Transcript Primary Headache

Approach to the Patient with Head
and Facial Pain
Neurology 2014-15
• A headache which your history and physical exam suggests is
due to the headache condition itself and not a separate cause.
While they are likely triggered by genetic, developmental, and
environmental factors, they are “idiopathic” in the sense that
they do not arise from another underlying disease.
• Symptoms
•
•
•
•
•
bilateral
band-like
dull
worse with activity
age 20-50
• Treatment
• NSAIDS or Tylenol
• Symptoms
• unilateral
• Pulsating
• moderate to severe
• lasts 4-72 hours
• worse with activity
• may have aura, nausea and/or vomiting, photophobia and
photophobia
• often triggered by stress/foods/alcohol/sleep deprivation
• Treatment
• Acute setting: sumatriptan, DHE
• Earlier treatment delivery is associated with better outcomes.
• Prophylaxis: beta-blockers, calcium channel blockers, amtriptyline,
nortriptyline
• Symptoms
•
•
•
•
•
unilateral
stabbing
retro-orbital
lasts 15 minutes to 3 hours
ipsilateral lacrimation, ptosis, nasal congestion, rhinnorrhea
• Patients are M>F, age 20-30
• Treatment
• 100% oxygen or low-dose prednisone
•
A secondary headache is a headache that is
present because of another condition (such as a
sinus headache from sinusitis). They are less common
than primary headaches.
•
•
Headache occurs in close temporal relation to the other
disorder and/or there is other evidence of a causal
relationship.
Headache is greatly reduced or resolved within 3 months
after successful treatment of the causative disorder.
• Presentation
• often caused by head trauma
• associated with berry aneurysm rupture
• thunderclap "worst headache of my life"
• Diagnosis
• noncontrast head CT
• lumbar puncture (RBCs and xanthochromia)
• Treatment
• neurosurgical evaluation
• calcium channel blocker (nimodipine) to prevent vasospasm
• blood pressure control (MAP <110 for unsecured aneurysm, <130 for
coiled/clipped aneurysm)
• Symptoms
• unilateral
• temporal
• associated with jaw claudication
• temporal artery tenderness to palpation
• Diagnosis
• ESR >50
• temporal artery biopsy
• often associated with polymyagia rheumatica
• Treatment
• steroids
• do not delay steroids for biopsy!
• can lead to blindness if not treated early
• Symptoms
•
•
•
•
•
•
unilateral facial pain
episodic, severe, shooting
Lasts seconds to minutes
Often triggered by light touch, cold air, chewing
hemifacial spasm: “tic douloureux”
One, two, or three branches of the facial nerve may be affected; usually
V2-3; (10% are bilateral)
• Treatment
• carbamazepine
• second line treatments are also in the AED family: lamotrigine,
oxcarbazepine, phenytoin, gabapentin
• Meningitis
• Intracranial Neoplasm
• Pseudotumor cerebri
• New onset of headache or new pattern of headache and age
> 40
• Focal signs or symptoms occurring with the headache, including
auras
• Headaches worse with valsalva or worse in the laying down
position (venous sinus thrombosis, intracranial hypertension)
• Headaches associated with severe vomiting
• obese patient with intractable headaches or papilledema
(pseudotumor)
• focal neurologic signs or symptoms or MRI findings needing
cytological diagnosis (malignancy)
• subarachnoid hemorrhage older than 6 hours
• A 65 y/o gentleman presents to his PCP with
headache and transient “funny vision” in the R eye.
Headache was in the right-sided, intermittent, pressure
pain, started 2 weeks ago, progressively worse. He
never had similar headache in the past. Also felt
fatigue recently and had a low grade fever. Two days
ago, he had an episode of right temporal vision loss
for about 10 mins. Today, he had another similar
episode for about 15 mins.
• What is your diagnosis?
• 55 yo man presents to the ER 36 hours after sudden
onset severe headache. He initially rated the pain
10/10; now 8/10. He endorses neck pain,
nausea/vomiting, and photophobia. His BP is
170/100, P 120. Exam is normal except for
meningismus. A noncontrast head CT is normal. LP is
performed. CSF has 3 WBC, 1200 RBCs/mm3 in tube
1 and 1220 RBCs/mm3 in tube 4. Protein is 85 mg/dL
and glucose 32 mg/dL.
• What is your diagnosis?
• A 48y/o F with h/o migraine presents with severe persistent
headache for 1 week. The headache was similar to her previous
migraine, but much more severe. Throbbing, left frontal
temporal area, nausea, photophobia and phonophobia, worse
with movement. No focal weakness, loss of consciousness, jerky
movements, gait instability or other complaints. She tried
Maxalt, but the pain only went away for two hours. She tried
Topamax, Lyrica, Nortriptyline, Propranolol and Zonegran.
None of these medications helped her headache very much.
She used Tylenol, Ibuprofen and Vicodin almost every day.
• What is your diagnosis?