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The Differential Diagnosis of Headaches Richard B. Mangan, OD

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The Differential Diagnosis of Headaches Richard B. Mangan, OD The Differential Diagnosis of Headaches Richard B. Mangan, OD, FAAO The Eye Center of Richmond Adjunct Faculty, IU School of Optometry Kentucky Cadillac w 1 “Alice in Wonderland” Syndrome “13 year-old headache” (Val Akula) Get to the “Heart” of the Matter Headache History H = History (most important) PQRST E = Examination (both physical & ocular) P = Provocative & Palliative A = Assess the need for further testing and / Q = Quality or diagnose. R = Region R = Refer, or S = Severity T = Treat T = Temporal Aspects 2 Headache History FORD (PARTS) P = Provocative Factors F = Frequency A = Associating Factors O = Onset R = Relief R = Region T = Treatment D = Duration S = Severity 3 “Tension-Type” Headache Most Common Headache Females > Males; Age of Onset (13 – 38) Charac ter ize d by gra dua l onse t, bila tera l, non- throbbing aching pain over the frontal and temporal regions, which often spreads to the occipital. Pain often worsens as day goes on. Usually no abnormal findings on physical exam. “Knight-time” Tension Headache Tension Headache Tension Headache Management Episodic (several minutes – 7 days) Remove or Reduce Stressors -or- Relaxation Techniques Chron ic (a t leas t 15 days / month) Massage, Heat, Hot Shower, Exercise, Hobbies. Medication If Episodic => OTC Analgesics (aspirin, acetaminophen, R/O signs of depression, anxiety, or environmental ibuprofin +/- caffeine. causes. If Chronic => amitriptyline (tricyclic antidepressant) “What do you think is causing your headaches?” **Avoid narcotic pain medication** r1 4 Slide 23 r1 Incorporate video of guy going through a cluster. rbm, 6/4/2008 Cluster Headache Cluster Headache Is among the most severe pain conditions! Unilateral, penetrating, excruciating pain, affecting Vascular the retro-orbital temporal region. 8:1 Male : Female Ratio Patients prefer to be mobile, rather than lie down Onset usually > age 20 during an attack. 2-3 (usually nocturnal) attacks / day for months, Usually spontaneous, but may be provoked by then cease for months or years, only to recur. alcohol, change in barometric pressure or sleep patterns. Pain peaks at 10-15 minutes and last 45 to 180 minutes. Associated w/ conjunctival injection, lacrimation, rhinorrhea, & Horner’s syndrome. Cluster HA Management Avoid Trigger (mostly alcohol) Prophylactic Tx’s (Calcium Channel Blockers (Verapamil), Seratonin antagonist (Sansert - methysergide) Abortive TOC (Subcut. Sumatriptan) & Pure O2 Surgery (ablation of trigeminal nerve components) NSAID: Indomethacin (Indocin) Migraine Headache Migraine “Triggers” Inherited Neuronal / Vascular Disorder? Dietary (25%) Unifying Theory: Neurovascular “Ping-Pong” Chocolate 28 million Americans (1/2 being moderately to Cheeses, Dairy Products severely disabled). 3:1 female:male Alcohol (red wine) Onset +/- age 12; Peak 35-40; Subside +/- 50 Citrus fruits Nuts Accounts for 1 billion dollars in direct medical Chemical Additives costs (13 billion / indirect) Caffeine 75% self-medicate Skipping Meals Provocative (Trigger) Factors (85%) 5 Migraine “Triggers” The “Full House” Migraine Dietary (25%) Hormonal (Mensus, BC Pill) Prodrome (60%) Chocolate Environmental Aura (20%) lasting ½ to 1 hour Cheeses, Dairy Products Smells (perfume, Alcohol (red wine) aftershave lotion, cigarette “Ca lm be fore the s torm ” (15m in to 3 hours ) Citrus fruits smoke, cooking odors) Unilateral, Throbbing or Pulsing Pain of Nuts Changes in barometric pressure (worse weather) Moderate to Severe Intensity, lasting 3 to 72 Chemical Additives Stress, Excitement, Physical hours (Associated w/ nausea, vomiting, anorexia, Caffeine Activity (body movement, photophobia, phonophobia, & osmophobia) Skipping Meals sex) or disruption of Postdrome normal patterns. Migraine Prodrome Migraine Prodrome Depression or Elation “Alice in Wonderland” Polydipsia & Polyuria or Fluid Retention Syndrome Disoriented Diarrhea or Constipation Altered sense of time & Chills, Fatigue, Pallor self. Illusions: Food Cravings z Enlargement “Alice in Wonderland” Syndrome z Shrinking z Elongation Migraine “Aura” Migraine “Aura” (+) Visual Phenomena (-) Visual Phenomena Photopsias (flashes of Homonymous or ligg,pht, spots, ,p sparks, Quadrantic defects streaks of light, wavy Central Scotoma lines. Tunnel defect Scintillations Altitudinal Field defect (flickering lights) Complete Bilateral Fortification Spectra Blindness (jagged zigzag lines) 6 Unusual Auras: When to Worry Aura’s always on the same side. Aura’s of short duration (5-10 minutes). HdhHeadache s ttbftarts before or diduring thAthe Aura. Need vascular work-up to rule-out AV