Headaches

  1. Signs and Symptoms
  2. Migraine
  3. Premonitory symptoms (50-80% of patients)
  4. Variety of warnings that precede a migraine and are subjective for the patient
  5. Most commonly these are mood disruptions (agitation, emotional)
  6. Fully reversible “classic” aura- focal disruption of neurological function which begins and ends prior to onset
  7. Visual field defects
  8. Geometric patterns in field of vision
  9. Bitemporal hemianopsia
  10. Headache typically begins within 1 hour of aura resolution and lasts 4- 72 hours
  11. Recurring variable frequency
  12. Symptoms abate completely between attacks
  13. Gradual onset but progressively worsening
  14. Throbbing or pulsating
  15. Usually unilateral
  16. Associated symptoms
  17. Photophobia, Phonophobia, nausea, vomiting, diarrhea myalgias, light headedness, dizziness
  18. Headache terminates untreated
  19. “Postdrome” other manifestations linger after pain resolves: food intolerance, impaired concentration, fatigue, muscle soreness
  20. Tension
  21. Most common recurrent pain syndrome
  22. Episodic- usually associated with stressful event, is of moderate intensity and self-resolves
  23. Less than 15 per month
  24. Chronic- recurs daily, bilateral location, associated with contraction of neck and scalp muscles
  25. More than 15 per month
  26. Bilateral band-like quality of pain with moderate intensity
  27. May say pressing pain but not pulsatile
  28. Normal neurological examination
  29. Furrowed brow, tense masseter muscles
  30. Insomnia, teeth grinding, difficulty concentrating, not aggravated by physical activity
  31. 4-13 hour duration
  32. Cluster
  33. Recurring headaches (many over 24 hours)
  34. Most common recurring headache
  35. Sudden attacks of severe unilateral headaches localized to the periorbital and temporal area associated with ipsilateral lacrimation, miosis, conjunctiva injection, rhinorrhea, ptosis
  36. Piercing, penetrating, stabbing, exploding quality of pain
  37. Miosis, anhidrosis, ptosis = Horner’s syndrome
  38. 45- 60 minute duration
  39. Absence of aura (differentiates from migraine)
  40. Possibly Life-Threatening
  41. New onset- very young or old
  42. Severe headache or “worst headache of my life”
  43. Subarachnoid hemorrhage
  44. Abnormal vital signs, fever
  45. Diastolic BP >130mmHg
  46. Hypertensive headache
  47. Meningeal symptoms
  48. Focal neurological deficits
  49. Stroke
  50. Altered mental status with headache
  51. Variants of Migraine headache include:
  52. Transformed migraine- chronic headache pattern evolving from episodic migraine; migraine-like attacks are superimposed on a daily or near-daily headache patter (tension headache)
  53. Basilar migraine- Occipital headache with aura symptoms of dysarthria, vertigo, tinnitus, ataxia, and bilateral paresis or bilateral paresthesias, bilateral visual changes*****************************************
  54. Hemiplegic migraine- where the aura consists of hemiplegia or hemiparesis
  55. Ophthalmoplegic- palsy of the ipsilateral third cranial nerve during the headache phase
  56. Ptosis and midriasis
  57. Retinal- symptoms of retinal vascular involvement during headache
  58. Status Migranosus-Persistent migraine that does not resolve spontaneously
  59. Migrainosus stroke-Persistent or permanent neurological deficits that persist beyond the migraine attack
  60. Presents with neuroimaging findings
  61. Ischemic brain picture
  62. Chronic migraine- migraine-like headaches greater than 15 days a month for greater than 6 months
  63. Etiology
  64. Migraine
  65. In children more common in men, in adults more common in women
  66. Genetically linked neuronal disease with vascular disruption as phenomenon of underlying neurochemical disruption (serotonin, dopamine, Norepinephrine abnormalities play a role)
  67. Low serotonin brains are more pain sensitive
  68. Neurogenic inflammation and regional disruption of cerebral and/or extracranial blood flow
  69. Triggered by stress, hormonal change, menstrual cycle, lack of sleep, certain foods, alcohol, missing meals, fatigue
  70. Chocolate, red wine, cheese, coffee, artificial sweeteners
  71. Intra or extra cranial vasodilation which affects pain sensitive blood vessels
  72. Vasoconstriction is ischemia, vasodilation causes edema, inflammation, and pain
  73. Tension
  74. More common in females
  75. Muscle contraction headache where you get sustained contraction of head and neck
  76. Triggered by poor posture, stress, anxiety, depression, cervical osteoarthritis, intramuscular vasoconstriction, serotonin imbalance and decreased endorphins
  77. Cluster
  78. More common in adult male smokers
  79. Cause unknown; may be related to disruption of circadian rhythm, auto-regulation of cerebral arteries, serotonin CNS metabolism/transmission, histamine concentrations
  80. Triggered by: altered sleep patterns, strong emotions, alcohol, food
