Presentation on theme: "Approach to Acute Headache in Adults"— Presentation transcript:
1 Approach to Acute Headache in Adults Journal Review By: SHIRIN BITAJIAN, MDNEIMEF Residency ProgramBARRY L. HAINER, MD, and ERIC M. MATHESON, MD, Medical University of South Carolina, Charleston, South CarolinaAm Fam Physician. 2013 May 15;87(10):
2 You get a call from ER. 35 year old male presents to ER for right sided eye pain and headache. You are told by the first year resident, that the call from ER is in regards to a patient who came in with a C/O right sided eye pain. This is associated with drainage from same side and a severe unremitting headache which is sharp and knife like, 12/10 intensity, and mostly on right side. This started after an altercation. No nausea or vomiting.Patient has history of headaches.What is the diagnoses? Do you need any imaging?
4 Interns!!! Mention all the history but forget to mention the most important fact!!!
5 Types of Headaches The most common types of headaches are Tension-type headaches 40 % of adult populationMigraines 10% of adult populationCluster headaches 1 %of the adult populationMost headache diagnoses are based entirely on the patient history.Only rarely does physical examination provide clues to the diagnosis
6 International Classification of Headache Disorders, 2nd ed. (ICHD-2) Primary headachesMigraineTension-typeClusterOther (e.g., cold stimulus headache)Secondary headachesHeadache attributed to any of the following: head or neck trauma, cranial or cervical vascular disorder, nonvascular intracranial disorder, substance use or withdrawal, infection, disturbance of homeostasis, psychiatric disorderHeadache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures
7 Criteria for Low-Risk Headaches Age younger than 30 yearsFeatures typical of primary headachesHistory of similar headacheNo abnormal neurologic findingsNo concerning change in usual headache patternNo high-risk comorbid conditions (e.g., human immunodeficiency virus infection)No new, concerning historical or physical examination findings
8 History in Evaluation of Acute Headache Following require prompt evaluation:Thunderclap headache, which is characterized by sudden-onset headache pain, with peak intensity occurring within several minutes.Subarachnoid hemorrhagehypertensive emergenciesvertebral artery dissectionsacute angle–closure glaucomaIncrease the risk of intracranial bleeding or Stroke:Use of illicit drugs (cocaine , methamphetamine)Medications such as aspirin, other nonsteroidal anti-inflammatory drugs, anticoagulants, and glucocorticoids.HIV or other immunosuppressive conditions may suggest: a brain abscess, meningitis, or malignancy of the central nervous system (CNS).A patient who reports the worst headache of his or her life, especially if the patient is older than 50 years, or who has a headache that occurs with exertion (including sexual intercourse) could be experiencing intracranial hemorrhage or carotid artery dissection.
9 Physical Examination Findings Neurologic abnormalitiesA focal neurologic deficit should not be attributed to migraine headache unless a similar pattern has occurred with a previous migraine.Abnormal findings can be pronounced, such as meningismus or unilateral vision loss, or subtle, such as extensor plantar response or unilateral pronator drift.Obtundation or confusion suggests a dangerous headache because these signs do not occur with benign or primary headache.Patients with headache and fever, papilledema, or severe hypertension require evaluation for CNS infection and increased intracranial pressure.Contusions and facial or scalp lacerations increase the likelihood of associated intracranial hemorrhage.
12 DIAGNOSTIC TESTING Neuroimaging All patients who present with signs or symptoms of dangerous headache, because they are at increased risk of intracranial pathology.
13 DIAGNOSTIC TESTING Lumbar Puncture Identifying infection, the presence of red blood cells (which suggests bleeding), and abnormal cells associated with some CNS malignancies.In adults with suspected subarachnoid hemorrhage, it is important to perform lumbar puncture to check for blood or xanthochromia.Computed tomography of the head should be performed before lumbar puncture. In one supporting study, 5 percent of patients presenting to an emergency department with suspected subarachnoid hemorrhage and a normal neurologic examination had early intracranial herniation or midline shift.
15 ICHD-2 Diagnostic Criteria for Episodic /Chronic Tension-Type Headache A. Average frequency of greater than 15 attacks per month; Headache lasts 30 minutes to seven days (<12 is labeled as Infrequent chronic tension type headache)B. At least two of the following pain characteristics:1. Pressing/tightening quality2. Mild to moderate intensity (may inhibit, but does not prohibit activities)3. Bilateral location4. Not aggravated by routine physical activityC. Both of the following:1. No vomiting2. No more than one of the following: nausea, photophobia or phonophobiaD. Organic disorder is ruled out by the initial evaluation or by diagnostic studies. If another disorder is present, the headaches should not have started in close temporal relationship to the disorder.
