Approach to Patient With Headache

8/2/2019 Approach to Patient With Headache

1/89

Approach to patient with

Headache

Dr. Hemant M. Shah

Assistant Professor,

SMIMER


2/89

Headache is among the most common reasons patients seek

medical attention.

Diagnosis and management is based on a careful clinicalapproach augmented by an understanding of the anatomy,physiology, and pharmacology of the nervous system pathways

that mediate the various headache syndromes.


3/89

Old Ad-hoc Headache Classification1. Migraine Migraine variants, vascular headaches, atypical facial neuralgia

2. Tension headache (muscular contraction headache)

3. Headache associated with intracranial disturbances Arteriosclerotic brain diseases, vascular anomalies, aneurysms, tumor,

infections

4. Headache associated with extracranial disturbances Eye, ear, nose, bones of the skull and neck

5. Headache associated with cranial trauma6. Hypertension, allergy, arteritis (temporal), fevers,

infection

7. Psychogenic headaches Conversion, tension headaches


4/89

International Classificationof Headache Disorders

2nd edition

(ICHD-2)


5/89

ICHD-2 Classification

Part 1:

Primary headache disorders

Part 2:Secondary headache disorders

Part 3:

Cranial neuralgias, central and primary

facial pain and other headaches


6/89

Primary Headache Secondary Headache

Type % Type %

Tension-type 69 Systemic infection 63

Migraine 16 Head injury 4

Idiopathicstabbing

2 Vascular disorders 1

Exertional 1 Subarachnoid

hemorrhage


7/89

Anatomy and Physiology of Headache

Pain usually occurs when peripheral nociceptors are stimulated inresponse to tissue injury, visceral distension, or other factors .

In such situations, pain perception is a normal physiologic responsemediated by a healthy nervous system.

Pain can also result when pain-producing pathways of the peripheral orcentral nervous system (CNS) are damaged or activated inappropriately.Headache may originate from either or both mechanisms.

Relatively few cranial structures are pain-producing; these include the

scalp, middle meningeal artery, dural sinuses, falx cerebri, and proximalsegments of the large pial arteries.

The ventricular ependyma, choroid plexus, pial veins, and much of thebrain parenchyma are not pain-producing.


8/89

The key structures involved in primary headache appear to be

The large intracranial vessels and dura mater and the peripheralterminals of the trigeminal nerve that innervate these structures

The caudal portion of the trigeminal nucleus, which extendsinto the dorsal horns of the upper cervical spinal cord and receivesinput from the first and second cervical nerve roots (thetrigeminocervical complex)

Rostral pain-processing regions, such as the

ventroposteromedial thalamus and the cortex

The pain-modulatory systems in the brain that modulate inputfrom trigeminal nociceptors at all levels of the pain-processingpathways


9/89

The innervation of the large intracranial vessels and duramater by the trigeminal nerve is known as thetrigeminovascular system.

Cranial autonomic symptoms, such as lacrimation andnasal congestion, are prominent in the trigeminal autonomiccephalalgias, including cluster headache and paroxysmalhemicrania, and may also be seen in migraine.

These autonomic symptoms reflect activation of cranialparasympathetic pathways, and functional imaging studiesindicate that vascular changes in migraine and clusterheadache, when present, are similarly driven by these cranialautonomic systems


10/89

Intensity of pain rarely has diagnostic value.

Headaches are usually benign, but sometimes

severe and disabling.

Its very important to distinguise serious frombenign illnesses.

Complete neurologic examination is alsonessesory.


