Transcript Headache: Determining The Appropriate Diagnostic and Treatment

Headache: Determining the
Appropriate Diagnostic &
Treatment Approach
Jose Paciano B.T. Reyes, MD,
FPNA
What is headache?
• Cephalalgia
• Diffuse pain in the various parts of
the head
• Not confined to the area of
distribution of a nerve
Prevalence of different types
Headache Type
Prevalence
Tension type
69%
Headache from systemic infection
63%
Migraine
16%
Headache after head injury
4%
Idiopathic stabbing headache
2%
Exertional headache
1%
Vascular disorders
1%
Subarachnoid hemorrhage
<1%
Brain tumors
0.1%
Types of Headaches
• Primary headaches
• Benign
• Recurrent
• No organic disease as their cause
• Secondary headaches
• Underlying organic disease
Primary Headache Disorders
• More common
• Migraine, with
or without aura
• Tension type
• Cluster
• Less common
• Paroxysmal hemicrania
• Idiopathic stabbing
• Cold-stimulus
• Benign cough
• Benign exertional
• Associated with sexual
activity
Secondary Headache Disorders
• Associated with vascular
disorders
• Subarachnoid
•
•
•
•
•
•
hemorrhage
Acute ischemic
cerebrovascular disorder
Unruptured vascular
malformation
Arteritis
Carotid or vertebral artery
pain
Venous thrombosis
Arterial hypertension
• Associated with
non-vascular
intracranial disorder
• Benign intracranial
hypertension
• Intracranial infection
• Low CSF pressure
• Associated with
noncepalic infection
• Viral infection
• Bacterial infection
Secondary Headache Disorders
• Associated with
head trauma
• Acute post-traumatic
headache
• Associated with
substance use or
withdrawal
• Acute use or
exposure
• Chronic use or
exposure
• Associated with
metabolic disorders
• Hypoxia
• Hypercapnia
• Mixed hypoxia &
hypercapnia
• Dialysis
Secondary Headache Disorders
• Associated with head trauma
• Acute post-traumatic headache
• Headache of facial pain associated with
disorder of cranium, neck, eyes, ears, nose,
sinuses, teeth, mouth or other facial or cranial
structures
• Cranial neuralgias, nerve trunk pain and
deafferentation pain
Headache History
• Is this your first or worst headache?
How bad is your pain on a scale of 1-10? Do you
have headaches on a regular basis? Is this
headache like the ones you usually have?
• What symptoms do you have before of
during the headache? What symptoms do
you have now?
• When did this headache begin? How did it
start (gradually, suddenly)?
Headache History
• Where is your pain?
Does the pain spread to any other area? Where?
• What kind of pain do you have (throbbing,
stabbing, dull, others)?
• Do you have other medical problems?
• Do you take medicines?
• Have you recently hurt your head or had a
medical or dental procedure?
Blue Flag Headaches
Red Flag Headaches
Other Red Flag Headaches
• Associated with rash
• May indicate Lyme disease or meningococcemia
• Non-migraine headache in pregnanacy or postpartum
• May indicate cerebral thrombosis
• Associated with changes in posture
• May indicate low CSF pressure due to spontaneous CSF
leak
• Associated with pressing visual disturbances
• May be due to glaucoma or optic neuritis
Headache Red Flags: S-N-O-O-P-S
• Systemic symptoms: fever, weight loss
• Neurological symptoms or abnormal signs:
confusion, impaired alertness or consciousness
• Onset: suddent, abrupt or split-second
• Older: new onset or progressive headache,
specially in patients > 50 yo
• Previous headache history:
first o new or
different headache
• Secondary risk factors:
systemic cancers, HIV
David Dodick, MD
Diagnostic Criteria for
Episodic Tension Type Headache
Diagnostic Criteria for
Cluster Headache
Diagnostic Tests for Headache
• Neuroimaging
• Indications:
• To rule out a structural disorder
• To assure anxious patient or his relatives
Diagnostic testing for the evaluation
of headaches
Yield of neuroimaging in the evaluation of patients with
headache and a normal neurologic examination is
quite low (N = 3026 scans)
Brain tumors
0.8%
AVMs
0.2%
Hydrocephalus
0.2%
Aneurysm
0.1%
Subdural hematoma
0.2%
Strokes
1.2%
Neurol Clin 1996 Feb; 14(1):1-26
Neuroimaging recommendations for
non-acute headache
Consider neuroimaging in:
• Patients with an unexplained abnormal finding on the
neurologic examination (Grade B)
• Patients with atypical headache features or
headaches that do not fulfill the strict definition of
migraine or other primary headache disorder (or
have some additional risk factor, such as immune
deficiency), when a lower threshold for neuroimaging
may be applied (Grade C)
• Neuroimaging is not usually warranted in patients
with migraine and a normal neurologic examination
(Grade B)
AAN Sept 2000
Neuroimaging algorithm for headache of
>4 weeks & normal neurologic exam
NO
Tension-type
headache?
