CMS200 - Week 11

Headache Classification

• Headaches can be primary or secondary.
• Primary headaches are conditions in and of themselves, including migraines, tension-type headaches, cluster headaches, and life-threatening headaches.
• Secondary headaches are symptoms of other illnesses, such as infections or vascular disorders.

Learning Outcomes

• Analyze classification, causes, and types of headaches (primary and secondary) and their characteristics.
• Evaluate common and rare headache types.
• Diagnose headaches using the International Headache Society's classification system and the POUND mnemonic.
• Conduct a thorough patient history, including physical and neurological examination, to identify red flags.
• Determine appropriate use of neuroimaging, lumbar puncture, and other diagnostic tests.
• Explain the significance of headache characteristics (onset, duration, frequency, pain character, location, and associated features) in diagnosis.
• Construct and rank a differential diagnosis based on demographic information, risk factors, symptoms, and signs.
• Assess the etiology, prevalence, and impact of headache disorders on patients' quality of life, including those in children and adolescents.
• Correlate modifiable risk factors, medication overuse, and lifestyle factors with headache severity and frequency.
• Monitor patient progress, reassess the working diagnosis, and address factors driving headache escalation.
• Provide patient reassurance and address concerns when appropriate.

Introduction

• Headaches can have various causes.
• Proper headache evaluation can be challenging.
• The burden of headaches may be underestimated.
• Headaches are unusually common among otherwise healthy young people, including children and adolescents.
• The prevalence of headaches peaks between the ages of 25 and 40, and decreases with age.
• Headaches are more common in women.
• Fewer than 1% of headaches are life-threatening, although anxiety related to headaches is common, especially those related to tumors.
• Assessing and treating benign headaches while identifying rare life-threatening headaches without excessive evaluation is crucial.

ICHD-III

• The International Classification of Headache Disorders (ICHD-III) is a formal, comprehensive system.
• It classifies over 200 headache disorders into categories and subcategories.
• This study focuses on a small fraction of these categories.
• The main categories include primary headaches, secondary headaches, neuropathies, and facial pain.
• Clinicians use these criteria to accurately diagnose various types of headaches.

Approaches to History Taking

• Focus on serious headache causes.
• Recognize alarm features that indicate possible serious pathologies (e.g., those suggesting a high likelihood of abnormalities on neuroimaging).
• Understand the typical features of common benign headache syndromes.

Physical Examination

• Physical exams are not always conclusive toward a headache diagnosis.
• Abnormalities in visual, motor, reflex, sensory, speech, or cognitive function warrant further investigations.
• Physical exams should be guided by diagnostic hypotheses.
• Common physical exams performed to investigate headaches may include neurological tests, cranial nerve exams, head, and neck exams.
• Focal neurological deficits, papilledema, bitemporal hemianopia, homonymous hemianopia, decreased visual acuity, or increased pain with Valsalva maneuver suggest secondary headache causes.

New or Old?

• New headache versus old headache distinctions:
• New headaches are those of recent onset or a change in character or quality.
• Although old headaches can be primary or secondary, they are frequently associated with migraines or tension headaches.
• Alarm features are important in assessing new headaches.

Primary or Secondary Headaches

• Headaches are categorized as primary or secondary.
• Common primary headaches include tension-type headaches, migraines, and cluster headaches.
• Secondary headaches are caused by other medical conditions.
• Determining whether a headache is primary or secondary helps determine appropriate treatment.

Red Flags: SNNOOP10

• The American Headache Society developed a diagnostic tool called SNNOOP10. This highlights red flags in a patient's history that may be associated with secondary headaches.
• Key findings include: systemic symptoms, neoplasm history, neurologic deficit, sudden onset, older age, pattern change, positional headache, precipitated by certain actions, papilledema, pregnancy, painful eyes with autonomic features, post-traumatic onset, pathology of the immune system, and overuse of pain relievers, among others.

Neuroimaging

• Neuroimaging is used for patients with red flags because of the increased risk of intracranial pathology.
• The 2019 American College of Emergency Physicians clinical policy recommends neuroimaging in specific scenarios. This includes headaches associated with new neurological deficits, new and severe sudden-onset headaches, HIV-positive patients, and those older than 50 with a new headache.
• Non-contrast head CT is often the initial test of choice for suspected emergent headaches, but other imaging modalities may be needed depending on the case.
• MRI with or without contrast is more appropriate for conditions that involve progressive worsening of headaches over weeks or months, acute trauma, or suspected intracranial hemorrhage

Lumbar Puncture

• Lumbar puncture is used in cases of suspected infection, bleeding, or other abnormalities within the central nervous system as a way of removing cerebrospinal fluid (CSF).
• This procedure is considered for patients with fever with altered mental status, meningeal signs (physical signs suggestive of inflammation of the meninges.), focal neurological deficits, suspected history of HIV, and cases of suspected idiopathic intracranial hypertension.

Other Labs

• Complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are used to investigate infection, vasculitis, or metabolic causes of headaches.
• Endocrine testing can be used to diagnose pituitary abnormalities that may cause some forms of headaches.

Rhinosinusitis

• Inflammation of the sinuses and nasal mucosa, commonly caused by viral or bacterial infections.
• Facial pain, pressure, or fullness are common symptoms.
• Acute bacterial rhinosinusitis (ABRS) is diagnosed when symptoms persist longer than 10 days or worsen after 5-7 days of a typical upper respiratory tract infection.
• Subacute rhinosinusitis refers to a condition lasting anywhere from 4 weeks to 12 weeks, while chronic rhinosinusitis persists continuously for 12 weeks or more, often associated with recurrent episodes.

