Headache Department of Family Medicine Case Discussion

A 22 years old female university student complained of headache for a week. The headache was continuous, almost daily She denied any other problem exept for the stress in her studies. Physical examination was not remarkable. Questions

1) What relevant history would you ask? 2) What are the differential diagnosis 3) What are the red flags of headache 4) What is the most probable cause of this patient’s headache 5) How will you treat this patient

Classification of the

Classification of headache according to Policy for the Initial Approach to Adolescents and Department With a Chief Complaint of Headache

Headache CategoryI Critical secondary causes requiring

emergent identification and treatmentII Critical secondary causes not necessarily

requiring emergent identification or treatment

III Generally benign and reversible secondary causes

IV Primary headache syndromes

Classification of the headache

Classification of headache according to American College of Emergency Physicians, “Policy for the Initial Approach to Adolescents and Adults Presenting to the Emergency

hief Complaint of Headache”, 1996

Headache Category Examples Critical secondary causes requiring emergent identification and treatment

Subarachnoid hemorrhage, meningitis, brain tumor with raised ICP

Critical secondary causes not necessarily requiring emergent identification or

Brain tumor without raised ICP

Generally benign and reversible secondary Sinusitis, hypertension, post–headache

headache syndromes Migraine, tension type, or cluster

American College of Emergency Physicians, “Clinical Adults Presenting to the Emergency

Subarachnoid hemorrhage, meningitis, brain

Brain tumor without raised ICP

–lumbar puncture

Migraine, tension type, or cluster

Pathophysiology of pain in headache Extracted from Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache, 2008 Headache can be caused by (1) distention, traction, or dilation of intracranial or extracranial arteries; (2) traction or displacement of large intracranial veins or the dural envelope; (3) compression, traction, or inflammation of cranial and spinal nerves; (4) head and neck muscle spasm, inflammation, or trauma; (5) meningeal irritation; (6) raised intracranial pressure; and (7) disturbance of intracerebral serotonergic projections Maltifactorial triggers stimulating trigeminal nerve from the blood vessels of the pia mater and

dura mater

Onset of pain and releasing of neurogenic peptides from afferent C fibers innervating cephalic blood vessels

These vasoactive substance stimulate endothelial cell, mast cells and platelets

Activate inflammatory cascade known as “neurogenic inflammation”

Vasodilatation with enhanced permeability of plasma proteins follows with a perivascular inflammatory reaction

Notes: Brain cell do not have pain receptor. Therefore headache mainly arise due to stimulation of pain receptor on vessel, meningeal irritation or by direct stimulation of adjacent nerve.

Eventhough neurogenic inflammation was proposed as pathogenic mechanism of pain, however selective and potent inhibitors of neurogenic are proven ineffective in clinical trials. Serotonin (5-HT) receptors are the main focus of pain management because they are known to modulate neurogenic peptide release and vasoconstrict dilated dural vessels.

5-HT agonist (Triptans) or, dihydroergotamine, prochlorperazine, and metoclopramide, act at a variety of 5-HT and other aminergic receptors

Further history to elicit in this patient

1) Elicit the life threatening cause of headache first a) Is it the worst headache of life and characterized by thunder clap at occipital region-

subarachnoid hemorrhage b) Any sign and symptoms of increase ICP (blurring of vision, projectile vomiting

especially in the morning, severe headache, altered mental status) c) Fever, neck stiffness and vomiting to rule out meningitis. d) Presence of neurological deficit to rule out stroke.

2) Once the life threatening causes has been rule out, then elicit history to exlude differential

diagnosis which is commonly primary headache. a) Tension headache – diffuse and dull aching headache, tight band headache around

head, associated with stress, relieve on weekend b) Migraine headache - pain in relationship to food like alcohol, chocolate and cheese,

relieve by sleep, family history of migraine, sensory aura c) Cluster headache – Severe unilateral headache accompanied with tearing of the left

eye, left ptosis, rhinorrhea, left facial redness, pain on awakening from sleep, recurrent attack with one episode lasting for 20-30 minutes.

3) If still no clue, then elicit the secondary causes of headache

a) Optic causes- any recent change of spectacle, blurring of vision, astigmatism b) Ophthalmology pathology – acute closure glaucoma c) Other secondary causes – VITAMIN CDE.

The Red Flag of Headache

Red flag means emergency and require further evaluation

including CT Scan.

1) Acute onset of first most severe headache ever in life.

2) Headache that is increase in frequency or intensity

3) New onset of headache after age of 50 years old

4) Present of mental state changes

5) Associated with fever, neck stiffness and vomiting

6) Presence of neurological deficit

7) Headache with evidence of increase ICP

Additional note: HIV-positive patients with a new type of headache

should be considered for an emergent neuroimaging study.

