Headache for the PCP: Evaluation and Initial Management

1. Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director, Riley Headache Center

2. Objectives • Identify a systemic evaluation of a headache patient • Evaluate for causes of secondary headache • Recognize how to diagnose common primary headache symptoms of childhood • Identify how to treat primary headache syndromes

3. Initial Evaluation

4. 1. Shoulder shrug and look to parents2. “I don’t know”3. “Headaches?”

5. It’s in the history • Time course • Time course • Time course • Pain description • Location • Severity • Quality • Associated symptoms

6. Other questions: • Pain description • Location • Severity • Quality • Associated symptoms • Aura • Nausea, vomiting • Photophobia, phonophobia • Light-headedness, vertigo • Autonomic features

7. Time course Progressive Morning Location Posterior Postural Focal neurologic signs Any Systemic signs Fevers, rash Family history As in, none Age Under 6 years Red Flags

8. Physical exam • Eyes / Fundus • TMJ • Face • Muscles • Skin • Neurologic

9. Secondary Headaches

10. Non-neurologic causes of secondary headaches • Dental/ TMJ • Allergies/ congestion • Sinus inflammation/ infection • Ear infection/ Mastoiditis • Hypothyroidism • Pheochromocytoma (Hypertension) • Eye-strain

11. It is (probably) not a tumor • Brain tumors are very rare • BUT… • You only need to miss one to be incompetent • The chance of finding a tumor in a patient with headaches and a normal neurological exam is…

12. It is not a tumor • Very low, but not quite zero • Brain tumors typically cause headache when they cause increased pressure • A much more common presentation is focal neurologic signs with minor headache

13. It is a tumor • Key features • Time course (Progressive) • Timing (On awakening) • Postural (Supine) • Focal Neurologic signs • Seizures

14. If it’s not a tumor, what is it?

15. Intracerbral Hemorrhage • Features • Time course (Acute) • History of trauma • Focal Neurologic signs • Types of hemorrhage • Subdural • Epidural • Subarachnoid • Paranchymal • Interventricular

16. Venous sinus thrombosis • Associated with primary or secondary hypercoagulable state • Present with signs of increased intracranial pressure • Sometimes hemorrhage • Red Flags • Time course (Progressive or static) • Postural • Neurologic signs • Papilledema • 6th nerve palsies

17. Ideopathic intracranial hypertension • Mechanism unknown • More female, more obese • Headache with visual loss • Red Flags • Time course (Progressive or static) • Postural • Neurologic signs • Papilledema • 6th nerve palsies

18. Ideopathic intracranial hypotension • Seen in some connective tissue diseases from dural ectasia (or ideopathic) • Mimics LP headache • Red Flags • Time course (Progressive or static) • Postural

19. Meningitis / Encephallitis • Red flags: • Systemic signs (fever) • Focal Neurologic signs (meningismus, encephalopathy, seizures)

20. Chiari I Malformation • Protrusion of cerebellar tonsils below the foramen of Monro • Red flags: • Location (posterior) • Postural, pain with neck movements • Focal Neurologic signs (ataxia) • Worse with cough, sneezing, valsalva

21. Post-traumatic or Post-concussiveHeadache • Red flags: See hemorrhage • Will get better, may take months • Cognitive changes are common, will also improve

22. Headache Evaluation

23. Do I order LABS?

24. Headaches in children younger than seven years of ageChu ML, Shinnar S. Arch Neurol, 49:1992; 79-82 • Study of 104 children referred to Child Neurology • Studies performed prior by the pediatrician • Studies included: • Cell counts • Basic electrolytes • Tranaminases • Urinalysis • “Uniformly unrevealing” • Similar prospective study in adults of 193 patients showed same results

25. Do I order a SCAN?

26. American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches 2002 • Neuroimaging • Combined 6 studies • 605 of 1275 had imaging (CT in 116, MRI in 483, both in 75) • 97 children with imaging abnormalities (16%) • 79 considered incidental • 14 surgically treatable • 4 medically treatable

27. American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches 2002 • Of the 14 surgical lesions: • 10 tumors • 3 symptomatic vascular malfomations • 1 significant arachnoid cyst • All had an abnormal neurologic examination • Papilledema • Abnormal eye movements • Motor dysfunction • Gait dysfunction

28. American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches 2002 • Parameters which distinguish headache patients with space occupying lesions • Headache of less than one month duration • Absence of a family history of migraine • Abnormal neurological examination • Gait abnormalities • Seizures • Those patients with headaches for less than 6 months and at least one of the above symptoms are considered “high-risk” • “High-risk” = 4% chance of space occupying lesion

