1. Headache Holly Cronau, MD Associate Professor of Family Medicine Holly.cronau@osumc.edu

2. Objectives  In an adult patient with symptoms of illness, abnormal physical findings, or abnormal lab findings, identify age appropriate differential diagnoses.  Identify the differential diagnosis for headache.

3. Instructions Articulate Module Review content Complete Quiz Utilize Learning Resources Virtual Patient Interview Carmen Flores Obtain a Patient History and History of Chief Complaint IHIS Learn Access the Patient Chart in IHIS Learn Review Physical Findings Interpret Patient Data Place Appropriate Orders Document Encounter

4. Learning  Define Headache  Identify Life Threatening Causes/”Red-Flag Warnings”  Recognize presentations for Tension and Migraine Headaches  Identify Key History and Physical examination Components  List Primary and secondary causes of headache  List an appropriate Differential Diagnosis for Headache  Determine when imaging is indicated  Develop working knowledge of the assessment of headache

5. Learning Resources Cephalgia 2004; (Suppl 1): 1-160.Cephalgia 2004; (Suppl 1): 1-160. ICHD, change from 1988 to 2004 Neurology April 24, 2012 vol. 78 no. 17 1337-1345, Neurology April 24, 2012 vol. 78 no. 17 1346-1353

6. PCMH Standards Enhance Access and ContinuityIdentify and Manage PopulationsPlan and Manage CareProvide Self Care Support and Community ResourcesTrack and Coordinate CareMeasure and Improve Performance

7. Initial Management Headache Appears Life Threatening GET MOVING!! No evidence of life threatening cause Primary Headache Disorder HA due to secondary cause

8. New onset Atypical Neurologic abnormalities Cancer Trauma Awakens from sleep Red Flag Warnings

12. Key History and Physical Examination components History Onset Previous Worsening Trauma Cancer Medication use Family history Physical Exam BP Papilledema Head and Neck Neurologic exam

13. Migraine Headaches TimingHistorySymptomsWomenAura

14. Pediatric Migraine without Aura History At least 5 attacks Duration From 1-72 hours Symptoms Unilateral OR bilateral Pulsating quality Moderate to severe intensity Worse with activity Associated Symptoms Nausea or vomiting Phonophobia or photophobia Cephalgia 2004; (Suppl 1): 1-160.

15. Complications of Migraine Frequent Migraine Chronic Migraine Status Migranosis Persistent Aura without infarct Migranous Infarct Migraine Triggered Seizures

16. Strategies for Acute Management Severe TriptansErgotamines Mild- Moderate NSAIDsAspirinCombination Antiemetics at all stages if necessary

17. When to Consider Preventive Therapy for Migraine Recurrent headache Contraindication to abortive therapy Failure of acute therapy Adverse effects of acute therapy Preference for preventive therapy Uncommon Migraine

18. Preventive Therapy Options Level A: Established Efficacy TriptansBeta BlockersAnti-EpilepticsHerbals ButterburBotox Level B: Probable Efficacy NSAIDSAntidepressantsBeta BlockersHerbals Feverfew Riboflavin high dose Magnesium Level C: Possible Efficacy Ace InhibitorsARB’sAlpha AgonistsAnti-EpilepticsAntihistaminesNSAIDSHerbals CoQ10 Level U: Use NOT Supported or Refuted FluoxetineGabapentinAspirin Calcium channel blockers Omega 3 FA Hyperbaric oxygen Neurology April 24, 2012 vol. 78 no. 17 1337-1345, Neurology April 24, 2012 vol. 78 no. 17 1346-1353

19. Avoid Triggers Stress, EmotionsPhysical exertionDehydrationLack of sleepToo much sleepSkipping mealsAlcohol, especially wine, beerPreserved meatsCaffeine and chocolateArtificial sweeteners

20. Tension Type Headache Two of the Four Symptoms Bilateral Steady, non throbbing Mild to Moderate Intensity Not aggravated by normal activity

21. Referred to a Headache Specialist? Chronic Daily Headache Chronic Migraine Unresponsive to Prophylaxis Refractory to Therapy Rebound Headaches Atypical Features Trigeminal autonomic cephalgia syndromes

22. Summary Description, onset, history, symptom pattern Associated neurological signs Personal history, trauma, cancer, vascular disease, medications Family history Age Gender Focused History Blood pressure HEENT, papilledema Look for secondary causes Detailed neurological exam Physical Exam Based upon diagnosis Remember prophylaxis Avoid overuse of pain medication Treatment

24. Thank you Questions? Contact me at: holly.cronau@osumc.edu

25. IHIS Instructions 1.View the articulate module associated with this activity, “Headache” and review basic IHIS navigation information including the creation and documentation of a patient encounter. You may access the IHIS Ambulatory Modules via the NetLearning site at mylearning.osumc.edu. Please be sure you are familiar with access to IHIS Learn before beginning. 2.Interview the patient “Carmen XX Flores” by performing a focused patient history for documentation in your Progress Note. You may click on the link below to access a hyperlink to meet the patient and perform your interview. 3.Access IHIS Learn and review your assigned patient chart “Carmen XX Flores”,” documenting Chief Complaint, Vital Signs, Allergies, Medication Documentation, History, and Progress Note in the appropriate sections. 4.Review and document the Physical Examination findings using the dot phrase “.EXAMCARMENFLORES” in the Objective section of your progress note. 5.Review and document lab testing results using the dot phrase “.LABCARMENFLORES.” 6.Review and document imaging results using the dot phrase “.IMAGECARMENFLROES.” 7.Create an assessment based upon the findings of the History and Physical Examination, lab and imaging, and choose an appropriate diagnosis in IHIS Learn Dx and Orders. 8.Select additional orders as indicated, and associate a corresponding diagnosis to each order. 9.Create a plan in the Progress Note, documenting orders placed, medication ordered, patient education and follow up instructions given in the appropriate sections. Remember to include any plans you may have for the patient for routine preventive care and return appointment. 10.Enter “NCNC” and desired follow up for the patient in the LOS &Follow-up section. 11.Close the encounter by clicking on the appropriate tab at the bottom of the Navigation bar on the lower left column on the screen. Access IHISLearn Access IHISLearn Interview Carmen Flores

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