Headaches Melitza Cobham-Browne MD Clinical Professor of Pediatrics University of California, Irvine
Transcript
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Melitza Cobham-Browne MD Clinical Professor of Pediatrics
University of California, Irvine
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Objective Identify key history features and physical exam
features to help asses a patient with headaches Identify Red flags
that are suggestive of a more serious underlying condition Review
indications for imaging
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Question Comorbid means... a) Existing simultaneously with and
usually independently of another medical condition. b) A situation
where two patients die at the same time of the same condition. c)
Having two potentially fatal conditions. d) Being made more ill by
a minor illness than a potentially fatal one
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Question Photophobia is... a) abnormal fear of being
photographed. b) abnormal fear of bright lights. c) abnormal
sensitivity sound. d) abnormal sensitivity to light
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Characteristics of Pain Location Quality Severity Timing
Setting in which it occurs Remitting or exacerbating factors
Associated symptoms
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Headaches Common symptom in clinical practice Prevalence of 30%
in the General Population Tension headache most common 40% Migraine
Headache is second most common 10% Cluster Headaches 1%
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International Headache Society Classification Primary Headaches
Tension Migraine Cluster Secondary Headaches Head and Neck trauma
Cranial or cervical vascular pathology Substance use or withdrawal
Infection Disorder of homeostasis Psychiatric disorders Pathologies
of face
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Brief Headache Screen How often do you get severe headaches
(i.e. without treatment it is difficult to function)? How often do
you get other (milder) headaches? How often do you take headache
relievers or pain pills? Has there been any recent change in your
headaches?
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Low Risk No substantial change in their typical headache
pattern No new concerning historical features (i.e. seizure,
trauma, fever) No focal neurologic symptoms or abnormal neurologic
examination findings No high-risk comorbidity
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Red Flags Recent onset (less than 6 months) Onset after 50
years Acute Onset like a thunderclap or the worst headache of my
life Markedly elevated Blood pressure Presence of rash or signs of
infections Presence of Cancer, HIV or pregnancy Vomiting Head
trauma Persistent neurologic deficits
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History Age of onset Presence or absence of aura and prodrome
Frequency, intensity, and duration of attack Number of headache
days per month Time and mode of onset Quality, site, and radiation
of pain Precipitating and relieving factors Effect of activity on
pain Relationship with food/alcohol Response to any previous
treatment
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History Any recent change in vision Association with recent
trauma Any recent changes in sleep, exercise, weight, or diet
Change in method of birth control (women) Possible association with
environmental factors Effects of menstrual cycle and exogenous
hormones (women)
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History State of general health Change in work or lifestyle
(disability) Family history (migraine, SAH, aneurism) Medications:
anticoagulants, glucocorticoids, and analgesics Comorbidities-liver
disease or clotting disorders may predispose patients to
intracranial bleeding, while hypercoagable states may increase the
risk of stroke or cerebral venous thrombosis
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Danger signs on History Sudden onset of headache, or severe
persistent headache that reaches maximal intensity within a few
seconds or minutes after the onset of pain SAH Carotid and
vertebral artery dissection Venous sinus thrombosis Pituitary
apoplexy Acute angle-closure glaucoma Hypertensive emergencies
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Danger signs on History The absence of similar headaches in the
past, the "first" or "worst" headache of my life Intracranial
hemorrhage Central nervous system infection. Headache with exertion
Carotid artery dissection Intracranial Hemorrhage Illicit
drugs-cocaine, methamphetamine
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Danger signs on History A worsening pattern of headache Focal
neurologic symptoms other than typical visual or sensory aura Fever
associated with headache Any change in mental status, personality,
or fluctuation in the level of consciousness New headache type in a
patient with cancer, HIV
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Danger signs on History New headache in patients under the age
of 5 or over the age of 50 Intracranial mass lesion Temporal
arteritis Head pain that spreads into the lower neck and between
the shoulders may indicate meningeal irritation
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Physical exam Obtain blood pressure and pulse Listen for bruit
at neck, and head for clinical signs of arteriovenous malformation
Check temporal and neck arteries Examine the spine and neck muscles
Palpate the head, neck, and shoulder regions
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Physical Exam Complete Neurological exam getting up from seated
position walking on tiptoes and heels Romberg Motor Sensory, reflex
Coordination (cerebellar Fundoscopic exam Testing of Visual Fields
Testing of visual acuity
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Danger signs of Examination Neck stiffness and especially
meningismus Papilledema suggests the presence of an intracranial
mass lesion, benign intracranial hypertension Focal neurologic
signs suggest an intracranial mass lesion, arteriovenous
malformation, or collagen vascular disease Altered level of
consciousness
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Abnormal Neurological Signs Slight pupillary asymmetry
Unilateral pronator drift or extensor plantar response Unilateral
vision loss Ataxia seizure Retinal or subhyaloid hemorrhage can
result from SAH. Decline or loss of vision- temporal arteritis or
carotid artery dissection, or increased intraocular pressure in
acute narrow angle glaucoma (ANAG). Ciliary flush and sluggish
pupillary light response can also occur with ANAG.