16 Tension-Type Headache For Chronic, all of the following:Frequency: average of 15 or more headache days per month for more than 3 monthsNo vomitingNo more than one of nausea, photophobia or phonophobiaFor Episodic, all of the following:Frequency: less than 15 headache days per monthNo vomiting or nauseaNo more than one of photophobia or phonophobia
17 Tension-Type Headache Most common form of headache, and affects more than 40 percent of the adult population worldwide.Women are affected slightly more often than men.Nociceptors in the pericranial myofascial tissues are a likely source of tension headaches.Individuals who meet the criteria for tension-type headache but who have normal neurologic examination results require no additional laboratory testing or neuroimaging.
18 Tension-Type Headache Treatments: AcetaminophenAspirinNSAIDsMidrin (Acetaminophen, Isometheptene and Dichloralphenazone)Avoid overuse of treatment meds
20 CLUSTER HEADACHESRelatively rare, and are characterized by brief (15 to 180 minutes) episodes of severe head pain with associated autonomic symptoms.Although cluster headaches are less common than migraines and tension-type headaches, an estimated 500,000 Americans experience them at least once in a lifetime.The age of onset of cluster headaches varies, with 70 percent of patients reporting onset before 30 years of age.
21 CLUSTER HEADACHES Family history appears to have a role in some cases. A number of comorbidities are associated with cluster headaches, including:Depression (24 percent)Sleep apnea (14 percent)Restless legs syndrome (11 percent)Asthma (9 percent)Depression is an important diagnosis, because many individuals who have cluster headaches report suicidal thoughts, and 2 percent of patients in one study had attempted suicide.
22 CLUSTER HEADACHESOnly 25 percent of patients with cluster headaches are diagnosed correctly within one year of symptom onset, and more than 40 percent report a delay in diagnosis of five years or longer.The most common incorrect diagnoses reported in one study were migraine (34 percent), sinusitis (21 percent), and allergies (6 percent).
23 CLUSTER HEADACHES Frequency: one every other day to 8 per day Severe unilateral orbital, supraorbital and/or temporal pain most common but can present as bilateral.Pain lasting 15 to 180 minutes untreatedOne or more of the following occur on same side as the pain:Conjunctival injectionLacrimation (tearing)Nasal congestionRhinorrheaForehead and facial swellingMiosis (constricted pupil)Ptosis (eyelid drooping)Eyelid edemaAgitation, unable to lie down
24 CLUSTER HEADACHES Episodic form (80 to 90 percent of cases): episodes occur daily for a number of weeks followed by a period of remission.On average, a period of cluster headaches lasts six to 12 weeks, with remission lasting up to 12 months.Chronic form (10 to 20 percent of cases):episodes occur without significant periods of remission.
25 CLUSTER HEADACHES Acute treatment: OxygenSumatriptan SQ (self-management)Zolmitriptan nasal (self-management)DHEBridge treatment (for quick suppression of attacks until maintenance treatment reaches therapeutic level):CorticosteroidsOccipital nerve blockMaintenance treatment (for sustained suppression of attacks over the expected cluster cycle):Avoid alcohol during cycleVerapamilSteroidsLithiumDepakoteTopiramate
27 Sinus HeadacheMigraine-associated symptoms are often misdiagnosed as "sinus headache" by patients and clinicians. Most headaches characterized as "sinus headaches" are migraines.The International Classifications of Headache Disorders (ICHD-II) defines sinus headache by:Purulent nasal dischargePathologic sinus finding by imagingSimultaneous onset of headache and sinusitisHeadache localized to specific facial and cranial areas of the sinuses
28 Chronic daily headache Headache more than 15 days per month for greater thanthree months. Chronic daily headache is not a diagnosis but a category that may be due to disorders representing primary and secondary headaches.Secondary headaches are typically excluded with appropriate neuroimaging and other tests.Chronic daily headache can be divided into:Those headaches that occur nearly daily that last four hours or less and those that last more than four hours, which is more common.The shorter-duration daily headache contains less-common disorders such as chronic cluster headache and other trigeminal autonomic cephalgias.
