POM II - Headaches - Exam 2

Headache

-very common complaint

-new, severe, or acute HA are more likely than chronic HA to relate to an intracranial d/o

-chronic HA may be primary or secondary to another d/o

Primary HA Syndromes

-Migraine

-Tension-type HA

-cluster HA

Secondary HA Causes

-intracranial lesions

-head injury

-cervical spondylosis

-dental or ocular disease

-TMJ dysfunction

-sinusitis

-HTN

-depression

-wide variety of general medical d/o

HA warning signs

-a progressive HA disorder

-new onset of HA in middle or later life

-HA that disturb sleep or are related to exertion

-HA that are associated with neurologic symptoms or a focal neurologic deficit

MRI or CT

HA with warning signs require cranial ________ or ________ to exclude an intracranial mass lesion

HA - Hx

-quality, site, and radiation of pain

-nature of pain -- throbbing, dull, aching, burning

-severity -- disabling, variable

-age at onset

-nature of onset -- thunderclap or gradual, timing

-frequency, duration, intensity

-exacerbating/relieving factors

-family hx

-relationship to food, ETOH, or prev tx

-number of HA and number of tx per month

-review of all current meds

-change in vision, recent or with HA

-recent trauma

HA - Important Hx

-presence of aura or prodrome

-recent changes in sleep, exercise, weight, diet

-change in work or lifestyle

-non-prescribed drugs

-associated with environmental factors

-women: change in birth control method, relation to menses or exogenous hormones

HA - Examination

-vital signs

-listen for bruits --> neck, eyes, head

-palpation --> head, neck, shoulders

-temporal and neck arteries

-spine and neck muscles

-fundoscopy and otoscopy

-oral and jaw exam

HA - neuro exam

-CN II-XII

-mental status

-strength

-sensation, including allodynia

-cerebellar tests

-gait

Red Flags - be SNOOPPPy

-Systemic Features - fever, weight loss, symptoms in other systems

-Neuro deficits

-Onset that is new (esp > 50) or sudden

-Other features: precipitated by cough or sex; nighttime awakening, recent head trauma, toxic exposure, neck stiffness, eye pain

-Progression or unexplained change in Pattern or Papilledema

Migraine - pathophys

probably relates to neuronal dysfunction in the trigeminal system = release of vasoactive neuropeptides such as calcitonin gene-related peptide leading to neurogenic inflammation, sensitization, headache

Migraine - Dx

-at least 5 attacks

-duration: 4-72 hours (untreated or inadequately treated)

-at least 2 of: unilateral location, pulsating/throbbing quality, mod or severe intensity, aggravation by or avoidance of usual daily activities

-associated symptoms: at least one of N/V, photophobia, phonophobia

Migraine Aura

Two attacks that have:

-1 or more fully reversible visual, sensory, speech or language, motor, retinal, or brainstem symptoms

-at least 3 of: one sxs spreads gradually >5 min, 2 or more sx in succession, lasts 5-60 min, unilateral, positive, followed by HA

Basilar Artery Migraine

-an uncommon migraine variant in which blindness or visual disturbances throughout both visual fields are accompanied or followed by: dysarthria, disequilibrium, tinnitus, and perioral and distal paresthesias

-sometimes followed by transient loss or impairment of consciousness or by confusional state

-followed by a throbbing HA, often with N/V

Mild Migraine Tx

NSAIDs with or without anti-emetics

Moderate or Severe Migraine Tx

-triptans, with or without NSAIDs

-antiemetics (metoclopramide is best studied)

Migraines - Other Tx

-dihydroergotamine, butalbital combo, haloperidol, dexamethasone, opioids

-transcranial magnetic stimulation

-acupuncture

-caffeine

Migraine Prophylaxis

-antihypertensives: metoprolol, propranolol, timolol

-Antidepressants: amitriptyline

-Anticonvulsants: valproate, topiramate

-Gabapentin is probably NOT effective

-Other: MABs, botox, butterbur, manual therapy, acupuncture, magnesium, NSAIDs, riboflavin, TMS

Cluster HA

-at least 5 attacks of unilateral severe orbital, supraorbital, or temporal pain

-Either: autonomic symptoms ipsilateral to pain, agitation or restlessness

-frequency between one every day and eight per day

Cluster HA - Autonomic Sx

-ipsilateral to pain

-conjunctival injection and/or lacrimation

-nasal congestion and/or rhinorrhea

-eyelid edema

-forehead and facial sweating

-miosis and/or ptosis

Cluster HA - Other Characteristics

-Episodic (most common) --> bouts lasting from 7 days to 1 year and separated by pain-free remissions of 3 months or more

-chronic -- without remissions

-male predominance

-exposure to tobacco smoke is a RF (but quitting doesn't help)

Cluster HA - Acute Tx

-oxygen

-triptans (subq or intranasal)

-intranasal lidocaine, ergotamine, octreotide

-ergotamine

-not particularly responsive to indomethacin

Cluster HA - Prevention

-verapamil

-glucocorticoids, lithium, topiramate

-greater occipital nerve blocks

Tension-Type HA - Dx

-at least two of: B/L location, pressing or tightening, mild-moderate, not aggravated by physical activity

