Evaluation of Headache

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Evaluation of Headache

• Andrew McMarlin DO

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Prevalence

• 31-74 of Americans have episodic tension-type HA
  each year
• 12-16 of North Americans and Europeans have
  migraine HAs
• 0.1 of population has Cluster HAs

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Societal Impact

• In addition to the affected individuals quality
  of life, a 1993 survey revealed a larger cost of
  HAs
• 150 million lost work days each year in US
• 329,000 lost school days annually

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Systemic Etiologies

• In a recent Brazilian primary care study, 39 of
  the patients who presented c/o HA had a systemic
  disorder causing the HA
• Fever
• Acute HTN (a recent Norwegian study demonstrated
  chronic hypertensives actually had lower
  incidence chronic HA)
• Sinusitis

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Neurologic etiologies

• 5 of the patients c/o HA in the same study had
  neurologic based HAs
• 1) Most commonly posttraumatic
• 2) Secondary to cervical spine dz
• 3) Secondary to intracranial processes

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Patient History

• FamHx of migraine
• General health
• Age at onset
• Presence of auras/prodrome
• Frequency, intensity, duration, time of day of
  onset
• Quality, site, radiation of pain

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Hx (contd)

• Associated symptoms
• Precipitating factors
• Relieving factors
• Previous treatment
• Recent physical, work, medicine, activity, diet
  changes
• Associated environmental factors

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Hx (contd)

• Effect of activity on pain
• Recent visual changes
• Recent trauma
• How did HA respond to tx in the past?

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Headache screen

• The American Academy of Neurology has adopted a
  4-question screen
• How often do you get severe HAs (and is it
  difficult to function without tx)?
• How often do you get milder HAs?
• How often do you take HA medication/pain pills?
• Has there been any recent change in HA?

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Danger signs

• First HA or worst HA intracranial hemorrhage
  or CNS infection
• Worsening pattern mass lesion, subdural
  hematoma, medication overuse syndrome
• Focal neurologic sx (non-aura/visual) mass
  lesion, AVM, collagen vascular dz

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Danger signs (contd)

• Fever a/w HA concern for intracranial causes
  including infection and systemic infection
• Change in MS or personality
• Rapid onset of headache or recent, significant
  change in chronic headache

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Danger sign mnemonic

• SNOOP
• Systemic sx
• Neurologic si/sx
• Onset is sudden/recent change
• Onset after 40 years of age
• Previous HA hx is different or progressive

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HA examination

• BP and pulse
• Listen for carotid bruit and orbital bruit
• Palpate head, neck, and shoulders
• Examine temporal and neck arteries and muscles of
  the spine and neck
• Perform functional neuro exam

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Functional Neuro Exam

• Arising from seated position without support
• Walking on tiptoes and heels
• Cranial nerve exam
• Fundoscopy and otoscopy
• Tandem gait and Romberg test
• Symmetry on motor, sensory, reflex, and
  cerebellar/coordination tests

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Neuro exam positives

• Resistance to passive neck flexion (meningismus)
  and neck stiffness suggest meningitis
• Papilledema- encephalitis, intracranial mass,
  meningitis, pseudotumor cerebri
• Focal neurologic signs- AVM, collagen vascular
  dz, intracranial mass

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Indications for Imaging

• Change in a chronic headache (pattern, frequency,
  severity)
• Progressive worsening despite tx
• Focal neurologic findings
• Onset of HA with exertion, cough, sexual activity
• Orbital bruit
• Onset after 40 y.o.

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CT or MRI?

• Head CT with and without contrast usually
  sufficient
• MRI and MRA if posterior fossa or vascular
  lesions are suspected

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Lumbar puncture?

• If you suspect subarachnoid hemorrhage from the
  pt history and the CT is negative or if you
  suspect intracranial infection

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Most common Primary HAs

• Migraine
• Without aura
• With aura
• Tension-type HA (TTH)
• Cluster HA

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Migraine characteristics

• 60-70 unilateral, 30 bifrontal or global
• gradual onset, crescendo pattern, pulsating,
  aggravated by physical activity
• lasts 4-72 hours
• A/w nausea, vomiting, photo/phonophobia, may have
  aura (usually visual but sometimes other senses
  and can have speech or motor deficits)

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Description of aura

• typical visual aura- flickering uncolored zig-zag
  line in the center of visual field which
  progresses to periphery leaving scotoma along
  path
• sensory aura usually unilateral starts in hand
  and gradually progress proximally up the arm to
  the face and tongue
• motor aura typically involve hand/arm on one side
• Visual/sensory auralt 1hr, motor aura last gt1hr

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HA triggers

• Stress
• Diet (etOH, chocolate, aged cheeses, MSG,
  aspartame, caffeine, nuts, nitrites, and
  nitrates)
• Hormones (menses, ovulation, progesterone in HRT
  or OCPs)
• Sensory stimuli (strong sound/light/smell)
• Changes of environment or schedule

