Approach to headaches
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Approach to Headaches. AIMGP Seminar April 2004 Gloria Rambaldini. Case 1. A 28 y.o. woman is referred to you for management of her headaches Headaches are described as right-sided pounding, with associated nausea and photophobia Aggravated by activity

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Approach to headaches

Approach to Headaches

AIMGP Seminar

April 2004

Gloria Rambaldini


Case 1

Case 1

  • A 28 y.o. woman is referred to you for management of her headaches

  • Headaches are described as right-sided pounding, with associated nausea and photophobia

  • Aggravated by activity

  • ASA and Tylenol have not provided relief

  • What next?


Case 2

Case 2

  • A 72 y.o. woman presents with a four month history of a bitemporal headache with aching and morning stiffness of her shoulders

  • She has noted a low grade fever and some weight loss

  • What next?


Case 3

Case 3

  • A 62 y.o. man is referred for new onset headaches

  • For the last 4 weeks he has awoken with a diffuse headache and nausea

  • What next?


Objectives

Objectives

  • To learn about the major types of headaches

  • To understand the difference between primary and secondary headaches

  • Be familiar with the ‘RED FLAGS’

  • Treatment and prophylaxis of primary headaches


Origins of pain in the head

Extra-cranial pain sensitive structures:

Sinuses

Eyes/orbits

Ears

Teeth

TMJ

Blood vessels

Intra-cranial pain sensitive structures:

Arteries

Veins

Meninges

Dura

Origins of Pain in the Head


Classification of headaches

PRIMARY - NO structural or metabolic abnormality:

Tension

Migraine

Cluster

SECONDARY – structural or metabolic abnormality:

Extracranial: sinusitis, otitis media, glaucoma, TMJ ds

Inracranial: SAH, vasculitis, dissection, central vein thrombosis, tumor, abscess, meningitis

Metabolic disorders: CO2 retention, CO poisoing

Classification of Headaches


History

HISTORY

  • Headache Characteristics:

    • Temporal profile: acute vs chronic, frequency

    • Location and radiation

    • Quality

    • Alleviating and exacerbating factors

    • Associated symptoms

  • Constitutional symptoms

  • PMH: HTN, DM, hyperlipidemia, smoking


Red flags

RED Flags


Red flags1

RED Flags

  • New onset headache in a patient >50 y.o.

  • Sudden, worst headache of one’s life

  • Morning headache associated with N/V

  • Fever, weight loss

  • Worsens with valsalva maneuvers

  • Focal neurologic deficits, jaw claudication

  • Altered LOC

  • Hx of trauma, cancer or HIV


Physical exam

Physical Exam

  • Blood pressure

  • Fundoscopy

  • Auscultation for bruits in H/N

  • Temporal artery inspection and palpation

  • Meningismus

  • Neurologic exam: motor, sensory, coordination and gait


Migraine headaches

MIGRAINE Headaches

  • Affects 15% of the general population

  • Female > Males

  • Family History present in 70%

  • Pathophysiology: vascular vs neurologic

  • Precipitants: caffeine, chocolate, alcohol, cheese, BCP/HRT, menses, stress


Migraine headaches1

MIGRAINE Headaches

  • Diagnostic criteria:

    1. 5 attacks in 6 months

    2. Headaches lasting 4-72 h with >/= 2:

    - unilateral

    - pulsatile

    - moderate to severe in intensity

    - aggravated by activity

    3. Associated with >/= 1:

    - nausea/vomiting

    - photophobia/phonophobia


Migraine headaches2

MIGRAINE Headaches

  • Subtypes:

    • Auras – visual or sensory

    • Scintillating scotoma

    • Fortification spectra

    • Ophthalmoplegic

    • CN III palsy

    • Vertbrobasilar

    • hemiplegic


Visual auras patient drawings

Visual Auras: Patient drawings

Scintillating Scotomas

Progression of a typical aura over 30 minutes

BMJ 2002; 325:881-6


Migraine acute treatment

MIGRAINE: Acute Treatment

  • Mild attacks: NSAIDS +/- dopamine antagonists

    • eg. ASA 650-1300 mg q4h + metoclopromide 10 mg PO/IV

  • Moderate attacks:

    • NSAIDS (ibuprofen 400-800 mg PO q2-6h)

