1. Workshop on Syndrome Recognition and Management
HEADACHE
Workshop on Syndrome Recognition and Management
James J. Foody, MD, FACP
Feinberg School of Medicine
Northwestern University

2. Headache Workshop Goals
Recognition of Several Headache Syndromes
Management Strategies

3. Headache Classification
Primary v Secondary
Paroxysmal v Chronic
Episodic v Recurrent
Mild to moderate v Moderate to severe

4. What is This?

6. Case #1 CHARACTER THROBBING UNILATERAL QUALITY SEVERITY DISABLING
ONSET
MAXIMAL IN 1 HOUR
DURATION
HOURS
RELIEF
NSAID INADEQUATE
FREQUENCY
2-4 PER WEEK
CATAMENEAL

7. DIAGNOSIS #1
MIGRAINE

8. Migraine Morphology
Diagnostic criteria for migraine without aura From:   Goadsby: BMJ, Volume 312(7041).May 18,

9. Migraine Aura Spreading electrochemical depression across cortex
Typically occurs minutes before onset of head pain
>80% migraineurs never experience aura
Aura can occur w/o headache

10. Migraine Associations
Colic in infancy
Motion sickness
Ice pick-like head pains
“Freezer brain”
Increased psycho-sensory sensitivity before migraine
Increased appetite (especially for chocolate)
Sleeplessness
Burst of activity

11. Migraine Triggers Sleep deprivation/excess
Caffeine ingestion or caffeine withdrawal
Wine, especially red, & alcohol in general
Fasting
Sex hormones
Most migraines have no trigger
Strong familial pattern

12. Case #2 CHARACTER DULL BIFRONTAL QUALITY SEVERITY MODERATE ONSET
UPON AWAKENING
DURATION
ALL DAY
RELIEF
FIORINAL INADEQUATE
FREQUENCY
DAILY

13. CHRONIC DAILY HEADACHE
DIAGNOSIS #2
CHRONIC DAILY HEADACHE
TRANSFORMED MIGRAINE

14. Chronic Daily Headache
Rebound effect from analgesic
Rebound headaches begin to overlap
More analgesics due to more headaches
Worst offenders:
Caffeine
Barbiturate combinations e.g Fiorinal
Narcotics

15. Chronic Daily Headache Alternative Hypothesis
Supraspinal pain regulatory pathways are dysfunctional
Overuse of analgesics is associated, not causative
At least 2/3 had prior typical migraine

16. Case #3 CHARACTER BORING UNILATERAL QUALITY SEVERITY DISABLING ONSET
AWAKENS FROM SLEEP
DURATION
10-20 MINUTES
RELIEF
SPONTANEOUS
FREQUENCY
2-4 PER NIGHT FOR 10 NIGHTS

17. DIAGNOSIS #3
CLUSTER HEADACHE

18. Cluster Headache Clustering refers to calendar 80-90% affect males
Never throbbing
Always unilateral
Often awaken 2-3 hours after falling asleep
Alcohol invariable trigger during cluster

19. Case #4 CHARACTER SHARP WORST PAIN OF LIFE QUALITY SEVERITY DISABLING
ONSET
INTERCOURSE
DURATION
20 MINUTES
RELIEF
SPONTANEOUS
FREQUENCY
ONCE

20. DIAGNOSIS #4
THUNDERCLAP HEADACHE

21. Thunderclap Headache No known cause Benign Triggers Exertion
Sexual activity
Weight lifting
Prolonged Valsalva

22. Case #5 CHARACTER DULL BIFRONTAL QUALITY SEVERITY SOME DISABLING ONSET
6 MONTHS
DURATION
CONSTANT
RELIEF
NSAID / NARCOTIC
FREQUENCY
DAILY

23. CHRONIC DAILY HEADACHE
DIAGNOSIS #5
CHRONIC DAILY HEADACHE
TRANSFORMED MIGRAINE

24. “Sinus” Headache Pain from sinusitis is usually easily distinguishable
Sinusitis can trigger migraine headache
Migraineurs often give a family history of sinus headaches that are actually misnamed migraine

25. Bethany is a 26 year old woman c/o headache.
Case #1
Bethany is a 26 year old woman c/o headache.
She has a headache every Saturday morning for the past 4 years. She reports more frequent headaches beginning 1 week before menses and lasting until the 2nd or 3rd day of menses. The headache gradually builds until it is at its maximum in an hour. It throbs, usually on the left side, although occasionally on the right or across the front of the head. She feels nauseated and vomits rarely.
Social history: single, lives in Lincoln Park, condoms and diaphragm for contraception, works as attorney in large firm 6 days a week; no smoking; drinks alcohol only on Saturday night; sleeps from midnight-5:30 except sleeps until noon Sunday; drinks a Starbucks Venti latte every morning on the way to work and 2-3 cups coffee during the morning. Usually skips breakfast, eats light lunch.
ROS Her mother said she had colic as an infant. She hates amusement parks. She cannot read in a car.
FH: Her mother and father both get sinus headaches.

