Headache – AAFP 2013

International Classification of Headache Disorders, 2nd ed. (ICHD-2)

Primary:

1. Tension-type
2. Migraine
3. Cluster
4. Other: cold-stimulus headache, exertional, cervical OA, TMJ syndrome

Secondary:

• Head or neck trauma: SAH, ICH
• Cranial or cervical vascular disorder: stroke, venous sinus thrombosis
• Nonvascular intracranial disorder: increased ICP – space-occupying lesion, malignant HTN or pseudotumour cerebri
• Infection: meningitis / encephalitis
• temporal arteritis
• pre-eclampsia
• post lumbar puncture
• Substance (drugs/toxins) use or withdraw: nitroglycerin use, analgesia withdrawal, CO exposure
• Pyschiatric disorder
• Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures: sinusitis, acute-angle closure glaucoma

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1  Given a patient with a new-onset headache, differentiate benign from serious pathology through history and physical examination.

Hx:

• Pain: OPQRST- AAA – worse in AM, with bending / cough / valsalva
• Associated symptoms:
  • visual / mental status changes,
  • N/V
  • Fever / meningismus
  • photophobia, phonophobia
  • TMJ popping / clicking, jaw claudication
  • neurological Sx
• precipitating / alleviating factors:
  • Analgesics used
  • medications: nitrates, CCBs, NSAIDs, anticoagulants,
• PMH, FHx

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Criteria for Low-Risk/Benign H/A

•  <30yo
• Features typical of primary H/A
• Hx of similar H/A, no concerning change in usual H/A pattern
• NO abn neurologic findings
• No high-risk comorbid conditions: HIV etc
• No new, concerning Hx or PE findings (red flags below)

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Red flags – indications for CT scan ± ESR / lumbar puncture / b/w / temporal artery biopsy

Hx

• New-onset h/a >50yo: mass lesion or temporal arteritis
• Hemorrhage:
  • First or worst H/A of pt’s life: CNS infection, intracranial hemorrhage
  • Sudden onset (max intensity within seconds to minutes) and severe (thunderclap) h/a:
    • Bleeding into a mass or AV malformation
    • mass lesion (posterior fossa), subarachnoid hemorrhage
• ↑ICP:
  • H/A triggered by cough / exertion, or while engaged in sexual intercourse: Mass lesion, subarachnoid hemorrhage
• H/A with change in personality, mental status, LOC: CNS infection, intracerebral bleed, mass lesion
• Rapid onset with strenuous exercise: carotid artery dissection, intracranial bleed
• Worsening pattern: Hx of medication overuse, mass lesion, subdural hematoma
• New onset of severe h/a in pregnancy or postpartum: Cortical vein / cranial sinus thrombosis, carotid artery dissection, pituitary apoplexy, preeclampsia
• Comorbidities – New H/Aina pt with
  • Immunocompromised (HIV) – opportunistic infection, tumor
  • Cancer – metastasis
  • Lyme dz – Meningoencephalitis
•  trauma

 PEx

• Papilledema: Encephalitis, mass lesion, meningitis, pseudotumor
• Neck stiffness or meningismus: Meningitis
• focal neurological deficits (not typical aura): AV malformation, collagen vasculardz, intracranial mass lesion
• Tenderness over Temporal artery: Polymyalgia rheumatica, temporal arteritis
• fever, rash – systemic illness with H/A: Arteritis, collagen vascular dz, encephalitis, meningitis

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H/A DDX: ER VISIT

• Eye – acute angle closure glaucoma, sinusitis
• Recurrent / chronic – migraine, tension, cluster, TMJ dz, cervical OA
• Vascular – SAH, ICH, temporal arteritis
• Infections – meningitis, encephalitis
• Systemic: anemia, anoxia, CO poisoning (cold winter with fire place), pre-eclampsia
• ICP: mass / abscess, HTN, encephalopathy, pseudotumour cerebri
• Trauma – concussion, SDH, EDH
• PEx
• VS (BP and temperature)
• Kernig’s / Brudzinski’s
• MSK exam of H/N
• HEENT: fundi (papilledema, retinal hemmorrhages), red eye, temporal artery tenderness, sinus palpation, TMJ
• Full neurological exam: LOC, AxO, pupils, focal neurological deficits
• Red flags:
  • papilledema,
  • altered LOC, fever
  • meningismus
  • focal neurological deficits
  • signs of head trauma

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2  Given a patient with worrisome headache suggestive of serious pathology (e.g., meningitis, tumour, temporal arteritis, subarachnoid bleed):
a)  Do the appropriate work-up (e.g., biopsy, computed tomography [CT], lumbar puncture [LP], erythrocyte sedimentation rate).
b)  Make the diagnosis.
c)  Begin timely appropriate treatment (i.e., treat before a diagnosis of temporal arteritis or meningitis is confirmed).
d)  Do not assume that relief of symptoms with treatment excludes serious pathology.

