Headache

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Introduction

With over 300 different causes, 'headache' is the biggest differential in medicine.

headache

Marcos Arinatwe (age 10, Uganda)

 

 

 

 

 

 

 

 

 

 

 

 

 

The Case of...

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Differential Diagnosis

 

  • primary headaches
  • secondary headaches

Primary Headaches

 

 

migraine

tension

cluster

epidemiology

12% of adults; F>M

20% with aura; 80% without

40% of adults

can be episodic or chronic

<0.1% of adults M>>F

 

duration

5-72 hours

variable duration; may be isolated or daily

<3hrs; same time of day

aura

  • lasts 20-25 min
  • lights most common
  • slow migrainers march: hand, face, legs
  • smell

 

 

pain

  • classically unilateral and throbbing
  • 40% bilateral
  • moderate-severe intensity
  • nausea/vomiting
  • photo/phonophobia
  • mild-to-moderate pain
  • bilateral
  • fronto-occipital or generalized
  • bandlike
  • +/- contracted neck muscles
  • associated with little disability
  • sudden, unilateral, severe
  • usually centred around eye
  • frequently awakens patient

family history

strong

 

   

associated features

strong correlation with sleepwalking and motion sickness

 

   

triggers

numerous: food, sleep disturbance, stress, hormonal, fatigue, weather, altitude

aggravated by physical activity

post-menopausal women can experience intense migraine, with possible only

stressful events

not aggrevated by physical activity

often alcohol

can't sit or lay down - walking, agitation

treatment

1st: acetaminophen, ASA +/- caffeine

2nd: NSAIDs

3rd: 5HT agonists, +/- amtiemetics

R and R

NSAIDs

imitrex

ergotamine

inhaled O2

lidocaine by nasal installation

prophylaxis

1st: beta blockers

2nd: TCAs

3rd: anticonvulsants

R and R, physical activity, biofeedback

 

lithium carbonate, prednisone, methysergide

 

 

Secondary Headaches

Secondary headaches account for less than 10% of all headaches, but can be life-threatening.

They include:

  • space-occupying lesions (50-60% of cases of brain tumour have headache)
  • systemic infections: meningitis, encephalitis
  • subarachnoid hemmorhage or other stroke
  • systemic disorders: thyroid disease, hypertension, phaeochromocytoma
  • temporal arteritis
  • traumatic head injuries
  • TMJ or C-spine pathology
  • serious opthalmological/otolaryngological causes
  • glaucoma

 

Avoid suggesting symptoms

 

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History and Physical Exam

  • history
  • physical exam

History

Patient demographics: age, race, occupation

History of presenting illness

  • pain: OPQRST
  • course over time
  • past events
  • medications

Risk factors

  • constitutional symptoms: night sweats, weight loss, fatigue
  • infectious symptoms: fever, changes in LOC, travel, sick contacts, myalgias, recent infection, immunosuppression
  • subarachnoid hemorrhage: trauma, alcohol, age
  • possible toxic exposure: anyone else around with the same type of symptoms

 

Specific presentations

Brain tumours or other space-occuping lesion

  • headache present upon wakening, or worse in morning
  • nausea, vomiting
  • visual changes
  • new headache after age 50
  • focal signs
  • papilledema
  • triggered by cough, exertion, Valsava

 

Hemorrhage

  • worsening pattern
  • sudden onset ("thunderclap")
  • worst headache ever
  • systemic illness

Physical Exam

Vital signs: fever? hypertension? HR, RR (decreased with increased ICP)

neurological exam

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Investigations

  • lab investigations
  • diagnostic imaging

Lab Investigations

Warranted if red flags are present. They include:

  • CBC for systemic/intracranial infection
  • ESR for temporal arteritis
  • neuroimaging (CT/MRI) to r/u intracranial pathology
  • CSF analysis for suspected hemorrhage, infection, tumour

Lumbar puncture for suspected meningitis or subarachnoid hemorrhage; contraindicated if mass suspected or seen on CT, or if skin at site of injection is infected.

Diagnostic Imaging

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Management

In many people, the worry of brain tumour is substantial and needs to be addressed during the interview.

Migraine

Cluster

Tension

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Pathophysiology

Migraine - Moves at 3 mm/min - very difficult to explain (slow depression of Leyo (sp)

 

Pain when lying down: there are no valves between head and the heart; venous congestion in the head, even of a few cc's, will increase ICP and pain

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Resources and References

 

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Topic Development

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