HEADACHE

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HEADACHE

• Norma Jo Waxman MD
• R2 Seminar
• November 17, 2004

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HEADACHES

• INCIDENCE/PREVALENCE 70-95 of population
  experience headache/year
• 18 women/ 15 men will consult MD
• CC in 1-4 Outpt. Visits, 2-4 ED visits
• COSTS 50 billion/yr in missed workdays and
  medical benefits

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Work Up of Headache

• Current Presenting Illness
• Past Medical History
• Red Flags
• Medications
• Physical Exam
• Imaging

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Current Presenting Illness

• When did your headaches first start?
• Have they changed in character or frequency?
• Do you headaches ever alter your ability to work,
  study, play?
• How many headaches total /month, disabling
  headaches/month?

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Current Presenting Illness

• What triggers your attacks? How do they start
  (gradually, suddenly, other)?
• Recent trauma, medical or dental procedure?
• Family history of headache?
• for chronic H/As also ask about mood, sleep
  disturbance, hormonal changes
• For women, relationship to menses, experience
  with pregnancy

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Past Medical History

• Headache History
• Head trauma
• HIV
• Current or past history of Cancer
• Allergic Rhinitis
• Recent Lumbar Puncture

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Medications

• Overuse of OTC and combination analgesics
  frequently cause rebound headaches.
• HA is listed as a side effect of treatment or
  withdrawal in more than a 1000 medications.
• Steroids, Accutane, Tamoxifen, and Cimetidine are
  known to cause increased intracranial pressure.
• Substance Abuse- ETOH, opiates, caffeine

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Red Flags

• Headaches begin after age 50
• Very sudden onset of Headache
• Change in frequency or severity
• Immunosupresion
• Fever, stiff neck, rash, trauma
• Focal neurologic symptoms or signs
• Papilledema

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Physical Exam

• General appearance and vital signs
• head (including palpation)
• pupil reaction, visual field testing
• fundiscopic exam ( normal exam does not mean
  normal intracranial pressure
• ears, sinuses, teeth, oropharynx
• neck and neuro exam

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Primary Headache Disorders

• Benign, usually recurrent headaches with no
  organic cause
• Rarely have physical findings and account for
  greater than 90 of all headaches
• Migraines, tension-type and cluster are most
  common

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Secondary Headache Disorders

• Headaches with organic etiology
• Underlying disease may range from mild viral
  infections to metastatic cancer
• Pain reduction with triptans or other acute
  headache therapy does not rule out an organic
  etiology.

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Vascular Causes

• SUBARACHNOID HEMORRAGE
• an abrupt onset headache that is often severe,
  but may be subtle. Patient may have transient LOC
  or meningeal symptoms.
• Noncontrast CT will dx 90 of SAH, but LP is
  required to rule out this treatable condition.

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Vascular Causes

• SUBDURAL HEMATOMA
• Lateralizing features may be subtle or absent.
• Besides trauma, risk factors include cerebral
  atrophy, bleeding diathesis, alcoholism, old age
  and dialysis.

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Vascular Causes

• TEMPORAL ARTERITIS
• rapidly leads to permanent loss of vision if not
  treated. Patients gt50 years old present with new
  headache
• May have temporal artery tenderness, decreased
  vision, or abnormal fundiscopic exam, symptoms of
  jaw claudication, or consititutional symptoms
  such as weight loss, anemia, elevated LFTS, or
  polymyalgia rheumatica.

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Temporal Arteritis- Continued

• Because no findings may be present, a new
  headache in someone greater than 50 years old
  warrants an ESR.
• ESR is greater than 50/mm3 in gt 95 of patients
  with temporal arteritis.
• To prevent blindness, steroid therapy should be
  started while awaiting temporal artery biopsy
  and opthomalogic consult
• Treat with prednisone tapered over 12 to 24
  months guided by ESR levels.

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Nonvascular Causes

• INTRACRANIAL TUMORS
• About one-third of patients with brain tumors
  present with a primary complaint of headache.
• Pain is usually intermittent, dull, bi-frontal,
  with nausea (50 of the time)
• Headache rarely starts in the morning or wakes
  patient from sleep.

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Pseudotumor Cerebri

• Idiopathic intracranial hypertension presents
  with headache and transient visual symptoms
• Young overweight woman with a normal neuro exam
  except for papilledema
• LP is diagnostic with CSF pressure gt250mm Hg and
  normal CSF composition
• Treatment includes weight loss, acetazolamide and
  furosemide in idiopathic cases

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Decreased Intracranial Pressure

• CSF pressure below 50-90 mm Hg
• Dull, throbbing headache, worse with sitting or
  standing
• Usually after LP, Trauma, Surgery, can happen
  spontaneously
• Treatments include fluids, steroids,
  tetracycline, IV caffeine, or blood patch.
  

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Post-Concussive Syndrome

• Headache, vertigo, and cognitive complaints
• Pathology is poorly understood and symptoms
  correlate poorly to severity of trauma
• Head CT may be necessary to exclude chronic
  subdural hematoma or hydrocephalus
• Treatment includes counseling, physical therapy,
  and medications used for tension-type headache.

