HEADACHE
Causes of Headache: There is a very broad differential for headache but you can narrow it down with a good history and physical exam. The important thing to do is remember and consider conditions that are life-threatening and/or treatable. Your differential should include:
-Vascular etiologies: Stroke, subarachnoid hemorrhage (SAH), subdural hematoma, Arteriovenous malformation (AVM), unruptured aneurysm, venous thrombosis
-Infectious etiologies: Meningitis, encephalitis, abscess, malaria, typhoid, arboviral and typhus fever, fungal infections, sinusitis
-Malignancy: Brain tumor
-Hypertensive emergency
-Giant cell arteritis (GCA): generally seen in pts >50 yrs old; may have constitutional symptoms such as low-grade fevers, fatigue, weight loss; also may have tender temporal arteries and scalp, jaw claudication; if ophthalmic artery becomes involved can lead to optic neuritis, diploplia, and blindness—**visual loss is preventable with early recognition and treatment of GCA but irreversible once it occurs**.
If you are convinced that there isn’t a secondary cause for the patient’s headache, consider a primary headache syndrome:
-Migraine: unilateral or bilateral, retro-orbital, throbbing or pulsitile, lasts 4-72 hours, often accompanied by nausea, vomiting, photophobia, can be preceded by a visual aura.
-Cluster headache: periodic, paroxysmal, brief, sharp, orbital HA that may wake the pt up from sleep, +/- lacrimation, rhinorrhea, conjunctival injection or unilateral Horner’s syndrome
-Tension headache: band-like pain associated often with muscle contraction in neck and lower head
Clinical Evaluation:
-History should focus on
-quality, severity, location, duration, time of onset, precipitants/relieving factors
-Associated symptoms (visual changes, nausea, vomiting, photophobia)
-Focal neurological symptoms
-Head or neck trauma, constitutional symptoms
-Medications, substance abuse
-PE should focus on
-Vital signs
-General and neurological exam, optic/fundoscopic exam
-Labs and studies should be driven by the history and physical. For example, CBC, LP, blood and CSF cultures, CT head if you are worried about meningitis or other infectious causes (see meningitis lecture for more details); check an ESR if considering giant-cell arteritis. Other warning signs that should prompt neuroimaging include:
worst headache ever
pain wakes pt up from sleep
vomiting
pain exacerbated by exertion or valsalva
fever
abnl neurological exam
Treatment:
-Treatment should be based on the underlying condition.
-Migraines can be treated conservatively with ASA, acetaminophen, caffeine, and high-dose NSAIDS; 5-HT1 agonists (triptans) are very effective however should be avoided in pt’s with a h/o CAD or stroke. Prophylactic therapy against migraines include TCAs, BBs, CCBs, valproic acid and topiramate
-If you suspect giant cell arteritis you should confirm the diagnosis with a biopsy however do not delay treatment if you are not able to get the biopsy in a timely manner or the patient is already c/o visual symptoms . Treatment consists of prednisone 40-60mg PO QD. Length of treatment is based on clinical status and ESR.
HEADACHE CASES
CASE #1
A 65 yo F with a history of well controlled diabetes comes in complaining of headache for 3 weeks. She has no other medical problems. She is on metformin for her diabetes
-What is on your differential? (Hypertension, migraine, giant cell arteritis, etc.. see above causes of headache)
-What questions do you want to ask the patient? (quality and location of pain, aggravating and alleviating symptoms, associated symptoms, medications, comorbididites)
She states that the pain is generally localized to her left temple. She also notes pain in her jaw with chewing. She has had some fatigue over the past few weeks and has felt a little feverish too. The pain does not wake her up from sleep. She denies neck stiffness, photophobia, confusion, nausea/vomiting. She denies any focal neurological deficits. She states that 2 days ago she had an episode where she saw double for about an hour but that it self-resolved and hasn’t occurred since then.
-What physical exam findings are you looking for? (tenderness over the temple region with decreased pulsation of temporal artery)
On exam she is afebrile with normal VS. She has mild tenderness to palpation on her left temple and decreased temporal artery pulsation. Her neurological exam is intact. Her fundoscopic exam is normal. She has no meningeal signs.
-What is your leading diagnosis? (Giant cell-arteritis)
-What tests do you want to order? (ESR, FBP)
-How do you want to treat her? (Prednisone)
You order a FBP and an ESR. You suspect that the patient has giant-cell arteritis and while you would like to confirm the diagnosis with biopsy before beginning treatment her visual complaints concern you. You start the patient on 60mg prednisone po qd.
CASE #2
A 19 yo F with no PMH complains of intermittent throbbing headaches which she has been having since she was 13 years old. The headaches occur about once a month, are always localized behind her right eye and are throbbing in nature. Occasionally they are associated with nausea and photosensitivity. She states that her mother and sisters have similar headaches. Her physical exam is unremarkable.
-What are the three primary headache syndromes? (Migraine, Cluster,Tension)
-What do you think this patient is suffering from? (High suspicion for migraine headache)
-How would you treat this patient? (Can start initally with acetaminophen, caffeine, and high-dose NSAIDS; If not controlled, 5-HT1 agonists (triptans) are very effective. In patients who get frequent debilitating migraines, it may be worthwhile to give prophylaxis with TCAs, BBs, CCBs, valproic acid and topiramate)
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