Headaches Jonathan Rochlin, MD January 9, 2008. 2 Outline Epidemiology Pathophysiology Differential Diagnosis and Work-Up Algorithmic Approach.

Headaches

Jonathan Rochlin, MD

January 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


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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


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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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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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Headaches Due To Compression/Traction:• Brain Tumor• Intracranial Hemorrhage• Pseudotumor Cerebri• Hydrocephalus• Post-LP Headache

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Headaches Due To Other Causes:• Psychogenic Headaches• Ocular Headaches

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Outline


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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 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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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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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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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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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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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


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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 Algorithm

Patient 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


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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

Headaches Jonathan Rochlin, MD January 9, 2008. 2 Outline Epidemiology Pathophysiology Differential Diagnosis and Work-Up Algorithmic Approach.

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