SAH – Subarachnoid hemorrhage

• sudden onset, increased with exertion, reaches max intensity within min
• N/V + meningeal signs (don’t delay abx for LP)
• Dx: CT, LP (5-10% SAH have negative initial CT)
  • CT sensitivity decreases with time, esp after 48-72h
  • If CT within 6h of headache onset, no need for LP
• DDx: BATS
  • Berry aneurysm
  • AV Malformation / Adult polycystic kidney dz
  • Trauma
  • Stroke
• Tx: urgent neurosurgery consult

Increased ICP

• worse in AM, when supine or bending down, with cough or Valsalva
• PE: neurological deficits, cranial nerve palsies, papilledema
• Dx: CT
• Tx: neuro Sx consult

Meningitis

• Flu-like (Fever, n/v, malaise), meningeal signs, purpuric rash
• Alt LOC & confusion
• Perform CT to r/o ↑ ICP then do LP for dx
• Tx: early empiric Abx &b steroid

Temporal arteritis (morbidity – blindness)

• Unilateral scalp tenderness, jaw claudication, visual disturbances
• Labs: elevated ESR / CRP
• Temporal artery biopsy is gold standard for dx
• Associated with polymyalgia rheumatica
• Tx: high-dose steroids immediately if suspected

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 3  Given a patient with a history of chronic and/or relapsing headache (e.g., tension, migraine, cluster, narcotic-induced, medication-induced), treat appropriately, and avoid narcotic, barbiturate dependence.

ICHD-2 Diagnostic Criteria for Episodic Tension-Type Headache

Infrequent:
≥10 episodes, fewer than 1d/month (<12 days /yr) and fulfilling the following criteria:

1. Headache lasts 30 minutes to seven days
2. Headache has ≥2 of the following features:
   • bilateral location,
   • pressing or tightening (nonpulsating) quality,
   • mild or moderate intensity,
   • not aggravated by routine physical activity such as walking or climbing stairs
3. Both of the following:
   • no nausea or vomiting (anorexia may occur)
   • no either photophobia or phonophobia
4. Headache is not attributed to another disorder

Frequent:
≥10 episodes [ >1d & <15d ] / month for >3months and fulfilling all of the criteria for infrequent episodic tension-type headache

Tx

1. OTC analgesic ± augment with a sedating antihistamine (Benadryl) or antiemetic (Metoclopramide)
2. Prophylaxis: Amitriptyline 10-75mg po qhs
   • s/e: anticholingergic – dry mouth, blurred vision, orthostatsis, wt gain

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ICHD-2 Diagnostic Criteria for Migraine with Typical Aura

≥2 episodes fulfilling the following criteria:

1. Aura consisting of ≥1 of the following, but no motor weakness:
   • fully reversible visual symptoms including positive features (e.g., flickering lights, spots or lines) and/or negative features (i.e., loss of vision);
   • fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness);
   • fully reversible dysphasic speech disturbance
2. At least two of the following:
   • homonymous visual symptoms and/or unilateral symptoms;
   • at least one aura symptom develops gradually over five or more minutes
     • and/or different aura symptoms occur in succession over five or more minutes;
   • each symptom lasts at >5min & <60min
3. A headache that fulfills the criteria for migraine without aura, and begins during the aura or follows the aura within 60 minutes
4. Headache not attributed to another disorder

ICHD-2 Diagnostic Criteria for Migraine Without Aura

≥5 episodes fulfilling the following criteria:

1. Headache episodes lasting 4 to 72 hours (untreated or unsuccessfully treated)
2. Headache has ≥2 of the following characteristics:
   • unilateral location,
   • pulsating quality,
   • moderate or severe pain intensity,
   • aggravated by (or causes avoidance of) routine physical activity such as walking or climbing stairs
3. During the headache, the patient experiences at least one of the following:
   • nausea or vomiting; and
   • photophobia and phonophobia
4. Headache is not attributed to another disorder

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ICHD-2 Diagnostic Criteria for Cluster Headache

≥ 5 episodes fulfilling the following criteria:

1. Severe or very severe unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 minutes if untreated
2. Headache is accompanied by at least one of the following ipsilateral autonomic symptoms:
   • conjunctival injection or lacrimation,
   • nasal congestion or rhinorrhea,
   • eyelid edema,
   • forehead and facial sweating,
   • miosis or ptosis,
   • restlessness or agitation
3. Headache episodes occur from one every other day to 8 per day
4. Not attributable to another disorder

Episodic cluster headache

• Fulfills all of the above criteria
• ≥2 cluster periods lasting seven to 365 days and separated by pain-free remissions of more than one month

Chronic cluster headache

• Fulfills all of the above criteria
• Episodes recur for more than one year without remission periods or with remission periods lasting less than one month

Tx:

First-line treatments for acute cluster headache:

1. Oxygen 100% via nonrebreather face mask at 12-15 L / min for 15-20min
2. ± Sumatriptan 6mg sc may repeat once at least 1hr later / 20mg nasal spray (max 40mg /day)
   1. s/e: Injection – dizziness, fatigue, injection site reaction, nausea, paresthesias, vomiting
3. ± zolmitriptan 5mg po / nasal sparay (max 10mg/day)
   1. s/e: asthenia, dizziness, heaviness, nausea, chest tightness, paresthesia, alone or in combination, and supplemental oxygen.

