Approach to Acute Headache in Adults

BARRY L. HAINER, MD, and ERIC M. MATHESON, MD, Medical University of South Carolina, Charleston, South Carolina

Am Fam Physician. 2013 May 15;87(10):682-687.

Journal Review By: SHIRIN BITAJIAN, MDNEIMEF Residency Program

• You get a call from ER. 35 year old male presents to ER for right sided eye pain and headache.

• You are told by the first year resident, that the call from ER is in regards to a patient who came in with a C/O right sided eye pain. This is associated with drainage from same side and a severe unremitting headache which is sharp and knife like, 12/10 intensity, and mostly on right side. This started after an altercation. No nausea or vomiting.

• Patient has history of headaches.• What is the diagnoses? Do you need any

imaging?

What’s up Doc??? What’s the Diagnosis???

What’s Up Doc??? What’s the diagnosis??

Interns!!! Mention all the history but forget to mention

the most important fact!!!

Types of Headaches• The most common types of headaches are – Tension-type headaches 40 % of adult population – Migraines 10% of adult population– Cluster headaches 1 %of the adult population

• Most headache diagnoses are based entirely on the patient history.

• Only rarely does physical examination provide clues to the diagnosis

International Classification of Headache Disorders, 2nd ed. (ICHD-2)

• Primary headaches– Migraine– Tension-type– Cluster– Other (e.g., cold stimulus headache)

• Secondary headaches– Headache attributed to any of the following: head or

neck trauma, cranial or cervical vascular disorder, nonvascular intracranial disorder, substance use or withdrawal, infection, disturbance of homeostasis, psychiatric disorder

– Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures

Criteria for Low-Risk Headaches• Age younger than 30 years• Features typical of primary headaches• History of similar headache• No abnormal neurologic findings• No concerning change in usual headache

pattern• No high-risk comorbid conditions (e.g.,

human immunodeficiency virus infection)

• No new, concerning historical or physical examination findings

History in Evaluation of Acute HeadacheFollowing require prompt evaluation:• Thunderclap headache, which is characterized by sudden-onset

headache pain, with peak intensity occurring within several minutes. – Subarachnoid hemorrhage– hypertensive emergencies – vertebral artery dissections– acute angle–closure glaucoma

• Increase the risk of intracranial bleeding or Stroke: – Use of illicit drugs (cocaine , methamphetamine)– Medications such as aspirin, other nonsteroidal anti-inflammatory drugs,

anticoagulants, and glucocorticoids.

• HIV or other immunosuppressive conditions may suggest: a brain abscess, meningitis, or malignancy of the central nervous system (CNS).

• A patient who reports the worst headache of his or her life, especially if the patient is older than 50 years, or who has a headache that occurs with exertion (including sexual intercourse) could be experiencing intracranial hemorrhage or carotid artery dissection.

Physical Examination Findings• Neurologic abnormalities

• A focal neurologic deficit should not be attributed to migraine headache unless a similar pattern has occurred with a previous migraine.

• Abnormal findings can be pronounced, such as meningismus or unilateral vision loss, or subtle, such as extensor plantar response or unilateral pronator drift.

• Obtundation or confusion suggests a dangerous headache because these signs do not occur with benign or primary headache.

• Patients with headache and fever, papilledema, or severe hypertension require evaluation for CNS infection and increased intracranial pressure.

• Contusions and facial or scalp lacerations increase the likelihood of associated intracranial hemorrhage.

DIAGNOSTIC TESTING

DIAGNOSTIC TESTING Neuroimaging

• All patients who present with signs or symptoms of dangerous headache, because they are at increased risk of intracranial pathology.

DIAGNOSTIC TESTING Lumbar Puncture

• Identifying infection, the presence of red blood cells (which suggests bleeding), and abnormal cells associated with some CNS malignancies.

• In adults with suspected subarachnoid hemorrhage, it is important to perform lumbar puncture to check for blood or xanthochromia.

• Computed tomography of the head should be performed before lumbar puncture. In one supporting study, 5 percent of patients presenting to an emergency department with suspected subarachnoid hemorrhage and a normal neurologic examination had early intracranial herniation or midline shift.

Tension-Type Headache

ICHD-2 Diagnostic Criteria for Episodic /Chronic Tension-Type Headache

A. Average frequency of greater than 15 attacks per month; Headache lasts 30 minutes to seven days (<12 is labeled as Infrequent chronic tension type headache)

B. At least two of the following pain characteristics:1. Pressing/tightening quality2. Mild to moderate intensity (may inhibit, but does not prohibit activities)3. Bilateral location4. Not aggravated by routine physical activity

C. Both of the following:1. No vomiting2. No more than one of the following: nausea, photophobia or phonophobia

D. Organic disorder is ruled out by the initial evaluation or by diagnostic studies. If another disorder is present, the headaches should not have started in close temporal relationship to the disorder.

