clinmed2test3 Headache ppt

Headache Overview

• Headache is one of the most common presentations in primary care, with more than 90% falling into either migraine or tension-type.
• Migraine headaches are the second most common disabling condition seen in adults, after back pain.

Primary Headache Syndromes

• Common primary headache syndromes include migraine, tension-type headache, and cluster headache.
• Secondary causes to consider include intracranial lesions, head injury, cervical spondylosis, dental or ocular disease, TMJ, sinusitis, hypertension, depression, and general medical disorders.

Headache Characteristics

• Quality of pain:
  • Migraine: pulsating or throbbing
  • Tension headache: sensation of tightness or pressure
  • Nerve headache: sharp, lancinating pain
  • Ocular or periorbital icepick-like pains: migraine or cluster headache
  • Dull, steady headache: intracranial mass
  • Ocular or periocular pain: ophthalmologic disorder
  • Lateralized pain: migraine or cluster
  • Tenderness of overlying skin and bone: sinus headache
• Precipitating factors:
  • SARS-CoV-2 can precipitate chronic headache
  • Migraine may be exacerbated by emotional stress, fatigue, foods containing nitrite or tyramine, or menstrual periods
  • Alcohol may precipitate cluster headache
• Timing of pain:
  • Headaches worse on awakening: intracranial mass or sleep apnea
  • Onset at same time each day or night: cluster headache
  • Worse with stress or end of the day: tension headache
• Associated symptoms:
  • Nausea, sensitivity to light, sound, exertion, and desire to retreat to a dark, quiet room: migraine
  • Anxiety, agitation, and even suicidality: cluster headache

Migraine

• Typically pulsatile, lasting 4-72 hours, and unilateral
• Nausea, vomiting, photophobia, and phonophobia are common accompaniments
• Pain is aggravated with routine physical activity
• Aura of transient neurologic symptoms may precede head pain
• Most often, head pain occurs with no aura
• Pathophysiology: probably relates to neuronal dysfunction in the trigeminal system, resulting in neurogenic inflammation, sensitization, and pain
• Typical onset in adolescence or early adulthood

Migraine Aura

• Visual disturbances may consist of:
  • Field defects (scotoma)
  • Luminous visual hallucinations (photopsia)
  • Geometric patterns or zigzags of light
  • Scintillating scotomas (combination of field defects and luminous hallucinations)
• Rarely, migrainous headaches occur without pain (migraine aura without headache)

Migraine Treatment

• Symptomatic therapy:
  • Rest in a quiet, darkened room until symptoms subside
  • Simple analgesics (aspirin, acetaminophen, ibuprofen) taken immediately often provide relief
  • To prevent medication overuse, use of simple analgesics should be limited to 15 days or less per month
  • Cafergot, eletriptan, and IV metoclopramide may be useful in some cases
• Preventive treatment:
  • May be necessary if migraine occurs more frequently than 2-3 times a month or with significant disability
  • Antiepileptics, CV medications, and antidepressants may be used

Tension Headache

• Most common type of primary headache disorder
• Patients frequently report pericranial tenderness, poor concentration, and a vise-like or tight pain
• Headaches may be exacerbated by emotional stress, fatigue, noise, or glare
• Usually generalized, may be most intense about the neck or back of the head
• Not associated with focal neurologic symptoms
• TCAs (amitriptyline) are supported for headache prophylaxis

Cluster Headache

• Affects predominantly middle-aged men
• Pathophysiology is unclear, may relate to activation of cells in the ipsilateral hypothalamus triggering the trigeminal autonomic vascular system
• Episodes of severe pain occur daily for several weeks
• Often accompanied by one or more of the following:
  • Ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of the eye, and Horner syndrome (ptosis, pupillary meiosis, and facial anhidrosis or hypohidrosis)
  • Restlessness and agitation during attacks
• Typically occur at night, awaken patient, and last 15 minutes-3 hours

Giant Cell Arteritis

• Affects patients over 50; incidence increases with each decade
• Previously called temporal arteritis because the temporal artery is frequently involved
• Polymyalgia rheumatica and giant cell arteritis frequently coexist
• Important differences: polymyalgia rheumatica is not a systemic vasculitis, does not cause blindness, and responds to low-dose prednisone
• Giant cell arteritis can cause blindness and large artery complications
• Classic symptoms: headache, scalp tenderness, visual symptoms, jaw claudication, or throat pain
• Jaw claudication has the highest PPV
• Fever can be as high as 40°C (104°F)

Giant Cell Arteritis: Emergency

• Early diagnosis and treatment required to prevent blindness
• Start prednisone 1 mg/kg/day immediately
• Biopsy is the gold standard

Intracranial Mass Lesions

• May cause headache due to displacement of vascular structures/other pain-sensitive tissues
• Headache may be worse upon lying down, awaken the patient at night, or peak in the morning after laying down overnight
• Other suggestive features: fever, night sweats, weight loss, immunocompromised, history of malignancy
• Signs of focal or diffuse cerebral dysfunction or of increased intracranial pressure also need evaluation

Medication Overuse

• Often responsible for chronic daily headaches
• Patients have chronic pain or severe headache unresponsive to medication (no effect after regular use for more than 3 months)
• Ergotamines, triptans, medications containing butalbital, and opioids cause medication overuse headache when taken on more than 10 days per month
• Acetaminophen, aspirin, NSAIDs may also cause headaches if taken on more than 15 days per month

When to Image

• Progressive headache disorder
• New onset headache in middle or later life
• Headaches that disturb sleep or are related to exertion
• Headaches associated with neurologic symptoms or a focal neurologic deficit
• Signs of meningeal irritation and impairment of consciousness also need further investigation

When to Refer

• Thunderclap onset
• Increasing headache unresponsive to simple measures
• History of trauma, hypertension, fever, visual changes
• Presence of neurologic signs or of scalp tenderness

When to Admit

• Suspected hemorrhage
• Structural intracranial lesion
• SNOOP10 “Danger Signs”