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 ASA and Tylenol have not provided relief What next?

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

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

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

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

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

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

Blood pressure Fundoscopy Auscultation for bruits in H/N Temporal artery inspection and palpation Meningismus Neurologic exam: motor, sensory,

coordination and gait

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 Headaches

Diagnostic criteria:1. 5 attacks in 6 months2. 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 Headaches

Subtypes: Auras – visual or sensory Scintillating scotoma Fortification spectra Ophthalmoplegic CN III palsy Vertbrobasilar hemiplegic

Visual Auras: Patient drawings

Scintillating Scotomas

Progression of a typical aura over 30 minutes

BMJ 2002; 325:881-6

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 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

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

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

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

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

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 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 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 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 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

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

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?