malformation, Intracranial neoplasm, epileptic aura, Cerebral venous malformation, CA or ICA dissection…Refer. The “Full House” Migraine The “Full House” Migraine Prodrome (60%) Prodrome (60%) Aura (20%) Aura (20%) “Ca lm be fore the s torm” (15m in to 3hours ) “Ca lm be fore the s torm” (15 mi n t o 3h ours) Unilateral, Throbbing or Pulsing Pain of Unilateral, Throbbing or Pulsing Pain of Moderate to Severe Intensity, lasting 3 to 72 Moderate to Severe Intensity, lasting 3 to 72 hours (Associated w/ nausea, vomiting, anorexia, hours (Associated w/ nausea, vomiting, anorexia, photophobia and phonophobia) photophobia and phonophobia) Postdrome Postdrome Migraine Postdrome Migraine (Classification) May persist for 24 hours following Classic (Migraine with Aura) resolution of the headache: Common (Migraine without Aura) Ocular (Aura without the Migraine) Body Aches Complicated Decreased Appetite Basilar Decreased Concentration Ophthalmoplegic Fatigue / Weakness Retinal 7 Complicated Migraine Migraine Management Basilar (bilateral visual field changes, frontal or bi-occipital headache, diplopia, Reassurance nystagmus, nausea an d vom itting) Headache Diary Ophthalmoplegic (CN 3, 4, or 6 involved Behavior Modification post headache) Abortive Treatment Retinal (monocular vision loss lasting 10 to 60 minutes followed by complete recovery) Prophylactic Treatment Migraine Management Migraine Management Headache Diary Behavioral Modification How many HA’s occurred in that month? AidTiAvoid Triggers How long each lasted? Don’t Skip Meals How severe was each one? (Scale of 1-10) What trigger factors were there? Get adequate / consistent hours of sleep What and how much medication was used? Rest in a quiet, darkened room when HA is Was the medication effective? developing. Migraine Management Abortive Treatment Prophylactic Treatment Analgesics Topomax (Topiramate) Migra ine Spec ific BtBeta-Bloc kers (In dera l) Ergotamine (Cafergot) Calcium Channel DHE (Migranol) Blockers (Procardia) Sumatriptan (Imitrex) Antidepressants (Elavil Zolmitriptan (Zomig) qhs) Rizatriptan (Maxalt) Serotonin Antagonists (Sansert) 8 Migraine Management What about Feverfew? Randomized double-blinded placebo controlled crossover study (1998) Retrospective study of 6 random placebo controlled studies (2000) City of London Migraine Clinic Study (1984) 200-250mg qd • 70% + effect • +/- 5 months “Break Time” Medication-Induced or “Rebound” Headache Analgesics + Opiate (Codeine) + Barbiturate (Butalbital) + Ergotamine + Caffeine Analgesics Alone? 9 Medication-Induced or “Rebound” Headache “Rebound” Headache Characteristics Migraine sufferers > Tension They take their meds preemptively “because I know Headaches are daily (or nearly daily) IIll’ll get a headache if I don ’t ” typically occurring between 2-5am. Prophylactic medication becomes useless and the causative abortive agent becomes less effective. HA varies in type, severity, and location Patients are depressed, experience sleep Pt uses abortive meds 20 or more disturbances, have difficulty concentrating, and are days/mos irritable. Mild physical/mental activity incites HA “Rebound” Headache Rebound Headache Management Patient counseling and support Lots of Love & Family education Support. HA diary Remember…it easier CBC, Liver (BUN, creatinine) & Kidney to prevent this, than fix (AST/SGOT) function studies. this. Abrupt d/c of responsible med(s), + / - Aleve, Feverfew, Magnesium inj. & Subcu Sumatriptan. “Fiorinal Call” – Val Akula Inflammatory Headaches Sinus Headache Sinus-related headache Sinusitis => The #1 health-care complaint in Temporal Arteritis (GCA) the US. Meningeal headaches Infectious (bacterial, viral, Affects 31.2 million people incl. HIV) Accounts for 16 million outpatient visits / Neoplasm (Carcinoma, lymphoma) year. Granulomatous (Sarcoid, TB) Chronic Sinusitis => most common chronic disease in the country. 10 Sinus Headache Sinus Headache Acute Chronic Most Common Infectious Non-infectious Typically occurs after a Symptoms have to Pathogens: Contributers: cold or bout of acute persist either: Haemophilus influenza Smoking allergic rhinitis. 2 or more months, or Strep pyogenes Habitual use of: 4+ episodes of acute Symptoms last < 3 wks Strep pneumoniae Nasal Sprays sinusitis that last Inhalers >10days within 1 year. Moraxella catarrhalis Staph (Chronic) Sinus Headache Sinus Headache Sinusitis results from infected, engorged and / or inflamed nasal structures. HA character => deepp,er, dull, aching gq quality with a heaviness & fullness. Aggravated by standing, walking, bending forward or coughing. Often interferes with sleep. Worse in AM, gets better. Rarely is there nausea & vomiting. Sinus Headache Sinus Trans-illumination Evaluation: Hx of cold, allergy, URI, or decreased sense
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