11/89

Headache Symptoms that Suggest a Serious

Underlying Disorder"Worst" headache ever

First severe headache

Subacute worsening over days or weeksAbnormal neurologic examination

Fever or unexplained systemic signs

Vomiting that precedes headache

Pain induced by bending, lifting, coughPain that disturbs sleep or presents immediately upon awakening

Known systemic illness

Onset after age 55

Pain associated with local tenderness, e.g., region of temporal artery


12/89

PRIMARY HEADACHE

1.) Migraine

2.) Tension-type headache

3.) Cluster headache


13/89

Migraine Facts Migraine is one of the common causes of recurrent headaches

According to IHS, migraine constitutes 16% of primary

headaches

Migraine afflicts 10-20% of the general population

More than 2/3 of migraine sufferers have never consulted a

doctor

Migraine is underdiagnosed and undertreated

Migraine greatly affects quality of life. The WHO ranks

migraine among theworlds most disabling medical illnesses


14/89

Burden Of Migraine World - 15-20% of women and 10-15% of men suffer from migraine

In India, 15-20% of people suffer from migraine

Adults Female: Male ratio is 2 : 1

In childhood migraine, boys and girls are affected equally until puberty,when the predominance shifts to girls.

NEJM 2002; 346(4): 257-269; XI Congress of the IHS, 2004


15/89

Migraine - Definition

Migraine is a familial disorder

characterized by recurrent attacks of

headache widely variable in intensity,frequency and duration. Attacks are

commonly unilateral and are usually

associated with anorexia, nausea andvomiting

-World Federation of Neurology


16/89

Migraine Triggers Food Disturbed sleep pattern

Hormonal changes

Drugs

Physical exertion

Visual stimuli

Auditory stimuli

Olfactory stimuli

Weather changes

Hunger

Psychological factors


17/89

Phases of Acute Migraine Prodrome

Aura Headache

Postdrome


18/89

PRODROME Vague premonitory symptoms that begin from 12

to 36 hours before the aura and headache

Symptoms include

Yawning

Excitation

Depression

Lethargy Craving or distaste for various foods

Duration 15 to 20 min


19/89

AURAAura is a warning or signal beforeonset of headache

Symptoms Flashing of lights

Zig-zag lines

Difficulty in focussingDuration : 15-30 min


20/89

HEADACHE Headache is generally unilateral and is

associated with symptoms like:

Anorexia

Nausea

Vomiting

Photophobia

PhonophobiaTinnitus

Duration is 4-72 hrs


21/89

POSTDROME (RESOLUTION PHASE)Following headache, patient complains of

Fatigue

Depression

Severe exhaustion

Some patients feel unusually fresh

Duration: Few hours or up to 2 days


22/89

MIGRAINE

CLASSIFICATIONAccording to Headache Classification Committee of the

International Headache Society, Migraine has been

classified as: Migraine without aura (common migraine)

Migraine with aura(classic migraine)

Complicated migraine


23/89

Migraine Without Aura Migraine With Aura

No aura or Prodrome Aura or prodrome ispresent

Unilateral throbbingheadache may beaccompanied by nausea and

vomiting

Unilateral throbbingheadache and later becomesgeneralised

During headache, patientcomplains of phonophobiaand photophobia

Patient complains of visualdisturbances and may havemood variations

MIGRAINE: CLINICAL FEATURES


24/89

MIGRAINE - PATHOPHYSIOLOGY

VASCULAR THEORY

Intracerebral blood vessel vasoconstriction aura

Intracranial/Extracranial blood vessel vasodilation headache

SEROTONIN THEORY

Decreased serotonin levels linked to migraine

Specific serotonin receptors found in blood vessels of brain

PRESENT UNDERSTANDING

Neurovascular process, in which neural events result in activation of bloodvessels, which in turn results in pain and further nerve activation


25/89

Brainstem pathways thatmodulate sensory input.

The key pathway for pain inmigraine is thetrigeminovascular input rom themeningeal vessels, which passesthrough the trigeminal ganglionand synapses on second-order

neurons in thetrigeminocervical complex.These neurons in turn project inthe quintothalamic tract and,after decussating in thebrainstem, synapse on neuronsin the thalamus. Importantmodulation of thetrigeminovascularnociceptivedorsal raphenucleus, locus input comes

from the coeruleus, and nucleusraphe magnus.


