Identify the typical presenting signs and symptoms of common as well as serious causes of headache

Family Medicine 18: 24-year-old female with headaches User: Ralph Marrero Email: ralph2888@stu.southuniversity.edu Date: March 9, 2022 8:53 PM

Learning Objectives

The student should be able to:

Identify the typical presenting signs and symptoms of common as well as serious causes of headache (tension, cluster, brain tumor, intracranial hemorrhage, medication use). Perform a reliable focused neurologic exam on a patient who presents with headache. Discuss the importance of continuity of care when treating a patient who presents with chronic headache. Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient presenting with headaches. Summarize the key features of a patient presenting with headache, capturing the information essential for differentiating between the common and “don’t miss” etiologies including tension, migraine, cluster, brain tumor, intracranial hemorrhage, medication use headaches. Propose a cost-effective diagnostic work-up for a patient presenting with headache. Describe the acute and prophylactic management of common headaches including migraine. Find and apply diagnostic criteria and surveillance strategies for substance use disorder.

Knowledge

Causes of Headache

Common types of headache seen in the outpatient setting:

1. Tension-type 2. Migraine 3. Medication overuse 4. Cluster headache

Serious causes of headache:

1. Meningitis 2. Brain tumor 3. Intracranial hemorrhage 4. Traumatic brain injury

Causes of Serious Secondary Headaches

Etiology of secondary headache

Findings

Meningitis Headache with fever, mental status changes, or stiff neck.

Intracranial hemorrhage Sudden onset of headache, severe headache, recent trauma, elevated blood pressure.

Brain tumor Cognitive impairment, weight loss or other systemic symptoms, abnormal neurologic examination.

Traumatic brain injury

Head injury with subsequent confusion and amnesia. Loss of consciousness sometimes occurs. Subsequent headache, dizziness, and nausea, and vomiting. Over hours and days: mood and cognitive disturbances, sensitivity to light and noise, and sleep disturbances.

Common Etiologies of Secondary Headaches

1. Headache due to depression or anxiety

Features

Similar to tension-type headache: Bilateral, pressing, and/or tight Last from 30 minutes to seven days

Some experts feel that depression or anxiety can trigger tension-type headaches. In those cases, tension-type headaches are considered secondary, not primary headaches. 2. Medication overuse headache

Chronic use of any analgesic can cause this type of headache in patients with pre-existing primary headache—it is an interaction between a therapeutic agent used excessively and a susceptible patient. Features

Mild to moderate in severity Diffuse, bilateral headaches that can occur almost daily and are often present on first waking up in the morning. Often aggravated by mild physical or mental exertion. Can be associated with restlessness, nausea, forgetfulness, and depression. Headaches may improve slightly with analgesics but worsen when the medication wears off. Tolerance develops to abortive medications and there is decreased responsiveness to preventive medications. Medication overuse headache can occur at varying doses for different types of medication; it may occur with as low as an average of 10 doses of triptans per month.

Diagnostic criteria

More than 15 headaches per month in a patient with pre-existing primary headache. Regular overuse of an analgesic taken for acute treatment of headache for more than three months. Not better accounted for by another diagnosis.

Treatment

Stop the overused medication.

Important Physical Exam Findings with Headache

Signs of increased intracranial pressure:

Papilledema Altered mental status

Other important findings to look for:

Signs of meningeal irritation such as Kernig’s sign or Brudzinski’s sign Focal neurologic deficits such as unilateral loss of sensation, unilateral weakness, or unilateral hyperreflexia.

Triggers for Tension & Migraine Headaches

Physical or environmental triggers:

1. Intense or strenuous exercise 2. Sleep disturbance 3. Menses 4. Ovulation 5. Pregnancy (though for many women, headaches improve during pregnancy) 6. Acute illness 7. Fasting 8. Bright or flickering lights 9. Emotional stress

Medications or substances that act as triggers:

1. Estrogen (birth control/hormone replacement) 2. Tobacco, caffeine, or alcohol 3. Aspartame and phenylalanine (from diet soda)

When to Initiate Prevention of Migraines

The American Migraine Prevalence and Prevention Study outlines recommendations as to when daily pharmacological treatment should be initiated:

At least six headache days per month At least four headache days with at least some impairment At least three headache days with severe impairment or requiring bed rest.

