5 - Halker-Rashmi Secondary-Headaches · RASHMI @MAYO.EDU Disclosures Rashmi Halker MD, FAHS Dr....

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6/2/2017 1 SECONDARY HEADACHES RASHMI HALKER MD, FAHS MAYO CLINIC HALKER.RASHMI@MAYO.EDU Disclosures Rashmi Halker MD, FAHS Dr. Halker has received honoraria from Medlink and Current Neurology & Neuroscience Reports. Learning Objectives LEARN how to recognize rare and unusual headache syndromes A VOID missing potentially life-threatening emergencies KNOW RED FLAGS that may indicate a secondary headache diagnosis

Transcript of 5 - Halker-Rashmi Secondary-Headaches · RASHMI @MAYO.EDU Disclosures Rashmi Halker MD, FAHS Dr....

Page 1: 5 - Halker-Rashmi Secondary-Headaches · RASHMI @MAYO.EDU Disclosures Rashmi Halker MD, FAHS Dr. Halker has received honoraria from Medlink and Current Neurology & Neuroscience Reports.

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SECONDARY HEADACHES

RASHMI HALKER MD, FAHS

MAYO CLINIC

[email protected]

Disclosures

Rashmi Halker MD, FAHS

Dr. Halker has received honoraria from

Medlink and Current Neurology & Neuroscience Reports.

Learning Objectives

LEARN how to recognize rare and unusual headache syndromes

AVOID missing potentially life-threatening emergencies

KNOW RED FLAGS that may indicate a secondary headache diagnosis

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Distinguish Primary from Secondary Headache Disorders

Silberstein SD, Lipton RB, Goadsby PJ. Headache in Clinical Practice. Oxford, UK: Oxford University Press; 1998:31-40.

Secondary HeadachesSNOOP4 Red Flags

• Systemic disease or symptoms

– Malignancy

– Fever

– Weight loss

• Neurologic signs or symptoms

• Onset that is sudden (acute or thunderclap)

• Onset after age 40

• Previous headache history with new or different headache features

• Progressive

• Postural

• Precipitation by Valsalva or exertion

Case 1: Male, Age 75

• 2-month history of mild left “boring” headache

• Visual loss like a curtain in left eye x 3 in last week, lasting

1 minute each time

• Medical history

–Has had some blood pressure elevation, which was treated

–Some CAD

• Examination

–General examination: heart, lungs, and abdomen normal

–Neurological examination normal

–There was “one thing. . .”

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This “One Thing. . .”

Case 1

What diagnostic test is priority at this point?

a. Blood tests (CBC, sedimentation rate, C-reactive protein)

b. Temporal artery biopsy

c. MRI brain without gadolinium

d. Carotid ultrasound

e. Lumbar puncture

Laboratory Results

Erythrocyte sedimentation rate 124

Hemoglobin 12.3

White blood cell count 6.2

Platelets 252

C-reactive protein 10.0

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Case 1

What diagnostic test is priority at this point?

a. Temporal artery biopsy

b. Carotid ultrasound

c. Lumbar puncture

d. MRA head and neck

Biopsy Done

Case 1

What is the most important thing to do now?

a. Bilateral temporal artery biopsy

b. Carotid ultrasound

c. Lumbar puncture

d. MRA head and neck

e. Trial of prednisone 1 mg/kg

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??

What Do They Have in Common?

Case 1

What do the previous two patients have in common?

a. Nothing in common

b. Both are elderly with headaches

c. They both have similar imaging

d. They both share the same diagnosis

Case 1: Clinical Pearls

1. Don’t depend on imaging

2. TA can present with amaurosis fugax

3. Requires index of suspicion, patient can look normal or ”sick” looking. . .

4. There are causes other than GCA of new

onset headache in the elderly with

elevated ESR, but few more important

than TA for neurologists!

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Case 2: Male, age 79

• 1 month history of headache unresponsive to OTC meds

• No prior history of headache

• Severe left temporal headache, worse with lying supine, associated with scalp sensitivity

• Partial loss of vision in left eye 1 week prior

Case 2

• PMH:

–Follicular grade 2 non-Hodgkin’s lymphoma, completed chemotherapy

6 weeks prior

–Obstructive sleep apnea on CPAP

–Hypertension

–Hyperlipidemia

–Prostate cancer

• Exam:

–Visual acuity OD 20/25, OS 20/40; IOP 17/16

Case 2

What diagnostic test would be a priority at this point?

