Evaluation of HeadacheEvaluation of Headache

Dr. Mohammed Tahir Kurmanji Neurologist FICMS

University of SuleimaniaDepartment of Neurology

Pain Sensitivity of Cranial StructuresPain Sensitivity of Cranial Structures

Cranial venous sinuses with afferent veins

Arteries at base of brain and their major branches

Arteries of the dura Dura near base of brain and large

arteries Dural, Cranial and extracranial

nerves All extracranial structures

Brain parenchyma

Ependyma

Choroid

Pia

Arachnoid

Dura over convexity

Skull

Pain-Sensitive Pain-Insensitive

Overall ApproachOverall Approach

Chief Complaint: Headache

Headache AlarmsEvidence of serious headache disorder

by history or physical exam

Diagnosis ofPrimary Headache Disorder

Work-up to identify/exclude secondary headache etiology

Treat Primary Headache

NO YES

YES NO

Consider work-up for secondary headache

General Mechanisms of HeadacheGeneral Mechanisms of Headache

Traction on major intracranial vessels

Distention, dilation of intracranial arteries

Inflammation near pain sensitive structures

Direct pressure on cranial or cervical nerves

Sustained contraction of scalp or neck muscles

Stimulation from disease of eye, ear, nose and sinuses (referred pain)

EpidemiologyEpidemiology

60-75% of adults have at least one headache/year

5-10% will seek physician evaluation

Less than 10% of ED patients with chief complaint of headache will have emergent secondary cause

EpidemiologyEpidemiology

Tension Migraine Cold Stimulus Headache Cluster

69% 15%15%

0.1%

Primary Headache Lifetime Prevalence

Hangover Fever Metabolic disorder Disorders of nose/sinuses Head trauma Disorders of eyes Vascular disorders

72% 63%22%15%

4%3%1%

Secondary Headache

Headache in the EDHeadache in the ED

Tension Migraine Cluster

32 %22 %

< 1 %

Primary Headache

Subarachnoid Hemorrhage Meningitis Temporal Arteritis Subdural Hematoma CNS tumor Miscellaneous illness No specific diagnosis

< 1 %< 1 %< 1 %< 1 %

3 %33 %

7 %

3%

Secondary Headache

Leicht M, Ann Emerg Med 1980;9:404

Primary HeadachePrimary Headache

Migraine

TensionCluster

Tension HeadacheTension Headache

Duration 30 min to 7 days

Pain characteristics (at least 2) Pressing/tightening quality Mild to moderate severity Bilateral location No aggravation by routine physical activity

Associate symptoms (Must have both) No vomiting No more than one of: nausea, photophobia, phonophobia

H&P and diagnostic tests do not suggest underlying organic disease

International Headache Society Diagnostic Criteria

Migraine Without AuraMigraine Without Aura

At least 6 or more periodic attacks Duration

4-72 h if untreated or unsuccessfully treated Pain characteristics (at least 2)

Unilateral location Pulsating quality Moderate to severe intensity Aggravation by walking stairs or similar physical activity

Associated symptoms (at least 1) Nausea, vomiting, or both Photophobia or phonophobia

H&P and diagnostic tests do not suggest underlying organic disease

International Headache Society Diagnostic Criteria

Migraine With AuraMigraine With Aura

At least 3 periodic attacks

Aura characertistics (At least 3 )

One or more fully reversible aura symptoms indicating focal cerebral cortical or brain-stem dysfunction

At least 1 aura symptom develops gradually over >4 minutes or 2 or more symptoms occur in succession

No single aura symptom lasts > 60 minutes

Headache begins within 60 minutes of aura onset

History, physical, and diagnostic tests do not suggest underlying organic disease

International Headache Society Diagnostic Criteria

Cluster HeadacheCluster Headache

Duration 15 to 180 minutes untreated

Pain characteristics Severe unilateral orbital, supraorbital, or temporal pain

Associated symptoms (at least 1, ipsilateral to pain) Conjunctival injection, Lacrimation Nasal congestion, Rhinorrhea Forehead and facial swelling Miosis, Ptosis Eyelid Edema

Frequency: between 1 every other day to 8/day

International Headache Society Diagnostic Criteria

Secondary HeadacheSecondary Headache

Intracranial hemorrhage

– Subarachnoid Hemorrhage

– Intracerebral hemorrhage

– Subdural/epidural hematoma

Meningitis/encephalitis

Hypertensive encephalopathy Ischemic stroke Venous sinus thrombosis

Hypoxia, hypercarbia, carbon monoxide

Secondary HeadacheSecondary Headache

Temporal arteritis

Mass lesions

Tumor, abscess, arteriovenous malformation

Altitude sickness

Metabolic

Hypoglycemia, fever, hypothyroid, anemia

Glaucoma

Pseudotumor cerebri (benign intracranial hypertension)

Secondary HeadacheSecondary Headache

Trigeminal Neuralgia

Post-concussion syndrome

Sinusitis without complication

Post-lumbar puncture

Diet

Medications

Fatigue, postexertion, postcoital

Overall ApproachOverall Approach

Chief Complaint: Headache

Headache AlarmsEvidence of serious headache disorder

by history or physical exam

Diagnosis ofPrimary Headache Disorder

Work-up to identify/exclude secondary headache etiology

Treat Primary Headache

NO YES

YES NO

Consider work-up for secondary headache

HistoryHistory

Why did this headache bring you to the Emergency Department?

