melitza cobham-browne md clinical professor of pediatrics university of california, irvine

Melitza Cobham-Browne MD Clinical Professor of Pediatrics University of California, Irvine

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

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

Question Photophobia is... a) abnormal fear of being photographed. b) abnormal fear of bright lights. c) abnormal sensitivity sound. d) abnormal sensitivity to light

Characteristics of Pain Location Quality Severity Timing Setting in which it occurs Remitting or exacerbating factors Associated symptoms

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%

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

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?

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

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

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

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)

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

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

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

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

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

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

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

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

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.

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

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.

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

Primary Headache- No identifiable cause Secondary Headache Cranial Neuralgias

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

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

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

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

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

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

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

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

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

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

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)

Cluster Headaches Associated Comorbidities Depression Sleep apnea Restless leg syndrome Asthma Narcolepsy Insomnia

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

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

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.

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

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

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

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

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

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%)

Giant Cell (Temporal) Arteritis Associated Symptoms -Visual loss or blindness ( 15-20%) - polymyalgia rheumatica (50%) Symptoms aggravated by movement of neck and shoulders

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

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

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

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

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.

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

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

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

Question Which group is more likely to have migraines a) Men b) Women c) Teens d) Children

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

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.

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

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

melitza cobham-browne md clinical professor of pediatrics university of california, irvine

Documents

imaging slide

irvine slide

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previous treatment slide

migraine headache

highrisk comorbidity

cluster headaches

recent trauma