Neuroimaging unlikely
to show abnormality
YES
Migraine-type
headache?
NO
See other pathway
YES
Any atypical
features?
YES
NO
CONSIDER BRAIN IMAGING
Neuroimaging algorithm for headache of
>4 weeks
Abnormal neuro
findings?
NO
YES
Worse with
Valsalva?
Consider Brain Imaging
(CT or MRI)
YES
NO
Brain Imaging Not
Necessary
Wakes patient from
YES
sleep?
NO
New headache in
older patient?
YES
YES
NO
NO
Headache
progressively
worsening?
YES
NO
Other RED
FLAGS?
•Exertion induced
•Maximum severity at onset
•Seizures
•Systemic illness
•Worst headache ever
•Strong patient or family concerns
•Family history of tumors or
aneurysms
Computed Tomographic Scanning
Advantages
• Procedure of choice
for acute
hemorrhage and
skull fractures
• Cheaper than MRI
• Faster testing time
• CT angiography
Disadvantages
• False negative results
for small lesions
• Radiation exposure
• Allergic reaction to
contrast dye
• Contraindicated in
pregnancy
• Monitor creatinine
levels in elderly and
renal disease
Magnetic Resonance Imaging
Advantages
• Better images,
brainstem lesions
• Detect vascular
anatomy for
suspected aneurysms
and vasculitis
• Detect small
aneurysms
• No radiation
Disadvantages
• Metal implants
contraindicated
• Pregnancy up to 2nd
trimester
contraindicated
• Costly
• Availability
• Long testing time
Electroencephalography
Indications
• Loss of consciousness
• Depressed sensorium or alertness
• Seizures
• Suspected metabolic encephalopathy
Electroencephalography in headache
…not useful in the routine evaluation of
patients with headache. This does not exclude
the use of EEG to evaluate headache patients with
associated symptoms suggesting a seizure
disorder, such as atypical migrainous aura or
episodic loss of consciousness. Assuming head-
imaging capabilities are readily available,
EEG is not recommended to exclude a
structural cause for headache.
•Practice Guideline, AAN, 1995
Other Diagnostic Tests
• Lumbar puncture
• CNS infection
• MS
• Increased or decreased CSF pressure
• Blood examination
Symptomatic Therapy
• As abortive therapy
• Goal: to abort, reduce or stop a headache,
head pain or symptoms accompanying a
headache
• Purpose:
• for acute attacks that are infrequent
• for breakthrough attacks while on preventive
therapy
Symptomatic Therapy
• Notes:
• Better used at onset of headache
• Frequently combined with preventive
therapy
• Can cause rebound headaches
• Should not exceed 3 days/week
Preventive Therapy
• As prophylaxis or prevention of recurrence
• Goal: reduce frequency, severity and
duration of attacks
• Purpose:
• For frequent attacks of headache
• For moderate to severe headaches
• For those on excessive use of symptomatic
medication without relief
Preventive Therapy
• Notes:
• Given daily for at least 3-6 months
• Begin at lower dose with upward titration
• Reassess every 6 months
• Some medications need tapering before
discontinuation
• Encourage effective birth control in fertile
women while on preventive therapy
Thank You!