Prevention should be considered: Four to five migraine days per month with normal functioning Two to three migraine days per month with some impairment Two migraine days with severe impairment.

http://www.nlm.nih.gov/medlineplus/ency/imagepages/19077.htm
http://www.nlm.nih.gov/medlineplus/ency/imagepages/19069.htm
DSM-5 Substance Use Disorder

The DSM-5 substance use disorder criteria combine the DSM-4 criteria for dependence, addiction, and tolerance. There is now one term, “substance use disorder,” that encompasses a continuum of problems with substances from mild to severe. Each specific substance use disorder is diagnosed in similar fashion, using a list of 11 symptoms to determine the severity of illness. For opioid use disorder, the 11 symptoms are:

Opioids taken in larger amounts than intended Unsuccessful efforts to control use Significant time spent in opioid-related activities Craving Use results in unmet obligations at work, school, or home Continued use despite significant interpersonal problems related to use Other activities neglected due to use Use in physically hazardous situations Continued use despite physical or psychological problems related to use Tolerance Withdrawal

Note: The last two symptoms do not apply to patients taking opioids solely under appropriate medical supervision.

Clinical Skills

How to Perform a Neurological Exam

Test cranial nerves II through XII:

Cranial Nerves Test

II and III Pupils are equal, round, and reactive to light.

Use Snellian Chart to test visual acuity

Test visual fields with confrontation.

Confrontation: Ask the patient to look with both eyes into your eyes. While returning their gaze, place your hands about 2 feet apart, lateral to their ears, and instruct them to point to your fingers as soon as they are seen. Then slowly move your wiggling fingers on both hands along an imaginary bowl encircling their head toward the line of gaze until they identify them. Do this in the upper and lower temporal quadrants.

III, IV, and VI

Extraocular eye movements are intact.

Convergence intact.

Extraocular eye movements:

Ask the patient to refrain from moving their head while following your finger movements with their eyes, and make a wide H in the air, leading their gaze:

(1) To the extreme right

(2) To the right and upward

(3) Down on the right

(4) Then, without pausing in the middle, to the extreme left

(5) To the left and upward

(6) Down on the left

Convergence:

Ask the patient to follow your fingertip with their eye as you move it towards the bridge of her nose.

V Ask the patient to close her eyes and then ask if the two stimuli feel the same when you lightly touch their right, then leftforehead; right, then left cheek; right, then left chin.

VII

Observe for facial asymmetry while the patient is talking or performing the following maneuvers:

1. Raise eyebrows

2. Frown

3. Close both eyes tightly while you try to open them

4. Show both upper and lower teeth

5. Smile

6. Puff out both cheeks

VIII Rub your fingers near each ear

XI Ask the patient to elevate their shoulders against resistance

IX, X, and XII Note if speech is clear and tongue and palate are midline

Management

Patient Management of Migraine and Tension-Type Headaches

1. Headache diary

Make note each day of whether or not you have a headache. Keep track of the severity of the headaches and which treatments are effective. Identify and avoid headache triggers. Use a list of things that trigger headaches, and monitor which of these triggers worsen your headaches. You can find an example of a headache diary here.

2. Caffeine

Caffeine can help headaches but an excess can make them worse, especially when stopping it abruptly. Slowly decrease the use of diet sodas. The caffeine worsens both migraines and tension-type headaches, but coming off of caffeine too quickly may make things worse in the short term. 3. Sleep

Try to get more sleep. Aim for seven to nine hours each night and establish a regular sleep routine, meaning try to go to sleep at the same time each night. Make sure the bedroom is quiet, dark and relaxing, and at a comfortable temperature. Remove electronic devices like TVs, computers, and smartphones from the bedroom. Avoid large meals, caffeine, and alcohol before bedtime.