2nd-line

• Lidocaine, octreotide (s/e: bloating, diarrhea, lethary, nausea), ergotamine (s/e: angina, MI, fibrosis, pruritis, vertigo)

Prophylaxis: Verapamil and lithium are the mainstays of treatment for chronic cluster headache

1. Verapamil 240 mg po daily is recommended to reduce headache severity and decrease the frequency of episodes during a cluster period.
   • ECG to monitor prolonged PR / axis / broadening QRS
   • s/e: abd discomfort, bradycardia, constipation, edema, HoTN
2. Lithium 800-900mg po with meals in divided doses
   • s/e: hypothyroidism, nephrogenic diabetes insipidus, polyuria, tremor
   • Monitor level Q6m & thyroid / renal functions
3. Steroids: Prednisone 50-80mg po daily and tapered over 10-12 days
   • s/e: hyperglycemia, HTN, inc appetite, insomnia, nervousness
4. Valproic acid, Topiramate, Ergotamine, Melatonin, Capsaicin

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4  In a patient with a history of suspected subarachnoid bleed and a negative CT scan, do a lumbar puncture.

• If CT negative but clinically, there is suspicion of SAH or meningitis, perform a lumbar puncture.
• Up to 5% SAH have a normal CT scan

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5  In a patient suffering from acute migraine headache:
a)  Treat the episode.
b)  Assess the ongoing treatment plan. (referral when necessary, take a stepwise approach).

Migraine classification:

1. Common migraine: no aura
2. classic migraine: with aura (h/a follows reversible aura within 60min)
3. Complicated migraine: with severe / persistent sensorimotor deficits
   1. eg. basilar-type migraine: occipital h/a with diplopia, vertigo, ataxia, alt LOC
   2. hemiplegic / hemisensory migraine
   3. ophthalmoplegic migraine
4. Acephalgic migraine: aura w/o h/a

Migraine Dx: POUND

• Pulsatile quality
• hOurs of duration (4-72 hours)
• Unilateral location
• N/V
• Disabling intensity

Common Migraine

• ≥ 5 attacks fulfillingeachcriteria
  • 4-72hr duration
  • 2 of the following: unilateral, pulsating, mod-severe (interferes with daily activity), aggravated by routine physical activity
  • 1 of the f0llowing: N/V, photophobia / phonophobia / osmophobia

Stages of uncomplicated migraine

1. Prodrome: hr to days before onset
2. aura: fully reversible focal cerebral dysfunction < 60min
   • eg. visual disturbance, fortification spectra, scotomata, unilateral paresthesia, numbness / weakness, aphasia
3. H/A
4. Postdrome

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Tx:

1. Avoid triggers
2. Mild to moderate: OTC NSAIDs (ibuprofen, naproxen) + tylenol / aspirin / caffeine
   • Triptans if not responding to NSAIDs
3. Moderate to severe: Triptans (most effective), ergots (dihydroergotamine, DHE)
   • Avoid triptans in pt with vascular dz, uncontrolled HTN, or hemiplegic migraine.
   • Intranasal sumatriptan and zolmitriptan seem to be effective in children
4. Avoid opiates / barbiturates for acute migraine

Migraine prophylaxis
severe migraine causing impairment of life or >3 migraine / month not responded to Tx

1. anticonvulsants – divalproex, topiramate, gabapentin
2. TCA – amitryptiline, nortriptyline
3. β-B: propranolol
4. CCB: verapamil

ED Tx:

• Abortive Tx for N/V/H/A: effectively reduce or eliminate migraine headache pain within two hours
  • Parenteral sumatriptan – not usually given
    • Sumatriptan 5-20mg intranasal or 4 – 6 mg sc
    • Sumatriptan 25-100mg po
    • Zolmitriptan 5mg intranasal or 2.5mg po
  • 1) metoclopramide 10mg IV Q8H +
    • akathisia (Parkinsonism) is associated with neuroleptics and metoclopramide.
  • (neuroleptics – ergot) 2) DHE / Dihydroergotamine 0.5mg-1mg IV/sc Q8H, and
  • (NSAIDs) 3) Ketorolac / Toradol 30-60mg IV / IM Q6h
• Migraine recurrence is less likely in patients receiving 4) dexamethasone 10-25mg IV x 1 with abortive therapy.

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References:

• http://www.aafp.org/afp/2013/0515/p682.html
• http://www.aafp.org/afp/2013/0715/p122.html
• http://www.aafp.org/afp/2002/0901/p797.html
• TN 2014