– First or Worst– Accompanied by new or frightening features– Last straw

How did this headache start?

Have you had previous similar headaches; if so when did this headache type start?

HistoryHistory

Where does it hurt?– Unilateral/bilateral– Frontal/occipital/facial

What is the character of the pain?– Pulsatile, steady, shocklike, tightness

What other symptoms do you experience? – Nausea, vomiting, LOC, flushing,

lacrimation, drop attack, neck stiffness, photophobia, dizziness

HistoryHistory

Precipitating/aggravating factors– Trauma, exertion, noise, position, foods, drugs,

weather, anxiety, menstration

Relieving factors– Darkroom, position, pressing on scalp, medication

Medical history– HIV, Cancer, HTN– Recent procedure (LP)– Change in medications

HistoryHistory

Family History– Migraine headaches, subarachnoid hemorrhage

Environment– Carbon monoxide

Physical ExamPhysical Exam

Vital signs– fever, hypertension, hypoxia

Head/face– trauma, bruits, tenderness

Eyes– conjunctiva, cornea, pupils,

fundi:papilledema Ears

– OM or hemotympanum Mouth

– Teeth, TMJ

Neck– pain/stiffness/tenderness– Carotid and/or vertebral

bruits Skin

– rash Neurologic

– Mental status– Pupils, EOM, Visual fields– Focal deficits– Horner's syndrome– Ataxia

Diagnostic AlarmsDiagnostic Alarms

Onset after age 50

Sudden onset

Increased frequency and severity

New onset with risk factors for HIV or cancer

Associated with systemic illness (HT,DM,fever, meningismus, rash)

Altered consciousness or focal neurologic deficits

Papilledema

Significant trauma

Overall ApproachOverall Approach

Chief Complaint: Headache

Headache AlarmsEvidence of serious headache disorder

by history or physical exam

Diagnosis ofPrimary Headache Disorder

Work-up to identify/exclude secondary headache etiology

Treat Primary Headache

NO YES

YES NO

Consider work-up for secondary headache

ED Treatment of Primary HeadacheED Treatment of Primary Headache

Tension Oral Analgesics (NSAIDS, Acetaminophen)

Migraine Serotonin agonists

ie, Sumitriptan 50 mg PO or 6.0 mg SQ Narcotics IV or IM

Cluster 100% oxygen Intranasal lidocaine ? NSAIDS Migraine specific therapies

Prophylaxis Treatment of Primary Prophylaxis Treatment of Primary HeadacheHeadache

Tension Reassurance Antidepressant &/or Anxiolytic drugs (Tricyclic antidepressant or/& SSRI)

Migraine Betablockers: Proponolol Ca channel blocker: Verapamile Antidepressant: (Tricyclic antidepressant or/& SSRI) Anticonvulsant: Na valproate, topiramate, Methysergid. Pizotifine.

Cluster Steroid Lithium carbonate Verapamile

Overall ApproachOverall Approach

Chief Complaint: Headache

Headache AlarmsEvidence of serious headache disorder

by history or physical exam

Diagnosis ofPrimary Headache Disorder

Work-up to identify/exclude secondary headache etiology

Treat Primary Headache

NO YES

YES NO

Consider work-up for secondary headache

Diagnostic StudiesDiagnostic Studies

Computerized tomography

– Hemorrhage, tumor, abscess, AVM

Lumbar puncture

– Hemorrhage, infection, increased CSF pressure

Limited indications for MRI, MRA, or Angiography

Laboratory studies based on suspected etiologies

– ESR: Temporal arteritis

– Carboxyhemoglobin: Carbon monoxide

Subarachnoid HemorrhageSubarachnoid Hemorrhage

Approximately 50% of have "sentinal bleed" 50% with "sentinal bleed" will rebleed within 2-6 wks Rebleed

– 50% mortality– > 50% of survivors have significant neurologic deficits

Head CT negative in 1-10% of cases– Sensitivity decreases with time from onset of sx

LP if head CT negative (RBC's 3 hrs, xanthochromia 12 hrs) Angiography if postive CT or LP

Temporal ArteritisTemporal Arteritis

Rare before age 50 Temporal artery tenderness, swelling, redness, nodularity Visual disturbance

– Visual loss in 7-60% if untreated Jaw claudication Systemic symptoms

– fever, wt loss, anorexia, malaise Polymyalgia rheumatica (prox muscle pain/tend./stiffness) ESR usually > 50 (mm/hr) Temporal artery biopsy

– multinucleated giant cells / inflammation Therapy: High dose steroids

Overall ApproachOverall Approach

Chief Complaint: Headache

Headache AlarmsEvidence of serious headache disorder

by history or physical exam

Diagnosis ofPrimary Headache Disorder

Work-up to identify/exclude secondary headache etiology

Treat Primary Headache

NO YES

YES NO

Consider work-up for secondary headache