26. Migraine Treatment (1) Eliminate triggers Regular sleep patterns
Stabilize caffeine
Decrease alcohol
Look for cycling with menses

27. Migraine Treatment (2) Triptans Dihydroergotamine intranasal
Sumatriptan intranasal or subcutaneous
Rizatriptan transbuccal
Zolmitriptan transbuccal
Dihydroergotamine intranasal

28. Case #2
Nancy is a 42 year old woman c/o headache.
She has a headache most of the time for the past 6 months. She had intermittent headaches since menarche. They responded to ibuprofen until the past year. The headaches became as frequent as 2-3 per week. She saw a doctor who prescribed Fiorinal. The headaches initially responded to Fiorinal, but gradually became worse and daily. She awakens with a dull bifrontal headache almost every day. By midmorning the pain is worse and involves her neck. She takes 6-8 Fiorinal every day. She avoids caffeine, alcohol, and chocolate.

29. Chronic Daily Headache Treatment
Treat underlying migraine
Trigger avoidance
Triptan or dihydroergotamine
Preventive
Divalproex (Depakote)
Amitriptyline

30. Case #3
Diane is a 35 year old woman c/o headache.
She was well until 10 days ago when she awoke at 2 AM with extreme pain behind the right eye. She describes the pain as boring like a drill, lasting for 10 minutes. The same pain returned an hour later, accompanied by right eye tearing and watery unilateral rhinorrhea. She reports 2-4 nearly identical episodes for 8/10 past days. She went to an ER the second night, but the headache had passed. She was given a prescription for Tylenol #3, which she took once and vomited. She admits to rare headaches in the past, which are not remarkable. She fell from a horse on vacation 2 years ago with a brief loss of consciousness. She was hospitalized for observation for 1 night. She takes no medications. She is married, no children, no contraception, works as an accountant, lives in Downers Grove in her own home.
FH Her brother committed suicide at age 39. He had disabling headaches that she thinks were similar to hers.

31. Cluster Headache Treatment
High-flow inhaled oxygen
Triptan injection or intranasal
4% lidocaine 1 mL in ipsilateral nostril

32. Case #4
Stu is a 49 year old man c/o headache.
While engaged in sexual intercourse with his wife this morning, he developed the sudden onset of the worst headache of his life. The pain was sharp, constant, in the back of the head, radiating through the vertex, maximal at onset, lasted for 20 minutes and remitted completely. He could only lie still during the headache. He did not take any medication. He is apprehensive now but feels otherwise perfectly well.
PH He has a 10 year history of hypertension, controlled on HCTZ 25 mg and atenolol 50 mg daily. His cholesterol was 245 six months ago. He is trying to exercise and lose weight in order to avoid more medication. He admits to very rare mild headaches.
PE Height 6 feet; weight 249 pounds dressed. BP 140/85, pulse 62 regular. Heart, lungs, and neurological exam are completely normal.

33. Thunderclap Headache Clinical emergency to R/O subarachnoid hemorrhage
CT w/o contrast highly sensitive & specific for subarachnoid hemorrhage
LP mandatory if CT is negative
MRA if suspect cerebral venous sinus thrombosis or arterial dissection
Headache is benign and infrequently recurs

34. Case #5
Marianne is a 38 year old woman c/o headache.
She started having sinus headaches as a teenager. She has been on antibiotic therapy innumerable times. Her sinuses always hurt, sometimes worse than others. The pain is dull & bifrontal. She began taking ibuprofen +/- Vicodin. She feels they help a little and takes at least some every day. Headaches are daily for at least 6 months.
PMH Recent CT scan of the sinuses show mucosal thickening and air fluid levels. She underwent a right Caldwell-Luc procedure (maxillary antrostomy) 4 years ago. She was diagnosed with Hashimoto disease last year and takes levothyroxine 75 mcg daily.
SH She is single. She is not sexually active and has never taken OCP. She misses 3-4 days of work each month. She is an office manager who lost her last job because of absences. She is afraid she will lose this job also. She likes her job and has excellent performance appraisals except for absences.
PE Height 5’ 4”; weight 262 pounds. Blood pressure 150/90, pulse 72, temperature Mild percussion tenderness both maxillary and frontal sinus areas. Funduscopy and neurological exam are completely normal.

35. Pearls (1) Find the best dose of a triptan
Treat only two headaches a week
Do not use oral medications if nausea occurs; gastroparesis is part of migraine
Always use preventive therapy
if > 5 headaches in a month
for chronic daily headache

36. Pearls (2) “Sinus” headache is really migraine
“Tension-headache” if it exists, is mild by definition.
People do not spend money to see doctors for mild conditions.
Methysergide works well for menstrual migraine

37. Pearls (3)
Always tell migraine patients that they do not have a brain tumor or
Get an imaging study