Evaluation of Headache in Adults

Bita Fakhri, MD, MPH

Boston Medical Center Shapiro Primary Care

Clinic 2/27/2013

Evaluation of Headache in Adults

HistoryDanger signs on historyPhysical exam Danger signs on physical examThree main classes of primary headachesIndications for imaging studies

History

Age at onsetPresence or absence of aura and prodromeFrequency, intensity, and duration of attackNumber of headache days per monthsTime and mode of onsetQuality, site and radiation of painAssociated symptoms and abnormalitiesFamily history of migrainePrecipitating and relieving factorsEffect of activity on pain

History

Relationship with food and alcoholResponse to any previous treatmentAny recent change in visionAssociation with recent traumaAny recent changes in sleep, exercise, weight, or

dietState of general healthChange in work or life style (disability)Change in method of birth controlPossible association with environmental factorsEffects of menstrual cycle and exogenous hormones

Danger Signs on history

Sudden onset of headache, or severe persistent headache that reaches maximal intensity within a few seconds or minutes (? SAH)

The absence of similar headaches in the past – the “first” or “worst” headache of my life (ICH, CNS infection)

A worsening pattern of headache (mass lesion, subdural hematoma, medication overuse headache)

Focal neurologic symptoms other than typical visual or sensory aura (mass lesion, AVM, collagen vascular disease)

Danger Signs on history

Fever (infection, SAH)Any change in mental status, personality, or

fluctuation in the level of consciousnessThe rapid onset of headache with strenuous

exercise (? Carotid artery dissection or ICH)Head pain that spreads into the lower neck

and between the shoulders may indicate meningeal irritation (infection, SAH)

New headache in patients <5 or >50

Danger Signs on history

New headache type in a patient with cancer suggests metastasis.

New headache type in a patient with Lyme disease suggests meningoencephalitis.

New headache type in a patient with HIV suggests an opportunistic infection or tumor.

Headache during pregnancy or postpartum suggests possible cortical vein or venous sinus thrombosis, carotid dissection

Physical Exam

Obtain BP and pulseListen for bruits at neck, eyes, and head for

clinical signs of AVMPalpate the head, neck, and shoulder regionsCheck temporal and neck arteriesExamine the spine and neck musclesFunctional neurologic examination

Danger Signs on Examination

Neck stiffness and especially meningismus (resistance to neck flexion) suggests meningitis

Papilledema (intracranial mass lesion, pseudotumor cerebri, encephalitis, or meningitis)

Focal neurologic signs (intracranial mass, AVM, collagen vascular disease)

Characteristics of Common Headache Syndromes

SYMPTOM MIGRAINE HEADACHE

TENSION HEADACH

E

CLUSTER HEADACHE

LOCATION Unilateral in 60-70% -- bilateral or

glabal in 30%

Bilateral ALWAYS unilateral

CHARACTERISTICS

Gradual in onset, crescendo pattern;

pulsating; moderate or

severe intensity; aggravated by

routine physical activity

Pressure or tightness

that waxes and wanes

Pain begins quickly,

reaches a crescendo

within minutes; pain is deep, continuous,

excruciating, and explosive

in quality

Characteristics of Common Headache Syndromes

SYMPTOM MIGRAINE HEADACHE

TENSION HEADACHE

CLUSTER HEADACHE

Patient appearance

Patient prefers to rest in a dark,

quiet room

Patient may remain active or may need

to rest

Patient remains active

Duration 4-72 hours Variable 0.5-3 hours

Associated symptoms

Nausea, vomiting, photophobia,

phonophobia; may have aura (usually

visual, but can invlove other

senses or cause speech or motor

deficits)

None Ipsilateral lacrimation and redness of the

eye, stuffy nose; rhinorrhea;

pallor; sweating; Horner’s

syndrome; focal neurologic

symptoms rare; sensitivity to

alcohol

Treatment of Migraine Headaches

• Abortive therapy: ASA, tylenol, caffeine, high dose NSAIDs,

triptans• Prophylaxis: TCA, BB, CCB, Valproic acid, topiramate

Criteria for Transformed Migraine and Medication-Overuse Headache.

Dodick DW. N Engl J Med 2006;354:158-165.

Preventive Medications Used in Cases of Transformed Migraine or Medication-Overuse Headache.

Dodick DW. N Engl J Med 2006;354:158-165.

Treatment of Cluster Headaches

Acute treatment: O2, triptansChronic prophylaxis: CCB

Indications for Imaging Studies

Recent significant change in pattern, ferequency, or severity of headache

Progressive worsening of headache despite appropriate therapy

Focal neurologic signs and symptomsOnset of headache with exertion, cough, or

sexual activityOrbital bruitOnset of headache after age 40

CT vs. MRI

There is no evidence that MRI > CTCT-brain and brainstem with and without

contrast is sufficient in most patients.MRI along with MRA are indicated when

posterior fossa or vascular lesions are suspected.

The Pain of Cluster Headache

http://www.youtube.com/watch?v=glBmSQRxaIg