26/89

NEUROVASCULAR PROCESS


27/89

ArterialActivation

Release ofNeurotransmitter

Worsening of Pain


28/89

MIGRAINE: DIAGNOSIS Medical History

Headache diary

Migraine triggers Investigations (only to exclude secondary causes)

EEG

CT Brain

MRI


29/89


30/89

DIFFERENTIATING COMMON PRIMARY

HEADACHES

Strictly unilateral

Tension headaches: Do not have the associated features like nausea,

vomiting, photophobia, phonophobia. The muscle contraction leads toheadache. Headache quality is of a tightening (non-pulsating) quality. Usuallybilateral. Intensity is mild or moderate

Cluster headaches: Severe unilateral pain. Headache associated withlacrimation, nasal congestion, rhinorrhea, facial sweating or eyelid edema.

Pain lasts for 15 to 180 minutes. More common in men


31/89

Migraine Disability Assessment Score (MIDAS)


32/89

THE TREATMENT

APPROACH TOMIGRAINE


33/89

LONG-TERM TREATMENT GOALS

FOR THE MIGRAINE SUFFERER

Reducing the attack frequency and severity

Avoiding escalation of headache medication Educating and enabling the patient to manage

the disorder

Improving the patients quality of life


34/89

MIGRAINE MANAGEMENT

Non-pharmacological treatment

Identification of triggers Meditation Relaxation training Psychotherapy

Pharmacotherapynon-specific

Abortive therapy

Specific Preventive therapy


35/89

Drug Dose Route

Aspirin 500-650 mg Oral

Paracetamol 500 mg-4 g Oral

MIGRAINE:ABORTIVE THERAPY

Non-specific treatment

Ibuprofen 200- 300 mg Oral

Diclofenac 50-100 mg Oral/IM

Naproxen 500-750 mg Oral


36/89

ABORTIVE THERAPY FOR MIGRAINE

Drug Dose Route

Ergot alkaloids

Ergotamine 1-2 mg/d; max-6g/d

Oral

Dihydroergotamine 0.75-1 mg SC

5-HT receptoragonists

Sumatriptan 25-300 mg

6 mg

Orally

SC, Nasally

Rizatriptan 10 mg Orally

Specific treatment


37/89

WHY THE NEED FOR PROPHYLAXIS ?Abortive drugs should not be used more than 2-3

times a week

Long-term prophylaxis improves quality of life by

reducing frequency and severity of attacks

80% of migraineurs may require prophylaxis


38/89

WHEN IS PROPHYLAXIS INDICATED?According to the US Headache Consortium Guidelines,

indications for preventive treatment include: Patients who have very frequent headaches (more than 2 per

week)

Attack duration is > 48 hours

Headache severity is extreme

Migraine attacks are accompanied by prolonged aura

Unacceptable adverse effects occur with acute migrainetreatment

Contraindication to acute treatment

Migraine substantially interferes with the patients dailyroutine, despite acute treatment

Special circumstances such as hemiplegic migraine or attackswith a risk of permanent neurologic injury

Patient preference


39/89

Drugs Dose (mg/d)1. Betablockers

Propranolol 40-320

2. Calcium Channel

Blockers Flunarizine

Verapamil

10-20

120-480

3. TCAs

Amitriptyline 10-20

4. SSRIs

Fluoxetine 20-60

PREVENTIVE THERAPY FOR MIGRAINE


40/89

Drugs Dose (mg/d)

5. Anti-convulsant

Sodium valproate 600-12006. Anti-histaminic

Cyproheptadine 4-8

PREVENTIVE THERAPY FOR

MIGRAINE(CONTD.)


