Transcript Approach to Acute Headache in Adults

Approach to Acute Headache in Adults
Journal Review By: SHIRIN BITAJIAN, MD
NEIMEF Residency Program
BARRY L. HAINER, MD, and ERIC M. MATHESON, MD,
Medical University of South Carolina, Charleston, South Carolina
Am Fam Physician. 2013 May 15;87(10):682-687.
• You get a call from ER. 35 year old male presents
to ER for right sided eye pain and headache.
• You are told by the first year resident, that the call
from ER is in regards to a patient who came in
with a C/O right sided eye pain. This is
associated with drainage from same side and a
severe unremitting headache which is sharp and
knife like, 12/10 intensity, and mostly on right
side. This started after an altercation. No nausea
or vomiting.
• Patient has history of headaches.
• What is the diagnoses? Do you need any imaging?
What’s Up Doc???
What’s the
What’s
up Doc??? What’s
diagnosis??
the Diagnosis???
Interns!!! Mention
all the history but
forget to mention
the most important
fact!!!
Types of Headaches
• The most common types of headaches are
– Tension-type headaches 40 % of adult population
– Migraines 10% of adult population
– Cluster headaches 1 %of the adult population
• Most headache diagnoses are based entirely on
the patient history.
• Only rarely does physical examination provide
clues to the diagnosis
International Classification of Headache
Disorders, 2nd ed. (ICHD-2)
• Primary headaches
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Migraine
Tension-type
Cluster
Other (e.g., cold stimulus headache)
• Secondary headaches
– Headache attributed to any of the following: head or neck
trauma, cranial or cervical vascular disorder, nonvascular
intracranial disorder, substance use or withdrawal, infection,
disturbance of homeostasis, psychiatric disorder
– Headache or facial pain attributed to disorder of the
cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or
other facial or cranial structures
Criteria for Low-Risk Headaches
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Age younger than 30 years
Features typical of primary headaches
History of similar headache
No abnormal neurologic findings
No concerning change in usual headache
pattern
• No high-risk comorbid conditions (e.g., human
immunodeficiency virus infection)
• No new, concerning historical or physical
examination findings
History in Evaluation of Acute Headache
Following require prompt evaluation:
• Thunderclap headache, which is characterized by sudden-onset headache pain, with peak
intensity occurring within several minutes.
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Subarachnoid hemorrhage
hypertensive emergencies
vertebral artery dissections
acute angle–closure glaucoma
• Increase the risk of intracranial bleeding or Stroke:
– Use of illicit drugs (cocaine , methamphetamine)
– Medications such as aspirin, other nonsteroidal anti-inflammatory drugs,
anticoagulants, and glucocorticoids.
• HIV or other immunosuppressive conditions may suggest: a brain abscess,
meningitis, or malignancy of the central nervous system (CNS).
• A patient who reports the worst headache of his or her life, especially if the
patient is older than 50 years, or who has a headache that occurs with exertion
(including sexual intercourse) could be experiencing intracranial hemorrhage or
carotid artery dissection.
Physical Examination Findings
• Neurologic abnormalities
• A focal neurologic deficit should not be attributed to migraine headache unless a
similar pattern has occurred with a previous migraine.
• Abnormal findings can be pronounced, such as meningismus or
unilateral vision loss, or subtle, such as extensor plantar response or
unilateral pronator drift.
• Obtundation or confusion suggests a dangerous headache because these
signs do not occur with benign or primary headache.
• Patients with headache and fever, papilledema, or severe hypertension
require evaluation for CNS infection and increased intracranial
pressure.
• Contusions and facial or scalp lacerations increase the likelihood of
associated intracranial hemorrhage.
DIAGNOSTIC TESTING
DIAGNOSTIC TESTING
Neuroimaging
• All patients who present
with signs or symptoms
of dangerous headache,
because they are at
increased risk of
intracranial pathology.
DIAGNOSTIC TESTING
Lumbar Puncture
• Identifying infection, the presence of red blood cells (which
suggests bleeding), and abnormal cells associated with some CNS
malignancies.
• In adults with suspected subarachnoid hemorrhage, it is
important to perform lumbar puncture to check for blood or
xanthochromia.
• Computed tomography of the head should be performed
before lumbar puncture. In one supporting study, 5 percent
of patients presenting to an emergency department with
suspected subarachnoid hemorrhage and a normal
neurologic examination had early intracranial herniation or
midline shift.
Tension-Type Headache
ICHD-2 Diagnostic Criteria for
Episodic /Chronic Tension-Type Headache
A. Average frequency of greater than 15 attacks per month; Headache lasts 30
minutes to seven days (<12 is labeled as Infrequent chronic tension type
headache)
B. At least two of the following pain characteristics:
1. Pressing/tightening quality
2. Mild to moderate intensity (may inhibit, but does not prohibit activities)
3. Bilateral location
4. Not aggravated by routine physical activity
C. Both of the following:
1. No vomiting
2. No more than one of the following: nausea, photophobia or phonophobia
D. Organic disorder is ruled out by the initial evaluation or by diagnostic studies. If
another disorder is present, the headaches should not have started in close
temporal relationship to the disorder.
