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Approach to Headaches

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

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  1. Approach to Headaches AIMGP Seminar April 2004 Gloria Rambaldini

  2. 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?

  3. 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?

  4. 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?

  5. 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

  6. 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

  7. 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

  8. 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

  9. RED Flags

  10. 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

  11. Physical Exam • Blood pressure • Fundoscopy • Auscultation for bruits in H/N • Temporal artery inspection and palpation • Meningismus • Neurologic exam: motor, sensory, coordination and gait

  12. 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

  13. 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

  14. MIGRAINE Headaches • Subtypes: • Auras – visual or sensory • Scintillating scotoma • Fortification spectra • Ophthalmoplegic • CN III palsy • Vertbrobasilar • hemiplegic

  15. Visual Auras: Patient drawings Scintillating Scotomas Progression of a typical aura over 30 minutes BMJ 2002; 325:881-6

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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)

  23. 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

  24. 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

  25. 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

  26. 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?

  27. 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?

  28. 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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