Tension-Type Headache

• For Chronic, all of the following:– Frequency: average of 15 or more headache

days per month for more than 3 months– No vomiting– No more than one of nausea, photophobia or

phonophobia

• For Episodic, all of the following: – Frequency: less than 15 headache days per

month– No vomiting or nausea– No more than one of photophobia or

phonophobia

Tension-Type Headache

• Most common form of headache, and affects more than 40 percent of the adult population worldwide.

• Women are affected slightly more often than men.

• Nociceptors in the pericranial myofascial tissues are a likely source of tension headaches.

• Individuals who meet the criteria for tension-type headache but who have normal neurologic examination results require no additional laboratory testing or neuroimaging.

Tension-Type Headache Treatments:

– Acetaminophen– Aspirin– NSAIDs–Midrin (Acetaminophen, Isometheptene and

Dichloralphenazone)– Avoid overuse of treatment meds

CLUSTER HEADACHES

CLUSTER HEADACHES

• Relatively rare, and are characterized by brief (15 to 180 minutes) episodes of severe head pain with associated autonomic symptoms.

• Although cluster headaches are less common than migraines and tension-type headaches, an estimated 500,000 Americans experience them at least once in a lifetime.

• The age of onset of cluster headaches varies, with 70 percent of patients reporting onset before 30 years of age.

CLUSTER HEADACHES• Family history appears to have a role in some cases.

• A number of comorbidities are associated with cluster headaches, including:– Depression (24 percent)– Sleep apnea (14 percent)– Restless legs syndrome (11 percent)– Asthma (9 percent)

• Depression is an important diagnosis, because many individuals who have cluster headaches report suicidal thoughts, and 2 percent of patients in one study had attempted suicide.

CLUSTER HEADACHES• Only 25 percent of patients with cluster

headaches are diagnosed correctly within one year of symptom onset, and more than 40 percent report a delay in diagnosis of five years or longer.

• The most common incorrect diagnoses reported in one study were migraine (34 percent), sinusitis (21 percent), and allergies (6 percent).

CLUSTER HEADACHES1. Frequency: one every other day to 8 per day2. Severe unilateral orbital, supraorbital and/or temporal

pain most common but can present as bilateral. 3. Pain lasting 15 to 180 minutes untreated4. One or more of the following occur on same side as the

pain: Conjunctival injection Lacrimation (tearing) Nasal congestion Rhinorrhea Forehead and facial swelling Miosis (constricted pupil) Ptosis (eyelid drooping) Eyelid edema Agitation, unable to lie down

CLUSTER HEADACHES• Episodic form (80 to 90 percent of cases):– episodes occur daily for a number of weeks

followed by a period of remission.– On average, a period of cluster headaches lasts

six to 12 weeks, with remission lasting up to 12 months.

• Chronic form (10 to 20 percent of cases):– episodes occur without significant periods of

remission.

CLUSTER HEADACHES• Acute treatment:

– Oxygen– Sumatriptan SQ (self-management)– Zolmitriptan nasal (self-management)– DHE

• Bridge treatment (for quick suppression of attacks until maintenance treatment reaches therapeutic level):– Corticosteroids– Occipital nerve block

• Maintenance treatment (for sustained suppression of attacks over the expected cluster cycle):– Avoid alcohol during cycle– Verapamil– Steroids– Lithium– Depakote– Topiramate

Sinus Headache

Sinus Headache Migraine-associated symptoms are often misdiagnosed as

"sinus headache" by patients and clinicians. Most headaches characterized as "sinus headaches" are migraines.

The International Classifications of Headache Disorders (ICHD-II) defines sinus headache by:

Purulent nasal discharge

Pathologic sinus finding by imaging

Simultaneous onset of headache and sinusitis

Headache localized to specific facial and cranial areas of the sinuses

Chronic daily headache• Headache more than 15 days per month for greater

thanthree months. Chronic daily headache is not a diagnosis

but a category that may be due to disorders representing primary and secondary headaches.

• Secondary headaches are typically excluded with appropriate neuroimaging and other tests.

• Chronic daily headache can be divided into:– Those headaches that occur nearly daily that last four

hours or less and those that last more than four hours, which is more common.

– The shorter-duration daily headache contains less-common disorders such as chronic cluster headache and other trigeminal autonomic cephalgias.