Tension-Type Headache
• For Chronic, all of the following:
– Frequency: average of 15 or more headache days per
month for more than 3 months
– No vomiting
– No more than one of nausea, photophobia or
phonophobia
• For Episodic, all of the following:
– Frequency: less than 15 headache days per month
– No vomiting or nausea
– No more than one of photophobia or phonophobia
Tension-Type Headache
• Most common form of headache, and affects more
than 40 percent of the adult population worldwide.
• Women are affected slightly more often than men.
• Nociceptors in the pericranial myofascial tissues are a
likely source of tension headaches.
• Individuals who meet the criteria for tension-type
headache but who have normal neurologic
examination results require no additional laboratory
testing or neuroimaging.
Tension-Type Headache Treatments:
– Acetaminophen
– Aspirin
– NSAIDs
– Midrin (Acetaminophen, Isometheptene and Dichloralphenazone)
– Avoid overuse of treatment meds
CLUSTER HEADACHES
CLUSTER HEADACHES
• Relatively rare, and are characterized by brief (15 to
180 minutes) episodes of severe head pain with
associated autonomic symptoms.
• Although cluster headaches are less common than
migraines and tension-type headaches, an estimated
500,000 Americans experience them at least once in a
lifetime.
• The age of onset of cluster headaches varies, with 70
percent of patients reporting onset before 30 years of
age.
CLUSTER HEADACHES
• Family history appears to have a role in some cases.
• A number of comorbidities are associated with cluster
headaches, including:
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Depression (24 percent)
Sleep apnea (14 percent)
Restless legs syndrome (11 percent)
Asthma (9 percent)
• Depression is an important diagnosis, because many
individuals who have cluster headaches report suicidal
thoughts, and 2 percent of patients in one study had
attempted suicide.
CLUSTER HEADACHES
• Only 25 percent of patients with cluster
headaches are diagnosed correctly within one
year of symptom onset, and more than 40
percent report a delay in diagnosis of five years
or longer.
• The most common incorrect diagnoses
reported in one study were migraine (34
percent), sinusitis (21 percent), and allergies (6
percent).
CLUSTER HEADACHES
1. Frequency: one every other day to 8 per day
2. Severe unilateral orbital, supraorbital and/or temporal pain
most common but can present as bilateral.
3. Pain lasting 15 to 180 minutes untreated
4. One or more of the following occur on same side as the
pain:
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Conjunctival injection
Lacrimation (tearing)
Nasal congestion
Rhinorrhea
Forehead and facial swelling
Miosis (constricted pupil)
Ptosis (eyelid drooping)
Eyelid edema
Agitation, unable to lie down
CLUSTER HEADACHES
• Episodic form (80 to 90 percent of cases):
– episodes occur daily for a number of weeks followed
by a period of remission.
– On average, a period of cluster headaches lasts six to
12 weeks, with remission lasting up to 12 months.
• Chronic form (10 to 20 percent of cases):
– episodes occur without significant periods of
remission.
CLUSTER HEADACHES
• Acute treatment:
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Oxygen
Sumatriptan SQ (self-management)
Zolmitriptan nasal (self-management)
DHE
• Bridge treatment (for quick suppression of attacks until
maintenance treatment reaches therapeutic level):
– Corticosteroids
– Occipital nerve block
• Maintenance treatment (for sustained suppression of attacks
over the expected cluster cycle):
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Avoid alcohol during cycle
Verapamil
Steroids
Lithium
Depakote
Topiramate
Sinus Headache
Sinus Headache
 Migraine-associated symptoms are often misdiagnosed as
"sinus headache" by patients and clinicians. Most
headaches characterized as "sinus headaches" are migraines.
 The International Classifications of Headache Disorders
(ICHD-II) defines sinus headache by:
 Purulent nasal discharge
 Pathologic sinus finding by imaging
 Simultaneous onset of headache and sinusitis
 Headache localized to specific facial and cranial areas of the
sinuses
Chronic daily headache
• Headache more than 15 days per month for greater than
three months. Chronic daily headache is not a diagnosis
but a category that may be due to disorders representing
primary and secondary headaches.
• Secondary headaches are typically excluded with
appropriate neuroimaging and other tests.
• Chronic daily headache can be divided into:
– Those headaches that occur nearly daily that last four hours
or less and those that last more than four hours, which is
more common.
– The shorter-duration daily headache contains less-common
disorders such as chronic cluster headache and other
trigeminal autonomic cephalgias.
Hemicrania Continua
A. Headache for more than three months
fulfilling criteria B-D
B. All of the following characteristics:
– unilateral pain without side-shift
– daily and continuous, without pain-free periods
– moderate intensity, but with exacerbations of severe pain
C. At least one of the following autonomic features occurs during
exacerbations and ipsilateral to the side of pain:
– conjunctival injection and/or lacrimation
– nasal congestion and/or rhinorrhoea
– ptosis and/or miosis
D. Complete response to therapeutic doses of indomethacin
MIGRAINE HEADACHES
What are Migraines?
