Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of...

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Headache for the PCP: Evaluation and Initial

Management

Chris Jackman, MDAssistant Professor of NeurologyChild Neurology of Riley HospitalDirector, Riley Headache Center

Objectives

• Identify a systemic evaluation of a headache patient

• Evaluate for causes of secondary headache

• Recognize how to diagnose common primary headache symptoms of childhood

• Identify how to treat primary headache syndromes

Initial Evaluation

1. Shoulder shrug and look to parents

2. “I don’t know”

3. “Headaches?”

It’s in the history

• Time course• Time course• Time course

• Pain description– Location– Severity – Quality

• Associated symptoms

Other questions:

• Pain description– Location– Severity – Quality

• Associated symptoms– Aura– Nausea, vomiting– Photophobia, phonophobia– Light-headedness, vertigo– Autonomic features

Red Flags

• Time course– Progressive– Morning

• Location– Posterior

• Postural• Focal neurologic

signs– Any

• Systemic signs– Fevers, rash

• Family history– As in, none

• Age– Under 6 years

Physical exam

• Eyes / Fundus

• TMJ

• Face

• Muscles

• Skin

• Neurologic

Secondary Headaches

Non-neurologic causes of secondary headaches

• Dental/ TMJ

• Allergies/ congestion

• Sinus inflammation/ infection

• Ear infection/ Mastoiditis

• Hypothyroidism

• Pheochromocytoma (Hypertension)

• Eye-strain

It is (probably) not a tumor

• Brain tumors are very rare• BUT…

– You only need to miss one to be incompetent

• The chance of finding a tumor in a patient with headaches and a normal neurological exam is…

It is not a tumor

• Very low, but not quite zero

• Brain tumors typically cause headache when they cause increased pressure

• A much more common presentation is focal neurologic signs with minor headache

It is a tumor

• Key features– Time course (Progressive)

– Timing (On awakening)

– Postural (Supine)

– Focal Neurologic signs

– Seizures

If it’s not a tumor, what is it?

Intracerbral Hemorrhage

• Features– Time course (Acute)– History of trauma– Focal Neurologic signs

• Types of hemorrhage– Subdural– Epidural– Subarachnoid– Paranchymal– Interventricular

Venous sinus thrombosis

• Associated with primary or secondary hypercoagulable state

• Present with signs of increased intracranial pressure

• Sometimes hemorrhage• Red Flags

– Time course (Progressive or static)

– Postural– Neurologic signs

• Papilledema• 6th nerve palsies

Ideopathic intracranial hypertension

• Mechanism unknown• More female, more obese• Headache with visual loss• Red Flags

– Time course (Progressive or static)– Postural– Neurologic signs

• Papilledema• 6th nerve palsies

Ideopathic intracranial hypotension

• Seen in some connective tissue diseases from dural ectasia (or ideopathic)

• Mimics LP headache

• Red Flags– Time course (Progressive or static)– Postural

Meningitis / Encephallitis

• Red flags:– Systemic signs (fever)– Focal Neurologic signs (meningismus,

encephalopathy, seizures)

Chiari I Malformation

• Protrusion of cerebellar tonsils below the foramen of Monro

• Red flags:– Location (posterior)– Postural, pain with

neck movements– Focal Neurologic signs

(ataxia)– Worse with cough,

sneezing, valsalva

Post-traumatic or Post-concussiveHeadache

• Red flags: See hemorrhage

• Will get better, may take months

• Cognitive changes are common, will also improve

Headache Evaluation

Do I order LABS?

Headaches in children younger than seven years of age

Chu ML, Shinnar S. Arch Neurol, 49:1992; 79-82

• Study of 104 children referred to Child Neurology

• Studies performed prior by the pediatrician• Studies included:

– Cell counts– Basic electrolytes– Tranaminases– Urinalysis

• “Uniformly unrevealing”• Similar prospective study in adults of 193

patients showed same results

Do I order a SCAN?

