Headache for the PCP: Evaluation and Initial
Management
Chris Jackman, MDAssistant Professor of NeurologyChild Neurology of Riley HospitalDirector, Riley Headache Center
Objectives
• Identify a systemic evaluation of a headache patient
• Evaluate for causes of secondary headache
• Recognize how to diagnose common primary headache symptoms of childhood
• Identify how to treat primary headache syndromes
Initial Evaluation
1. Shoulder shrug and look to parents
2. “I don’t know”
3. “Headaches?”
It’s in the history
• Time course• Time course• Time course
• Pain description– Location– Severity – Quality
• Associated symptoms
Other questions:
• Pain description– Location– Severity – Quality
• Associated symptoms– Aura– Nausea, vomiting– Photophobia, phonophobia– Light-headedness, vertigo– Autonomic features
Red Flags
• Time course– Progressive– Morning
• Location– Posterior
• Postural• Focal neurologic
signs– Any
• Systemic signs– Fevers, rash
• Family history– As in, none
• Age– Under 6 years
Physical exam
• Eyes / Fundus
• TMJ
• Face
• Muscles
• Skin
• Neurologic
Secondary Headaches
Non-neurologic causes of secondary headaches
• Dental/ TMJ
• Allergies/ congestion
• Sinus inflammation/ infection
• Ear infection/ Mastoiditis
• Hypothyroidism
• Pheochromocytoma (Hypertension)
• Eye-strain
It is (probably) not a tumor
• Brain tumors are very rare• BUT…
– You only need to miss one to be incompetent
• The chance of finding a tumor in a patient with headaches and a normal neurological exam is…
It is not a tumor
• Very low, but not quite zero
• Brain tumors typically cause headache when they cause increased pressure
• A much more common presentation is focal neurologic signs with minor headache
It is a tumor
• Key features– Time course (Progressive)
– Timing (On awakening)
– Postural (Supine)
– Focal Neurologic signs
– Seizures
If it’s not a tumor, what is it?
Intracerbral Hemorrhage
• Features– Time course (Acute)– History of trauma– Focal Neurologic signs
• Types of hemorrhage– Subdural– Epidural– Subarachnoid– Paranchymal– Interventricular
Venous sinus thrombosis
• Associated with primary or secondary hypercoagulable state
• Present with signs of increased intracranial pressure
• Sometimes hemorrhage• Red Flags
– Time course (Progressive or static)
– Postural– Neurologic signs
• Papilledema• 6th nerve palsies
Ideopathic intracranial hypertension
• Mechanism unknown• More female, more obese• Headache with visual loss• Red Flags
– Time course (Progressive or static)– Postural– Neurologic signs
• Papilledema• 6th nerve palsies
Ideopathic intracranial hypotension
• Seen in some connective tissue diseases from dural ectasia (or ideopathic)
• Mimics LP headache
• Red Flags– Time course (Progressive or static)– Postural
Meningitis / Encephallitis
• Red flags:– Systemic signs (fever)– Focal Neurologic signs (meningismus,
encephalopathy, seizures)
Chiari I Malformation
• Protrusion of cerebellar tonsils below the foramen of Monro
• Red flags:– Location (posterior)– Postural, pain with
neck movements– Focal Neurologic signs
(ataxia)– Worse with cough,
sneezing, valsalva
Post-traumatic or Post-concussiveHeadache
• Red flags: See hemorrhage
• Will get better, may take months
• Cognitive changes are common, will also improve
Headache Evaluation
Do I order LABS?
Headaches in children younger than seven years of age
Chu ML, Shinnar S. Arch Neurol, 49:1992; 79-82
• Study of 104 children referred to Child Neurology
• Studies performed prior by the pediatrician• Studies included:
– Cell counts– Basic electrolytes– Tranaminases– Urinalysis
• “Uniformly unrevealing”• Similar prospective study in adults of 193
patients showed same results
Do I order a SCAN?
American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches
2002• Neuroimaging
– Combined 6 studies– 605 of 1275 had imaging (CT in 116, MRI in
483, both in 75)– 97 children with imaging abnormalities (16%)
• 79 considered incidental• 14 surgically treatable• 4 medically treatable
• Of the 14 surgical lesions:– 10 tumors– 3 symptomatic vascular malfomations– 1 significant arachnoid cyst
• All had an abnormal neurologic examination– Papilledema– Abnormal eye movements– Motor dysfunction– Gait dysfunction
American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches
2002
– Parameters which distinguish headache patients with space occupying lesions
• Headache of less than one month duration• Absence of a family history of migraine• Abnormal neurological examination• Gait abnormalities• Seizures
– Those patients with headaches for less than 6 months and at least one of the above symptoms are considered “high-risk”
• “High-risk” = 4% chance of space occupying lesion
American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches
2002
CT vs. MRI?