29. CT vs. MRI?

30. Primary Headache Disorders

31. Migraine Diagnosis and Treatment: Results From the American Migraine Study IIHeadache 2001;41:638-645 • Survey mailed to 20,000 homes, identified 3577 individuals who met criteria for migraine • 48% had previously received a physician diagnosis • 24% of those undiagnosed had missed at least one day of work or school in the previous three months • Those missed were: • Lower income • Younger age (18-29) • Male

32. Migraine epidemiology • Headache prevalence • Tension type HA 78% • Migraine 16% • Children • 3-8% by age 3 • 37-52% by age 7 • 57-82% in 7-15 year olds • Peak incidence • Women – age 12-13 (aura), 14-17 (without) • Men – age 5 (aura), 10-11 (without) Comprehensive Review of Headache Medicine; Levin M Ed; Oxford 2008

33. “If nothing is wrong with me, doctor, why do I have these headaches?”

34. Migraine pathophysiology • Primarily a NEUROGENIC process • We think • For now

35. Migraine pathophysiology • Aura • Cortical spreading depression • Front of profound depolarization • Moves across cortex ~ 3mm/min • Following by suppression of neural activity lasting minutes A.P. Leão.

36. Cortical Spreading Depression

37. Migraine pathophysiology

38. Migraine without aura Pediatric diagnostic criteria • At least five attacks fulfilling criteria B-D (below) • Headache attacks lasting 1 to 72 h • Headache having at least two of the following characteristics: • Unilateral location, may be bilateral, frontotemporal (not occipital) • Pulsing quality • Moderate or severe pain intensity • Aggravation by or causing avoidance of routine physical activity (eg, walking, climbing stairs) • During the headache, at least one of the following: • Nausea or vomiting • Photophobia and phonophobia, which may be inferred from behavior • Not attributed to another disorder

39. Migraine with aura Pediatric diagnostic criteria • At least two attacks fulfilling the criteria B-D (below) • Aura consisting of at least one of the following, but no motor weakness: • Fully reversiblevisual symptoms, including positive features or negative features (e.g., flickering lights, spots, or lines) • Fully reversiblesensory symptoms, including positive features (i.e., pins and needles) or negative features (ie, numbness) • Fully reversible dysphasicspeech disturbances • At least two of the following: • Homonymous visual symptoms or unilateral sensory symptoms • At least one aura symptom develops gradually over 5 min or different aura symptoms occur in succession over 5 min • Each symptom lasts between 5 min and 60 min • Not attributable to another disorder

40. And…

41. …Chronic Daily Headache…

42. Chronic Daily Headache • Transformed (or chronic) migraine • History of migraine • Progresses to chronic, low level headache with periodic migraines • Chronic tension type headache • Lack significant migranous features • Less severe intensity • Tightening more than pulsating • New daily persistent headache

43. Chronic daily headaches - evaluation • Look for red flags* • Ask about analgesic overuse * Especially in New Daily Persistent Headache

44. Practice Parameter: Pharmacologicaltreatment of migraine headache in children and adolescents D. Lewis, MD; S. Ashwal, MD; A. Hershey, MD; D. Hirtz, MD; M. Yonker, MD; and S. Silberstein, MD NEUROLOGY 2004; 63: 2215–2224

45. Migraine treatment - Abortive • Ibuprofen, acetaminophen, ketorolac, indomethacin, ASA • Combinations (Acetaminophen/ASA/caffeine) • Antiemetics (promethazine, chlorpromethazine • Opiates, barbituates (no, no, never…) • Corticosteroids • Triptans • 5HT1b, 1d, and 1f agonists • Contraindications include cardiovascular disease or risk factors, Reynaud’s, hemiplegic migraine • Side effects include nausea, dizziness, chest and throat tightness

47. Migraine treatment - Abortive

48. Migraine treatment - Prophylactic • When to use prophylaxis • Headaches frequent • Headaches severe • Headaches disruptive • Side effects and burden of taking a daily medicine < the life disruption caused by (appropriately treated) headaches

49. Migraine treatment - Prophylactic • Antihistamines • Beta-blockers • Tricyclics • Anticonvulsants • Calcium channel blockers

50. Migraine treatment - Prophylactic • Antihistamines • Cyproheptadine • Little studied, often used • Reduce headaches from 8.4 to 3.7 per month • Somnolence, weight gain • Initial dose 1-2 mg QHS, max 4 mg BID Lewis D, Diamond S, Scott D, et al. Prophylactic treatment of pediatric migraine. Headache 2004;44:230–237.