Headaches Jonathan Rochlin, MD January 9, 2008
Feb 05, 2016
Headaches
Jonathan Rochlin, MDJanuary 9, 2008
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Outline
Epidemiology Pathophysiology Differential Diagnosis and Work-Up Algorithmic Approach A Closer Look at Migraine Headaches
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Outline
Epidemiology Pathophysiology Differential Diagnosis and Work-Up Algorithmic Approach A Closer Look at Migraine Headaches
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Epidemiology
Headaches are common complaints Most headaches are cared for at home Headaches are usually one in a number of
complaints Headache as a chief complaint: 1% of patients
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Outline
Epidemiology Pathophysiology Differential Diagnosis and Work-Up Algorithmic Approach A Closer Look at Migraine Headaches
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Pathophysiology of Pain Sensation
Extracranial structures: all sensitive to pain Intracranial structures: some sensitive, some not
• Insensitive to pain: brain, ependymal lining, choroid plexus, dura mater, arachnoid, pia mater
• Sensitive to pain: proximal portions of cerebral arteries, venous sinuses and the cerebral veins
Attempting to locate the anatomic site of the pain source is difficult
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Pathophysiologic Classification
Vascular Headaches:• Due to Vasodilation• Include Headaches Due To:
Migraines Hypertension Hypoxia Fever
Muscle Contraction Headaches:• Tension
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Pathophysiologic Classification
Headaches Due To Inflammation:• Intracranial Infections:
Bacterial Meningitis Encephalitis Orbital Cellulitis Cerebral Abscess
• Extracranial Infections: Strep Throat AOM/Otitis Externa Sinus Infections Dental Infections
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Pathophysiologic Classification
Headaches Due To Compression/Traction:• Brain Tumor• Intracranial Hemorrhage• Pseudotumor Cerebri• Hydrocephalus• Post-LP Headache
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Pathophysiologic Classification
Headaches Due To Other Causes:• Psychogenic Headaches• Ocular Headaches
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Outline
Epidemiology Pathophysiology Differential Diagnosis and Work-Up Algorithmic Approach A Closer Look at Migraine Headaches
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Another Word About Epidemiology
Causes of headache in the pediatric emergency department:
Viral Illness 39.2%Sinusitis 16.0%Migraine 15.6%Post-traumatic Headache 6.6%Strep Throat 4.9%Tension Headache 4.5% Total of benign causes 86.8%
Burton LJ et al. “Headache etiology in a pediatric emergency department.” Pediatric Emergency Care 1997. Feb; 13 (1): 1-4.
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Differentiating the Benign From the Bad
History Physical Exam Laboratory and Radiology Testing
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History
Temporal Pattern:• Acute:
Localized:– Dental Infections– Sinus Infections– Otitis Media/Externa– Post-Traumatic– First Migraine
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History
Temporal Pattern:• Acute:
Generalized:– Intracranial Hemorrhage– Hypertension– Hypoxia– Systemic Infections:
» Bacterial Meningitis» Encephalitis» Febrile Illnesses
– First Migraine
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History
Temporal Pattern:• Acute and Recurrent:
Migraine Headaches Tension Headaches
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History
Temporal Pattern:• Chronic But Non-Progressive:
Tension Headaches Psychogenic Headaches Medication Overuse Headaches
• Chronic And Progressive: Brain Tumor Cerebral Abscess Hydrocephalus Intracranial Hemorrhage Pseudotumor Cerebri
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History
Characteristic Historical Findings of Brain Tumor Headaches in Children:• Headaches that wake the patient up• Headaches that are present when waking up in
the morning• Headaches that worsen over time (chronic and
progressive)• Headaches associated with vomiting• Behavioral changes• Polydipsia/polyuria (craniopharyngioma)• History of neurologic deficits
Honig PJ, Charney EB. “Children with brain tumor headaches: distinguishing features.” American J Dis Child 1982. 136: 121-141.
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History
Other Historical Findings Worrisome For Intracranial Pathology:• Headache worsened by cough, urination or defecation• Headache < 6 months duration• Pulsatile tinnitus• “Worst headache”/thunderclap headache• Growth abnormalities• PMedHx risk factors for intracranial pathology:
VP Shunt Neurocutaneous syndromes Coagulopathic patients Sickle cell patients
• Absence of family history of migraines
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History
Other Key Points To Address:• Fever• Mental Status Changes• Past Medical History• Family History• Trauma• Environmental Exposure• Headaches Worse With Bending Over• Visual Changes
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Physical Exam
General Appearance Vital Signs:
• Temperature• BP• O2 Sats
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Physical Exam
Head and Neck Exam:• Signs of Trauma• Otitis Media/Externa• Strep Throat• Teeth and Gingiva• TMJ and Masseter Muscles• Nuchal Rigidity• Sinus Tenderness• Head Circumference• Muscle Tenderness
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Physical Exam – The Skin
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Physical Exam – The Skin
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Physical Exam – The Skin
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Physical Exam – The Skin
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Physical Exam – The Skin
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Physical Exam – The Skin
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Physical Exam – The Skin
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Physical Exam – The Skin
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Physical Exam – The Skin
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Physical Exam – The Skin
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Physical Exam
The Neurologic Exam:• Funduscopic Examination• Extraocular Muscle Movement• Pupillary Light Reflex• Other Cranial Nerves• Gait• Motor Examination
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Studies
CT LP Bloodwork Most Patients Do Not Need Any of These
• Based on Lewis DW et al. “Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002. 59: 490-498.
