Objectives Headache Pain Generators Extracranial 1. Define the major categories of headache. Musculoskeletal (spine, muscle) 2. Take a history directed at characterizing a headache pattern in an individual patient and identify the cause or triggers of the Oral (dental) headache. 3. Understand the distinguishing features and patterns of migraine Ocular headache. Ear 4. Know first line treatments for tension versus migraine headaches. Vascular: branches of extracranial carotid, e.g. 5. Recognize warning signs for secondary headache syndromes due to intracranial structural lesions or increased intracranial pressure. temporal arteritis Intracranial Dural and pial sensory fibers Trigeminovascular pathways Intracranial: Dural and pial sensory fibers Primary Headache Disorders 1. Migraine Headache • With or without aura 2. Tension-type Headache 3. Trigeminal Autonomic Cephalgias Secondary Headache Disorders Primary or Secondary Headache 1. Increased Intracranial Pressure headaches • Mass lesions • Chronic Daily Headache • Idiopathic Intracranial Hypertension (IIH) • Tension-type Headache 2. Vascular • Medication Overuse Headache • Inflammation – example: Temporal Arteritis • “Transformed” Migraine • Thrombosis – example: Cerebral Venous Thrombosis • New Daily Persistent Headache • Sub-arachnoid hemorrhage (“worst headache of life”) 3. Cervicogenic (spine, nerve roots) • Rule out Secondary Headache 4. Temporal Mandibular Joint (TMJ) 5. Medication Overuse Headache Headache Exam: History Headache Exam: History Headache onset aura or warning? Triggers: sounds, smells, movements? sudden (thunderclap) or gradual Aggravating factors prior head or neck trauma posture, cough, exertion, straining, neck or jaw movements previous attacks (progression of symptoms?) Headache severity duration of attacks (< 3 hours, > 4 hours, continuous) effect on work and family activities frequency: days per month with headache Pain location (unilateral, bilateral, cervical, retro- Acute and preventive medications orbital, face or jaw) effectiveness, side effects Radiation of pain? Co-morbid medical or mental health conditions Headache-associated symptoms History of heart disease or stroke nausea, vomiting Visual disorders photophobia, phonophobia conjunctival injection, rhinorrhea, diaphoresis Family history of headache disorders Headache for the first time OR change in pattern? Headache Exam: Physical Headache Exam: Physical Screening neurologic examination HEENT examination: eyes, ears, jaw movements general assessment of mental status Palpate occiput cranial nerve examination Palpate temple fundoscopy, pupils, eye movements, visual fields, face sensory and motor for Palpate muscles of mastication for tender points asymmetry and/or weakness Listen for bruits: head, eyes, neck assessment for unilateral limb weakness or dyscoordination, deep tendon reflex asymmetry Blood pressure measurements – check orthostatic BP assessment of gait, including heel-toe walking (tandem gait) The majority of patients with primary headache disorders have a Neck examination normal neurological exam posture, range of motion, palpation for muscle tender points Tender points in neck, shoulders, and/or occiput can point to cervicogenic headache Check for cervical paraspinal muscle spasm, trapezius tender points Red Flags for Secondary Red Flags for Secondary Headache Headache First or worst headache of life Emergent (immediate attention): Abrupt-onset headache – “thunderclap headache” Change in pattern, frequency, or severity of headaches Thunderclap onset (fast, maximal pain) Headaches ALWAYS on the same side “worst headache of my life” Headaches refractory to treatment New onset headache after age 50 Fever and meningismus New onset headache with cancer, immunosuppression, or pregnancy Papilledema with focal signs or reduced level of Associated signs/symptoms: fever, stiff neck, papilledema, cognitive impairment consciousness Headache with syncope or seizure Acute glaucoma Headache triggered by exertion, valsalva maneuver, or sex Neurologic symptoms >1 hour Urgent (attention within hours to days) Abnormal general or neurologic examination Papilledema without focal signs or reduced level of consciousness Relevant systemic illness Neuroimaging is warranted Elderly patient: new headache with cognitive change Red Flags for Secondary General Practice Points Headache Rule out secondary headache when diagnosing a Less urgent (attention within days to few weeks, usually) primary headache disorder Unexplained focal signs Migraine is the most common headache type in Atypical headaches (not consistent with migraine or tension-type patients seeking medical care for headache Unusual headache precipitants Migraine is underdiagnosed and