Examples of Effective Stress Relievers

Meditation or a scheduled moment of stillness Listening to a relaxation audio program Setting limits on other people’s expectations Talking with trusted family and friends Getting moderate, regular exercise Getting at least seven to nine hours of restful sleep each night

Migraine Medications

Migraine- specific treatments:

Treatment Generic name(trade name) Contraindications Side effects

https://aqmedia.org/filestore/1/4/2_deb876402e76226/241_895f1099472a8f2.pdf
triptans

sumatriptan (Imitrex, Imigran), naratriptan (Amerge, Naramig), rizatriptan (Maxalt), zolmitriptan (Zomig), frovatriptan (Frova, Migard), almotriptan (Axert), eletriptan (Relpax)

Concurrent use of ergotamine, MAOIs; history of hemiplegic or basilar migraine; significant cardiovascular, cerebrovascular, or peripheral vascular disease; severe hypertension; in combination with SSRI’s, may cause serotonin syndrome. There is a theoretical risk of vasoconstriction impacting a pregnancy, so they should be used with caution in pregnancy.

Dizziness, sleepiness, nausea, fatigue, paresthesia, throat tightness/closure, chest pressure.

ergot alkaloids

ergotamine (Ergostat), ergotamine/caffeine (Cafergot), dihydroergotamine (DHE)

Concurrent use of triptans, many possibly serious drug interactions; heart disease or angina, hypertension, peripheral vascular disease, pregnancy, renal insufficiency, breastfeeding.

Severe reactions possible. MI, ventricular tachyarrhythmias, stroke, hypertension, nausea, vomiting, diarrhea, dry mouth, rash.

Non-specific treatments (effective for any pain disorder):

Treatment Generic name(trade name) Contraindications Side effects

acetaminophen/aspirin/caffeine (Excedrin) Pregnancy; sensitivity to aspirin.

Nausea; GI bleed; hypertension.

Older medications no longer recommended because of increased risk of overuse:

Treatment Generic name(trade name) Contraindications Side effects

aspirin/butalbital/caffeine (Fiorinal)

Risk of chronic daily use or dependence higher; history of porphyria or peptic ulcers; bleeding risk; pregnancy.

Anaphylaxis, toxic epidermal necrolysis, Stevens-Johnson syndrome, myelosuppression/thrombocytopenia, GI bleed.

acetaminophen/butalbital/caffeine (Esgic, Fioricet, Phrenilin (lacks caffeine))

History of porphyria; pregnancy; caution in drug abuse.

Dizziness, drowsiness, dyspnea, nausea, vomiting, abdominal pain, agranulocytosis, thrombocytopenia, respiratory depression, Stevens- Johnson syndrome.

acetaminophen/dichloralphenazone (Midrin (discontinued in the U.S.))

Hepatorenal insufficiency; diabetes; hypertension; glaucoma; heart disease; MAOI use.

Hypertension, dizziness, rash.

Opioid/Butalbital Last Resort Migraine Therapy

Note: Don’t use opioid or butalbital treatment for migraine except as a last resort.

According to the Choosing Wisely Campaign, “Opioid and butalbital treatment for migraine should be avoided because more effective, migraine-specific treatments are available. Frequent use of opioid and butalbital treatment can worsen headaches. Opioids should be reserved for those with medical conditions precluding the use of migraine-specific treatments or for those who fail these treatments.

Migraine prophylaxis

Patients who have migraines more frequently than twice weekly are at risk for medication overuse headache. Migraine prophylaxis should be considered in these patients if lifestyle changes aren’t effective .

Drugs used (daily dose range)

FDA Approved? Efficacy/cost

Contraindications / Cautions

Pregnancy Category Side effects

Beta-blockers

First line:

Metoprolol (47.5- 200 mg)

Propranolol (20- 160 mg)

Timolol (10-30 mg)

Second line:

Atenolol

Nadolol

Yes Good-excellent/cheap

Asthma, depression, severe COPD, DM requiring insulin, Raynaud’s disease

Category C

Fatigue, bronchospasm, lightheadedness, insomnia, bradycardia, depression, sexual dysfunction

Tricyclic Antidepressants

First line:

Amitriptyline (10- 150 mg)

No (off- label)

Excellent/cheap and also work for fibromyalgia and tension-type headache

Cardiac conduction defects, MAOI Category C

Drowsiness, weight gain, dry mouth

Neurostabilizers

Second line:

Divalproex sodium (500-1500 mg); Topiramate (25- 200 mg)

Yes Good/expensive

Pregnancy/risk of pregnancy

Divalproex: hepatic disease

Divalproex: Category D

Topiramate: Category D

Divalproex: birth defects, weight gain, alopecia, pancreatitis, ovarian cysts

Topiramate: abdominal pain, change in tastes, renal stones, weight loss

Goals of Headache Treatment

The American Migraine Prevalence and Prevention Study outlined recommendations as to when daily pharmacological treatment should be initiated: Prevention should be initiated:

American Academy of Neurology

At least six headache days per month. At least four headache days with at least some impairment. At least three headache days with severe impairment or requiring bed rest.

