Headaches in Primary Care

1. Headaches in Primary Care Steve Cobb MD Residency Program Director ESJH Family Medicine Residency

3. Headaches in Primary Care Steve Cobb MD Residency Program Director ESJH Family Medicine Residency

10. Headaches in Primary Care – Objectives • Use IHS criteria to diagnose common primary headache syndromes. • Treat common primary headaches. • Recognize symptoms and signs associated with secondary and worrisome headaches

11. Why Us? • Family Physicians and Internists • Headache is the second most common pain complaint seen in primary care • 63% of migraineurs see their PCP alone for care • 18M patients visit PCPs per year for HA • Over 1,000 visits to the OU FMC annually

12. Case 1 • 26 year old female presents with CC of headache x 6 months. Headaches occur everyday, are usually unilateral, but not always. They often improve with Midrin, but sometimes she misses work when it fails. Sometimes she is nauseated enough that she vomits. Physical exam, including vital signs, fundoscopic, and neurologic exams are normal today.

13. Strategy for Headache Evaluation and Treatment • 1. Ensure this is a benign primary Headache disorder. • 2. Determine the type. • 3. Determine treatment goals and prioritize and communicate them clearly. • 4. Arrange for periodic review and oversight. • 5. Know when to refer and to whom.

14. Clinical Approach to Headache • How many headache types are there? • Headache history for each type • Physical Exam • Differential Diagnosis • Indications for Neuroimaging • Classification • Treatment

15. History • Age of onset • Frequency • Character • Aura or prodrome • Neurologic symptoms • Precipitating factors • PMHx/Meds/Trauma/Procedures

16. Migraine aura • Visual disturbances confined to one field • phosphenes, eg, sparks, flashes, geometric forms • scotoma, area of diminished vision moving across visual field • scintillating scotoma, flickering spectrum at margin of scotoma • Sensory: unilateral paresthesias and/or numbness • Weakness, or more commonly a sense of limb heaviness: unilateral • Speech: dysphasia

17. Migraine Aura: Scintillating Scotoma Reprinted with permission from Fisher CM. Late-life (migrainous) scintillating zigzags without headache: one person’s 27-year experience. Headache. 1999;39:391-397.

19. Physical • BP, fundoscopy, temporal and scalp area palpation • Neuro Exam

26. Abnormal neurologic findings Confusion, somnolence Post-traumatic An isolated severe headache Abrupt onset, or onset during exercise Pain severe enough to disturb sleep Age less than 5 years Onset in late life Family history of aneurysm or polycystic kidney disease Consistently localized head pain Progressively worsening Indications for Neuroimaging

28. “SNOOP” • Systemic symptoms-fever, weight loss, stiff neck, rash • Secondary risk factors-HIV, cancer, coagulopathy • Neurologic symptoms or signs-confusion, change in alertness or LOC • Onset is sudden-abrupt or split second onset • Older age at onset-new or progressive headache, first at age>50 • Previous Headache history-first/worst headache, different progressive type, change in clinical features

31. Strategy for Headache Evaluation and Treatment • 1. Ensure this is a benign primary Headache disorder. • 2. Determine the type. • 3. Determine treatment goals and prioritize and communicate them clearly. • 4. Arrange for periodic review and oversight. • 5. Know when to refer and to whom.

32. Make the diagnosis Pearls • Use a validated screening tool • ID Migraine TM • Listen (3 minute rule) • Make a follow up appointment specifically to discuss headache and do a careful neurologic exam • Headache diaries • Neuro-imaging is seldom necessary

33. Primary Migraine Tension type Cluster “Miscellaneous headache not associated with structural lesion” Secondary Increased (or decreased) intracranial pressure Vascular disorders (Temporal arteritis) Substance associated Infection Metabolic disorder Trauma Neuralgias Associated with other diseases of the cranium Make the Diagnosis International Headache Society Classification

34. Differential Diagnosis - Pearls • 90% of HA’s are Primary HA’s • Life-threatening causes are rare • Evaluate carefully for Secondary and life-threatening HA’s • If exam is normal, then neuroimaging is usually normal • If history supports intracranial bleed and CT is normal, LP • Once you R/O Secondary HA….. • Determine what type(s) of primary headache your patient has.