Hemicrania Continua

A. Headache for more than three months fulfilling criteria B-D

B. All of the following characteristics:– unilateral pain without side-shift– daily and continuous, without pain-free periods– moderate intensity, but with exacerbations of

severe pain

C. At least one of the following autonomic features occurs during exacerbations and ipsilateral to the side of pain:– conjunctival injection and/or lacrimation– nasal congestion and/or rhinorrhoea– ptosis and/or miosis

D. Complete response to therapeutic doses of indomethacin

MIGRAINE HEADACHES

What are Migraines?

MIGRAINE HEADACHES

• Useful clinical criteria from the history and physical examination for distinguishing migraine from tension-type headache include nausea, photophobia (sensitivity to light), and phonophobia (sensitivity to sound).

• Physical activity often exacerbates migraine headache.

• Combined findings useful for distinguishing migraine can be summarized by the POUND mnemonic (pulsatile quality, duration of four to 72 hours, unilateral location, nausea or vomiting, and disabling intensity). Patients who meet at least four of these criteria are most likely to have a migraine.

Migraine with or without auraA. Two or more of the following:1. Unilateral location2. Pulsating or throbbing quality3. Moderate to severe intensity4. Aggravated by routine activity

B. Plus 1 or both of the following:5. Nausea/vomiting6. Photophobia and phonophobia

C. Previous similar headaches

Aura criteria: • One or more reversible aura symptoms• One or more aura symptoms develop over more than 4 minutes, or two

or more symptoms occur in succession• Symptoms do not last more than 60 minutes• Headache follows within 60 minutes

MIGRAINE HEADACHES

• One study of 1,500 adults with migraine headache found that the presence of nausea alone, or the presence of two of three features had positive likelihood ratios for migraine of 4.8 or greater and negative likelihood ratios of less than 0.23.

MIGRAINE HEADACHES• Accurate categorization and characterization

by both clinicians and patients is important. The categorization of migraine influences choice of treatment method.

• Severity levels:–Mild : Patient is aware of a headache but is

able to continue daily routine with minimal alteration.–Moderate : The headache inhibits daily

activities but is not incapacitating.–Severe : The headache is incapacitating.–Status : A severe headache that has lasted

more than 72 hours.

Factors That May Trigger MigraineEnvironmental:

• Temperature (exposure to heat/cold) • Bright lights or glare • Noise• Head or neck injury • Weather changes • Motion• Odors (smoke, perfume) • Flying/high altitude • Physical strain

Lifestyle Habits:• Chronic high levels of stress • Skipping meals and/or poor diet• Disturbed sleep patterns • Smoking

Hormonal:• Puberty • Menopause• Menstruation or ovulation • Pregnancy• Using oral contraceptives or estrogen therapy

Emotional:• Anxiety • Depression• Anger (including repressed anger) • Excitement or exhilaration• "Let-down" response

Medications:• Nitroglycerin • Nifedipine• Oral contraceptives • Hormone therapy

Dietary Factors That May Trigger Migraine

• Dietary triggers vary considerably from patient to patient, are overall a minor and infrequent trigger for migraine headaches, and will not consistently precipitate a migraine headache in an individual for whom they have been a trigger in the past.

• Triggers:– Citrus fruit – Aspartame– Caffeine – Aged cheese– Chocolate – Alcohol (red wine, beer)– Foods containing nitrites – Foods containing monosodium glutamate

Migraine TreatmentMild migraine treatment

(self-management):– APAP/ASA/Caffeine– ASA alone– Lidocaine nasal– Midrin– NSAIDs– Triptans

Moderate migraine treatment:– DHE (dihydroergotamine

mesylate)– Lidocaine nasal– Midrin– NSAIDs– Triptans

Severe migraine treatment:– Prochlorperazine– Chlorpromazine– DHE– Ketorolac IM– Magnesium Sulfate IV– Triptans

Adjunctive therapy for all migraines:– Rest in quiet, dark room– IV rehydration– Antiemetics:

• Hydroxyzine• Metoclopramide• Prochlorperazine• Promethazine• Caffeine

Status Migrainus (lasting > 72 hrs) treatment:

• Hydration: It is recommended that the patient be hydrated prior to neuroleptic administration.

• The patient should be observed in a medical setting as clinically appropriate after administration of a neuroleptic and should not drive for 24 hours.

Status Migrainus (lasting > 72 hrs) treatment:

1. DHE (dihydroergotamine mesylate) unless contraindicated. Must not be given within 24 hours of receiving any triptan or ergot

derivative. Must not be used in patients with:

• Pregnancy• History of ischemic heart disease• History of variant angina• Severe peripheral vascular disease• Cerebrovascular disease• Hemiplegic or basilar-type migraine• Onset of chest pain following DHE test dose

2. If not DHE, then: Chlorpromazine Valproate sodium IV Magnesium Sulfate IV Prochlorperazine

3. If treatment unsuccessful: Opiates (not meperidine) Dexamethasone