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Case Study 1 and Q & AContent developed by:
Lawrence C. Newman, MD, FAHS
Donna Gutterman, PharmD
Faculty Disclosures
LAWRENCE C. NEWMAN, MD, FAHS
Dr. Newman has received consulting fees and/or honoraria from Allergan, Inc., Labrys Biologics, NuPathe, and Zogenix. Dr. Newman
is on the speaker bureaus for Allergan, Inc. and Zogenix.
DONNA GUTTERMAN, PHARMD
Dr. Gutterman has received consulting fees and/or honoraria from
NuPathe, Teva Pharmaceuticals, Dr. Reddy Pharmaceuticals.
Learning Objectives
At the conclusion of this talk, participants will be able to:
1. Screen for secondary headache disorders using the SNOOP4 paradigm
2. Evaluate the need for ancillary testing in patients presenting with headache
3. Order and analyze appropriate test results in
patients in whom headache patterns have changed
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Terri, Age 30
15-year history of migraine without aura
Stress and changes in weather
are triggers
Typically associated with her
menstrual cycle
Daily headache
Increasing in frequency for the last 4 months
Terri Presents with…..
Headache Frequency: September–December
X
X X X
XX
X X
X
XX
X X
X X X
X X X
X X X
X X XX X X
X X X
XX X X
X X X X
September October
November December
X
X XX
X X X
XX XX
X
XX
X
X
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X
X X X
X
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X
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What else would you like to know?
What Else Would You Like To Know?
Is this different than her prior attacks?
What Else Would You Like To Know?
• Pain is generalized, dull, and associated with nausea
• Awakens with headache every morning for past 2 months
• Only pain-free time was during a ski trip 2 weeks ago
• Medical and neurological exams (while pain-free) are normal
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What Else Would You Like To Know? cont.
Is this different than her prior attacks? Yes
Are there other features associated with
these “new” attacks. . .
Photo-, phono-, or osmophobia? No
Autonomic signs? No
Weakness, numbness, speech disturbances?
Generalized weakness
Systemic signs/symptoms? Fatigue
Symptoms of allodynia? Hurts to brush hair
Do the HAs remit spontaneously? “I don’t know; I always treat them”How does she treat the HA?
Sumatriptan 6 mg sc almost every morning for the past 2 months
Previously used OTC aspirin/acetaminophen/caffeine tablets
Next Steps?
Diagnose Chronic migraine with MOH*
Limit acute treatment Sumatriptan ≤2 days/week
Begin preventionTopiramate 25 mg hs and titrate up to 100 mg hs
Follow-up 1 month
*Medication Overuse Headache
1-Month Follow-Up
• No improvement
• Daily headache persists
• On days without sumatriptan notes that headache spontaneously remits while at work
• Fatigue, nausea, and weakness persist all day
• Exam still normal
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Terri’s Headache Diary
ARS Question
What is the most appropriate next step with this patient?
