  Hot dog headache – eating cured meats ? Nitrites  MSG  Hangover – secondary to acetaldehyde/acetate  Fasting  Exertion
  50. 50. Other ‘non-serious’ headaches  Post-herpetic neuralgia  Occipital neuralgia  Cervicogenic headaches  Analgesia rebound headaches  TMJ dysfunction  “Sinusitis”  Low pressure headache – post lumbar puncture
  51. 51. Case presentation 1  17 y.o. white female comes to your office complaining of Headaches.  She states the headache started 2 wks ago  At first she thought it was her usual HA  This one not relieved by Tylenol or Advil  “Worst headache of my life”
  52. 52. Case presentation  Headache for 2 weeks  Intensity 9/10  Constant over the past 2 wks  Nondescript headache  Unable to go to school due to the pain
  53. 53. Case presentation  No significant PMH but is taking medication for acne  Minocycline x 6 mo  OrthoTricyclen x 1 mo
  54. 54. Case presentation  PE: BP: 110/70 HR:72 RR:14 T: 97.8  NAD WNWD  HEENT: Funduscopic exam shows papilledema; sclerae white; PERRLA; EOMI; OP moist ,w/o exudate; tongue protrudes in midline
  55. 55. Case presentation  Heart: RRR w/o murmur  Lungs: BCTA  Derm: no rashes or petechia  Neuro: CN CN III – XII grossly intact by exam; motor 5+/5+ BUE/LE; sensation intact to light touch, pinprick, vibration; DTR’s 2+/4+ BUE/LE
  56. 56. Case presentation  What is significant in the history and physical?  What is your differential diagnoses at this point?  What tests would you order if any?
  57. 57. Case presentation  In this case the patient was sent to E.D. that same day  She had an MRI that afternoon  Normal  She had an LP after MRI  Opening pressure was markedly elevated
  58. 58. Case presentation  Patient was diagnosed with Pseudotumor cerebri  She as taken off both medications  Her headache resolved  One week f/u with neurologist revealed resolution of the papilledema  No further LP’s needed
  59. 59. Case history 2  25 y.o.female  Previously well. No past medical history.  1 day history of gradual onset generalised headache, throbbing quality  Vomited x 1, photophobia, phonophobia  ? Diagnosis  ? Investigation  ? Treatment
  60. 60. Case history 3  80 year old female  3 week history of intermittent but daily bifronto-temporal headache  Non-specific visual disturbances with episodic blurring  Associated myalgias  ? Diagnosis  ? Investigations
  61. 61. Case history 4  35 year old male  Sudden onset of severe generalised headache whilst lifting weights at gym  Resolved within 10 minutes of ceasing activity but recurred at same level of activity if repeated  ? Diagnosis  ? Investigations  ? Treatment
  62. 62. SUMMARY  Priority : Distinguish primary from secondary  Hx & P.E.  Secondary types  Primary Types
  63. 63. QUESTIONS

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