Prevention should be considered: Four to five migraine days per month with normal functioning. Two to three migraine days per month with some impairment. Two migraine days with severe impairment.

The 2000 US Headache Consortium defined the following goals for preventive treatment: 1. Decrease attack frequency by 50% and decrease intensity and duration. 2. Improve responsiveness to acute therapy. 3. Improve function and decrease disability. 4. Prevent the occurrence of a medication overuse headache (MOH) and chronic daily headache.

Studies

Indications for Brain Imaging in the Evaluation of Headache

Don’t do imaging for uncomplicated headache. The “Choosing Wisely” campaign of the American Board of Internal Medicine Foundation states that “imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expenses that do not improve patient wellbeing.” The American Academy of Neurology and the U.S. Headache Consortium guidelines recommend neuroimaging only if:

1. The patient has migraine with atypical headache patterns or unexplained abnormalities on neurological examination 2. The patient is at higher risk of a significant abnormality including: …a. Patients with associated head trauma …b. New or changing headache over the age of 50 …c. New or changing headaches in those less than 6 years old 3. The results of the study would alter the management of the headache Symptoms that increase the odds of positive neuroimaging results include:

Rapidly increasing frequency of headache Abrupt onset of severe headache Marked change in headache pattern A history of poor coordination, focal neurologic signs or symptoms, and a headache that awakens the patient from sleep. A headache that is worsened with use of Valsalva’s maneuver Persistent headache following head trauma New onset of headache in a person age 35 or over History of cancer or HIV

Clinical Reasoning

Defining Characteristics of Primary Headaches

Migraine Tension type Cluster

Severity of pain Moderate to severe. Mild to moderate. Severe.

Associated symptoms

Often occurs with nausea and vomiting, photophobia, or hyperacusis. May occur with aura.

May occur with photophobia or hyperacusis.

Associated with rhinorrhea, lacrimation, facial sweating, miosis, eyelid edema, conjunctival injection, and ptosis.

Quality of pain Pulsating and can be unilateral.

Pressing, tightening, and bilateral.

Severe unilateral orbital, periorbital, supraorbital, or temporal pain.

Aggravating factors Worsened with physical activity.

Typically not worsened with physical activity.

ACR – Imaging for uncomplicated headache

Duration of symptoms Last from 4-72 hours.

Last from 30 minutes to 7 days. Last 15-180 minutes.

Number of episodes 5 episodes needed for diagnosis.

10 episodes needed for diagnosis. 5 episodes needed for diagnosis.

Screening for Anxiety and Depression

The two questions you asked are a screening tool for anxiety in the primary care setting known as the GAD-2. There is a similar screening tool for depression known as the PHQ-2. GAD-2

Over the last two weeks, how often have you been bothered by the following problems?

Not at all

Several days

Nearly half the days

Nearly every day

Feeling nervous, anxious, or on edge? 0 1 2 3

Not being able to stop or control worrying 0 1 2 3

(For office scoring, total score T = __ ___ + ___ + ___ )

A positive screening test is a score > 2 points. PHQ-2

Over the last two weeks, how often have you been bothered by the following problems?

Not at all

Several days

More than one-half the days

Nearly every day

Little interest or pleasure in doing things 0 1 2 3

Feeling down, depressed, or hopeless 0 1 2 3

A negative response to both questions is considered a negative result for depression. A positive response to either question in the PHQ-2 or the GAD-2 is highly sensitive for either depression or anxiety, respectively. However, neither test is very specific . If a patient has a positive response to one of the questions, a more comprehensive screening tool, the PHQ-9 or the GAD-7, should be administered. These longer questionnaires are more specific in identifying depression or anxiety.

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing; 2013.

Andress-Rothrock D, King W, Rothrock J. An analysis of migraine triggers in a clinic-based population. Headache. 2010;50(8):1366-70.