-both of: no nausea and vomiting, no more than one of photophobia or phonophobia

Infrequent Episodic Tension HA

<1 day per month on average

Frequent Episodic Tension HA

1-14 days per month on avg

Chronic Episodic Tension HA

>= 15 days per month on average for more than 3 months

Episodic Tension HA - Pathophys

-peripheral activation or sensitization of myofascial nociceptors

-increased muscle tenderness, increased trigger points

-normal central pain processing

Chronic tension HA - Pathophys

-sensitive pain pathways in the CNS

-reduction in diffuse noxious inhibitory control

Acute Tension HA - Tx

-ibuprofen, naproxen, aspirin

-acetaminophen (1000 mg) - may be less effective

-alternatives with higher risk: combo products with caffeine, butalbital combo, opioid combo

Chronic Tension HA - Tx

-amitriptyline, nortriptyline

-everything else has very limited evidence

Giant Cell Arteritis

-most common systemic vasculitis in the US

-Sx: jaw claudication, amaurosis fugax, HA, fever, weight loss, fatigue, polymyalgia rheumatica

-Labs: elevated ESR and CRP, normochromic anemia, reactive thrombocytosis, hepatic enzyme elevation, reduced albumin

aortic branches

most symptoms of Giant Cell Arteritis arise form vasculitis in the cranial branches of the _____________. (temporal artery, external carotid branches, posterior ciliary artery)

GCA - Tx

-high dose steroids, start at 60 mg daily; increase if needed to resolve sx

-then taper

Medication Overuse HA - Dx

-Headache >= 15 days per month in patient with pre-existing HA disorder

-more than three months one of the following:

-regular intake >= 10 days per month of ergotamines, triptans, opioids, or combo analgesics

-regular intake for >= 15 days per month of simple analgesics

Med Overuse HA - Mechanisms

-genetic predisposition

-central sensitization of trigeminal pain processing

-biobehavioral factors: rarely occur in patients taking analgesics for arthritis

Sinus HA

-more common in children than adults, can occur at any age

-dull, aching HA

-can be severe and confused with migraines

-acute, lasts 1 day to 3 weeks

-fever in 50%

-worse in AM

Sinus HA - S/S

-pain over sinuses

-tenderness of sinuses on palpation

-nasal congestion

-purulent discharge

-intensifies with leaning forward

CT scan of sinuses

what is the best imaging to dx sinus HA?

Subarachnoid Hemorrhage - Incidence

-32,500 cases of nontraumatic per year

-18,000 result in death per year

-80% d/t ruptured intracranial aneurysms

-5% d/t rupture of atriovenous malformation

-15% arteriogram does not show source of bleeding

Aneurysmal SAH

-thunderclap HA --> severe, maximal at onset

-neck and intrascapular pain, photophobia

-20% have minimal or mild HA, gradually worsening

-HA worsened by movement

-75% have meningismus

Subarachnoid hemorrhage

-"worst headache of my life"

-result of ruptured aneurysm or AVM

-approx 25% of patients die within 24 hours even if treated

-focal neuro deficits in 25%

Subarachnoid hemorrhage - s/s

-acute, severe, continuous, generalized HA

-associated with N/V and meningismus

-may have LOC

-12% report feeling a "burst"

-onset: instantaneous 50%, 2-60 sec 24%, 1-5 min 19%

Spontaneous Int. Carotid A Dissection

-pain in face, head, or neck, followed by retinal or brain stroke within hours to days; most common in anterior neck, frontal, or parietal area

-may be thunderclap or insidious

-Horner's Syndrome in about half of pts

-CN palsies (IX-XII) in 12%, pulsatile tinnitus in 10%

-TIAs or strokes of retina and brain develop in 50-95% of patients

CNS Mass lesion

-1/3 have HA as early symptom

-localized to side of lesion

-intensity and quality varies

-HA remains in the same location, but is progressive

-as ICP elevates, it may intensify with lying down, straining, valsalva

-may later become diffuse HA

Bacterial meningitis

-classically presents with fever, HA, meningismus, pain with eye movement, and AMS

-occurs more often in the winter

-median age is 25 y/o

-most common cause is pneumococcus

-HA is generalized, severe, and unremitting; may be thunderclap

-N/V + photophobia + myalgias are common

-kernig's + brudzinski's in 50%, CN findings in <20%

Viral Meningitis

-usually occurs in the summer months

-typically in children and young adults

-mc organisms are enteroviruses, mumps, and arboviruses

-severe, sudden onset HA

-fever, malaise, anorexia, pain with eye movement, photophobia, phonophobia, and nuchal rigidity

Encephalitis

-occurs mostly in summer and early fall

-may be caused by numerous viruses: mumps, arboviruses, enteroviruses, herpes, EBV, influenza, measles, varicella zoster, mycoplasma, and west nile

-may have fever, altered consciousness, meningeal signs, focal neural deficits, seizures

-may have thunderclap HA, flu-like illness, photophobia, drowsiness, coma, lethargic

Idiopathic intracranial HTN

-pseudotumor cerebri

-young, obese women predominate

-HA, papilledema, visual loss; few cases without papilledema

-CSF pressure >20 cm H2O

-normal CSF formula

-may be due to intracranial sinus thrombosis, esp PP women

-rarely d/t hypervitaminosis A

HA - post LP

-starts after procedure, may be d/t other leaks

-positional: decreases with lying down, increases with sitting/standing

-small leak of CSF

-reduce risk by having patient remain flat 3 hr after procedure

-treated with epidural blood patch, caffeine infusion