A. Sedimentation rate

B. Bilateral temporal artery biopsy

C. MRI brain without gadolinium

D. Carotid ultrasound

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Lab results

• ESR 61

• Hemoglobin 12.3

• WBC 6.2

• Platelets 252

• CRP 4.6

MRI brain

Biopsy results

• Bilateral temporal artery biopsies negative

• Despite prednisone, patient blind in left eye 1 month later

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MRI (2 weeks later)

Diagnosis: fungal sphenoid sinusitis Treatment: voriconazole

1-Month Follow-Up MRI

Biopsy consistent with aspergillous

Case 2: Pearls

• Sphenoid sinusitis is a medical emergency

• Requires a high index of suspicion, especially in

immunocompromised, elderly, patients with headache worsening with Valsalva / in supine position

• There are other causes of new-onset headache in the elderly with elevated ESR

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Case 3: Female, age 61

• 61 y/o F presents with chronic daily headache x 1 year

• Headache mainly right-sided, but can become holocephalic,

throbbing, 10/10 max intensity, associated with nausea, photophobia, phonophobia

• PMH: Chronic insomnia, depression (current PHQ-9 score 24-2)

Case 3

• Tests done, negative: MRI brain, MRA head/neck, lumbar puncture, labs (CBC, CMP)

• Previous medications tried: gabapentin, valproic acid, carbamazepine, primidone

• Current medications: topiramate 100mg TID, nortriptyline 25mg qHS, oxycodone/APAP 5/325mg PRN (1 tablet daily)

• Exam: BMI 28.0 kg/m2, BP 127/76, HR 86; patient tearful and anxious; no papilledema; general medical, musculoskeletal, and neurological exams normal

Case 3

What is the next step in the evaluation of this patient?

A. MRV head with gadolinium bolus

B. MRI C-spine without contrast

C. EKG

D. Psychiatry consult

E. Increase nortriptyline to 50mg qHS

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Case 3: Baseline EKG

Case 3

• Nortriptyline 25mg qHS discontinued

• Repeat EKG

• Cardiology consult

Case 3: Repeat EKG 3 weeks later

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Case 5 Pearls

• Know potential common and serious side effects of

medications.

• Periodic EKG monitoring should be done in patients on meds with potential QT prolongation.

Case 4: Female, Age 70

• Patient for 5-month history of throbbing headache, in left

occipital region. . .

• Pain radiates to neck region and is worse with exertion, walking for 12 minutes. . .

• She needs to lay down and rest, and headache improves in 1 to 2 hours. . .

• Examination normal except tender to palpation over left occipital nerve. . .BP is 148/78

Case 4: More History

• Retired and has been under some stress. . .

• On statin for elevated lipids and BP medication for

hypertension. . .

• Complains of arthritis in neck and thinks this is causing her

headache. . .

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Case 4: Investigations

• Neck x-rays show DDD at C5 to C7 levels. . .

• MRI brain, MRA head/neck, MRV head are normal

Case 4: Some Blood Work. . .

Ordered CBC, ESR, and CRP — only ESR elevated at 36

Arrange for her to be on ASA 81 mg a day

Blood otherwise normal, but CRP is high level of normal

Case 4: Other Options

• More episodes of pain. . .

• Maybe an occipital nerve block, so arranged to be done the

next week. . .

• Start on nortriptyline and see how she does, but before that. . .

Ordered something else!

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Case 4: Just Checking!

Case 4

• Stress echo shows new areas of regional wall motion

abnormality

• Test triggered headache, but no chest pain

• Headache responded to isosorbide mononitrate

ICHD-3: Cardiac Cephalalgia

A. Any headache fulfilling criterion C

B. Acute myocardial ischemia has been demonstrated

C. Evidence of causation demonstrated by at least 2 of the following:

1. Headache has developed in temporal relation to onset of acute myocardial ischemia

2. Either or both of the following:

D. Not better accounted for by another ICHD-3 diagnosis

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Case 4: Cardiac Cath. . .

Sathirapanya P. J Neurol Res. 2012;2(5):224-225.

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Case 4: Clinical Pearls

1. Headache is primary pain location in 3.5% of

patients with angina/myocardial infarction

2. Exertional headache may be a manifestation of cardiac disease, even with negative

treadmill exercise ECG testing

3. Cardiac cephalalgia should be considered in

patients who present with new onset

headache, especially when headache is exertional, patient is over 50 years, or has

cardiac risk factors

Case 5: Male, Age 32

Persistent headache for 2 months

Case 5

What is the next step in the workup of this patient?

a. Lumbar puncture

b. MRI brain with gadolinium

c. Sedimentation rate and C-reactive protein

d. Head CT with contrast

e. Neurosurgery referral for posterior fossa decompression

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Case 5: MRI brain with gadolinium

SEEPS

Subdural fluid collection

Enhancement of meninges

Engorgement of veins

Pituitary hyperemia

Sagging of brain Hypermobile joints

sometimes seen in those with SIH

Case 5: Pearls

• If diagnostic imaging is needed in the evaluation of chronic

daily headache, MRI is necessary.

