Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of...

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Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director, Riley Headache Center

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Transcript of Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of...

Page 1: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Headache for the PCP: Evaluation and Initial

Management

Chris Jackman, MDAssistant Professor of NeurologyChild Neurology of Riley HospitalDirector, Riley Headache Center

Page 2: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Objectives

• Identify a systemic evaluation of a headache patient

• Evaluate for causes of secondary headache

• Recognize how to diagnose common primary headache symptoms of childhood

• Identify how to treat primary headache syndromes

Page 3: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Initial Evaluation

Page 4: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

1. Shoulder shrug and look to parents

2. “I don’t know”

3. “Headaches?”

Page 5: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

It’s in the history

• Time course• Time course• Time course

• Pain description– Location– Severity – Quality

• Associated symptoms

Page 6: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Other questions:

• Pain description– Location– Severity – Quality

• Associated symptoms– Aura– Nausea, vomiting– Photophobia, phonophobia– Light-headedness, vertigo– Autonomic features

Page 7: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Red Flags

• Time course– Progressive– Morning

• Location– Posterior

• Postural• Focal neurologic

signs– Any

• Systemic signs– Fevers, rash

• Family history– As in, none

• Age– Under 6 years

Page 8: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Physical exam

• Eyes / Fundus

• TMJ

• Face

• Muscles

• Skin

• Neurologic

Page 9: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Secondary Headaches

Page 10: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Non-neurologic causes of secondary headaches

• Dental/ TMJ

• Allergies/ congestion

• Sinus inflammation/ infection

• Ear infection/ Mastoiditis

• Hypothyroidism

• Pheochromocytoma (Hypertension)

• Eye-strain

Page 11: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

It is (probably) not a tumor

• Brain tumors are very rare• BUT…

– You only need to miss one to be incompetent

• The chance of finding a tumor in a patient with headaches and a normal neurological exam is…

Page 12: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

It is not a tumor

• Very low, but not quite zero

• Brain tumors typically cause headache when they cause increased pressure

• A much more common presentation is focal neurologic signs with minor headache

Page 13: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

It is a tumor

• Key features– Time course (Progressive)

– Timing (On awakening)

– Postural (Supine)

– Focal Neurologic signs

– Seizures

Page 14: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

If it’s not a tumor, what is it?

Page 15: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Intracerbral Hemorrhage

• Features– Time course (Acute)– History of trauma– Focal Neurologic signs

• Types of hemorrhage– Subdural– Epidural– Subarachnoid– Paranchymal– Interventricular

Page 16: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Venous sinus thrombosis

• Associated with primary or secondary hypercoagulable state

• Present with signs of increased intracranial pressure

• Sometimes hemorrhage• Red Flags

– Time course (Progressive or static)

– Postural– Neurologic signs

• Papilledema• 6th nerve palsies

Page 17: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Ideopathic intracranial hypertension

• Mechanism unknown• More female, more obese• Headache with visual loss• Red Flags

– Time course (Progressive or static)– Postural– Neurologic signs

• Papilledema• 6th nerve palsies

Page 18: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Ideopathic intracranial hypotension

• Seen in some connective tissue diseases from dural ectasia (or ideopathic)

• Mimics LP headache

• Red Flags– Time course (Progressive or static)– Postural

Page 19: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Meningitis / Encephallitis

• Red flags:– Systemic signs (fever)– Focal Neurologic signs (meningismus,

encephalopathy, seizures)

Page 20: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Chiari I Malformation

• Protrusion of cerebellar tonsils below the foramen of Monro

• Red flags:– Location (posterior)– Postural, pain with

neck movements– Focal Neurologic signs

(ataxia)– Worse with cough,

sneezing, valsalva

Page 21: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Post-traumatic or Post-concussiveHeadache

• Red flags: See hemorrhage

• Will get better, may take months

• Cognitive changes are common, will also improve

Page 22: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Headache Evaluation

Page 23: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Do I order LABS?

Page 24: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Headaches in children younger than seven years of age

Chu ML, Shinnar S. Arch Neurol, 49:1992; 79-82

• Study of 104 children referred to Child Neurology

• Studies performed prior by the pediatrician• Studies included:

– Cell counts– Basic electrolytes– Tranaminases– Urinalysis

• “Uniformly unrevealing”• Similar prospective study in adults of 193

patients showed same results

Page 25: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Do I order a SCAN?