MIGRAINE HEADACHES
• Useful clinical criteria from the history and physical
examination for distinguishing migraine from tensiontype headache include nausea, photophobia (sensitivity
to light), and phonophobia (sensitivity to sound).
• Physical activity often exacerbates migraine headache.
• Combined findings useful for distinguishing migraine
can be summarized by the POUND mnemonic
(pulsatile quality, duration of four to 72 hours,
unilateral location, nausea or vomiting, and disabling
intensity). Patients who meet at least four of these
criteria are most likely to have a migraine.
Migraine with or without aura
A. Two or more of the following:
1. Unilateral location
2. Pulsating or throbbing quality
3. Moderate to severe intensity
4. Aggravated by routine activity
B. Plus 1 or both of the following:
1. Nausea/vomiting
2. Photophobia and phonophobia
C. Previous similar headaches
Aura criteria:
• One or more reversible aura symptoms
• One or more aura symptoms develop over more than 4 minutes, or two or
more symptoms occur in succession
• Symptoms do not last more than 60 minutes
• Headache follows within 60 minutes
MIGRAINE HEADACHES
• One study of 1,500 adults with migraine
headache found that the presence of
nausea alone, or the presence of two of
three features had positive likelihood
ratios for migraine of 4.8 or greater and
negative likelihood ratios of less than 0.23.
MIGRAINE HEADACHES
• Accurate categorization and characterization by both
clinicians and patients is important. The
categorization of migraine influences choice of
treatment method.
• Severity levels:
– Mild : Patient is aware of a headache but is able to
continue daily routine with minimal alteration.
– Moderate : The headache inhibits daily activities but is
not incapacitating.
– Severe : The headache is incapacitating.
– Status : A severe headache that has lasted more than 72
hours.
Factors That May Trigger Migraine
Environmental:
• Temperature (exposure to
heat/cold)
• Bright lights or glare
• Noise
• Head or neck injury
• Weather changes
• Motion
• Odors (smoke, perfume)
• Flying/high altitude
• Physical strain
Lifestyle Habits:
• Chronic high levels of stress
• Skipping meals and/or poor
diet
• Disturbed sleep patterns
• Smoking
Hormonal:
• Puberty
• Menopause
• Menstruation or ovulation
• Pregnancy
• Using oral contraceptives or
estrogen therapy
Emotional:
• Anxiety
• Depression
• Anger (including repressed
anger)
• Excitement or exhilaration
• "Let-down" response
Medications:
• Nitroglycerin
• Nifedipine
• Oral contraceptives
• Hormone therapy
Dietary Factors That May Trigger Migraine
• Dietary triggers vary considerably from patient to patient,
are overall a minor and infrequent trigger for migraine
headaches, and will not consistently precipitate a migraine
headache in an individual for whom they have been a trigger
in the past.
• Triggers:
– Citrus fruit
– Aspartame
– Caffeine
– Aged cheese
– Chocolate
– Alcohol (red wine, beer)
– Foods containing nitrites
– Foods containing monosodium glutamate
Migraine Treatment
 Mild migraine treatment
(self-management):
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APAP/ASA/Caffeine
ASA alone
Lidocaine nasal
Midrin
NSAIDs
Triptans
 Moderate migraine
treatment:
– DHE (dihydroergotamine
mesylate)
– Lidocaine nasal
– Midrin
– NSAIDs
– Triptans
 Severe migraine treatment:
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Prochlorperazine
Chlorpromazine
DHE
Ketorolac IM
Magnesium Sulfate IV
Triptans
 Adjunctive therapy for all
migraines:
– Rest in quiet, dark room
– IV rehydration
– Antiemetics:
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Hydroxyzine
Metoclopramide
Prochlorperazine
Promethazine
Caffeine
Status Migrainus (lasting > 72 hrs) treatment:
• Hydration: It is recommended that the
patient be hydrated prior to neuroleptic
administration.
• The patient should be observed in a
medical setting as clinically appropriate
after administration of a neuroleptic and
should not drive for 24 hours.
Status Migrainus (lasting > 72 hrs) treatment:
1.
DHE (dihydroergotamine mesylate) unless contraindicated.
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Must not be given within 24 hours of receiving any triptan or ergot
derivative.
Must not be used in patients with:
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If not DHE, then:
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3.
Pregnancy
History of ischemic heart disease
History of variant angina
Severe peripheral vascular disease
Cerebrovascular disease
Hemiplegic or basilar-type migraine
Onset of chest pain following DHE test dose
Chlorpromazine
Valproate sodium IV
Magnesium Sulfate IV
Prochlorperazine
If treatment unsuccessful:
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Opiates (not meperidine)
Dexamethasone