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Indications for Imaging Neuroimaging should be considered in
patients with non acute headache and an unexplained abnormal
finding on neurologic examination. Evidence is insufficient to make
specific recommendations in the presence or absence of neurologic
symptoms Recent significant change in the pattern, frequency, or
severity of headaches Progressive worsening of headache despite
appropriate therapy Focal neurologic signs or symptoms
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Indication for Imaging Onset of headache with exertion, cough,
or sexual activity Orbital bruit Onset of headache after age 40
years A head CT scan (without and with contrast) is likely to be
sufficient in most patients MRI along with magnetic resonance
angiogram (MRA) are indicated when posterior fossa or vascular
lesions are suspected.
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Indication for LP Lumbar puncture (LP) for cerebrospinal fluid
analysis is urgently indicated in patients with headache when there
is clinical suspicion of subarachnoid hemorrhage in the setting of
a negative or normal head CT scan. LP is indicated when there is
clinical suspicion of an infectious or inflammatory etiology of
headache
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Primary Headache- No identifiable cause Secondary Headache
Cranial Neuralgias
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Migraine Headache With or without aura Primary neuronal
dysfunction, possibly of brainstem origin, causing imbalance of
excitatory and inhibitory neurotransmitters and affecting cranio
vascular modulation
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Migraine Headaches Unilateral in 70%, bifrontal or global in
30% Throbbing or aching variable severity Rapid onset reaching a
peak in 1-2 hours Last 4-72 hours Peak incidence 30-39 years
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Migraine Headache 17% of women and 6% men Recurrent monthly,
but weekly in 10% Associated symptoms: nausea, vomiting,
photophobia, visual aura flickering, motor auras sensory auras
Aggravated by: alcohol, certain foods, tension, PMS, noise and
bright light Improves with quiet, dark rooms, sleep, sometimes
transient relief from pressure on the involved artery
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Migraine with aura Migraine with brainstem aura (MBA),
previously called basilar-type migraine Positive family history
Attacks of aura lasting 2 to 45 minutes Unilateral or bilateral
hemianopic visual disturbance, vertigo, ataxia, dysarthria,
bilateral tingling, or numbness The aura was typically followed by
a throbbing occipital headache and nausea. Loss of consciousness
lasting 2 to 30 minutes
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Migraine without aura Headache attacks lasting 4 to 72 hours
Unilateral location Pulsating quality Moderate or severe pain
intensity Aggravation by or causing avoidance of routine physical
activity (eg, walking or climbing stairs) During headache at least
one of the following: Nausea, vomiting, or both Photophobia and
phonophobia
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Tension Headaches Cause- unclear maybe muscle contraction or
vasoconstriction Usually bilateral Localized to the back of the
head, upper neck, fronto temporal area Pressing or tightening pain
mild to moderate intensity Onset is gradual
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Tension Headaches Last minutes to days Recurrent or persistent
over long periods, annual prevalence 40% Sometimes photophobia, no
nausea Aggravated by muscle tension as in driving or typing
Improves with massage, relaxation
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Cluster Headaches Etiology unclear- possible extra cranial
vasodilation from neural dysfunction with trigeminal vascular pain
Prevalence 1%, more in men Pain is deep, continuous, sharp,
pulsatile or pressure like
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Cluster Headaches The pain then spreads to the forehead, jaw,
upper teeth, temples, nostrils, shoulder or neck Unilateral, behind
or around the eyes Abrupt onset and peaks within minutes Last 15
min to 3 hours
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Cluster Headaches Associated symptoms, lacrimation, rhinorrhea,
miosis, ptosis, eye lid edema Cluster headache may sometimes be
confused with a serious headache, since the pain from a cluster
headache can reach full intensity within minutes. It is Episodic
(up to 8 in the same day) cluster last 6-12 weeks with remissions