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Cluster HA

• Always unilateral, usually around eye or temple
• Fast onset, reaching peak within minutes
• Pain is deep, continuous, excruciating and
  explosive in quality
• Last 30minutes to 3 hours
• A/w ipsilateral lacrimation/redness of eye, nasal
  congestion or rhinorrhea, pallor, sweating,
  Horners syndrome. Sensitivity to alcohol. Rare
  focal neurologic sx

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Tension-type HA (TTH)

• Episodic lt15 attacks/month
• 30min-7days
• Chronic gt/15 attacks/month
• Hours-continuous
• Both types have at least two of following
  bilateral, pressing or tightening, mild/moderate
  intensity, not aggravated by physical activity
• Neither include more than mild nausea or
  vomiting. May have either photophobia or
  phonophobia, not both

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Other primary HA

• Primary stabbing HA- episodic stabbing pains in
  distribution of 1st division of trigeminal nerve
• Primary cough HA- sudden onset with coughing,
  straining, or val salva maneuver
• Primary exertional HA-pulsating pain lasting
  5min-48 hrs brought on by exercise

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other Primary HA

• Sexual activity HA-
• pre-orgasmic dull ache in the head and neck
• orgasmic explosive and severe HA occurring with
  orgasm (need to exclude SAH and arterial
  dissection)

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other Primary headaches

• Hypnic HA- 30 min of nocturnal head pain in
  elderly pt, same time each night
• Thunderclap - sudden severe onset with peak pain
  within one minute, may last 1hr-10 days
• Hemicrania continua- daily, continuous unilateral
  HA which completely resolves with indomethacin

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Primary HAs

• New Daily persistent headache- resembles chronic
  TTH but unremitting within 3 days of onset and no
  progression from episodic TTH. Needs to be
  present at least 3 months for dx. Same
  characteristics otherwise as TTH

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Primary HA gt4 hours

• Chronic migraine
• Chronic TTH
• New daily persistent HA
• Hemicrania continua

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Primary HA lt4 hours

• Unilateral-
• Cluster HA
• Paroxysmal hemicrania
• Unilateral or bilateral-
• trigeminal neuralgia
• idiopathic stabbing HA
• cough HA
• benign exertional HA
• sexual activity HA

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Secondary HA

• Vascular disorders AVM, giant cell arteritis,
  carotid dissection, vasculitis
• Neoplasm
• Pseudotumor cerebri
• Infection
• Post-traumatic
• Subdural hematoma

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Secondary HA continued

• Myofascial pain
• Cervical spine disorders
• TMJ dysfunction
• Sleep disorders including obstructive sleep apnea
  (can be related to hypoxia and/or hypercapnea)

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Caffeine withdrawal HA

• Criteria
• Pt consumes gt/ 15mg/month caffeine q for at
  least 3 months
• HA starts within 24 hrs of last caffeine intake
• HA relieved within 1 hr by 100mg caffeine
• HA disappears within 14 days after withdrawal

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Medication overuse HA (MOH)

• Suspect in pts with frequent HA despite regular
  use of headache medications
• Continuous exposure causes anti-nociceptive
  tolerance- this tolerance and dependence result
  in mini-withdrawals and rebound headaches with
  fluctuations of serum drug levels
• Tylenol, Fiorinal (butalbital-ASA-caffeine), ASA,
  ergotamines, opioids, and triptans most common
  and in that order

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Sinus HA

• True sinus HA occurs in conjunction with acute
  sinusitis, fever, and purulent discharge
• Absence of these should lead diagnosis towards
  migraine HA with associated sinus pain/pressure

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Psychiatric related HA

• Comorbidity of
• Depressive disorders
• Anxiety disorders
• Chemical dependency
• Personality disorders

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Briefly, treatments

• To do this justice, it really should be a
  complete lecture unto itself

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MIGRAINE PROPHYLAXIS

• beta-blockers may take 3-4 weeks for effect,
  have caution with asthmatics, diabetics, or heart
  block
• TCAs especially amitriptyline and nortriptyline
  caution in pts with urinary retention, glaucoma,
  BBB
• Anticonvulsants, antiemetics and ergot derivatives

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Cluster HA tx

• Prophylaxis verapamil 120mg TID, lithium,
  prednisone, ergotamines, and indomethacin (vs
  surgery of trigeminal N.)
• Acute tx
• 100 O2 for 20min
• Sumatriptan subq, intranasal, PO
• Octreotide
• Intranasal DHE

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Tension HA tx

• Episodic HA- NSAIDs
• Chronic HA-
• TCAs
• SSRIs (less evidence)
• Biobehavioral techniques psychotherapy,
  relaxation therapy, biofeedback, stress
  management therapy

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Summary

• Rule out serious pathology
• Look for secondary causes of HA (especially
  sinusitis)
• If a primary HA, determine which type principally
  through history
• Be aware of overlap in migraine and tension HA
  symptoms
• Imaging is rarely necessary