    • 5-HT1 receptor agonists

      • Selective – sumatriptan 50-100 mg PO

      • Nonselective – ergot 1-2 mg PO q1h x 3

CMAJ 1997; 156: 1273-87


Migraine acute treatment1

MIGRAINE: Acute Treatment

  • Severe & Ultra-severe attacks:

    • First line:

      • DHE 0.5-1 mg q1h IM/SC/IV

      • sumatriptan 50-100 mg PO or 6 mg SC

    • Second line:

      • chlorpromazine 50 mg IM

      • Prochlorperazine 5-10 mg IV/IM

      • dexamethasone 12-20 mg IV

CMAJ 1997; 156: 1273-87


Migraine prophylaxis

MIGRAINE: Prophylaxis

  • Consider if >/3 attacks/month, impaired quality of life:

    • B-blockers

    • Calcium channel blockers

    • TCA (amitriptyline)

    • NSAIDS

    • Valproic acid

    • 5HT2 Antagonists (methysergide, pizotyline)

CMAJ 1997; 156: 1273-87


Tension headaches

TENSION Headaches

  • Most common type, typically brought on by stress, lasting 30 min to 7 d

  • Diagnostic Criteria >/= 2:

    • Pressing/tightening, non-pulsating

    • Mild-moderate

    • Bilateral

    • Not worsened by ADLs

    • Photo or phonophobia (not coincident)

    • Not associated with N/V

  • Treatment: reassurance, NSAIDS


Cluster headaches

CLUSTER Headaches

  • Age of onset 25-50 y.o., M>F

  • Features:

    • Attacks clustered in time (>5)

    • Severe unilateral, orbital or temporal pain

    • Lasting 15 min – 3 h

    • Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead/facial swelling, miosis, ptosis

  • Treatment:

    • Acute: O2, 5HT1 antagonists, DHE

    • Prophylaxis: Calcium Channel Blockers, ergots, Li


Medication induced headaches

Medication Induced Headaches

  • Rebound headaches due to overuse of analgesics or prophylactic meds

  • 25% of patients referred to neurologists for ‘intractable’ headaches have medication-overuse or medication-induced headaches


Giant cell arteritis

Giant Cell Arteritis

  • Chronic granulomatous vasculitis affecting the arteries originating from the aortic arch

  • 18/100 000 persons >50 y.o.

  • Features:

    • Headache 2/3 of patients (LR 1.2)

    • Fever, weight loss, malaise

    • Scalp tenderness

    • Jaw claudication (LR 4.2)

    • Diplopia (LR 3.4)

    • PMR related Sx (50% of GCA patients have PMR)


Giant cell arteritis1

Giant Cell Arteritis

  • Physical Exam:

    • BP and pulse deficits in arms

    • Fundoscopy

    • Temporal Artery: beaded (LR 4.6), prominent (LR 4.3), tender (LR 2.6)

    • H/N and subclavian bruits

    • MSK exam

  • Investigations:

    • Normocytic normochromic anemia

    • ESR (typically > 50)

    • TA biopsy

JAMA 2002; 287(1): 92-101


Giant cell arteritis2

Giant Cell Arteritis

  • Diagnostic Criteria – 3/5 (Sn 94%, Sp 91%)

    • Age > 50 y.o.

    • New onset headache

    • TA tender +/- decreased pulse

    • ESR > 50

    • Bx: necrotizing granulomatous arteritis


Giant cell arteritis3

Giant Cell Arteritis

  • Treatment:

    • Prednisone 40-80 mg PO od until symptoms resolve and ESR normalizes

    • Once in remission decrease dose by 10% q1-2w

    • Osteoporosis prevention: vitamin D and calcium +/- bisphosphonate

AIM 2003; 139:505-515


Case 11

Case 1

  • A 28 y.o. woman is referred to you for management of her headaches

  • Headaches are described as right-sided pounding, with associated nausea and photophobia

  • Aggravated by activity

  • ASA and Tylenol have not provided relief

  • What next?


Case 21

Case 2

  • A 72 y.o. woman presents with a four month history of a bitemporal headache with aching and morning stiffness of her shoulders

  • She has noted a low grade fever and some weight loss

  • What next?


Case 31

Case 3

  • A 62 y.o. man is referred for new onset headaches

  • For the last 4 weeks he has awoken with a diffuse headache and nausea

  • What next?


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