undertreated Consider migraine in patients with recurrent moderate or Unusual aura symptoms severe headaches and normal neurologic exam Onset after age 50 y Headaches that interfere with daily activities are more likely Aggravation by neck movement; abnormal neck examination to be migraine, less likely tension type (consider cervicogenic headache) Medication overuse is a risk in patients using Jaw symptoms; abnormal jaw examination (consider temporomandibular joint disease) combination analgesics or frequent NSAID or acetaminophen General Practice Points General Practice Points Common headache triggers Headache management may require: Emotional stress Change in work or lifestyle (disability) Hormones (women) Change in method of birth control (women) Skipping meals Consideration of effects of menstrual cycle (women) Weather Change in environment Sleep disturbance Possible association with environmental factors Odors Patient may be able to identify headache triggers through careful headache diary Neck pain Lights Caffeine, Alcohol, Smoking Heat Food Exercise/sexual activity General Practice Points Diagnosing primary headache syndromes Headache management includes: Consideration of the complexity of the medication plan Patients with recurrent headache attacks and normal Can the patient follow the schedule? neurologic examination findings 1. Migraine with or without aura if at least 2 of: Consideration of the side effects of the medications proposed for nausea (with or without vomiting) treatment light sensitivity /sound sensitivity Sedation, cognitive side effects some of the attacks interfere with daily activities Beneficial side effects, e.g mood stabilization, may make some 2. Episodic tension-type headache if attacks are not medications more effective associated with nausea, and at least 2 of: bilateral headache Consideration of the teratogenic potential of headache medications nonpulsating pain Always counsel patients and document counseling mild to moderate intensity Considerations before and during pregnancy headache is not worsened by activity Diagnosing primary headache Diagnosing primary headache syndromes syndromes CHRONIC HEADACHES Cluster headache or another trigeminal autonomic Patients with headache on ≥ 15 d/mo for > 3 months and with normal cephalalgia if all of the following criteria: neurologic examination Frequent Chronic migraine if headaches meet migraine diagnostic criteria Severe (above) or are quickly aborted by migraine-specific medications Brief (duration < 3 h) (triptans or ergots) on ≥ 8 d/mo Unilateral Chronic migraine with medication overuse if the patient uses ergots, triptans, opioids, or combination analgesics on ≥ 10 d/mo or uses plain Ipsilateral conjunctival injection, tearing, or restlessness acetaminophen or NSAIDs on ≥ 15 d/mo during the attacks (ipsilateral ptosis or miosis on exam). Chronic migraine without medication overuse if patients do not have Need Neurologist referral*** medication overuse Diagnosing primary headache Diagnosing primary headache syndromes syndromes CHRONIC HEADACHES Patients with continuous daily headache for > 3 mo with normal neurologic examination Patients with headache on ≥ 15 d/mo for > 3 months and with normal neurologic examination Hemicrania continua if the headache is strictly unilateral, is always on the same side of the head ptosis or miosis might be present on examination Chronic tension-type headache if headaches fit episodic tension-type diagnostic criteria (above), but > 15 d/mo for >3 months responds dramatically to indomethacin May refer to neurologist May have nausea but mild, not moderate or severe New daily persistent headache if the headache is unremitting since No more than one of photophobia, phonophobia, mild nausea onset Episodes last 30 min to few days Evaluate for secondary headache Refer to neurologist Medication Overuse Headache: Diagnosing Medication Overuse Headache Who is at risk? Patients with headache for > 15 days per month Patient with an episodic headache disorder Use of triptans, ergots, combination analgesics, or opioid-containing usually migraine or tension-type headache medications ≥ 10 days per month treated with frequent and excessive amounts of acute symptomatic Use of acetaminophen or NSAIDs ≥ 15 days per month medications Patients may have psychiatric co-morbidities Headache present or develops upon awakening, and commonly depression and anxiety occurs daily or nearly daily psychological and physical drug dependence Patients may have pain-related co-morbidities Orthopedic, musculoskeletal pain generators Taking multiple analgesics for different disorders Diagnosing Medication Overuse Headache All acute symptomatic medications used to treat headaches have the potential for