41/89

Tension Headache

Most common type of headache Higher prevalence in middle aged women Usual frequency is 5 episodes per month Clinical features include

-tight, band-like discomfort around the head-intensity of pain is not severe and thus not

debilitating

-headache does not worsen with physicalactivity-coexisting anxiety and depression arecommon


42/89

Tension headache-TreatmentAspirin, acetaminophen, NSAIDs

T/t-Amytriptyline

Exercise program Nonpharmacologic regimen like massage, mediation,

and biofeedback

Psychotherapy


43/89

CLUSTER HEADACHE Rare form of primary headache

More common in men

Recurrent, deep, nocturnal, unilateral, retroorbital searingpain

Awackening 2-4hrs after sleep onset with severe pain,unilateral lacrimation and nasal and conjunctivalcongestion.


44/89


45/89

Visual complaints,nausea,or vomitting are rare.

Tend to move during attacks (unlike migrain)

Presence of periodicity

Pain last 30-210 min but tend to recurat the same time ofnight or several times each 24 h over 4-8 weeks (a cluster)

A pain free period of months or years may be followed byanother cluster of headaches.

T/t: High flow oxygen of 7-10 l/min

Prophylaxis with

Verapamil

Lithium

Prednisolon

Clinical Features of the Trigeminal Autonomic Cephalalgias


46/89

Clinical Features of the Trigeminal Autonomic CephalalgiasCluster Headache Paroxysmal Hemicrania SUNCT(short-lasting

unilateral neuralgiform

headache attacks with

conjunctival injection and

tearing.)

Gender Pain M > F F = M F M

Type Stabbing, boring Throbbing, boring, stabbing Burning, stabbing, sharp

Severity Excruciating Excruciating Severe to excruciating

Site Orbit, temple Orbit, temple Periorbital

Attack frequency 1/alternate day8/d 140/d (>5/d for more than

half the time)

3200/d

Duration of attack 15180 min 230 min 5240 s

Autonomic features Yes Yes Yes (prominent conjunctival

injection and lacrimation)a

Migrainous featuresb Yes Yes Yes

Alcohol trigger Yes No No

Cutaneous triggers No No Yes

Indomethacin effect Yesc Abortive treatment Sumatriptan injection or

nasal spray

No effective treatment Lidocaine (IV)

Oxygen

Prophylactic treatment Verapamil Indomethacin Lamotrigine Topiramate

Methysergide

Lithium Gabapentin


47/89

Chronic Daily Headache

The broad diagnosis of chronic daily headache (CDH)can be applied when a patient experiences headache on15 days or more per month.

CDH is not a single entity; it encompasses a numberof different headache syndromes, including chronicTTH as well as headache secondary to trauma,

inflammation, infection, medication overuse, and othercauses


48/89

Classification of Chronic Daily HeadachePrimary>4 h Daily


49/89

New Daily Persistent Headache

Differential Diagnosis of New Daily Persistent Headache

Primary Secondary

Migrainous-type Subarachnoid hemorrhageFeatureless (tension-type) Low CSF volume headache

Raised CSF pressure headache

Posttraumatic headachea

Chronic meningitis

a

Includes postinfectious forms.

Clinical Presentation The headache usually begins abruptly, but onset may be more gradual; evolution over3 days has been proposed as the upper limit for this syndrome. Patients typically recallthe exact day and circumstances of the onset of headache; the new, persistent head paindoes not remit. The first priority is to distinguish between a primary and a secondary cause of this

syndrome. Subarachnoid hemorrhage is the most serious of the secondary causes andmust be excluded either by history or appropriate investigation


50/89

Subarachnoid Hemorrhage (SAH) Extravasation of blood in subarachnoid space activates

meningeal nocireceptors causing occipital pain andmeningismus.

SAH accounts for 10% of all strokes and is mostcommon cause of death from a stroke.

Causes are saccular aneurysms (80%), blooddyscrasias, arteriovenous malformations, mycotic

aneurysms, cavernous angiomas. Risk factors include increased age,hypertension,

smoking, excessive alcohol consumption andsympathomimetic drugs.