American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches

2002• Neuroimaging

– Combined 6 studies– 605 of 1275 had imaging (CT in 116, MRI in

483, both in 75)– 97 children with imaging abnormalities (16%)

• 79 considered incidental• 14 surgically treatable• 4 medically treatable

• Of the 14 surgical lesions:– 10 tumors– 3 symptomatic vascular malfomations– 1 significant arachnoid cyst

• All had an abnormal neurologic examination– Papilledema– Abnormal eye movements– Motor dysfunction– Gait dysfunction

– Parameters which distinguish headache patients with space occupying lesions

• Headache of less than one month duration• Absence of a family history of migraine• Abnormal neurological examination• Gait abnormalities• Seizures

– Those patients with headaches for less than 6 months and at least one of the above symptoms are considered “high-risk”

• “High-risk” = 4% chance of space occupying lesion

CT vs. MRI?

Primary Headache Disorders

Migraine Diagnosis and Treatment: Results From the American Migraine Study II

Headache 2001;41:638-645

• Survey mailed to 20,000 homes, identified 3577 individuals who met criteria for migraine

• 48% had previously received a physician diagnosis

• 24% of those undiagnosed had missed at least one day of work or school in the previous three months

• Those missed were:– Lower income– Younger age (18-29)– Male

Migraine epidemiology

• Headache prevalence– Tension type HA 78%– Migraine 16%– Children

• 3-8% by age 3• 37-52% by age 7• 57-82% in 7-15 year olds

• Peak incidence– Women – age 12-13 (aura), 14-17 (without)– Men – age 5 (aura), 10-11 (without)

Comprehensive Review of Headache Medicine; Levin M Ed; Oxford 2008

“If nothing is wrong with me, doctor, why do I have these headaches?”

Migraine pathophysiology

• Primarily a NEUROGENIC process

• We think

• For now

• Aura– Cortical spreading depression– Front of profound depolarization– Moves across cortex ~ 3mm/min– Following by suppression of neural activity

lasting minutes

A.P. Leão.

Cortical Spreading Depression

Migraine without aura Pediatric diagnostic criteria

• At least five attacks fulfilling criteria B-D (below)• Headache attacks lasting 1 to 72 h• Headache having at least two of the following characteristics:

– Unilateral location, may be bilateral, frontotemporal (not occipital)

– Pulsing quality– Moderate or severe pain intensity– Aggravation by or causing avoidance of routine physical

activity (eg, walking, climbing stairs)• During the headache, at least one of the following:

– Nausea or vomiting– Photophobia and phonophobia, which may be inferred

from behavior• Not attributed to another disorder

Migraine with aura Pediatric diagnostic criteria

• At least two attacks fulfilling the criteria B-D (below)• Aura consisting of at least one of the following, but no

motor weakness: – Fully reversible visual symptoms, including positive features or

negative features (e.g., flickering lights, spots, or lines)– Fully reversible sensory symptoms, including positive features

(i.e., pins and needles) or negative features (ie, numbness)– Fully reversible dysphasic speech disturbances

• At least two of the following: – Homonymous visual symptoms or unilateral sensory

symptoms– At least one aura symptom develops gradually over 5 min or

different aura symptoms occur in succession over 5 min– Each symptom lasts between 5 min and 60 min

• Not attributable to another disorder

And…

…Chronic Daily Headache…

Chronic Daily Headache

• Transformed (or chronic) migraine– History of migraine– Progresses to chronic, low level headache

with periodic migraines

• Chronic tension type headache– Lack significant migranous features– Less severe intensity– Tightening more than pulsating

• New daily persistent headache

Chronic daily headaches - evaluation

• Look for red flags*

• Ask about analgesic overuse

* Especially in New Daily Persistent Headache

Practice Parameter: Pharmacological

treatment of migraine headache in children and adolescents

D. Lewis, MD; S. Ashwal, MD; A. Hershey, MD; D. Hirtz, MD; M. Yonker,

MD; and S. Silberstein, MDNEUROLOGY 2004; 63: 2215–2224

Migraine treatment - Abortive

• Ibuprofen, acetaminophen, ketorolac, indomethacin, ASA

• Combinations (Acetaminophen/ASA/caffeine)• Antiemetics (promethazine, chlorpromethazine• Opiates, barbituates (no, no, never…)• Corticosteroids• Triptans

– 5HT1b, 1d, and 1f agonists– Contraindications include cardiovascular disease or risk

factors, Reynaud’s, hemiplegic migraine– Side effects include nausea, dizziness, chest and throat

tightness

Migraine treatment - Abortive

Migraine treatment - Prophylactic

• When to use prophylaxis– Headaches frequent

– Headaches severe

– Headaches disruptive

• Side effects and burden of taking a daily medicine < the life disruption caused by (appropriately treated) headaches

• Antihistamines• Beta-blockers• Tricyclics• Anticonvulsants• Calcium channel blockers

• Antihistamines– Cyproheptadine

• Little studied, often used• Reduce headaches from 8.4 to 3.7 per month• Somnolence, weight gain• Initial dose 1-2 mg QHS, max 4 mg BID

Lewis D, Diamond S, Scott D, et al. Prophylactic treatment of pediatricmigraine. Headache 2004;44:230–237.

