Transcript Approach to Headaches - General Internal Medicine

Approach to
Headaches
AIMGP Seminar
October 2004
Manaf Qahtani
Outline:
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Learning Objectives
Case Studies
General Principles
IHS Classification
“Red Flags”
The Headache Diary
Therapy
Review Case Studies
Summary
Resources
Learning Objectives
1.
Become aware of the IHS classification
2.
Be able to diagnose and treat the
common types of Primary headache
3.
Be able to recognize the “Red Flags” of
dangerous Secondary Headaches
General Principles
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There are lots of pain sensitive
structures in the head and neck
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The key to proper management is to
make an accurate diagnosis.
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Recognize the features of “dangerous”
headaches, and know how to “rule out”.
IHS Diagnostic Classification
1- Primary Headache: 90%
2-Secondary Headaches: 10%
HISTORY
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Headache Characteristics:
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Temporal profile: acute vs chronic, frequency
Location and radiation
Quality
Alleviating and exacerbating factors
Associated symptoms
Constitutional symptoms
PMH: HTN, DM, hyperlipidemia, smoking
Physical Exam
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Blood pressure
Fundoscopy
Auscultation for bruits in H/N
Temporal artery inspection and palpation
Meningismus
Neurologic exam: motor, sensory,
coordination and gait
Primary Headache
1.
Migraine without aura
2.
Migraine with aura
3.
Tension headache
4.
Combination headache
5.
Cluster headache
Primary Headache
1.
Migraine without aura; > 5 attacks with:
A- duration 4-72 hours
B- > 2 of:
i.
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iii.
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unilateral
pulsating
interferes with daily activity
aggravated by routine activity
C- > 1 of:
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nausea and/or vomiting
and/or
ii. photophobia and/or phonophobia
D- No secondary cause
Primary Headache
2- Migraine with aura; > 2 attacks of:
A- Any 3 or more of:
1-one or more reversible aura symptoms
2-At least one aura symptom develops over > 4 min., or
two or more symptoms in succession
3-No single symptom lasts > 60 min.
4-Headache follows aura with free interval < 60 min, or
begins before or with aura.
B- No evidence of secondary cause.
Primary Headache
3.
Tension-type headache: At least 10 attacks of:
A- Duration 30 min – 7 days.
B- > 2 of the following characteristics:
i. Pressing/ tightening (non-pulsating)
ii. Mild/Moderate intensity. “Inhibits but doesn’t prohibit
activity”.
iii. Bilateral
iv. Not aggravated by routine activity
C- Both of:
i. absence of nausea and vomiting (anorexia may occur)
ii. absence of photophobia or phonophobia
N.B. > 15 days/ month = Chronic Tension Headache.
Primary Headache
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Combination Headache
Tension-type headache + migraine.
The tension headache may precipitate a
migraine.
Primary Headache
5. Cluster headache
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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
Secondary Headache:
Pain-sensitive structures in the head and neck
Extra-cranial
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Scalp
Scalp muscles
Skull
Carotid and vertebral arteries
Paranasal sinuses
Eyes and orbits
Mouth, teeth, and pharynx
Ears
Cervical spine and ligaments
Cervical muscles
Intracranial
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Periosteum
Cranial nerves
Meninges
Meningeal arteries and dural
sinuses
Proximal intracranial arteries
Sphenoid sinus
Thalamic nuclei
Brainstem pain-modulating
centers
“Red Flags”
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New headache especially in over 50 y.o.
Abrupt onset, unusually severe
Change in usual headache pattern
Associated with focal neurologic findings
Change in LOC, personality, lethargy
Fever, neck stiffness
Systemic signs/symptoms
Temporal artery tenderness
The Headache Diary
Purpose:
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To aid diagnosis
To identify triggers
To provide a self-monitoring tool for
patients
The Headache Diary
Frequency of pain
Quality of pain
Duration of pain:
Intensity of pain: Use a rating scale 1-5
Accompanying symptoms: Neurologic
e.g. visual disturbance, hemiparesis,
hemianopsia, etc., and Autonomic e.g.
nausea, vomiting, diarrhea
 Mental, cognitive and mood disturbance
 Triggers: hormonal, environmental, food, drug
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Therapy of Primary Headaches
Principles of Therapy:
Stratified approach rather than a stepped care approach i.e.
treat according to severity
Determine level of intensity and frequency of headache to
decide on appropriate acute treatment.
Determine whether to use a combination of pharmacologic and
non-pharmocologic therapies.
Determine whether prophylactic therapy is indicated.
Therapy
Migraine – Acute Attacks
 set limits on treatments, i.e. no more than 2
days/week
 if oral agents not tolerated, use nasal
sprays, suppositories, or injectables
 for GI dysmotility/ nausea/ vomiting, use
metoclopromide 10mg.
 Can use”MIDAS” Scale to guide therapy
Tension-type headaches
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For moderate attacks NSAIDS useful
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For severe attacks triptan drugs effective
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Non-pharmacologic Therapy
Cluster headache:
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Rare but debilitating
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Carry high risk of suicide
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Agent must have rapid onset of action
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Acute treatment:
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Oxygen 100% (evidence?)
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Injectable sumatriptan (6mg.)
Summary
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Lots more to know about headache
IHS classification is the beginning of the
diagnositic pathway.
Most headaches will be Primary, but must
recognize the “Red Flags” of serious
Secondary Headache.
Use Patient Diary and MIDAS to guide
treatment.
Resources
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www.migraine.ca
http://www.zomigconsumer.com/talk/midas
Survey.html
http://www.ottawa-headache-centre.com/
www.aan.neurology.org
JAMA,march 19,2003-vol 289, No 11
“headache assessment and management”