SECONDARY HEADACHE


51/89

Clinical Features of SAH Sudden thunderclap

headache

Can be associated withexertional activities

Nausea/vomitng-75%

Neck stiffness-25%

Seizures-10%

Meningismus-50%

Subhyloid or retinalhemorrhages

Oculomotor nerve pulsywith dilated pupil

Restlessness and alteredlevel of consciousness


52/89


53/89

Prognosis It depends on neurological

status at the time ofpresentation

Hunt and Hess scale Grades I and II have good

prognosis

Grades IV and V have

grave prognosis

Grade Condition

0 Unruptured Aneurysm

I No symptoms or minimal

headache

II Moderate/Severe HA,nuchal rigidity, no neuro

deficit other than CN pulsy

III Drowsiness, confusion, ormild focal deficit

IV Stupor, severe hemiparesis

V Deep coma, decerebrate


54/89

Diagnostic Studies Emergent CT scan of

head

CT is greater than90% sensitive foracute bleeding-lessthan 24 hr

Sensitivity decreasesto 50% by the end ofthe first week


55/89

Diagnostic Studies When CT is negative a lumbar

puncture should be performed

The CSF should be spun andthe supernatant fluid should

be observed forxanthochromia (develops after12 hrs)

CSF xanthochromia withnegative CT is diagnostic

Xanthochromia byspectophotometry is moresensitive


56/89

Diagnostic Studies Patients with persistent bloody CSF without

xanthochromia should go vascular imaging

Up to 90% of patients with SAH have cardiacarrhythmias or EKG findings suggestive of ischemia

Typical EKG changes include ST-T wave changes, Uwaves, and QT prolongation


57/89

TreatmentAirway, breathing, circulation and neurosurgical

consultation.

Patients with Grade III SAH usually require

endotracheal intubation Nimodipine 60 mg PO or NG to lessen the chance of

ischemic stroke due to vasospasm

Anticonvulsants for patients with evident seizure


58/89

Intracranial Infection

HA is commoncomplaint in meningitis,brain abscess,

encephalitis or AIDS Diagnostic tools include

CT of head and LP

Meningitis Severe HA, nuchalrigidity,

meningismus

Encephalitis HA, confusion,

fever, change ofmental status,

seizures

Brain

Abscess

HA, vomiting, focal

neurological signs,depressed level of

consciousness

AIDS Toxoplasmosis,

CMV, Cryptococcus


59/89

Brain Tumor In elderly, brain tumor is usually metastatic from lung

or breast carcinoma.

Primary brain tumor are more common in adults

younger than 50 years HA is caused either by direct pressure on the brain or

elevated ICP

Typical presentation is headache that worsens over

over weeks to months HA is usually present on awakening initially, then it

becomes continuous.


60/89

Brain Tumor HA is often worse

with sneezing,bending, coughing.

Diagnostic toolsinclude CT with IVcontrast or MRI(best

test)


61/89

Giant Cell Arteritis Systemic inflammatoryprocess of small andmedium size arteries.

Mean age of onset is 71

years, rare before 50 Headache is intermittent,

worse at night or onexposure to cold

Associated symptoms

include jaw claudication,fever, anorexia, pain andstiffness in joints akapolymyalgia rheumatica

On exam there is tendernessof temporal artery.

Its a medical emergencybecause long term sequelae is

permanent visual loss. Diagnostic tests include ESR,

CRP, LFTs, platelet count

Definite diagnosis is bytemporal artery biopsy

Treatment is prednisone 60-120mg daily.


62/89

Acute Glaucoma Sudden onset of eye pain

radiating to head, ear,teeth, and sinuses.

Visual symptoms includeblurriness, halos aroundlights, and scotomas.