35. Common Primary Headaches • Migraine • Tension • Cluster • Chronic Daily Headache

36. Migraine - Epidemiology • 25 – 30 Million sufferers in the U.S. • One year prevalence • Women – 18% • Men – 6% • Many Still Undiagnosed – 14.6M Lipton et al Headache 2001;41:638-645. • Women – 49% • Men – 59%

39. Make The Diagnosis S evere U nilateral 2 of these L ocation T hrobbing A ctivity N ausea 1 of these S ensory

40. Migraine - Pathophysiology • The Neurovascular Theory = Vasodilatation may be secondary to Neurogenic Inflammation • Trigeminal Nerve Activation • Dural Blood Vessel Dilation AND Inflammation • 5HT 1B1D Receptors - Where Triptans Work • 1B Cranial Blood Vessel Constriction • 1D Inhibits Neurogenic Inflammation

42. Central Activation • Periaqueductal Grey Area • Trigeminal Nucleus Caudalis • Cranial nerve stimulated by abnormal signaling centrally

43. Strategy for Headache Evaluation and Treatment • 1. Ensure this is a benign primary Headache disorder. • 2. Determine the type. • 3. Determine treatment goals and prioritize and communicate them clearly. • 4. Arrange for periodic review and oversight. • 5. Know when to refer and to whom.

44. Treatment Goals • Eliminate Pain and other associated symptoms • Preserve/Restore function • Prevention (reduce number and intensity of headaches).

45. Migraine - Treatment • Non-pharmacologic efforts • Meds • Treat concomitant mood disorders • Follow-up and re-evaluation

46. -Menstruation, pregnancy, menopause -Hormonal contraceptives or hormone replacement therapy -Intense or strenuous activity/exercise -Sleeping too much/too little/jet lag -Fasting/missing meals -Bright or flickering lights -Excessive or repetitive noises Odors/fragrances/tobacco smoke -Weather/seasonal changes -High altitudes -Medications -Stress/stress letdown Migraine- Associated triggers

47. Probably: ·Monosodium glutamate (MSG) (soy sauce, meat tenderizers, seasoned salt) ·Alcoholic beverages (wine, beer, whiskey, etc.) Possibly: ·Ripened cheeses (cheddar, ernmenthaler, stilton, brie, camembert) ·Sausage, bologna, salami, pepperoni, summer sausage, hot dogs, pizza ·Herring (pickled or dried) ·Any food pickled, fermented, or marinated ·Broad beans, lima beans, fava beans, snow peas ·Caffeinated beverages (tea, coffee, cola, etc.) ·Aspartame/phenylalanine-containing foods or beverages Migraine Triggers - Dietary

48. Grade A Evidence Relaxation Therapy Thermal Biofeedback Cognitive behavioral therapy Grade B Evidence Behavioral therapy with medication Grade C Evidence Hypnosis Acupuncture TENS Unit Cervical spine manipulation Occlusal Adjustment Hyperbaric O2 Non-pharmacologic

49. Prophylactic Antiepileptics Antidepressants B-Blockers CCB NSAIDS Serotonin Agonists Vitamins and Herbs Abortive Specific Triptans Ergots General Antiemetics NSAIDS Opioids Barbiturates Corticosteroids* Pharmacologic Treatment Episodic Migraine

50. Prophylaxis Level A Depakote (Topamax) Sansert Propranolol Level B Tegretol Gabitrol Other B-blockers Verapamil Feverfew, B2, Mg Abortive Level A Triptans Intra-nasal DHE Level B Exedrine in non-disabling migraines Caffeine Corticosteroids in status migranosis Evidence