Approach to the patient with…

Approach to the patient with…

HEADACHES

Most people experience headaches at some point in their lives

- one of the most common reasons for ER & MD visits (up to 5%)

- major source of lost productivity and missed work

- majority not ominous but need to be able to differentiate

The most important step in deciphering headache etiology is the:

Headache History:

* classify the patients HA into a type to aid in diagnosis

Characteristics of the headache:

1. Acuity:

- recent onset (acute) vs. subacute vs. chronic HA disorder

- was the onset sudden and severe? (ie. thunderclap headache)

- is this different from previous history of headaches?

2. Pattern:

- episodic / relapsing vs chronic

- static vs. progressive

- if episodic - what is the frequency? (many times a day, daily, infrequently)

- certain time of day when starts?

(eg. cluster starts consistently few hours after sleep as does hypnic headache)

- does it change through the day? (worse in morning or at night vs. worsens through the day)

3. Duration:

- does the headache last seconds, minutes, hours, or days?

- neuralgiform headaches brief vs tension headaches often long-lasting

4. Location:

- where does the pain start, radiate, and settle?

- unilateral vs. bilateral

- frontal vs. temporal vs. occipital ?

- localised vs. generalized?

- is it facial pain?

5. Severity:

- best assessed by alteration in ability to perform usual activities

(eg. carry on work, social interactions)

- if progressive = severity changed since onset

- what does patient usually do during attacks? (eg. lie in dark room vs. pacing about)

- does it awaken patient from sleep?

6. Quality:

- ask patient to describe how it feels in their own words

- does their description fit with a pulsating / throbbing headache vs. stabbing vs. pressure / tightening

7. Associated features: ***

- nausea and/or vomiting

- photophobia and/or phonophobia

- neck stiffness

- autonomic features incl. conjunctival injection, lacrimation, nasal congestion, rhinorrhea, ptosis, facial sweating, eyelid edema

- features indicative of focal cortical and/or brainstem dysfunction either preceding, during or following headache (ie. aura)

- visual loss

(consider acute glaucoma, optic neuritis or temporal arteritis vs. late-severe papilledema)

- fever or constitutional symptoms (infections, inflammatory conditions)

- jaw claudication & myalgias in temporal arteritis with polymyalgia rheumatica

8. Precipitating factors:

- menstrual cycle, stress, food, exertion, hunger, loud noises, weather (typical in migraine)

- coughing, bending over, straining

- sexual activity / orgasm (coital headache)

- touching head, brushing hair (temporal arteritis)

- positional = headache reliably comes on with standing, relieved with lying (intracranial hypotension)

9. Response to treatment / medication use:

- what has been tried, how often, and in what doses?

- any features of medication overuse?

- response to analgesia vs. unresponsiveness does not necessarily differentiate serious from benign headache etiologies

- exquisite responsiveness to indomethacin may indicate one of indomethacin-responsive headache disorders (paroxysmal hemicrania / hemicrania continua)

Characteristics of the Patient:

1. Age:

- in the elderly always consider temporal arteritis

2. Comorbidity:

- immunocompromised state (CNS infections / lymphoma)

- head trauma

- substance use (alcohol, drugs, toxin exposure)

- Hx of recent lumbar puncture or epidural ('low pressure' headache)

3. Family History:

- migraines

- aneurysms / connective-tissue disease

Examination:

1. Appearance

- does patient look ill?

- is there a rash (esp purpuric)?

2. Vitals

- temperature, BP, pulse

3. Examination of the head, face, and neck

- scalp and sinus tenderness

- temporal artery pulses (is the artery tortuous, thickened or tender?)

- meningismus (meningitis, subarachnoid hemorrhage)

- temporomandibular joint dysfunction

- signs of head trauma

- carotid bruits

- trigger areas for eliciting pain of trigeminal neuralgia

4. Cranial Nerves:

- pupils (abnormal with glaucoma, compressive lesion with herniation, miosis with carotid dissection or autonomic cephalgia)

- fundoscopy (absence of papilledema does not rule-out acute raised intracranial pressure but useful if normal disc with chronic headache, presence of spontaneous venous pulsations also suggests normal ICP, but absent in 15-20% of normal people)

5. Neurological Examination:

- looking for any focal abnormality to suggest structural intracranial lesion as cause

Indications for Urgent Imaging in Headache Patients

* Worst ever headache (especially if rapid onset)