  81. Intracranial
  82. These mass lesions stretch or compress arteries or other pain sensitive structures
  83. Pathology from an extracranial site causing pain in a peripheral nerve of the head and neck
  84. Generally through traction, tension, or inflammation of the pain-sensitive structures; the vasculature, meninges, and cranial nerves V, IX, and X
  85. Diagnosis- in terms of detailed history and CNS examination
  86. Workup is strongly dependent on the clinical differential diagnosis
  87. ESR- If temporal arteritis is suspected
  88. Tests appropriate for patient’s underlying medical condition (e.g. ABG, glucose)
  89. Tests appropriate for physical examination abnormalities
  90. Head CT scan- signs of increased ICP, worst or first headache, acute onset, focal neurological abnormalities, papilledema, recurrent morning headache, persistent vomiting, concurrent fever or rash, head trauma with loss of consciousness, altered mental status, meningismus
  91. 90% sensitive for a subarachnoid hemorrhage that is less than 24 hours old
  92. Lumbar puncture- for intracranial infections (meningitis) or to detect blood not evident on the CT scan
  93. Sinus imaging-when sinus infection is suspected, use Water’s view
  94. MRI- suspected posterior fossa lesion (not well imaged on CT scan)
  95. Differential Diagnosis of Headache
  96. Hypertensive headache:throbbing occipital headaches with diastolic BP greater than 130mmHg
  97. Hypoxia-induced headache: carbon monoxide toxicity, sleep apnea, anemia
  98. AMS and agitation
  99. Subarachnoid hemorrhage:Worst headache of their life
  100. Nausea, vomiting, causes meningismus
  101. Aneurysm/AVM: sudden onset, unilateral, severe, decreased vision
  102. Meningitis/encephalitis:Meningeal signs, photophobia, fever, generalized neurological findings (not focal)
  103. Acute subdural hematoma: mental status, depression, or focal findings
  104. Venous bleed
  105. Chronic subdural hematoma: hemiparesis, focal seizures
  106. Slow leak over 1-2 weeks
  107. Epidural hematoma:Patients have trauma which shears arteries
  108. Patient will lose consciousness after major trauma
  109. Classic presentation is trauma, brief loss of consciousness, lucid interval, rapid progression of neurological symptoms
  110. Brain tumor: pain on awakening, progressively worsens, worse with valsalva, ataxia, increased ICP
  111. Headache, vomiting, and papilledema
  112. May have new onset seizure with no past history
  113. Brain abscess: fever, nausea/vomiting, seizures
  114. Can be caused by meningitis, penetrating trauma, ear/throat/sinus infections, hematologic spread
  115. Pseudotumor cerebri: young obese female, irregular menses, papilledema, increased intracranial pressure (no mass lesion)
  116. Otherwise everything is normal
  117. Treat with diuretic, decreased salt, weight loss
  118. Trigeminal neuralgia:Transient, sharp, lancing pain along the trigeminal nerve
  119. Usually unilateral
  120. Treat with carbamazepine
  121. Temporal arteritis: elderly, severe, scalp artery pain/swelling; swollen temporal area with pain on palpation
  122. Associated with polymyalgia rheumatica
  123. Diagnosed with ESR and biopsy (giant cells)
  124. Treatment is high dose steroids which is given immediately to prevent blindness
  125. Sinusitis: stabbing/aching, worse with bending or coughing, purulent nasal discharge, tenderness to palpation and percussion
  126. Treatment is amoxicillin
  127. Metabolic: fever, hypoglycemia, high altitude, acute anemia
  128. Acute glaucoma:headache, nausea, vomiting, eye pain, mid-dilated pupil with steamy cornea, conjunctival injection, IOC greater than 21mmHg
  129. Patient usually in dark area then steps into light
  130. Cervical: spondylosis, trauma, arthritis
  131. Temporomandibular joint syndrome: Temporal headache, ear pain, with crepitus on palpation
  132. Treatment
  133. Migraine
  134. Abortive therapy:Treats vasodilation, decreasing pain, and decreasing inflammation, take as soon as you realize you’re having the headache
  135. 5-HT-1- receptor agonists (Triptan Class)
  136. Ergotamine
  137. Drug of choice in status migranosus
  138. NSAIDS and/or narcotics
  139. Supportive- dark quiet room and withdrawal from stressful surroundings, sleep, compression to ipsilateral temporal artery or tender areas of scalp or neck, cold compress
  140. Prophylactic measures- Beta blockers, calcium blockers
  141. Prevent initial vasoconstriction
  142. Tension
  143. Acute attack: NSAIDS- naproxen, ibuprofen (rarely use narcotics)
  144. Prophylaxis: anti-depressants- amitriptyline, nortriptyline, imipramine
  145. Supportive- relaxation routine, rest, massage, and heat packs
  146. Cluster- prophylactic therapy is paramount
  147. Acute attack- oxygen 100% at 7-10L for 10-15 minutes, Sumatriptan, ergot medications
  148. Prophylaxis- Verapimil, lithium, ergot medications, steroids