Provisional diagnosis In this patient, the most likely diagnosis is TENSION HEADACHE because of few parameters

1) Young female 2) university student with stressful study life. 3) onset start within one week and continuous almost daily 4) unremarkable physical examination

Management for this patient

a) Pharmacological Analgesic; paracetamol (1g PRN or QID) , Aspirin, NSAIDS (Tab Mefenamic acid 500 mg or sodium diclofenac 50 mg) + anti emetic like tab. Metaclopromide (maxalon) 10 mg stat.

b) Non pharmacology

1. Ice pack 2. Relaxation technique

c) Other management

1. Caunselling on stress management.

Evidence Based Medicine Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues). Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (ie, based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies). Level C recommendations. Other strategies for patient management that are based on preliminary, inconclusive, or conflicting evidence, or in the absence of any published literature, based on panel consensus.

Extracted from Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache, 2008

1) Response to therapy for prediction of acute headache aetiology Level C recommendations. Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache. Serotonin (5-HT) receptors are the main focus of pain management because they are known to modulate neurogenic peptide release and vasoconstrict dilated dural vessels. Despite many adverse effects, 5-HT is a potent vasoconstrictor, a property that may be a factor in its ability to treat migraines Some agents, such as the triptans, are specific agonists at the 5-HT1 receptor, whereas other medications, such as dihydroergotamine, prochlorperazine, and metoclopramide, act at a variety of 5-HT and other aminergic receptors Numerous artile describes that most secondary headache show clinical improvement to many different analgesic but not limited to the following. intracerebral hemorrhage/subarachnoid hemorrhage (ibuprofen, ketorolac, prochlorperazine), viral meningitis/meningeal carcinomatosis (dihydroergotamine and metoclopramide) carbon monoxide–induced headache (sumatriptan), cerebral venous thrombosis (sumatriptan and various common analgesics),carotid artery

dissection (sumatriptan), subarachnoid hemorrhage (sumatriptan), and cysts of the cavum septi pellucidi (indomethacin). 2) Which patient should be evaluated with CT Scan Level B recommendations.

a. Patients presenting to the ED with headache and new abnormal findings in a neurologic examination (eg, focal deficit, altered mental status, altered cognitive function)- noncontrast head CT.

b. Patients presenting with new sudden-onset severe headache - head CT. c. HIV-positive patients with a new type of headache - neuroimaging study.

Level C recommendations

a. Patients who are older than 50 years and presenting with new type of headache but with a normal neurologic examination

3) Role of Lumbar puncture in ED patient who being worked up for non traumatic SAH

but with normal non contrast CT Scan Level B recommendations. In patients presenting to the ED with sudden-onset, severe headache and a negative noncontrast head CT scan result, lumbar puncture should be performed torule out subarachnoid hemorrhage. 4) Lumbar puncture in patient complaint of lumbar puncture but no prior neuroimaging

study Level C recommendations.

a. Adult patients with headache and exhibiting signs of increased intracranial pressure (eg, papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation) should undergo a neuroimaging study before having a lumbar puncture.

b. In the absence of clinical findings suggestive of increased intracranial pressure, a lumbar puncture can be performed without obtaining a neuroimaging study. (Note: A lumbar puncture does not assess for all causes of a sudden severe headache.)

5) Role of Emergent angiography in patient presented with sudden-onset, severe headache

who has negative findings in both CT and lumbar puncture

Level B recommendations.

Patients with a sudden-onset, severe headache wnormal opening pressure, and negative findings in CSF analysis do not need emergent angiography and can be discharged from the ED with follow

6) Indication for imaging for children with headache in ED

Ref: Faiqa Qureshi &Donald Lewis 7) Acute Migraine Treatment (update in medicine)

FJ, Rieg TS, Moore TS, Gendron RT. Emerg Med. 2009 Dec 31, “A Prospective, Randomized Trial of Intravenous Prochlorperazine versus Acute Migraine Therapy in the Emergency Department", and summarized by Associate Professor Rashidi Ahmadhttp://drcd2009.wordpress.com/2010/01/07/579/

1) Single dose aspirin 1000 mg + 10 mg Metoclopramide- Effective in more than half of the patient.- Aspirin reduced associated symptoms of nausea, vomiting, photophobia, and phonophobia- More superior to sumatriptan 50 mg 2) Sumatriptan 100 mg - Superior to aspirin plus Metoclopramide for 2 h pain free.Ref: Emma Hitt, " Single Dose of Aspirin Effective in Relieving Migraine Pain", http://cme.medscape.com/viewarticle/720439?src=cmenew 3) 500mL NS + IV stemetil 10 mg + IV promethazine 12.5 mg- IV prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine.

onset, severe headache who have negative findings on a head CT, normal opening pressure, and negative findings in CSF analysis do not need emergent angiography and can be discharged from the ED with follow-up recommended.