Nausea and Vomiting

Due to congenitalnarrowing of the anteriorchamber angle that leads

to elevated intraocularpressure (IOP)

Medications that elevateIOP include mydriatics,sympathomimetics


63/89

Acute Glaucoma Physical exam shows a red

eye with a fixed middilatedpupil and shallow anteriorchamber (separates it from

cluster HA) IOP in the range of 60 to 90

mmHg ( not found in iritis)

Treatment includes topicalmiotics, b-blockers,carbonic anhydraseinhibitors, optho consult


64/89

Posttraumatic Headache(PTHA) Estimated that 30-50% of 2

million closed headinjuries per year developheadache.

Associated with dizziness,fatigue, insomnia,irritability, memory loss,and difficulty with

concentration. Acute PTHA develops

hours to days after injuryand may last up to 8 weeks.

Chronic PTHA may lastfrom several months to

years.

Patients have normalneurological examinationand imaging

Treatment for acute PTHAis symptomatic while for

chronic PTHA, adjuncttherapies include beta-blockers andantidepressants.


65/89

Postdural Puncture Headache Most common

complication followinglumbar puncture (up to

40%) Most common in 18 to 30

year old patients

It can last up to 5 days

Bilateral throbbing HAthat worsens with uprightposition

Thought to be due topersistent leak of CSFthat exceeds its

production Treatment includes rest,

fluids, and blood patch,caffeine or theophylline

for persistent HA


66/89

Medication-Induced Headache Medication use, abuse or

withdrawal s the cause.

Common in patients with

chronic headachedisorders like migraine ortension-type.

Most common medsinclude ASA, NSAIDs,

Tylenol, barbiturate-analgesic combinations,caffeine, and ergotamine

Patients build toleranceto the meds andsubsequently require

higher doses forsymptomatic relief.

Treatment includeswithdrawal of the

overused medications


67/89

High Altitude Headache Main symptom of Acute Mountain Sickness

Can occur at altitudes higher than 5000 feet inunacclimatized individuals.

HA is throbbing, located in temporal or occipitalarea and worsens at night or early in the morning.

Treatment includes supplemental oxygen anddescent to a lower altitude.


68/89

Carbon Monoxide Poisoning Usually gradual, subtle, dull, nonfocal throbbing pain

associated with nausea, chest pain.

Symptoms may wax and wane as patients may enter

and leave the area of carbon monoxide Exposure to engine exhaust, old or defective heating

systems, most common in winter months.

Non focal neurological exams.

Diagnosis is made by elevated carboxyhemoglobin Treatment is oxygen


69/89

Hypertensive Headache Elevated blood pressure isnot as important in HA asthe rate by which the bloodpressure increases

Nonetheless, HA withsevere HTN is welldocumented especially inhypertensiveencephalopathy

Treatment is directed atlowering blood pressureslowly

HA may last for days untilbrain edema has resolved


70/89

COUGH HEADACHETransient severe pain withcoughing,bending,sneezing or stooping

Last for sec to few min Usually benign Posterior fossa mass lesion in 25% cases Indomethacin 25-50mg tid


71/89

Key Concepts HA is a challenging yet common complaint in ED

Diseases that we cannot afford to miss are SAH,CO poisoning, temporal arteritis, bacterial

meningitis/encephalitis Be liberal with use of CT

Remember CT doesnt rule out SAH-need LP.

If CT and LP are negative think of temporalarteritis if older than 50 years, and CO poisoning.

Dont forget the eyes!


72/89

Case Studies


73/89

Headache Case #1 40-year-old man presents with a history of headache

since adolescence

Over the past two years, headaches gradually have

increased in frequency and severity; daily head painfor past 6 months

Functionally incapacitated by headache7 days per month


74/89

Headache Case #1(cont.)

