Primary vs Secondary Headaches & Migraine

• Headache disorders are the most common disorders of the nervous system.
• 90-95% of the population experiences headaches, making it one of the top 10 complaints in outpatient settings.
• Headaches affect people of all ages, races, income levels, and geographic areas; 47% lifetime prevalence in adults.
• it is important to distinguish between primary and secondary headaches.

Primary vs. Secondary Headaches

• Primary headaches are more common and not symptomatic of another medical condition.
• Secondary headaches are less common and result from an underlying condition or disease.

Migraine Clinical Presentation

• Onset: Rapid
• Location: Unilateral or bilateral
• Duration: Episodic, 4-72 hours
• Intensity: Moderate to severe
• Characteristics: Throbbing, pulsating
• Associated symptoms: Nausea/vomiting (N/V), photophobia, phonophobia, with or without aura
• Common triggers: Medications, obesity, depression, stress, sleep troubles, food, alcohol, and hormonal changes.
• Migraines are more common in women with a 3:1 ratio.

Tension-Type Headache Clinical Presentation

• Onset: Gradual
• Location: Bilateral headache, described as a "tight band."
• Duration: Present most of the day, less than 15 days per month.
• Intensity: Mild to moderate
• Characteristics: Tightness, non-throbbing, non-pulsatile
• Common triggers: Stress, anxiety, depression
• Tension-type headaches are more common in women with a 4:5 ratio.

Cluster Headache Clinical Presentation

• Onset: Abrupt (cyclical pattern)
• Location: Unilateral
• Duration: 15-180 minutes
• Intensity: Severe
• Characteristics: Continuous, burning, piercing, excruciating, stabbing
• Associated symptoms: Lacrimation, rhinorrhea, ptosis
• Common triggers: Alcohol, stress, heat exposure
• Cluster headaches are more common in men.

Risk Factors for Headaches

• Emotional stress
• Anxiety, depression
• Changes in sleep
• Overexertion
• Jaw clenching/teeth grinding
• Certain medications like nitrates, antihypertensives, SSRIs
• Hormonal changes
• Consumption of high nitrite foods such as cured meats and red wine
• Excessive caffeine/alcohol intake

Headache Evaluation: History

• It is the most important aspect, and diagnosis is often based on it
• Age at onset
• Time and mode of onset
• Presence or absence of aura
• Frequency, intensity, and duration of the attack
• Quality, site, and radiation of pain
• Associated symptoms such as fever
• Family history of migraine
• Precipitating/relieving factors
• Exacerbation or relief with change in position
• Association with food/alcohol
• Recent changes in sleep, exercise, weight, or diet
• Effect of activity on pain
• Response to previous treatments
• Change in method of birth control for women

Headache Evaluation: Physical Exam

• A targeted physical exam is important for ruling out harmful secondary causes.
• Obtain blood pressure and pulse
• Fundoscopic and pupillary assessment
• Listen for bruit at neck, eyes, and head to identify clinical signs of arteriovenous malformation
• A neuro exam should include mental status examination, cranial nerve examination, symmetry on motor reflex, cerebellar coordination, and sensory test.
• Gait examination elements are standing up without support, walking on tiptoes and heels, performing tandem gait, and Romberg test.

Danger Signs: SNNOOP10 Mnemonic

• Systemic symptoms including fever, weight loss
• Neoplasm history
• Neurologic deficit (including decreased consciousness)
• Onset is sudden or abrupt
• Older age (onset after age 50 years)
• Pattern change or recent onset of new headache
• Positional headache
• Precipitated by sneezing, coughing, or exercise
• Papilledema
• Pregnancy or puerperium
• Painful eye with autonomic features
• Progressive Headache or atypical feature
• Painkiller (analgesic) overuse or onset with new medication use
• Post-traumatic onset of headache
• Pathology of immune system such as HIV

Diagnostics for Headaches

• Laboratory: CBC and differentials; ESR, CRP; Thyroid function tests; Lyme titer; Rheumatoid factor; CSF cell count, protein, glucose
• Imaging: CT scan, MRI recommended only for patients presenting with danger signs
• Lumbar puncture: CSF analysis can be done to show subarachnoid hemorrhage or with suspicion of infectious, inflammatory or neoplastic etiology.

Differential Diagnosis for Headaches

• Medication overuse headache
• Meningitis
• Pseudotumor cerebri
• Hemorrhage
• Thyroid dysfunction
• Lyme disease
• Rheumatologic disorders - SLE, RA
• Sphenoid sinusitis
• Brain or pituitary tumor

Pharmacologic Management of Headaches

• Simple analgesics are used for management in mild to moderate headaches.
• Beta-blockers and Calcium Channel Blockers
• Antidepressants are used off-label for tension headaches
• Verapamil and Lithium (not common) is used off-label for cluster attack, and lithium levels should be closely monitored.

Pharmacologic Management Options for Headaches

• Preventive therapy has the potential to decrease headache intensity and frequency, given daily
  • Anticonvulsants - Topiramate
  • Calcium channel blockers-Verapamil
  • Beta Blockers-Propranolol
• Abortive therapy is used to treat the intensity and duration of pain during an attack, used to manage associated symptoms
  • NSAIDs- Motrin
  • Muscle Relaxants-Carisoprodol (Soma)
  • Triptans- Sumatriptan, Zolmitriptan

Non-Pharmacologic Management of Headaches

• Behavior Modification - Relaxation training, stress management
• Biofeedback
• Wellness program: Balanced meals, regular exercise, adequate sleep, counseling/therapy
• Accupressure/Accupuncture
• Keeping a headache diary to documents the number of headaches, triggers, and treatment successes

Headache Considerations

• Follow up- go to the ER if you experience neurological symptoms or more severe pain, return to clinic if things change.
• Referral to neurologist for headaches unresponsive to treatment.

Possible Complications of Headaches

• Misdiagnosis can be serious
• GI bleed from continued use of NSAIDs
• Rebound headaches
• Dependence on medication such as opioids or caffeine-containing analgesics
• High risk of epilepsy
• Patient education is key