Primary and Secondary

Headache: What the internist may need to know

2020

JAY K. JOHNSON D.O.

CLINICAL ASSOCIATE PROFESSOR

DEPARTMENT OF INTERNAL MEDICINE-NEUROLOGY

Disclosures

Eli Lilly- PI for the EVOLVE-1and REGAIN clinical trials, 2016-2017

Galcanezumab-gnlm- Completed.

OBJECTIVES

Develop a clinical approach, and differential diagnosis, to the patient with headache.

Review indications for diagnostic imaging in patients presenting with primary and secondary headache.

Discuss recently FDA approve therapies for migraine.

General Principles

Headache is a near universal experience. It’s the rare person who hasn’t

experienced at least one headache.

Migraine is the 3rd most common disorder, and 7th for disability worldwide.

Every physician who evaluates patients, evaluates headache!

90+% of headaches in patients with a normal neurologic exam, and no

“red flags” are primary headaches (migraine, tension, cluster etc.)

The remaining % are Secondary headaches.

There is only so many ways your head can hurt, therefore the history and

supportive exam features will help you differentiate primary from

secondary headaches, the first step in any headache evaluation.

HEADACHESPatients seek medical attention with headache when:

They have a headache unlike any other (first or worst syndrome).

The headache is accompanied by new features which are new or

frightening. Visual symptoms, numbness, weakness.

They take various OTC combinations and have no consistent relief.

They have chronic headaches and can’t take it any more

(last straw syndrome).

What are the Pain sensitive structures

in the head?

Cranial nerves V, VII, IX,X

The circle of Willis and proximal continuations.

Meningeal arteries, large veins in the brain, superior sagittal sinus,

transverse sinus (SSS,TS) and dura.

Structures external to the skull, including eyes, paranasal sinuses, teeth,

TMJ, cervical nerves and roots, external cervical arteries, external auditory

canal, salivary glands.

Pain is registered in the brain but the brain parenchyma is insensate.

Unless a pain sensitive structure is involved pain is not perceived.

PRIMARY VS SECONDARY HEADACHES

Patients presenting to you with the chief complaint of headache should be

placed in one of two groups. This is the first step in headache diagnosis.

The first task is to exclude a secondary headache! (SNOOP5)

The history and physical, appropriate lab, and or imaging will determine the

correct diagnosis.

Based on the correct diagnosis, treatment is instituted for the appropriate

etiology.

HISTORY WHEN DID IT START?

Headaches after the age of 50 suggest a secondary disorder - mass

lesion, CVA, temporal arteritis etc.

Migraine often begins before the age of 30.

Cluster headaches have onset between the ages of 20-50. Male

predominance, often heavy smokers.

Tension type headaches begin before the age of 50.

How many headache days per month?

What’s the PMH, ROS, medications, etc.

Headache History

Attack onset - What's the duration, frequency. How long has the problem

been going on. Are the events stereotyped.

Pain location - severity, quality. Does it move around, switch sides, or stay

side locked.

Associated symptoms – aggravating and ameliorating factors, autonomic

features, (tearing, conjunctival injection, ptosis)

How many days per month do they have headache of any kind.

Ask what they are taking for headache even if it doesn’t work, or is not

prescribed. “I know it isn’t working but what are you taking for

headache?”

HISTORY ASSOCIATED SYMPTOMS

Fever – infection of any kind, meningitis, Sub-dural

empyema, cavernous sinus thrombosis, venous sinus

thrombosis.

Temporal arteritis - Jaw claudication, malaise, myalgia,

arthralgia, scalp tenderness, rare under the age of 55.

Migraine- Photopsias, scotoma visual loss hemiparasis

Cluster - autonomic symptoms - conjuctival injection ptosis,

nasal congestion.

HISTORY WHAT IS THE CHARACTER OF THE PAIN

CNS neoplasm - often a dull ache.

SAH – Usually sudden, continuous, intense, throbbing pain.

Migraine - typically throbbing and pulsitile

Cluster - deep boring pain periorbital, side locked.

Trigeminal neuralgia - paroxysmal brief (seconds) electrical shocks.