A. More history
B. Imaging
C. Blood work
D. All of the above
More History and Investigations
MRI with and without contrast
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More History and Investigations
MRI with and without contrast Normal
More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs
More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
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More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
Sed rate
More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
Sed rate 30 mm/hr
More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
Sed rate 30 mm/hr
EKG
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More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
Sed rate 30 mm/hr
EKG Sinus tachycardia at 120 bpm
More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
Sed rate 30 mm/hr
EKG Sinus tachycardia at 120 bpm
More history
More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
Sed rate 30 mm/hr
EKG Sinus tachycardia at 120 bpm
More history Boyfriend, with whom she lives, has
same symptoms
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More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
Sed rate 30 mm/hr
EKG Sinus tachycardia at 120 bpm
More history Boyfriend, with whom she lives, has
same symptoms
Consultation was called. . .with a plumber
More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
Sed rate 30 mm/hr
EKG Sinus tachycardia at 120 bpm
More history Boyfriend, with whom she lives, has
same symptoms
Consultation was called. . .with a plumber
More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
Sed rate 30 mm/hr
EKG Sinus tachycardia at 120 bpm
More history Boyfriend, with whom she lives, has
same symptoms
Consultation was called. . .with a plumber
Hot water heater has a leak
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More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
Sed rate 30 mm/hr
EKG Sinus tachycardia at 120 bpm
More history Boyfriend, with whom she lives, has
same symptoms
Consultation was called. . .with a plumber
Hot water heater has a leak
Carboxyhemoglobin level
More History and Investigations
MRI with and without contrast Normal
CBC / Routine Labs Normal
Sed rate 30 mm/hr
EKG Sinus tachycardia at 120 bpm
More history Boyfriend, with whom she lives, has
same symptoms
Consultation was called. . .with a plumber
Hot water heater has a leak
Carboxyhemoglobin level 10%
Carbon Monoxide Toxicity
• Carbon monoxide (CO) is a colorless, odorless gas
• CO binds to hemoglobin >200 times higher affinity than oxygen so even small
concentrations can result in significant levels of carboxyhemoglobin (HbCO)
Ernst A et al. NEJM. 1998;339:1603–1608.
• CO toxicity causes impaired cellular oxygen delivery and utilization
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CO Toxicity
• CO has its most profound impact on the organs with the highest oxygen requirement
• Brain
• Heart
• Kidney
• Headaches occur at levels around 10%
• Levels of 50–70% may cause:
– Seizure
– Coma
– Death
Ernst A et al. NEJM. 1998;339:1603–1608.
HbCO levels often
do not reflect the clinical picture
Symptoms of Acute CO Poisoning
Malaise, flulike symptoms,
fatigueAgitation
Dyspnea on exertion Nausea, vomiting, diarrhea
Chest pain, palpitations Abdominal pain
Lethargy Headache, drowsiness
Confusion Dizziness, weakness, confusion
Depression Visual disturbance, syncope, seizure
Impulsiveness Fecal and urinary incontinence
Distractibility Memory and gait disturbance
Hallucination, confabulation Bizarre neurologic symptoms, coma
Ernst A et al. NEJM. 1998;339:1603–1608.
Physical Findings of CO Poisoning
Heart • Tachycardia• Hypertension or hypotension
• Hyperthermia• Tachypnea
Skin • Classic cherry red skin is rare (ie, "When you're cherry red,
you're dead”)• Pallor is present more often
Eyes • Flame-shaped retinal hemorrhages• Bright red retinal veins (a sensitive early sign)
• Papilledema• Homonymous hemianopsia
Lungs • Noncardiogenic pulmonary edema
Neurologic /Psychiatric
• Memory disturbances (most common), including retrograde and anterograde amnesia with amnestic confabulatory
states• Emotional lability
• Stupor, coma, gait disturbance, movement disorders, rigidity
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Exclude Secondary Headache
History and examination
Assess for worrisome signs and symptoms Look for atypical features
SNOOP4
S Systemic symptoms (weakness, fatigue, nausea)
N Neurologic symptoms or signs
O Onset: abrupt, peak <1 min
O Older: >50 (GCA; glaucoma, cardiac cephalalgia)
P Previous headache history (symptoms changed over the past 4 months)
P Postural, positional
P Precipitated by Valsalva, exertion
P Papilledema (pulsatile tinnitus, diplopia, transient visual obscurations)
P Progressive (intractable)
Screen forRed Flags
Evaluate for Secondary HeadacheYes?
Dodick DW. Adv Stud Med. 2003;3:550–555.
Pitfalls in This Case
• Remember SNOOP4:
–Systemic features
o Generalized weakness
o Fatigue
o Nausea
–Change in headache pattern/history
• Don’t be fooled by response to treatment
• Medication overuse doesn’t always cause
Medication Overuse Headache
Lipton RB et al. Headache. 1997;37:392–395.