of 6-12 months Chronic form occurs without significant periods of
remission. Pain free periods are less than 1 month
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Cluster Headaches Triggers Alcohol and cigarette smoking
Weather changes High altitudes (trekking, air travel) Smells Bright
light (including sunlight or flashing lights) Exertion Cocaine Heat
(hot weather, hot baths or showers) Foods high in nitrites (such as
bacon and preserved meats) Certain medications (including those
that cause blood vessel dilation, such as nitroglycerin, and
various blood pressure medications)
Analgesic Rebound Withdrawal of medication Severity and onset
are variable Duration depends on prior headache pattern Aggravated
by fever, carbon monoxide, hypoxia, withdrawal of caffeine
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Eye Disorders Refraction Errors near or farsightedness,
astigmatism Mechanism- sustained contraction of the EOM, frontal,
temporal or occipital muscles Pain is around or over the eyes
radiates to the occipital area Described as a steady, aching &
dull Gradual onset with variable duration and course Associated eye
fatigue, sandy sensation, redness of the conjunctiva Improves with
eye rest
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Eye Disorders Acute Glaucoma Caused by sudden increase in the
intraocular pressure Headache is steady, aching and severe Rapid
onset Duration and course is variable There is associated decrease
vision, nausea and vomiting There can be a hx of using eye drops to
dilate pupils.
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Sinusitis Mucosal inflammation of the paranasal sinuses Pain is
over the maxillary of frontal sinus Pain is aching, throbbing,
variable severity Last several hour sometimes days
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Sinusitis Recurrent in a repetitive daily pattern There is
local tenderness, nasal congestion, discharge and fever Aggravated
by coughing, sneezing or jarring the head Dx - clinical Treatment
with decongestion and antibiotics
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Meningitis Infection of the meninges surrounding the brain
Generalized headache Steady, throbbing, very severe Onset is fairly
rapid Persistent headache during the acute illness There is fever
and stiff neck Dx- Lumbar puncture Treatment of the Infection
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Subarachnoid Hemorrhage Caused by bleeding most often from a
rupture intracranial aneurysm Generalized headache Very severe the
worst headache of my life Onset is abrupt, severe There is nausea,
vomiting, loss of consciousness, neck pain Diagnosis- Head CT
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Brain Tumor Mechanism: Displacement of or traction on pain
sensitive arteries and veins or pressure on nerves Location varies
with the location of the tumor Pain is aching, steady and of
variable intensity Pain is intermittent but progressive Aggravated
by cough, sneezing or sudden movement of the head Dx- MRI
Treatment- depended dx
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Giant Cell (Temporal) Arteritis Vasculitis from cell- mediated
immune response to the elastic lamina of the artery Pain localized
near the involved artery-temporal or occipital Throbbing,
generalized, persistent and often severe Recurrent or persistent
over weeks to months Associated symptoms -Tenderness of scalp
-Fever (50%) -Fatigue -Weight loss -Jaw claudication(50%)
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Giant Cell (Temporal) Arteritis Associated Symptoms -Visual
loss or blindness ( 15-20%) - polymyalgia rheumatica (50%) Symptoms
aggravated by movement of neck and shoulders
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Posttraumatic Headache Mechanism is unclear Maybe generalized
or localized to the area of trauma Generalized, dull, aching and
constant Onset within hours to days of the injury Can last weeks,
months to years There is poor concentration, problems with memory,
vertigo, irritability, restlessness, fatigue Worsen by mental and
physical exertion, straining, stooping, emotional excitement
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Trigeminal Neuralgia Mechanism: Compression of CN V, often by
aberrant loop or artery or vein Localized on the cheek, jaws, gums,
trigeminal nerves division Pain is shock like, stabbing, burning,
severe Onset is abrupt, paroxysmal Each jab last seconds but recurs
at intervals of seconds to minutes May last months, disappears, but