Bickley LS. Bates Guide to Physical Examination and History Taking. 10th edition. Philadelphia: Wolters Kluwer/Lippincott Williams & Williams; 2009.

CDC. Centers for Disease Control and Prevention. Violence Prevention. Coping With Stress. https://www.cdc.gov/violenceprevention/about/copingwith-stresstips.html. Reviewed November 25, 2020. Accessed February 10, 2021.

Diener HC, Holle D, Dodick D. Treatment of chronic migraine. Curr Pain Headache Rep. 2011;15(1):64-9.

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49. Published 2016 Mar 18.

Estemalik E, Tepper S. Preventive treatment in migraine and the new US guidelines. Neuropsychiatr Dis Treat. 2013;9:709-20.

Expert Panel on Neurologic Imaging, Whitehead MT, Cardenas AM, et al. ACR Appropriateness Criteria® Headache. J Am Coll Radiol. 2019;16(11S):S364-S77.

Hainer BL, Matheson EM. Approach to acute headache in adults. Am Fam Physician. 2013;87(10):682-7.

Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.

https://pubmed.ncbi.nlm.nih.gov/21044280/
https://www.cdc.gov/violenceprevention/about/copingwith-stresstips.html
https://pubmed.ncbi.nlm.nih.gov/21080112/
https://pubmed.ncbi.nlm.nih.gov/26987082/
https://pubmed.ncbi.nlm.nih.gov/23717045/
https://pubmed.ncbi.nlm.nih.gov/31685104/
https://pubmed.ncbi.nlm.nih.gov/23939446/
https://pubmed.ncbi.nlm.nih.gov/29368949/
International Headache Society. 2021. IHS Classification ICHD-3. Migraine. https://ichd-3.org/1-migraine/. Accessed February 4, 2021.

International Headache Society. 2021. IHS Classification ICHD-3. Tension-type headache (TTH). https://ichd-3.org/2-tension-type- headache/. Accessed February 4, 2021.

Jackman RP, Purvis JM, Mallett BS. Chronic nonmalignant pain in primary care. Am Fam Physician. 2008;78(10):1155-62.

Kristoffersen ES, Lundqvist C. Medication-overuse headache: a review. J Pain Res. 2014;7:367-78. Published 2014 Jun 26.

Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284-92.

Locke AB, Kirst N, Shultz CG. Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician. 2015;91(9):617-24.

Maurer DM, Raymond TJ, Davis BN. Depression: Screening and Diagnosis. Am Fam Physician. 2018;98(8):508-15.

Mayans L, Walling A. Acute Migraine Headache: Treatment Strategies. Am Fam Physician. 2018;97(4):243-51.

Modi S, Lowder DM. Medications for migraine prophylaxis. Am Fam Physician. 2006;73(1):72-8.

Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78(17):1337-45.

Work Group on Substance Use Disorders, Kleber HD, Weiss RD, et al. Treatment of patients with substance use disorders, second edition. American Psychiatric Association. Am J Psychiatry. 2006;163(8 Suppl):5-82.

Family Medicine 18: 24-year-old female with headaches
Learning Objectives
Knowledge
Causes of Headache
Causes of Serious Secondary Headaches
Common Etiologies of Secondary Headaches
Important Physical Exam Findings with Headache
Triggers for Tension & Migraine Headaches
When to Initiate Prevention of Migraines
DSM-5 Substance Use Disorder
Clinical Skills
How to Perform a Neurological Exam
Management
Patient Management of Migraine and Tension-Type Headaches
Examples of Effective Stress Relievers
Migraine Medications
Opioid/Butalbital Last Resort Migraine Therapy
Migraine prophylaxis
Goals of Headache Treatment
Studies
Indications for Brain Imaging in the Evaluation of Headache
Clinical Reasoning
Defining Characteristics of Primary Headaches
Screening for Anxiety and Depression
References

Identify the typical presenting signs and symptoms of common as well as serious causes of headache

Case study : A 42-year-old man comes to clinic with chief complaint of pain, redness, and swelling of his right calf.

Describe typical changes in each organ system that occur as part of the normal aging process

Identify the typical presenting signs and symptoms of common as well as serious causes of headache