29 Hemicrania Continua Headache for more than three months fulfilling criteria B-DB. All of the following characteristics:unilateral pain without side-shiftdaily and continuous, without pain-free periodsmoderate intensity, but with exacerbations of severe painC. At least one of the following autonomic features occurs during exacerbations and ipsilateral to the side of pain:conjunctival injection and/or lacrimationnasal congestion and/or rhinorrhoeaptosis and/or miosisD. Complete response to therapeutic doses of indomethacin
30 Medication Overuse Headache A. Headache greater than or equal to 15 days/month B. Regular overuse for greater than three months of one or more acute/symptomatic treatment drugs as defined under one or more treatment drugs as noted below: 1. Ergotamine, triptans, opioids or combination analgesic medications on greater than or equal to 10 days/month on a regular basis for greater than three months 2. Simple analgesic or any combination of ergotamine, triptans, analgesic opioids on greater than or equal to 15 days/month on a regular basis for greater than three months without overuse of any single class alone C. Headache has developed or worsened during medication overuse
33 MIGRAINE HEADACHESUseful clinical criteria from the history and physical examination for distinguishing migraine from tension-type headache include nausea, photophobia (sensitivity to light), and phonophobia (sensitivity to sound).Physical activity often exacerbates migraine headache.Combined findings useful for distinguishing migraine can be summarized by the POUND mnemonic (pulsatile quality, duration of four to 72 hours, unilateral location, nausea or vomiting, and disabling intensity). Patients who meet at least four of these criteria are most likely to have a migraine.
34 Migraine with or without aura A. Two or more of the following:Unilateral locationPulsating or throbbing qualityModerate to severe intensityAggravated by routine activityB. Plus 1 or both of the following:Nausea/vomitingPhotophobia and phonophobiaC. Previous similar headachesAura criteria:One or more reversible aura symptomsOne or more aura symptoms develop over more than 4 minutes, or two or more symptoms occur in successionSymptoms do not last more than 60 minutesHeadache follows within 60 minutes
35 MIGRAINE HEADACHESOne study of 1,500 adults with migraine headache found that the presence of nausea alone, or the presence of two of three features had positive likelihood ratios for migraine of 4.8 or greater and negative likelihood ratios of less than 0.23.
36 Severity levels: MIGRAINE HEADACHES Accurate categorization and characterization by both clinicians and patients is important. The categorization of migraine influences choice of treatment method.Severity levels:Mild : Patient is aware of a headache but is able to continue daily routine with minimal alteration.Moderate : The headache inhibits daily activities but is not incapacitating.Severe : The headache is incapacitating.Status : A severe headache that has lasted more than 72 hours.
37 Factors That May Trigger Migraine Environmental:• Temperature (exposure to heat/cold)• Bright lights or glare• Noise• Head or neck injury• Weather changes• Motion• Odors (smoke, perfume)• Flying/high altitude• Physical strainLifestyle Habits:• Chronic high levels of stress• Skipping meals and/or poor diet• Disturbed sleep patterns• SmokingHormonal:• Puberty• Menopause• Menstruation or ovulation• Pregnancy• Using oral contraceptives or estrogen therapyEmotional:• Anxiety• Depression• Anger (including repressed anger)• Excitement or exhilaration• "Let-down" responseMedications:• Nitroglycerin• Nifedipine• Oral contraceptives• Hormone therapy
38 Dietary Factors That May Trigger Migraine Dietary triggers vary considerably from patient to patient, are overall a minor and infrequent trigger for migraine headaches, and will not consistently precipitate a migraine headache in an individual for whom they have been a trigger in the past.Triggers:Citrus fruitAspartameCaffeineAged cheeseChocolateAlcohol (red wine, beer)Foods containing nitritesFoods containing monosodium glutamate
39 Migraine Treatment Severe migraine treatment: ProchlorperazineChlorpromazineDHEKetorolac IMMagnesium Sulfate IVTriptansAdjunctive therapy for all migraines:Rest in quiet, dark roomIV rehydrationAntiemetics:HydroxyzineMetoclopramidePromethazineCaffeineMild migraine treatment (self-management):APAP/ASA/CaffeineASA aloneLidocaine nasalMidrinNSAIDsTriptansModerate migraine treatment:DHE (dihydroergotamine mesylate)
40 Status Migrainus (lasting > 72 hrs) treatment: Hydration: It is recommended that the patient be hydrated prior to neuroleptic administration.The patient should be observed in a medical setting as clinically appropriate after administration of a neuroleptic and should not drive for 24 hours.
41 Status Migrainus (lasting > 72 hrs) treatment: DHE (dihydroergotamine mesylate) unless contraindicated.Must not be given within 24 hours of receiving any triptan or ergot derivative.Must not be used in patients with:PregnancyHistory of ischemic heart diseaseHistory of variant anginaSevere peripheral vascular diseaseCerebrovascular diseaseHemiplegic or basilar-type migraineOnset of chest pain following DHE test doseIf not DHE, then:ChlorpromazineValproate sodium IVMagnesium Sulfate IVProchlorperazineIf treatment unsuccessful:Opiates (not meperidine)Dexamethasone