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Migraines

• Epidemiology 18 of woman, 6 of men.
  Migraineurs suffer a median of 12 attacks/
  year. Onset usually before age 50.
• Terminology changed in 1988
• Migraine with aura, was Classic migraine
• Migraine without aura , was Common migraine

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Diagnostic Criteria for Migraine Without Aura

• Migraine is defined as episodic attacks of
  headache lasting 4-72 hours
• With two of the following symptoms
• Unilateral Pain (60)
• Throbbing (70)
• Aggravation on movement
• Pain of moderate or severe intensity
• And one of the following symptoms
• Nausea or Vomiting
• Photophobia or phonophobia

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Treatment of Migraines

• Triptans are more effective than NSAIDs and
  combination analgesics
• NSAIDS seem to act synergistically with the
  Triptans
• PO or PR Phenothiazines are also helpful in the
  outpt setting for treating both nausea and pain.
• Consider non-oral meds for patients whose
  headaches start with nausea vomiting.
• Sleep often abolishes the headache.

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Prophylaxis of Migraines

• Consider prophylaxis if acute medications are
  used more than two times a week, when rescue
  medications are necessary more than once a month,
  or if headaches are functionally limiting
• Prophylaxis should be started at low doses and
  titrated up over 2-3 months

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Triptans

• Highly Selective
• Highly Specific
• Rapid Onset of Action
• Multiple routes of administration
• Patients who do not respond to one triptan may
  respond to another

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Triptan Side Effects

• Flushing or Dizziness
• Tingling, parasthesias, and sensations of warmth
  in the head, neck, chest and limbs
• Chest tightness or SOB, which may mimic angina
• coronary vasoconstriction rare

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Risk of Cardiac Event

• 5 million migraineurs
• 100 million attacks treated with triptans
• 19 persons have died within 24 hrs of use
• 11 with injection
• 8 with tablet
• Some of these may have been coincidental
• Risk less than being struck by lightning or fatal
  GI Bleed from NSAIDS

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Triptan Contraindications

• CAD
• CVA
• Uncontrolled HTN
• PVD
• Use of ergots or DHE within 24 hours

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Migraine and Hormonal Cycles

• Can increase during or only occur with menses
  (falling estradiol)
• 70 of migraineurs improve during pregnancy
• rebound post-partum with falling estrogen levels
• Usually resolves, or markedly improves with
  menopause

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Tension-type Headache

• Lifetime prevalence of 69 in men and 88 in
  women
• Pain is typically bilateral (90 of the time),
  pressure or band-like
• Lasts hours to days
• Precipitants include anxiety, depression and
  situational stress

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Treatment of Tension-type Headache

• NSAIDs for occasional headaches, and combination
  analgesics for recurrent headaches. Both sedating
  antihistamines and antiemetics can potentiate
  analgesics
• Consider prophylactic therapy if meds are used
  more than 2 times a week. Amitriptyline has been
  shown most effective. TCAs are effective
  independent of their antidepressant effect
• Limited studies have shown biofeedback,
  relaxation training, spinal manipulation and
  physical therapy as helpful therapy

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Cluster Headache

• Affects men 6xgtwomen. Onset in 3rd through 6th
  decades. Prevalence .4 2.
• Pain is severe, recurrent unilateral, orbital,
  supraorbital or temporal, accompanied by
  ipsilateral autonomic signs.
• Lasts 15 minutes to 3 hours and occurs qod to 8
  times a day

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Cluster Headache

• Because pain is so severe, most patients will
  present to their physician
• Episodes cluster over weeks to months separated
  by months to years of remission
• Nitrates or alcohol may trigger attack during the
  cluster period but have no effect during
  remission

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Treatment of Cluster Headache

• Oxygen inhalation (100) at 8 L/minute for 15
  minutes via a loose fitting mask is a safe option
  and works within 10 minutes if patient is going
  to respond
• Sublingual ergotamine or DHE, SubQ sumitriptan
  (6mg), and nasal lidocaine are effective acute
  therapies
• Prophylactic Measurers include Verapamil,
  lithium, and methylsergide  

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Rebound Headache

• Also know as Chronic Daily Headache, chronic
  tension-type, medication induced, and transformed
  migraine
• An unrecognized epidemic accounts for the
  majority of referrals to headache clinics
• Depression, anxiety and drug abuse may complicate
  the presentation
• Diagnostic Criteria Occurs 15 or more days/month
  for at least 6 months. 2-5 prevalence
• CDH is usually associated with overuse of acute
  medications. The longer one has CDH, the harder
  it is to treat

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Rebound Headache

• Patients must be tapered off their acute
  medications. 6 RCTs found significant improvement
  with Amitriptyline.
• This syndrome emphasizes why a careful medication
  history is mandatory,
• This disabling and expensive syndrome speaks to
  the early use of prophylaxis