Primary Headache Disorders
Migraine Diagnosis and Treatment: Results From the American Migraine Study II
Headache 2001;41:638-645
• Survey mailed to 20,000 homes, identified 3577 individuals who met criteria for migraine
• 48% had previously received a physician diagnosis
• 24% of those undiagnosed had missed at least one day of work or school in the previous three months
• Those missed were:– Lower income– Younger age (18-29)– Male
Migraine epidemiology
• Headache prevalence– Tension type HA 78%– Migraine 16%– Children
• 3-8% by age 3• 37-52% by age 7• 57-82% in 7-15 year olds
• Peak incidence– Women – age 12-13 (aura), 14-17 (without)– Men – age 5 (aura), 10-11 (without)
Comprehensive Review of Headache Medicine; Levin M Ed; Oxford 2008
“If nothing is wrong with me, doctor, why do I have these headaches?”
Migraine pathophysiology
• Primarily a NEUROGENIC process
• We think
• For now
Migraine pathophysiology
• Aura– Cortical spreading depression– Front of profound depolarization– Moves across cortex ~ 3mm/min– Following by suppression of neural activity
lasting minutes
A.P. Leão.
Cortical Spreading Depression
Migraine pathophysiology
Migraine without aura Pediatric diagnostic criteria
• At least five attacks fulfilling criteria B-D (below)• Headache attacks lasting 1 to 72 h• Headache having at least two of the following characteristics:
– Unilateral location, may be bilateral, frontotemporal (not occipital)
– Pulsing quality– Moderate or severe pain intensity– Aggravation by or causing avoidance of routine physical
activity (eg, walking, climbing stairs)• During the headache, at least one of the following:
– Nausea or vomiting– Photophobia and phonophobia, which may be inferred
from behavior• Not attributed to another disorder
Migraine with aura Pediatric diagnostic criteria
• At least two attacks fulfilling the criteria B-D (below)• Aura consisting of at least one of the following, but no
motor weakness: – Fully reversible visual symptoms, including positive features or
negative features (e.g., flickering lights, spots, or lines)– Fully reversible sensory symptoms, including positive features
(i.e., pins and needles) or negative features (ie, numbness)– Fully reversible dysphasic speech disturbances
• At least two of the following: – Homonymous visual symptoms or unilateral sensory
symptoms– At least one aura symptom develops gradually over 5 min or
different aura symptoms occur in succession over 5 min– Each symptom lasts between 5 min and 60 min
• Not attributable to another disorder
And…
…Chronic Daily Headache…
Chronic Daily Headache
• Transformed (or chronic) migraine– History of migraine– Progresses to chronic, low level headache
with periodic migraines
• Chronic tension type headache– Lack significant migranous features– Less severe intensity– Tightening more than pulsating
• New daily persistent headache
Chronic daily headaches - evaluation
• Look for red flags*
• Ask about analgesic overuse
* Especially in New Daily Persistent Headache
Practice Parameter: Pharmacological
treatment of migraine headache in children and adolescents
D. Lewis, MD; S. Ashwal, MD; A. Hershey, MD; D. Hirtz, MD; M. Yonker,
MD; and S. Silberstein, MDNEUROLOGY 2004; 63: 2215–2224
Migraine treatment - Abortive
• Ibuprofen, acetaminophen, ketorolac, indomethacin, ASA
• Combinations (Acetaminophen/ASA/caffeine)• Antiemetics (promethazine, chlorpromethazine• Opiates, barbituates (no, no, never…)• Corticosteroids• Triptans
– 5HT1b, 1d, and 1f agonists– Contraindications include cardiovascular disease or risk
factors, Reynaud’s, hemiplegic migraine– Side effects include nausea, dizziness, chest and throat
tightness
Migraine treatment - Abortive
Migraine treatment - Prophylactic
• When to use prophylaxis– Headaches frequent
– Headaches severe
– Headaches disruptive
• Side effects and burden of taking a daily medicine < the life disruption caused by (appropriately treated) headaches
Migraine treatment - Prophylactic
• Antihistamines• Beta-blockers• Tricyclics• Anticonvulsants• Calcium channel blockers
Migraine treatment - Prophylactic
• Antihistamines– Cyproheptadine
• Little studied, often used• Reduce headaches from 8.4 to 3.7 per month• Somnolence, weight gain• Initial dose 1-2 mg QHS, max 4 mg BID
Lewis D, Diamond S, Scott D, et al. Prophylactic treatment of pediatricmigraine. Headache 2004;44:230–237.