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CT Evaluation of Headaches
1 fatal cancer for every 1,000 CTs performed• Rice HE et al. “Review of radiation risks from computed
tomography: essentials for the pediatric surgeon.” J Pediatric Surgery 2007. Apr; 42(4): 603-7.
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CT Evaluation of Headaches
Each year, 500 children will ultimately die from cancer due to CT scans• Brenner D et al. “Estimated risks of radiation-induced fatal cancer
from pediatric CT.” American J Roentgenol 2001. Feb; 176(2): 289-96.
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CT Evaluation of Headaches
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CT Evaluation of Headaches
Who Should Get a CT:• Points on the History Concerning For Intracranial
Pathology: Headaches that wake the patient up Headaches that are present when waking up
in the morning Headaches that worsen over time (chronic and
progressive) Headaches associated with vomiting Behavioral changes Polydipsia/polyuria (craniopharyngioma) History of neurologic deficits
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CT Evaluation of Headaches
Who Should Get a CT:• Points on the History Concerning For Intracranial
Pathology: Headache worsened by cough, urination or defecation Headache < 6 months duration Pulsatile tinnitus “Worst headache”/thunderclap headache Growth abnormalities PMedHx risk factors for intracranial pathology:
– VP Shunt– Neurocutaneous syndromes– Coagulopathic patients– Sickle cell patients
Absence of family history of migraines Altered mental status
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CT Evaluation of Headaches
Who Should Get a CT:• Points on the Physical Exam Concerning For
Intracranial Pathology: Abnormal Neurologic Exam Abnormal Skin Findings Suggestive of
Neurocutaneous Disorder Macrocephaly
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CT Evaluation of Headaches
Who Does NOT Need a CT:• Most Patients With Migraines• Those With Chronic But Non-Progressing
Headaches
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MRI Evaluation of Headache
Usually this is not practical in the ED For some lesions, MRI is better However, do not delay the CT in order to get an
MRI later
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LP for Evaluation of Headache
Who Should Get an LP:• Suspected Meningitis/Encephalitis• Suspected Pseudotumor Cerebri• Suspected Subarachnoid Hemorrhage
With Abnormal Neurologic Exam, Do a CT First
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Bloodwork for Evaluation of Headache
Rarely Indicated Exceptions Include:
• Serious Infectious Process (Meningitis Or Encephalitis): CBCD BCx
• Elevated BP: BMP UA
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Outline
Epidemiology Pathophysiology Differential Diagnosis and Work-Up Algorithmic Approach A Closer Look at Migraine Headaches
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Algorithm
History of acute and recurrent headaches
Yes No
Typical pattern with no new findings
Yes
No
MigraineTension
Abnormal neuro exam or Hx/PE findings concerning for intracranial pathology
Yes No
Go to CT scan algorithm
NoYes
Fever
Other abnormalities on Hx/PE
Yes No
Increased BP
Hypertensive headache*
Hypoxic
Hypoxic headache
History of trauma
Post-traumatic headache
CO poisoning
Exposure Focal tenderness
SinusitisDental infectionTMJ dysfunctionTension headache
Go to fever algorithm
MigraineTension
PsychogenicMed Overuse
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Fever Algorithm
Patient has fever
Meningeal signs
Yes No
Viral syndromeSinusitis
Dental infectionOtitis Media/Externa
Strep Throat
LP*
LP abnormal
Yes No
Bacterial meningitisEncephalitis Consider CT to rule
out bleed or tumor
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CT Scan AlgorithmPatient has abnormal neuro exam or Hx/PE
findings concerning for intracranial pathology
CT scan
CT scan abnormal
Yes No
Brain tumorIntracranial bleedHydrocephalus
Cerebral abscessOrbital cellulitis
Malfunctioning VP shunt*
Extremely severe headache or stiff neck
Yes No
LP with opening pressure
Pleocytosis
Yes No
Increased RBCs Increased WBCs
Bacterial meningitisEncephalitis
Subarachnoid hemorrhage
Elevated opening pressure
Yes No
Pseudotumor cerebri Pseudopapilledema
Neuro findings abnormal for >60 minutes
Yes No
MigraineMigraine
StrokeTodd’s paralysis (after unwitnessed seizure)
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Outline
Epidemiology Pathophysiology Differential Diagnosis and Work-Up Algorithmic Approach A Closer Look at Migraine Headaches
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Migraine Diagnosis
International Headache Society Criteria:• A. At least 5 attacks fulfilling B - D• B. Headache lasts 1 - 72 hours• C. Headache with at least 2 of following:
