Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Headache

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Headache - Key Features

1. Given a patient with a new-onset headache, differentiate benign from serious pathology through history and physical examination.

2. Given a patient with worrisome headache suggestive of serious pathology (e.g., meningitis, tumour, temporal arteritis, subarachnoid bleed):
a) Do the appropriate work-up (e.g., biopsy, computed tomography [CT], lumbar puncture [LP], erythrocyte sedimentation rate).
b) Make the diagnosis.
c) Begin timely appropriate treatment (i.e., treat before a diagnosis of temporal arteritis or meningitis is confirmed).
d) Do not assume that relief of symptoms with treatment excludes serious pathology.

3. Given a patient with a history of chronic and/or relapsing headache (e.g., tension, migraine, cluster, narcotic-induced, medication-induced), treat appropriately, and avoid narcotic, barbiturate dependence.

4. In a patient with a history of suspected subarachnoid bleed and a negative CT scan, do a lumbar puncture.

5. In a patient suffering from acute migraine headache:
a) Treat the episode.
b) Assess the ongoing treatment plan. (referral when necessary, take a stepwise approach).

APPROACH TO PRIMARY HEADACHE DISORDERS

MIGRAINE
Classification: POUND pneumonic - 4/5 features has LR = 24 for migraine

• Pulsatile
• 4-72 hOurs
• Unilateral pain
• Nausea
• Disabling intensity

• *photophobia and phonophobia are also often present
• visual auras assʼd with migraine = bilateral, coloured, and tunnel-vision Sxs, other auras include: disequilibrium/vertigo (common cause of vertigo in younger popʼn)
Triggers: Emotional stress, Hormones therapy, Not eating, Weather, Sleep disturbances, Odors, Neck pain, Lights, Alcohol, Smoke, Heat, Food, Exercise, Sexual activity
Rx:

• Tylenol/NSAIDS 1st line
• 2nd line: Triptans - oral, SL, SC, intranasal preparations available, tend to work best if taken early to abort migraine, theoretically faster-acting preparations best
avoid in HTN/CVD
• Status Migranous/ER Presentation
• 1L bolus NS
• Maxeran 10mg or Stemetil 5-10mg in mini bag over 15 mins +/- benadryl or benztropine to prevent akathesia
• consider single dose Dexamethasone 10-15mg to prevent rebound headache


TENSION-TYPE HEADACHE (TTH)
Most common headache, but most common seen in office = migraine since most TTH is mild and doesnʼt present to clinic
Classification:

• infrequent episodic <1d/month
• frequent episodic 1-14d
• chronic TTH 15+ days/month

Rx:

• Tylenol/NSAIDS 1st line
• combos with caffeine more effective but SEʼs, risk of Medication overuse headache (see below)
• if pt responds to triptans, likely migraine component
• muscle relaxants have NO evidence and are NOT recommended


Table 1. International Classification of Headache Disorders II: Criteria for Diagnosis of Tension-type Headache and Migraine(1)

Criteria Tension-type Headache Migraine
Number of Episodes At least 10 episodes At least 5 previous attacks
Duration 40 minutes to 7 days 4 to 72 hours (may be shorter in children)
Pain Characteristics At least two of the following:

Pressing or tightening, non-pulsating quality
Mild-to-moderate intensity, but does not preclude activity
Bilateral
Not aggravated by routine physical activity

At least two of the following pain characteristics:

Pulsating
Moderate-to-severe intensity
Unilateral (may be bilateral in children)
Aggravated by routine physical activity, or causing avoidance of routine physical activity

Associated Features Both of the following:

No nausea or vomiting
No photophobia or phonophobia or only one of photophobia or phono phobia

At least one of the following:

Nausea and/or vomiting (often more prominent in children)
Photophobia and phonophobia

Underlying Conditions Not caused by another disorder. Not caused by another disorder

(copied from McMaster module on headaches)

migraine and TTH can co-exist! similar triggers for both

Other Rx/prevention for both TTH and Migraine:

• non-pharmachologic options:
• heat/ice, massage, rest, biofeedback, meditation, exercise (relieve stress)
• prevention:
• good evidence for TCAs (amitryptilline most studied, nortriptylline less SEʼs)
• start at 10mg qhs, titrate up (q1-2 wks) to therapeutic effect (max 100mg/day) or SEʼs


CLUSTER HEADACHE:
Criteria:

• At least 5 attacks with severe unilat Sxs orbital or temporal,15-180 min untreated, freq q2d - 8/d
• Accompanied by 1 of the following autonomic Sxs (conjunctival injection/lacrimation, rhinorrhea, eyelid edema, facial sweating, miosis or ptosis, sense of agitation)

Classification:

• episodic - 2+ cluster periods for 7d-1y with pain-free intervals > 1/12
• chronic - last > 1y without remission (or remission < 1 month)
• probably cluster headache - fulfills all but 1 of above criteria

Acute Rx = oxygen (non rebreather, 12L/min+, 15min duration) + sumatriptan SC or intranasal

• 2nd line agents - octreotide, lidocaine intranasal, ergots

Prevention: Verapamil start 240mg/day BID or TID depending on prep, titrate up by 80mg/d q 10-14d until desired prophylaxis

• use with onset of clusters or continuously (depends on freq of episodes), attempt to wean slowly
• 2nd line prevention = high dose prednisone 5 days min +/- taper
• Topiramate may be useful adjunct with verapamil

• limitations = COPD (O2), triptans cause non-ischemic chest pain and distal paresthesias, use caution in CAD

MEDICATION OVERUSE HEADACHE:
• co-exists with chronic daily headache
• Hx of prn use of analgesics for headache >2-3d/week for > 3 months
• all meds used to treat acute headaches have potential to cause this but some higher risk (in order):

• highest with opioids, butalbital-containing combos, aspirin/acetaminophen/caffeine combos
• intermed-high with triptans, tylenol
• lowest with NSAIDS

• often presents on awakening, only temporary relief with analgesics
Rx is discontinuation - withdrawal Sxs 2-10 days (avg 3.5), include withdrawal headache, N&V, hypotension, tachycardia, insomnia, anxiety

• NB: taper opioids/barbituates over 1 month, others can be abruptly stopped
• need to do this to accurately Dx headache condition and treat appropriately
Withdrawal prevention: may consider TCA or prednisone during acute med withdrawal


“Sinus Headache” - overdx, most likely Sxs of congestion, sinus pressure, etc DUE TO migraine!

SERIOUS CAUSES OF HEADACHE:
Lesions on CT Scan (pus, blood, tumour):

• Blood - SAH, subdural, stroke, cerebral venous thrombosis
• Pus - Meningitis, encephalitis
• Tumor - primary vs metastatic, benign vs. malignant

Non-Intracranial pathology:

• Cervical A dissection (carotid or vertebral)
• Hypertensive encephalopathy
• Pre-eclampsia/eclampsia
• Idiopathic intracranial hypertension
• Glaucoma

• Temporal Arteritis

• Meds/toxins (ie CO poisoning)


RED FLAGS: New headache at age >50, sudden onset/maximal at onset, trauma, fever, vision loss, severe neck pain, morning emesis, significant worsening freq/intensity, constitutional Sxs, focal neuro findings, etc

Study Guide

Headache

Resources

McMaster module on Headache