Meningitis

• Inflammation of the meninges, typically caused by various pathogens, leading to headache, fever, and stiff neck.
• Bacterial meningitis is often associated with a rapid onset of symptoms and high mortality rates if left untreated.
• Viral meningitis is often self-limiting and has a better outcome, but still warrants appropriate diagnosis and treatment.
• Some risk factors for bacterial meningitis that are specific to both adults and children include prior travel to endemic areas for various infectious diseases.
• Specific risk factors for infants/children versus adults include issues like functional or anatomical asplenia, recent trauma, conditions impacting the immune system, and injection drug use.

Head Trauma

• Head trauma is a common cause of headaches in the emergency department, more common in males, children, and young adults, and in the elderly.
• Risk factors include motor vehicle accidents, falls, assaults, sports-related injuries, alcohol or drug intoxication, and previous neurosurgical procedures.
• The severity of head trauma varies, with minor cases being much more common (90%).
• More serious or severe intracranial injuries are found in 7% of cases.
• Symptoms may develop immediately, or appear days or weeks after the traumatic event.

Subarachnoid Hemorrhage

• A ruptured blood vessel in the space between the brain and the skull causing severe headache.
• Presenting symptoms include severe and sudden headache, nausea, vomiting, stiff neck, and loss of consciousness.
• The Ottawa SAH rule is a diagnostic tool specifically for identifying subarachnoid hemorrhage, primarily aimed at alert patients with sudden, severe, atraumatic headaches developing within 1 hour, to determine if more extensive studies (like noncontrast CT scans) should be performed.

Idiopathic Intracranial Hypertension

• Characterized by severe headaches, often in young obese women, and related to changes in vision.
• It may resolve spontaneously, or necessitate long-term treatment.
• Factors such as rapid weight gain or loss, female sex hormones, and certain medications (e.g., tetracyclines, vitamin A derivatives, corticosteroid withdrawal), are implicated in the development of this disorder.

Temporomandibular Disorder (TMD)

• A disorder involving the temporomandibular joints that can cause headache and facial pain in conjunction with chewing, mouth opening, or mouth closing.
• The condition is characterized by acute and chronic pain lasting over three months or more.
• Additional symptoms include potentially painful or limited movement of the jaw, various sounds (e.g., clicking, popping), and mild to debilitating pain in the preauricular, masseter, or temple regions.

Brain Tumors

• A primary brain tumor is an abnormal growth occurring within the brain.
• Metastatic brain tumors, much more common than primary brain tumors, are those developing in another part of the body and spreading to the brain.
• Headache is a common initial symptom.
• A key clinical feature is typically a gradual progression of headache.
• Further diagnosis may require a MRI with gadolinium contrast, biopsy, and other imaging tests.

Medication Overuse Headache (MOH)

• MOH is a secondary headache disorder triggered by overuse of pain relievers including but not limited to NSAIDs, acetaminophen, and opioids.
• Excessive intake of these medications may lead to reduced effectiveness and a potential increase in headaches/occurrences and intensity of headaches; increased frequency of headaches.
• A refractory, nearly constant, or daily pattern of headache symptoms and the presence of withdrawal symptoms with cessation of medication use are also used in diagnosis.

Temporal Arteritis

• A rare autoimmune disease involving the arteries of the head; associated with chronic inflammatory disorders and severe headaches, particularly in elderly patients over 50.
• Symptoms include headache, jaw claudication (pain when chewing), scalp tenderness, and vision problems (e.g., diplopia, sudden vision loss).
• A temporal artery biopsy is the gold-standard diagnostic method.
• Early diagnosis and treatment can be critical to preventing potential blindness.

Primary Headaches (Review)

• These include tension-type headaches, migraines, and cluster headaches.
• Diagnosis and initial assessment is often based on patient history and physical examination.
• The presence of red flags warrant further investigations and referral.

Chronic Headaches

• Defined by the presence of headaches occurring on most days during a period of 3 or more months
• Chronic headaches often emerge from episodic forms, particularly from migraines or tension-type headaches.
• A proper work-up that includes a thorough history, examination, and possibly imaging tests, is important in differential diagnosis and patient management.

Assessing Impact of Frequent Headache

• The headache impact test and headache diaries are useful tools for assessing the impact and frequency of headaches on a patient's daily life, including pain, symptom progression, treatment effectiveness, and any necessary and indicated adjustments for therapy and care.

Further Diagnostic Tips

• Obtaining a thorough history from both parents and children in pediatric patients.
• Considerations over time to evaluate and document any changes in the patient's conditions and/or progression, and how these changes relate to the natural history of the patient's disorder.
• A proper diagnosis should be accurate and complete and recognize that superimposed secondary headaches are possible concurrent pathologies.

Referral and Follow-Up

• Referral to a neurologist is often warranted in cases of unclear headaches, concerning red flags for more severe conditions, or for cases with a failure of treatment with a prior or current approach.
• Patients should be aware of factors to relay to their physicians to allow for prompt and accurate reassessment of the patient's condition.

Learning Outcomes Review (Repeated)

• Summarization of learned outcomes on reviewing topics in headache disorders.
• Comprehensive discussion of the analysis of causes, classification, and types of headaches.
• Description of diagnostic techniques and tools, risk assessment, impact on quality of life, and patient care management across various age groups.

This quiz explores the distinctions between primary and secondary headaches. Gain insights into their causes, symptoms, and treatments through a series of informative questions that enhance your understanding of headache classifications.