International Classification of Headache Disorders, 2nd ed. (ICHD-2)
Primary:
- Tension-type
- Migraine
- Cluster
- 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
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
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)
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
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
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
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:
- Headache lasts 30 minutes to seven days
- 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
- Both of the following:
- no nausea or vomiting (anorexia may occur)
- no either photophobia or phonophobia
- 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
- OTC analgesic ± augment with a sedating antihistamine (Benadryl) or antiemetic (Metoclopramide)
- Prophylaxis: Amitriptyline 10-75mg po qhs
- s/e: anticholingergic – dry mouth, blurred vision, orthostatsis, wt gain
ICHD-2 Diagnostic Criteria for Migraine with Typical Aura
≥2 episodes fulfilling the following criteria:
- 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
- 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
- A headache that fulfills the criteria for migraine without aura, and begins during the aura or follows the aura within 60 minutes
- Headache not attributed to another disorder
ICHD-2 Diagnostic Criteria for Migraine Without Aura
≥5 episodes fulfilling the following criteria:
- Headache episodes lasting 4 to 72 hours (untreated or unsuccessfully treated)
- 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
- During the headache, the patient experiences at least one of the following:
- nausea or vomiting; and
- photophobia and phonophobia
- Headache is not attributed to another disorder
ICHD-2 Diagnostic Criteria for Cluster Headache
≥ 5 episodes fulfilling the following criteria:
- Severe or very severe unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 minutes if untreated
- 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
- Headache episodes occur from one every other day to 8 per day
- 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:
- Oxygen 100% via nonrebreather face mask at 12-15 L / min for 15-20min
- ± Sumatriptan 6mg sc may repeat once at least 1hr later / 20mg nasal spray (max 40mg /day)
- s/e: Injection – dizziness, fatigue, injection site reaction, nausea, paresthesias, vomiting
- ± zolmitriptan 5mg po / nasal sparay (max 10mg/day)
- 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
- 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
- Lithium 800-900mg po with meals in divided doses
- s/e: hypothyroidism, nephrogenic diabetes insipidus, polyuria, tremor
- Monitor level Q6m & thyroid / renal functions
- Steroids: Prednisone 50-80mg po daily and tapered over 10-12 days
- s/e: hyperglycemia, HTN, inc appetite, insomnia, nervousness
- Valproic acid, Topiramate, Ergotamine, Melatonin, Capsaicin
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
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:
- Common migraine: no aura
- classic migraine: with aura (h/a follows reversible aura within 60min)
- Complicated migraine: with severe / persistent sensorimotor deficits
- eg. basilar-type migraine: occipital h/a with diplopia, vertigo, ataxia, alt LOC
- hemiplegic / hemisensory migraine
- ophthalmoplegic migraine
- 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
- Prodrome: hr to days before onset
- aura: fully reversible focal cerebral dysfunction < 60min
- eg. visual disturbance, fortification spectra, scotomata, unilateral paresthesia, numbness / weakness, aphasia
- H/A
- Postdrome
Tx:
- Avoid triggers
- Mild to moderate: OTC NSAIDs (ibuprofen, naproxen) + tylenol / aspirin / caffeine
- Triptans if not responding to NSAIDs
- 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
- Avoid opiates / barbiturates for acute migraine
Migraine prophylaxis
severe migraine causing impairment of life or >3 migraine / month not responded to Tx
- anticonvulsants – divalproex, topiramate, gabapentin
- TCA – amitryptiline, nortriptyline
- β-B: propranolol
- 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
- Parenteral sumatriptan – not usually given
- Migraine recurrence is less likely in patients receiving 4) dexamethasone 10-25mg IV x 1 with abortive therapy.
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
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