Page 26: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches

2002• Neuroimaging

– Combined 6 studies– 605 of 1275 had imaging (CT in 116, MRI in

483, both in 75)– 97 children with imaging abnormalities (16%)

• 79 considered incidental• 14 surgically treatable• 4 medically treatable

Page 27: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

• Of the 14 surgical lesions:– 10 tumors– 3 symptomatic vascular malfomations– 1 significant arachnoid cyst

• All had an abnormal neurologic examination– Papilledema– Abnormal eye movements– Motor dysfunction– Gait dysfunction

American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches

2002

Page 28: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

– Parameters which distinguish headache patients with space occupying lesions

• Headache of less than one month duration• Absence of a family history of migraine• Abnormal neurological examination• Gait abnormalities• Seizures

– Those patients with headaches for less than 6 months and at least one of the above symptoms are considered “high-risk”

• “High-risk” = 4% chance of space occupying lesion

American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches

2002

Page 29: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

CT vs. MRI?

Page 30: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Primary Headache Disorders

Page 31: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine Diagnosis and Treatment: Results From the American Migraine Study II

Headache 2001;41:638-645

• Survey mailed to 20,000 homes, identified 3577 individuals who met criteria for migraine

• 48% had previously received a physician diagnosis

• 24% of those undiagnosed had missed at least one day of work or school in the previous three months

• Those missed were:– Lower income– Younger age (18-29)– Male

Page 32: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine epidemiology

• Headache prevalence– Tension type HA 78%– Migraine 16%– Children

• 3-8% by age 3• 37-52% by age 7• 57-82% in 7-15 year olds

• Peak incidence– Women – age 12-13 (aura), 14-17 (without)– Men – age 5 (aura), 10-11 (without)

Comprehensive Review of Headache Medicine; Levin M Ed; Oxford 2008

Page 33: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

“If nothing is wrong with me, doctor, why do I have these headaches?”

Page 34: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine pathophysiology

• Primarily a NEUROGENIC process

• We think

• For now

Page 35: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine pathophysiology

• Aura– Cortical spreading depression– Front of profound depolarization– Moves across cortex ~ 3mm/min– Following by suppression of neural activity

lasting minutes

A.P. Leão.

Page 36: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Cortical Spreading Depression

Page 37: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine pathophysiology

Page 38: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine without aura Pediatric diagnostic criteria

• At least five attacks fulfilling criteria B-D (below)• Headache attacks lasting 1 to 72 h• Headache having at least two of the following characteristics:

– Unilateral location, may be bilateral, frontotemporal (not occipital)

– Pulsing quality– Moderate or severe pain intensity– Aggravation by or causing avoidance of routine physical

activity (eg, walking, climbing stairs)• During the headache, at least one of the following:

– Nausea or vomiting– Photophobia and phonophobia, which may be inferred

from behavior• Not attributed to another disorder

Page 39: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine with aura Pediatric diagnostic criteria

• At least two attacks fulfilling the criteria B-D (below)• Aura consisting of at least one of the following, but no

motor weakness: – Fully reversible visual symptoms, including positive features or

negative features (e.g., flickering lights, spots, or lines)– Fully reversible sensory symptoms, including positive features

(i.e., pins and needles) or negative features (ie, numbness)– Fully reversible dysphasic speech disturbances

• At least two of the following: – Homonymous visual symptoms or unilateral sensory

symptoms– At least one aura symptom develops gradually over 5 min or

different aura symptoms occur in succession over 5 min– Each symptom lasts between 5 min and 60 min

• Not attributable to another disorder

Page 40: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

And…

Page 41: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

…Chronic Daily Headache…

Page 42: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Chronic Daily Headache

• Transformed (or chronic) migraine– History of migraine– Progresses to chronic, low level headache

with periodic migraines

• Chronic tension type headache– Lack significant migranous features– Less severe intensity– Tightening more than pulsating

• New daily persistent headache

Page 43: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Chronic daily headaches - evaluation

• Look for red flags*

• Ask about analgesic overuse

* Especially in New Daily Persistent Headache

Page 44: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Practice Parameter: Pharmacological

treatment of migraine headache in children and adolescents

D. Lewis, MD; S. Ashwal, MD; A. Hershey, MD; D. Hirtz, MD; M. Yonker,

MD; and S. Silberstein, MDNEUROLOGY 2004; 63: 2215–2224

Page 45: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine treatment - Abortive

• Ibuprofen, acetaminophen, ketorolac, indomethacin, ASA

• Combinations (Acetaminophen/ASA/caffeine)• Antiemetics (promethazine, chlorpromethazine• Opiates, barbituates (no, no, never…)• Corticosteroids• Triptans

– 5HT1b, 1d, and 1f agonists– Contraindications include cardiovascular disease or risk

factors, Reynaud’s, hemiplegic migraine– Side effects include nausea, dizziness, chest and throat

tightness

Page 46: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,
Page 47: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine treatment - Abortive

Page 48: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine treatment - Prophylactic

• When to use prophylaxis– Headaches frequent

– Headaches severe

– Headaches disruptive

• Side effects and burden of taking a daily medicine < the life disruption caused by (appropriately treated) headaches

Page 49: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine treatment - Prophylactic

• Antihistamines• Beta-blockers• Tricyclics• Anticonvulsants• Calcium channel blockers

Page 50: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine treatment - Prophylactic

• Antihistamines– Cyproheptadine

• Little studied, often used• Reduce headaches from 8.4 to 3.7 per month• Somnolence, weight gain• Initial dose 1-2 mg QHS, max 4 mg BID

Lewis D, Diamond S, Scott D, et al. Prophylactic treatment of pediatricmigraine. Headache 2004;44:230–237.