Migraine treatment - Prophylactic
• Beta-blockers– Propranolol most studied
– Three small, prospective class II studies with conflicting results
– Exercise intolerance
– Contraindicated in asthma, depression
– Initial dose 20 mg, up to 160 mg
Migraine treatment - Prophylactic
• Tricyclics– Amitriptyline most studied
– Anticholinergic effects, somnolence
– Black box warning re: suicidality
– Baseline EKG and monitor for QT prolongation
– Initial dose 10 mg up to 100 mg
– Give at dinner
Migraine treatment - Prophylactic
• Anticonvulsants– Topiramate (or zonisamide)
• Best studied
– Valproate• Effective but side effects can be significant
– Levetiracetam/ Lamotrigine• Limited (poor) data
Migraine treatment - Prophylactic
• Calcium channel blockers– Conflicting data
– Familial hemiplegic migraine
– Abdominal discomfort
– Monitor EKG and blood pressure
Chronic Daily Headache - Treatment
• Preventative medications – – Evidence is spotty at best
• Topiramate is best studied, anecdotally all migraine medications may work
– Transformed migraine or for medication overuse – early prophylactic treatment
– Chronic tension type headache – late medical treatment
– New daily persistent headache – doesn’t matter
Non-pharmacologic Treatment
• Lifestyle! Lifestyle! Lifestyle!– Analgesic overuse– Sleep– Diet– Psychiatric
Non-pharmacologic Treatment
• Analgesic overuse– Opiotes/ barbiturates > triptans
>>NSAIDS– Any used over 15 days/month, some
over 10 days/month– Can treat by a period of elimination or
by moderation– Headaches may take 4-6 weeks to
improve
Non-pharmacologic Treatment
• Sleep– Snoring– Movements– Quality– Quantity– Continuity
Non-pharmacologic Treatment
• Diet– Meats (Iron, B12)– Vegetables (Folate?)– Skipping meals– Hydration– Caffeine
Non-pharmacologic Treatment
• Psychiatric evaluation– Anxiety– Depression– Obsessive-compulsive disorder
• Non-pharmocologic management– Biofeedback– Self-hypnosis– Relaxation
Take home points:
• Red flags– Progressive time course– Postural– Worse in the morning– Any neurologic sign or symptom– Worse with valsalva
• Practice your fundoscopic and cranial nerve exam
Closing thoughts…
• Watch for red flags• Know when to image• If unsure whether to image, refer• Know helpful lifestyle modifications• Know when to start or refer for prophylactic
medications
• Remember: “Your patient does not want to have a headache”
References• Sargent JD, Solbach P. Medical evaluation of migraineurs: review of the value of
laboratory and radiologic tests; Headache 1983; 23:62-65• Chu ML, Shinnar S. Headaches in children younger than seven years of age
Arch Neurol, 49; 1992; pp79-82• Maytal J, Robert S. Bienkowski, Patel M and Eviatar L. The Value of Brain Imaging in
Children With Headaches. Pediatrics 1995;96;413-416• Levin M Ed; Comprehensive Review of Headache Medicine: Oxford 2008• Lewis D, Ashwal, S; Hershey A; Hirtz D; Yonker, M; and Silberstein S, Practice
Parameter: Pharmacological Treatment of migraine headache in children and adolescents. Neurology 2004;63:2215–2224
• Ludvigsson J. Propranolol used in prophylaxis of migraine in children. Acta Neurol 1974;50:109–115.
• Forsythe WI, Gillies D, Sills MA. Propranolol (Inderal) in the treatment of childhood migraine. Dev Med Child Neurol 1984;26:737–741.
• Olness K, MacDonald JT, Uden DL. Comparison of self-hypnosis and propranolol in the treatment of juvenile classic migraine. Pediatrics 1987;79:593–597.
• D.W. Lewis, MD; S. Ashwal, MD; G. Dahl, BS; D. Dorbad, MD; D. Hirtz. Practice parameter: Evaluation of children and adolescents with recurrent headaches: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002;59:490–498
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