Only in the trigeminal nerve distribution.

HISTORY TEMPORAL PROFILE

Migraine typically begins slowly over minutes to hours peaks and gradually

resolves. Migraine is really a syndrome a component of which includes

headache.

Cluster headache begins suddenly but abruptly terminates. By definition

less than 3 hours, average is 45 minutes.

Tension type headaches wax and wane throughout the day. Usually

worse towards the end of the day.

PHYSICAL EXAM

General physical exam including vital signs.

Neurologic exam – Are there focal features?

Fundoscopy – Is papilledema present? Has the patient recently seen the Optometrist/Ophthalmologist.

When to consider Neuro-imaging in a

patient with headache.

The first or the worst headache.

Sub-acute headaches with increasing frequency or severity.

A progressive or new daily persistent headache.

Side locked headache.

Headaches triggered by cough, Valsalva, or exertional headache.

Postural, or positional headache.

When to consider Neuro-imaging in a

patient with headache.

Headaches occurring with seizures.

Headaches and a focal neurologic complaint and/or exam.

New onset headaches in a patient with cancer, or who is immunosuppressed.

New onset headache that develops during pregnancy or the post partum

period.

New onset of headache after the age of 50

Patients with fever, stiff neck, nausea, vomiting, papilledema.

CT or MRI?

When available MRI with and without contrast is the preferred study.

Without contrast if the patient has a contraindication to contrast

administration.

CT is preferred in acute situations such as head trauma, thunderclap

headache to rule out Sub-arachnoid hemorrhage, or in patients with

contraindication to MRI.

SECONDARY HEADACHES:

Increased intracranial pressure for whatever reason- Its, of course

important to know the reason.

CNS infection/inflammation- Meningitis, Encephalitis,Vasculitis, etc.

Subarachnoid hemorrhage.

Focal CNS ischemia or hemorrhage (ICH)

Arterial dissection – intracranial and/or cervical/vertebra

SECONDARY HEADACHES (SERIOUS HEADACHES)

Head trauma with subdural hematoma, epidural hematoma, or

subarachnoid hemorrhage.

Malignant hypertension

Acute Glaucoma

Cranial arteritis/vasculitis

Toxic-Metabolic disturbances, uremia, hepatic encephalopahy, Posterior

reversible encephalopathy syndrome (PRES)

SNOOP5

Systemic symptoms, fever, malaise, etc.

Neurologic signs or symptoms, mental status change, hemiparesis,

diplopia etc.

Older age of onset of headache. Onset of headache after the age of 50.

Onset of headache attack. Peak pain within 30-60 seconds, so called

thunderclap headache.

P5

Precipitation by Valsalva

Positional (just on looking up or turning head in a certain direction), or

postural (just on standing or lying down)

Papilledema

Pregnancy

Progressive or pattern change (history of typical migraine, but now

completely different type of headache)

PRIMARY HEADACHES

PAINFUL BUT BENIGN

Migraine with or without aura

Cluster headache and the trigeminal autonomic cephalgias.

Tension type headache

Chronic paroxysmal hemicranias, Hypnic headache, Trigeminal autonomic cephalgias and many others.

Trigeminal neuralgia (primary), occipital neuralgia etc. These headaches are usually benign but notable exceptions occur.

You differentiate these headaches and conditions by the duration, associated features, and frequency of occurrence.

Goals of Migraine Prevention

Decrease both headache and migraine headache days, intensity of

symptoms, duration of attacks, and migraine associated disability.

Improve function, less headache days

Have a reliable plan to deal with acute headaches which will still happen.

Encourage the patient to keep headache diary, (headache app) to

identify potential triggers that may exacerbate headache and therefore

improve control.

Principals of Migraine Prevention:

Start with low doses and increase slowly

Allow enough time on an adequate dose usually 1-3 months.

Avoid analgesic medication overuse

Treatment (Recent past)

Abortive: Off the shelf analgesics, prescription triptans (1992), prescription

combination analgesics.

Preventative- Certain anticonvulsants, blood pressure medication, and

antidepressants, biofeedback etc.

Botox- Only approved for chronic migraine.