* Change in frequency, severity or clinical features of prior headaches

* Abnormality on neurological examination (mental state, focal deficits)

(including persistent deficits not meeting criteria for migraine with aura)

* Meningismus

* Progressive / unremitting daily headache

* New-onset headache in those over 40 yrs old with no other etiology found

- also in those with cancer, immunosuppression, or during pregnancy

* CT Scan is adequate for initial work-up of thunderclap headache

- MRI (with MRA / MRV) preferred for undiagnosed progressive daily headache or if subtle focal deficits, suspicion of arterial dissection

Other Investigations to Consider:

1. Lumbar puncture:

- to rule-out meningitic infection or inflammatory process or subarachnoid hemorrhage, especially in thunderclap headache syndrome or in presence of fever or constitutional symptoms

- measure CSF pressure if suspicion of either benign intracranial hypertension (after imaging to rule-out mass lesion), in patient with papilledema, or if positional ('low pressure') headache suspected

2. ESR

- almost always elevated in temporal arteritis

3. Miscellaneous:

- measurement of intraocular pressure (glaucoma)

- trial of indomethacin

The Headache Differentials

The Thunderclap Headache:

1. Primary headache disorders

* Crash migraine

* Cluster headache

* Benign exertional headache

* Benign orgasmic cephalgia

2. Vascular

* Subarachnoid hemorrhage

- also intracerebral hemorrhage or ischemic stroke

* Unruptured aneurysm ("sentinel headache")

* Arterial dissection

* Cerebral venous sinus thrombosis

* Acute hypertension (eg. pheochromocytoma)

3. Non-Vascular disorders:

* Acute glaucoma

* Pituitary apoplexy

* Infection (sinusitis, meningitis)

Headaches of Recent Onset:

* Temporal arteritis

* Intracranial mass lesion (incl. neoplasm, abscess, hemorrhage - eg. subdural)

* 'Benign' Intracranial hypertension (a.k.a. pseudotumour cerebri)

* Cerebral venous sinus thrombosis

* Neuralgiform headaches (eg. trigeminal neuralgia)

Chronic Daily Headaches: affect 4% of population

Frequency > 15 days per month or > 180 days per year

1. Primary: all may be with or without features of medication overuse

a. Duration > 4 hrs per day

- Transformed migraine (History of distinct migraine attacks)

- Chronic tension-type headache

- New daily persistent headache (comes on over < 3 days, constant location)

- Hemicrania continua (persist for 1 month, strictly unilateral, moderate severity, no clear precipitating mechanisms, responsive to indomethacin, autonomic features if severe)

b. Duration < 4 hrs per day (see below "short-lasting headaches")

- Cluster headache

- Chronic paroxysmal hemicrania

- Hypnic headache

- Idiopathic stabbing headache

2. Secondary types:

- Post-traumatic

- Cervical spine disorders

- Vascular disorders (AVMs, arteritis, dissection, subdural hematoma)

- Intracranial masses (increased ICP, infection, neoplasm)

- Other (TMJ disorder, sinus infection)

Short-Lasting Headaches:

with autonomic features:

- Cluster headache (more in men, unilateral with autonomic, usually daily, 15 min - 2 hrs)

- Chronic & episodic paroxysmal hemicrania (shorter episodes than cluster; usually few minutes & more frequent, indomethacin-responsive more in women)

- SUNCT syndrome (15-120 seconds, autonomic features, unilateral mod.-severe & frequent)

- Cluster-tic syndrome (cluster & tic in same person with eventual fusing of both into one)

without prominent autonomic features:

- Trigeminal neuralgia

- Idiopathic stabbing headache

- Cough headache

- Benign exertional headache

- Headache associated with sexual activity

- Hypnic headache (most days, awaken from sleep, last < 1 hr, bilateral, minimal autonomic)

References:

Davenport R. Acute headache in the emergency department. J Neurol Neurosurg Psychiatry 2002; 72 (Supp II); ii33—ii37.

Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1998; 8(Supp 7); 1-96S.

Kaniecki R. Headache assessment and management. JAMA 2003; 289: 1430-33.

Steiner TJ, Fontebasso M. Headache. BMJ 2002; 325: 881-86.

Last update: 2003-05-04

Reviewed by: Dr. Paul Cooper

Neurological Medicine Pocketbook

http://www.uwo.ca/clinns/resident

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