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Transcript of Headache
Evaluation of Headache in Adults
Bita Fakhri, MD, MPH
Boston Medical Center Shapiro Primary Care
Clinic 2/27/2013
Evaluation of Headache in Adults
HistoryDanger signs on historyPhysical exam Danger signs on physical examThree main classes of primary headachesIndications for imaging studies
History
Age at onsetPresence or absence of aura and prodromeFrequency, intensity, and duration of attackNumber of headache days per monthsTime and mode of onsetQuality, site and radiation of painAssociated symptoms and abnormalitiesFamily history of migrainePrecipitating and relieving factorsEffect of activity on pain
History
Relationship with food and alcoholResponse to any previous treatmentAny recent change in visionAssociation with recent traumaAny recent changes in sleep, exercise, weight, or
dietState of general healthChange in work or life style (disability)Change in method of birth controlPossible association with environmental factorsEffects of menstrual cycle and exogenous hormones
Danger Signs on history
Sudden onset of headache, or severe persistent headache that reaches maximal intensity within a few seconds or minutes (? SAH)
The absence of similar headaches in the past – the “first” or “worst” headache of my life (ICH, CNS infection)
A worsening pattern of headache (mass lesion, subdural hematoma, medication overuse headache)
Focal neurologic symptoms other than typical visual or sensory aura (mass lesion, AVM, collagen vascular disease)
Danger Signs on history
Fever (infection, SAH)Any change in mental status, personality, or
fluctuation in the level of consciousnessThe rapid onset of headache with strenuous
exercise (? Carotid artery dissection or ICH)Head pain that spreads into the lower neck
and between the shoulders may indicate meningeal irritation (infection, SAH)
New headache in patients <5 or >50
Danger Signs on history
New headache type in a patient with cancer suggests metastasis.
New headache type in a patient with Lyme disease suggests meningoencephalitis.
New headache type in a patient with HIV suggests an opportunistic infection or tumor.
Headache during pregnancy or postpartum suggests possible cortical vein or venous sinus thrombosis, carotid dissection
Physical Exam
Obtain BP and pulseListen for bruits at neck, eyes, and head for
clinical signs of AVMPalpate the head, neck, and shoulder regionsCheck temporal and neck arteriesExamine the spine and neck musclesFunctional neurologic examination
Danger Signs on Examination
Neck stiffness and especially meningismus (resistance to neck flexion) suggests meningitis
Papilledema (intracranial mass lesion, pseudotumor cerebri, encephalitis, or meningitis)
Focal neurologic signs (intracranial mass, AVM, collagen vascular disease)
Characteristics of Common Headache Syndromes
SYMPTOM MIGRAINE HEADACHE
TENSION HEADACH
E
CLUSTER HEADACHE
LOCATION Unilateral in 60-70% -- bilateral or
glabal in 30%
Bilateral ALWAYS unilateral
CHARACTERISTICS
Gradual in onset, crescendo pattern;
pulsating; moderate or
severe intensity; aggravated by
routine physical activity
Pressure or tightness
that waxes and wanes
Pain begins quickly,
reaches a crescendo
within minutes; pain is deep, continuous,
excruciating, and explosive
in quality
Characteristics of Common Headache Syndromes
SYMPTOM MIGRAINE HEADACHE
TENSION HEADACHE
CLUSTER HEADACHE
Patient appearance
Patient prefers to rest in a dark,
quiet room
Patient may remain active or may need
to rest
Patient remains active
Duration 4-72 hours Variable 0.5-3 hours
Associated symptoms
Nausea, vomiting, photophobia,
phonophobia; may have aura (usually
visual, but can invlove other
senses or cause speech or motor
deficits)
None Ipsilateral lacrimation and redness of the
eye, stuffy nose; rhinorrhea;
pallor; sweating; Horner’s
syndrome; focal neurologic
symptoms rare; sensitivity to
alcohol
Treatment of Migraine Headaches
• Abortive therapy: ASA, tylenol, caffeine, high dose NSAIDs,
triptans• Prophylaxis: TCA, BB, CCB, Valproic acid, topiramate
Criteria for Transformed Migraine and Medication-Overuse Headache.
Dodick DW. N Engl J Med 2006;354:158-165.
Preventive Medications Used in Cases of Transformed Migraine or Medication-Overuse Headache.
Dodick DW. N Engl J Med 2006;354:158-165.
Treatment of Cluster Headaches
Acute treatment: O2, triptansChronic prophylaxis: CCB
Indications for Imaging Studies
Recent significant change in pattern, ferequency, or severity of headache
Progressive worsening of headache despite appropriate therapy
Focal neurologic signs and symptomsOnset of headache with exertion, cough, or
sexual activityOrbital bruitOnset of headache after age 40
CT vs. MRI
There is no evidence that MRI > CTCT-brain and brainstem with and without
contrast is sufficient in most patients.MRI along with MRA are indicated when
posterior fossa or vascular lesions are suspected.
The Pain of Cluster Headache
http://www.youtube.com/watch?v=glBmSQRxaIg