recurs Aggravated by chewing, talking, brushing teeth, touching
certain areas
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Headaches symptoms/Pathology Sudden onset- Subarachnoid
hemorrhage or meningitis Migraine and tension- episodic and tend to
peak over several hours New, persistent, progressively severe
headaches- tumor, abscess or mass lesion Unilateral headache-
migraine and cluster Tension headaches arise in the temporal areas
Cluster headaches- retro-orbital
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Headache symptoms/pathology Nausea and vomiting- migraine,
brain tumor, subarachnoid hemorrhage Prodrome 60-70% of migraine
with 20% aura (photophobia, scintillating scotomata, or reversible
visual or sensory symptoms Chronic daily headaches- medication
overuse Family history positive in patient with migraine
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Treatment- Tension Headaches Tension-type headache (TTH), we
recommend treatment with simple analgesics such as nonsteroidal
anti- inflammatory drugs (NSAIDs) or aspirin Reasonable choices
include a single dose of ibuprofen (400 mg), naproxen sodium (220
mg or 550 mg) or aspirin (650 to 1000 mg). Acetaminophen (1000 mg)
is probably less effective than NSAIDs or aspirin, but is preferred
in pregnancy.
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Treatment Migraines Nonsteroidal anti inflammatory drugs:
Aspirin, Ibuprofen, naproxen& diclofenac Triptans: Sumatriptan,
rizatriptan, eleptriptan, almotriptan, zolmotriptan, zolmitriptan
and frovatripta The combination of sumatriptan and naproxen
Antiemetic/dopamine receptor antagonists: Chlorpromazine,
prochlorperazine, metoclopramide, and droperidol
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Treatment- Cluster Headaches Initial treatment with either
triptans or oxygen Oxygen should be tried first if available since
it is without side effects. Otherwise, subcutaneous sumatriptan 6
mg can be used as initial therapy for patients with no
contraindications
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Treatment- Cluster Headaches For patients who have a suboptimal
response to inhaled oxygen and are unable to administer or tolerate
subcutaneous injections, alternatives include intranasal
sumatriptan or intranasal zolmitriptan For patients with acute
cluster headache who do not respond to or tolerate oxygen and
triptans, alternatives include octreotide, intranasal lidocaine and
oral ergotamine
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Question Which group is more likely to have migraines a) Men b)
Women c) Teens d) Children
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Question What is one of the aura that migraine sufferers have
a) Body temperature rises b) Body temperature falls c) Sensation of
flashing lights d) Severe nausea
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Summary Migraine is the most common diagnosis in patients
presenting to primary care physicians with headache Careful history
and physical exam should be performed to rule out serious
underlying pathology and look for other secondary causes of
headache Use of an instrument such as the brief headache screen
appears to be helpful in identifying patients with migraine in
particular An imaging study is not necessary in the vast majority
of patients presenting with headache.
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References Lynn S. Bickley- Bates Guide to Physical examination
and History taking, tenth edition 249-251 Morris Green Pediatric
Diagnosis, Interpretation of symptoms & signs in Infants,
children and adolsecents
http://www.uptodate.com/contents/evaluation-of- headache-in-adults
http://www.uptodate.com/contents/evaluation-of- headache-in-adults
http://www.uptodate.com/contents/evaluation-of-
the-adult-with-headache-in-the-emergency- department
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References www.uptodate.com/contents/tension-type-headache-
in-adults-acute-treatment
www.uptodate.com/contents/tension-type-headache-
in-adults-acute-treatment
www.uptodate.com/contents/acute-treatment-of- migraine-in-adults
www.uptodate.com/contents/acute-treatment-of- migraine-in-adults
www.uptodate.com/contents/cluster-headache- treatment-and-prognosis
www.uptodate.com/contents/cluster-headache- treatment-and-prognosis
Headaches - cluster | University of Maryland Medical Center
http://umm.edu/health/medical/reports/articles/hea
daches-cluster#ixzz3PtOHzCyGHeadaches - cluster | University of
Maryland Medical Center
http://umm.edu/health/medical/reports/articles/hea
daches-cluster#ixzz3PtOHzCyG