• When brain MRI is needed in the evaluation of chronic daily

headache, gadolinium is invariably indicated.

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Case 5 Pearls: Headache Diagnoses Missed by CT

• Vascular

– Saccular aneurysms

– SAH

– AVM

– Carotid or vertebral dissection

– Stroke

– Cerebral venous sinus thrombosis

– Vasculitis

– RCVS

• Neoplastic

– Parenchymal and extra-axial neoplasms (esp

in posterior fossa)

– Meningeal carcinomatosis

– Pituitary tumor/hemorrhage

– Brain metastasis

• Infectious

– Meningoencephalitis

– Cerebritis and brain abscess

• Cervicomedullary lesions

– Chiari malformation

– Foramen magnum meningioma

– Acoustic neuroma

• Other

– CSF leak/intracranial hypotension

– Intracranial hypertension

– Dural and leptomeningeal disease

Case 6: Female, 44

• 44 y/o F presents to outside ER with severe headache

associated with nausea, photophobia

• PMH: HTN, MS, migraine without aura, fibromyalgia

• Meds: fluoxetine, hydrocodone, lisinopril

• Exam: BP 168/98, mild gait unsteadiness, extensor right plantar response

Case 6

Patient discharged home with diagnosis of MS exacerbation vs migraine.

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Case 6

• Recurrent severe headaches over 5 days with visual

impairment and headaches

• Returns to ER, admitted to hospital

• CSF opening pressure and analysis normal

• 1 gram IV solumedrol x 3 days

Case 6: Repeat Brain MRI

Case 6

What is the next most appropriate step?

A. Continue IV solumedrol

B. MR angiography

C. Initiate plasma exchange

D. MR venography

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Case 6: MRA Head

Case 6

• MRA: CNS vasculitis

• Continued treatment with 14 days IV solumedrol

• Severe deterioration within 5 days with cortical blindness and quadriparesis

Case 6

What was the most likely cause of her headache?

a. Primary thunderclap headache

b. Crash migraine

c. Reversible cerebral vasoconstriction syndrome

d. Cerebral venous thrombosis

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Case 6: Thunderclap HeadacheReversible Cerebral Vasoconstriction Syndrome (RCVS)

• RCVS– Most commonly precipitated post-partum

or with the use of vasoactive substances

o Cannabis

o Cocaine

o SSRIs

o Binge drinking

o Nasal decongestants

– May result in:

o SAH

o ICH

o Stroke

o PRES

– Treated with IV/PO calcium channel blockers Ducros et al. Brain 2007; 130:3091-3101

Case 6

• RCVS

• After two days of IV nicardipine 7.5 mg/kg…

Case 6

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Case 6: Pearls

• Of patients who present with Thunderclap Headache, 10% have a serious cause

– Ask about mode of onset, especially for patients in ED and those who seek help for

‘a’ particular headache

– Know the differential diagnosis of Thunderclap Headache

• All patients should be aggressively evaluated with CT, CSF, and if negative,

MRI/MRA/MRV

– Those with negative CT/CSF require further workup

• Always suspect RCVS in patients who present with thunderclap headache, regardless

of trigger, and in patients suspected of CNS vasculitis

• 10-day history of severe orbital pain

• Normal examination and no orbital bruits. . .

• CT and MR head and orbits normal. . .

• Left occipital nerve block done and improved. . .

Case 7: Female, Age 66 — Left Orbital Pain

Recurrent Orbital Pain

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Now We See It. . .

Finally, an Answer!

Subarachnoid Hemorrhage: Beware of Blood in the PITS

Parenchymal

Intraventricular

Truncal

Sulcal

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Summary

• Secondary headaches not to miss include:

–Temporal arteritis

–Sphenoid sinusitis

–Cardiac cephalalgia (NSTEMI)

–Spontaneous intracranial hypotension

–Reversible cerebral vasoconstriction syndrome

–Subarachnoid hemorrhage

• Requires vigilance and high index of suspicion

• Pearls (eg, SNOOP4, SEEPS, PITS) can improve recognition and may be life-saving