Bilateral or unilateral (but not occipital) Pulsating Moderate to severe pain intensity Aggravated by or causing avoidance of routine
physical activity (walking, climbing stairs)• D. At least 1 of the following during headache:
Nausea and/or vomiting Photophobia and phonophobia (can infer)
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Migraine Diagnosis
Often Positive Family History Aura in 15-40% of Patients Characteristic Pattern
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Tension Headaches
Characteristics of Tension Headaches:• Duration 30 minutes - 7 days• No aura• 2 out of 4 of following:
Pressing, tightening, band-like, dull Nonpulsatile Mild or moderate Bilateral, often frontal Not aggravated by physical activity
• Both of following: No nausea or vomiting Photophobia or phonophobia (but not both)
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Migraine Treatment
Ask: What Usually Works Goal: Break the Headache Quickly First-Line Treatment:
• No Emesis: Ibuprofen PO:
– 10mg/kg q6hrs; max=800mg/dose Acetaminophen PO:
– 15mg/kg q4hrs; max=1,000mg/dose Naproxen PO:
– 5-7mg/kg q8hrs; max=1,250mg/day Some evidence that ibuprofen is better than
acetaminophen
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Migraine Treatment
First-Line Treatment:• Emesis:
Pain Medications:– Acetaminophen PR:
» 15mg/kg q4hrs; max=1,000mg/dose– Toradol IV:
» 0.5mg/kg q6hrs; max=30mg Antiemetics:
– Phenergan PR/IM/IV:» 1mg/kg/dose q4-6hrs; max=25mg» Only for children >2 years old
– Consider Reglan/Zofran/Compazine IV Hydration
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Migraine Treatment
Second-Line Treatment:• Triptans:
5HT1 Receptor Agonists Promote Vasoconstriction Sumatriptan (Imitrex)
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Migraine Treatment
Intranasal Sumatriptan (Imitrex):• Does Not Work If Under 6 Years Old• Dosage:
6-12 Years Old:– 5mg– If This Is Not Effective, Try 10mg in 2 Hours
> 12 Years Old:– 20mg– If This Is Not Effective, Try Again in 2 Hours
Do Not Give More Than Twice/24hrs• Usually There is Some Effect Within 30 Minutes• This Has a Bad/Salty Taste
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Migraine Treatment
Third-Line Treatment: Ergotamines• Contraindications:
Pregnancy Use of Triptans Within 24hrs
• Dihydroergotamine (DHE): Alpha-Adrenergic Blocker Vasoconstrictor Dosage:
– 0.5mg IV or 1mg SQ– Only in Children > 10 Years Old
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Migraine Treatment
Attempt to Induce Sleep• Place in a Quiet and Dark Room
Avoid Precipitating Factors Avoid Opioids
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Key Points
Most Headaches Have Benign Causes Remember The Uncommon But Serious Causes Address The Temporal Pattern Always Get Temperature and BP Readings Do a Complete Neurologic Exam, Including Fundi Only Patients With Abnormal Neurologic Exams or
Findings Suggestive of Intracranial Pathology Need a CT
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References
BEIR V (Committee on the Biological Effects of Ionizing Radiations). Health effects of exposure to low levels of ionizing radiation. Washington, DC: National Academy Press, 1990.
Brazis PW, Lee AG. “Approach to the child with headache.” www.uptodate.com.
Brenner D et al. “Estimated risks of radiation-induced fatal cancer from pediatric CT.” American J Roentgenol 2001. Feb; 176(2): 289-96.
Burton LJ et al. “Headache etiology in a pediatric emergency department.” Pediatric Emergency Care 1997. Feb; 13 (1): 1-4.
Burton LJ et al. “Headache in the Pediatric Patient.” The Clinical Practice of Emergency Medicine, 5th Edition. Draft.
Cruse RP. “Classification of migraine in children.” www.uptodate.com. Cruse RP. “Management of migraine headache in children.”
www.uptodate.com. Cruise RP. “Tension headache in children.” www.uptodate.com. Honig PJ, Charney EB. “Children with brain tumor headaches:
distinguishing features.” American J Dis Child 1982. 136: 121-141. International Commission on Radiological Protection. 1990
recommendations of the International Commission on Radiological Protection. Oxford, England: Pergamon, 1991. ICRP publication 60.
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References
King C. “Emergent evaluation of headache in children.” www.uptodate.com.
King C. “Headache.” Textbook of Pediatric Emergency Medicine, 5th edition. Fleisher GR et al Editors. Lippincott Williams & Wilkins: Philadelphia. 2006. 511-518.
Lewis DW et al. “Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002. 59: 490-498.
Lewis D et al. “Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology 2004. 63: 2215-2224.
Olsen J. “The International Classification of Headache Disorders.” Cephalagia 2004. 24; Suppl 1: 23-44.
Rice HE et al. “Review of radiation risks from computed tomography: essentials for the pediatric surgeon.” J Pediatric Surgery 2007. Apr; 42(4): 603-7.
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The End