Page 51: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine treatment - Prophylactic

• Beta-blockers– Propranolol most studied

– Three small, prospective class II studies with conflicting results

– Exercise intolerance

– Contraindicated in asthma, depression

– Initial dose 20 mg, up to 160 mg

Page 52: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine treatment - Prophylactic

• Tricyclics– Amitriptyline most studied

– Anticholinergic effects, somnolence

– Black box warning re: suicidality

– Baseline EKG and monitor for QT prolongation

– Initial dose 10 mg up to 100 mg

– Give at dinner

Page 53: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine treatment - Prophylactic

• Anticonvulsants– Topiramate (or zonisamide)

• Best studied

– Valproate• Effective but side effects can be significant

– Levetiracetam/ Lamotrigine• Limited (poor) data

Page 54: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Migraine treatment - Prophylactic

• Calcium channel blockers– Conflicting data

– Familial hemiplegic migraine

– Abdominal discomfort

– Monitor EKG and blood pressure

Page 55: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Chronic Daily Headache - Treatment

• Preventative medications – – Evidence is spotty at best

• Topiramate is best studied, anecdotally all migraine medications may work

– Transformed migraine or for medication overuse – early prophylactic treatment

– Chronic tension type headache – late medical treatment

– New daily persistent headache – doesn’t matter

Page 56: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Non-pharmacologic Treatment

• Lifestyle! Lifestyle! Lifestyle!– Analgesic overuse– Sleep– Diet– Psychiatric

Page 57: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Non-pharmacologic Treatment

• Analgesic overuse– Opiotes/ barbiturates > triptans

>>NSAIDS– Any used over 15 days/month, some

over 10 days/month– Can treat by a period of elimination or

by moderation– Headaches may take 4-6 weeks to

improve

Page 58: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Non-pharmacologic Treatment

• Sleep– Snoring– Movements– Quality– Quantity– Continuity

Page 59: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Non-pharmacologic Treatment

• Diet– Meats (Iron, B12)– Vegetables (Folate?)– Skipping meals– Hydration– Caffeine

Page 60: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Non-pharmacologic Treatment

• Psychiatric evaluation– Anxiety– Depression– Obsessive-compulsive disorder

• Non-pharmocologic management– Biofeedback– Self-hypnosis– Relaxation

Page 61: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Take home points:

• Red flags– Progressive time course– Postural– Worse in the morning– Any neurologic sign or symptom– Worse with valsalva

• Practice your fundoscopic and cranial nerve exam

Page 62: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

Closing thoughts…

• Watch for red flags• Know when to image• If unsure whether to image, refer• Know helpful lifestyle modifications• Know when to start or refer for prophylactic

medications

• Remember: “Your patient does not want to have a headache”

Page 63: Headache for the PCP: Evaluation and Initial Management Chris Jackman, MD Assistant Professor of Neurology Child Neurology of Riley Hospital Director,

References• Sargent JD, Solbach P. Medical evaluation of migraineurs: review of the value of

laboratory and radiologic tests; Headache 1983; 23:62-65• Chu ML, Shinnar S. Headaches in children younger than seven years of age

Arch Neurol, 49; 1992; pp79-82• Maytal J, Robert S. Bienkowski, Patel M and Eviatar L. The Value of Brain Imaging in

Children With Headaches. Pediatrics 1995;96;413-416• Levin M Ed; Comprehensive Review of Headache Medicine: Oxford 2008• Lewis D, Ashwal, S; Hershey A; Hirtz D; Yonker, M; and Silberstein S, Practice

Parameter: Pharmacological Treatment of migraine headache in children and adolescents. Neurology 2004;63:2215–2224

• Ludvigsson J. Propranolol used in prophylaxis of migraine in children. Acta Neurol 1974;50:109–115.

• Forsythe WI, Gillies D, Sills MA. Propranolol (Inderal) in the treatment of childhood migraine. Dev Med Child Neurol 1984;26:737–741.

• Olness K, MacDonald JT, Uden DL. Comparison of self-hypnosis and propranolol in the treatment of juvenile classic migraine. Pediatrics 1987;79:593–597.

• D.W. Lewis, MD; S. Ashwal, MD; G. Dahl, BS; D. Dorbad, MD; D. Hirtz. Practice parameter: Evaluation of children and adolescents with recurrent headaches: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002;59:490–498


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