Usual headache is of mild intensity, constant,nonpulsatile, nonlateralized, pressure-like, and notaccompanied by nausea, vomiting, photophobia or

phonophobia Most severe headaches last 1 to 2 days and involve pain

that is pulsatile, lateralized to the left, increased byroutine physical activity, and accompanied by nausea,

vomiting, photophobia, and phonophobia


75/89


Some of these attacks are preceded by tunnel visionand bright flashes at the periphery of both visualfields

Severe attacks typically begin with an intensificationof the usual headache, with severe tightness, stiffness,pain of the left lateral neck

Physical examination was notable only because ofmarked tenderness to palpation at the left occipitalskull base in the region of the greater occipital nerve


76/89

Headache Case #1: Questions1. What is your diagnosis?a. Chronic tension type headache

b. Mixed tension type and migraine headache

c. Transformed migraine

d. Probably primary headache syndrome but needs brainimaging and lumbar puncture to rule out organicdisorder


77/89

Headache Case #1: Questions(cont.)

2. This patients headaches are likely to respond to

a. Propranolol

b. Oral sumatriptan

c. Left greater occipital nerve block

d. All of the above


78/89

Headache Case #2 46-year-old woman presented for evaluation and

management of chronic daily headache

Significant headaches started at 12 years of age

Since then, she has had head pain with featurescharacteristic of migraine with and without sensory orvisual aura


79/89


Following surgery (hysterectomy/ oophorectomy) 10years ago, her headaches became more of a problem;she has had daily headaches for 5 years

She is functionally incapacitated by headache almostevery day


80/89


Has been to the emergency department for headache 7times within the last month, and called her physician 1week prior to her initial appointment to request acute

headache medication Past medical history is otherwise notable for

borderline personality disorder, chronicanxiety/depression, and 2 hospitalizations for suicidal

ideation (no attempt)


81/89

Headache Case #2: Questions1. The most likely diagnosis for this patient isa. Chronic tension type headache

b. Idiopathic intracranial hypertension

c. Transformed migraine with analgesic overuse

d. Brain tumor


82/89

Headache Case #3 31-year-old women with a long-standing history ofepisodic migraine without aura comes to see herphysician for urgent evaluation of a new problem:

while at work, she abruptly developed an out-of-bodysensation and a metallic taste in her mouth

According to onlookers, she stared blankly andstraight ahead for 45 seconds, failed to respond to

questions, and swallowed repeatedly; she did not losepostural tone or exhibit tonic-clonic activity


83/89


After this event, the patient appeared flustered andwas confused for a few minutes

Reviewing her past, she claimed that she may have had

this experience about 12 times over the previous 13years, though the episodes were less intense

She reported no recent change in the character orfrequency of her headache syndrome


84/89


The patient had about 15 headache days out of theprevious 30 days; 6 of these were functionallyincapacitating headaches, despite aggressive

treatment with oral sumatriptan, subcutaneoussumatriptan, and oral oxycodone/aspirin

Her medical history is otherwise unremarkable

Family history: her maternal grandmother and motherhave had migraine; a maternal aunt and cousin haveepilepsy


85/89

Headache Case #3: Questions1. Her episode at work last week likely representeda. Complicated migraine

b. Panic attack

c. Complex partial seizure

d. A transient ischemic attack (TIA)


86/89

Headache Case #4 45-year-old man presents for evaluation andmanagement of chronic daily headaches

Experienced his first significant headaches at age 36;

these headaches resolved spontaneously after 2months but then recurred 1 year later and have beendaily since then


87/89


The patient experiences 2 to 4 headaches each day,typically lasting 30 to 45 minutes and involving painthat is often prominent in the right eye, extending to

the temple Treatment with propranolol, amitriptyline, oral

sumatriptan, oral rizatriptan, and naproxen sodiumhave been ineffective for headache

Medical history: unremarkable

The patient smoked 1 pack of cigarettes per day for atleast 20 years


88/89

Headache Case #4: Questions1. The most likely diagnosis for this patient isa. Nasopharyngeal carcinoma

b. Chronic cluster

c. Chronic migraine

d. Chronic paroxysmal hemicrania


89/89

Approach to Patient With Headache

Documents

Transcript of Approach to Patient With Headache