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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 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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