• Beta-blockers– Propranolol most studied

– Three small, prospective class II studies with conflicting results

– Exercise intolerance

– Contraindicated in asthma, depression

– Initial dose 20 mg, up to 160 mg

• Tricyclics– Amitriptyline most studied

– Anticholinergic effects, somnolence

– Black box warning re: suicidality

– Baseline EKG and monitor for QT prolongation

– Initial dose 10 mg up to 100 mg

– Give at dinner

• Anticonvulsants– Topiramate (or zonisamide)

• Best studied

– Valproate• Effective but side effects can be significant

– Levetiracetam/ Lamotrigine• Limited (poor) data

• Calcium channel blockers– Conflicting data

– Familial hemiplegic migraine

– Abdominal discomfort

– Monitor EKG and blood pressure

Chronic Daily Headache - Treatment

• Preventative medications – – Evidence is spotty at best

• Topiramate is best studied, anecdotally all migraine medications may work

– Transformed migraine or for medication overuse – early prophylactic treatment

– Chronic tension type headache – late medical treatment

– New daily persistent headache – doesn’t matter

Non-pharmacologic Treatment

• Lifestyle! Lifestyle! Lifestyle!– Analgesic overuse– Sleep– Diet– Psychiatric

• Analgesic overuse– Opiotes/ barbiturates > triptans

>>NSAIDS– Any used over 15 days/month, some

over 10 days/month– Can treat by a period of elimination or

by moderation– Headaches may take 4-6 weeks to

improve

• Sleep– Snoring– Movements– Quality– Quantity– Continuity

• Diet– Meats (Iron, B12)– Vegetables (Folate?)– Skipping meals– Hydration– Caffeine

• Psychiatric evaluation– Anxiety– Depression– Obsessive-compulsive disorder

• Non-pharmocologic management– Biofeedback– Self-hypnosis– Relaxation

Take home points:

• Red flags– Progressive time course– Postural– Worse in the morning– Any neurologic sign or symptom– Worse with valsalva

• Practice your fundoscopic and cranial nerve exam

Closing thoughts…

• Watch for red flags• Know when to image• If unsure whether to image, refer• Know helpful lifestyle modifications• Know when to start or refer for prophylactic

medications

• Remember: “Your patient does not want to have a headache”

References• Sargent JD, Solbach P. Medical evaluation of migraineurs: review of the value of

laboratory and radiologic tests; Headache 1983; 23:62-65• Chu ML, Shinnar S. Headaches in children younger than seven years of age

Arch Neurol, 49; 1992; pp79-82• Maytal J, Robert S. Bienkowski, Patel M and Eviatar L. The Value of Brain Imaging in

Children With Headaches. Pediatrics 1995;96;413-416• Levin M Ed; Comprehensive Review of Headache Medicine: Oxford 2008• Lewis D, Ashwal, S; Hershey A; Hirtz D; Yonker, M; and Silberstein S, Practice

Parameter: Pharmacological Treatment of migraine headache in children and adolescents. Neurology 2004;63:2215–2224

• Ludvigsson J. Propranolol used in prophylaxis of migraine in children. Acta Neurol 1974;50:109–115.

• Forsythe WI, Gillies D, Sills MA. Propranolol (Inderal) in the treatment of childhood migraine. Dev Med Child Neurol 1984;26:737–741.

• Olness K, MacDonald JT, Uden DL. Comparison of self-hypnosis and propranolol in the treatment of juvenile classic migraine. Pediatrics 1987;79:593–597.

• D.W. Lewis, MD; S. Ashwal, MD; G. Dahl, BS; D. Dorbad, MD; D. Hirtz. Practice parameter: Evaluation of children and adolescents with recurrent headaches: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002;59:490–498

Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of...

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