Indication for imaging for children with headache in ED

Ref: Faiqa Qureshi &Donald Lewis

Acute Migraine Treatment (update in medicine) based on study by Kostic MA, Gutierrez FJ, Rieg TS, Moore TS, Gendron RT. Emerg Med. 2009 Dec 31, “A Prospective, Randomized Trial of Intravenous Prochlorperazine versus Subcutaneous Sumatriptan in Acute Migraine Therapy in the Emergency Department", and summarized by Associate

Rashidi Ahmad (Emergency specialist HUSM) in his blog, ress.com/2010/01/07/579/

1) Single dose aspirin 1000 mg + 10 mg Metoclopramide Effective in more than half of the patient. Aspirin reduced associated symptoms of nausea, vomiting, photophobia, and phonophobiaMore superior to sumatriptan 50 mg for 2 hours pain relief and pain free.

Superior to aspirin plus Metoclopramide for 2 h pain free. Ref: Emma Hitt, " Single Dose of Aspirin Effective in Relieving Migraine Pain", http://cme.medscape.com/viewarticle/720439?src=cmenews&uac=113567PT

3) 500mL NS + IV stemetil 10 mg + IV promethazine 12.5 mg IV prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the

ho have negative findings on a head CT, normal opening pressure, and negative findings in CSF analysis do not need emergent

up recommended.

based on study by Kostic MA, Gutierrez FJ, Rieg TS, Moore TS, Gendron RT. Emerg Med. 2009 Dec 31, “A Prospective,

Subcutaneous Sumatriptan in Acute Migraine Therapy in the Emergency Department", and summarized by Associate

in his blog,

Aspirin reduced associated symptoms of nausea, vomiting, photophobia, and phonophobia

Ref: Emma Hitt, " Single Dose of Aspirin Effective in Relieving Migraine Pain",

IV prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the

8) Common Causes of headache in pediatric population

Study Burton et al Kan et al Lewis DW &Qureshi F Sample 288 patients ranging in

age from 2 to 18 years who presented with the chief complaint of headache

130 children with the chief complaint of headache

prospectively investigated causes of abrupt headache onset in 150 consecutive children presenting to the ED

Result The most frequent etiologies were viral illness, sinusitis, and migraine. 19 (6.6%) patients had serious neurologic conditions - 15 had viral meningitis, and there was 1 case each of shunt malfunction, hydrocephalus, metastatic lymphoma, and punctuate hemorrhage following head trauma.

majority were due to concurrent viral /respiratory illness or minor head trauma Significant neurological abnormality was found in only 9 (6.9%) of these children and included 1 subdural hematoma, 1 epidural hematoma, 2 ventriculoperitoneal (VP) shunt malfunctions, 1 brain abscess, 1 pseudotumor cerebri, and 3 patients with meningitis

Upper respiratory tract infections with fever (viral URI, sinusitis, and strep pharyngitis) were diagnosed in 57% of cases, and 18% of the children had migraines 15% of patients had serious underlying etiologies for the headache, including viral meningitis (9%), tumor (2.6%),VP shunt malfunction (2%), and intracranial hemorrhage (1.3%)

Conclusion: most headaches in children and adolescents were due to upper respiratory infections or migraines. Children with serious underlying conditions had demonstrable objective finding on neurological examination Reference: Faiqa Qureshi &Donald Lewis, "Managing Headache in the Pediatric Emergency Department", Clin Ped Emerg Med 4:159-170. © 2003 Elsevier Inc

9) Post headache recurrence after ED discharge Regardless of type of primary headache disorder, ED headache patients frequently experience pain and functional impairment during the hours and months after discharge. [Ann Emerg Med. 2008;52:696-704.]

10) Treating headache recurrence within 48 hours post ED discharge In this trial, nearly three quarters of patients reported headache recurrence within 48 hours of ED discharge. Naproxen 500 mg and sumatriptan 100 mg taken orally relieve post-ED recurrent primary headache and migraine comparably. Clinicians should be guided by medication costs, contraindications, and a patient’s previous experience with the medication. [Ann Emerg Med. 2010;56:7-17.]

Take home message

Extra notes

1) Most of the headache are primary headache 2) Patient with Subarachnoid hemorrhage may explain the headache as acute onset, most

severe headache in their life, thunder clap around occipital area. 3) Primary headache can be safely manage with NSAIDs 4) Brain cell do not have pain receptor. Headache usually cause by stretching of pain

receptor in blood vessel either due to direct insult or increase ICP. 5) Although first line of treatment for migraine is 5HT3 antagonist or triptans group, patient

can be managed with IV NSAIDs + IV Maxalon. 6) Hypertension rarely cause headache unless the diastolic blood pressure more than 120

mmHg.