Headache for the PCP: Evaluation and Initial Management

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Headache for the PCP Evaluation and Initial
Management

• Chris Jackman, MD
• Assistant Professor of Neurology
• Child Neurology of Riley Hospital
• Director, Riley Headache Center

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Objectives

• Identify a systemic evaluation of a headache
  patient
• Evaluate for causes of secondary headache
• Recognize how to diagnose common primary headache
  symptoms of childhood
• Identify how to treat primary headache syndromes

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Initial Evaluation
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1. Shoulder shrug and look to parents2. I
dont know3. Headaches?
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Its in the history

• Time course
• Time course
• Time course
• Pain description
• Location
• Severity
• Quality
• Associated symptoms

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Other questions

• Pain description
• Location
• Severity
• Quality
• Associated symptoms
• Aura
• Nausea, vomiting
• Photophobia, phonophobia
• Light-headedness, vertigo
• Autonomic features

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Red Flags

• Time course
• Progressive
• Morning
• Location
• Posterior
• Postural
• Focal neurologic signs
• Any

• Systemic signs
• Fevers, rash
• Family history
• As in, none
• Age
• Under 6 years

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Physical exam

• Eyes / Fundus
• TMJ
• Face
• Muscles
• Skin
• Neurologic

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Secondary Headaches
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Non-neurologic causes of secondary headaches

• Dental/ TMJ
• Allergies/ congestion
• Sinus inflammation/ infection
• Ear infection/ Mastoiditis
• Hypothyroidism
• Pheochromocytoma (Hypertension)
• Eye-strain

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It is (probably) not a tumor

• Brain tumors are very rare
• BUT
• You only need to miss one to be incompetent
• The chance of finding a tumor in a patient with
  headaches and a normal neurological exam is

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It is not a tumor

• Very low, but not quite zero
• Brain tumors typically cause headache when they
  cause increased pressure
• A much more common presentation is focal
  neurologic signs with minor headache

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It is a tumor

• Key features
• Time course (Progressive)
• Timing (On awakening)
• Postural (Supine)
• Focal Neurologic signs
• Seizures

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If its not a tumor, what is it?
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Intracerbral Hemorrhage

• Features
• Time course (Acute)
• History of trauma
• Focal Neurologic signs
• Types of hemorrhage
• Subdural
• Epidural
• Subarachnoid
• Paranchymal
• Interventricular

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Venous sinus thrombosis

• Associated with primary or secondary
  hypercoagulable state
• Present with signs of increased intracranial
  pressure
• Sometimes hemorrhage
• Red Flags
• Time course (Progressive or static)
• Postural
• Neurologic signs
• Papilledema
• 6th nerve palsies

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Ideopathic intracranial hypertension

• Mechanism unknown
• More female, more obese
• Headache with visual loss
• Red Flags
• Time course (Progressive or static)
• Postural
• Neurologic signs
• Papilledema
• 6th nerve palsies

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Ideopathic intracranial hypotension

• Seen in some connective tissue diseases from
  dural ectasia (or ideopathic)
• Mimics LP headache
• Red Flags
• Time course (Progressive or static)
• Postural

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Meningitis / Encephallitis

• Red flags
• Systemic signs (fever)
• Focal Neurologic signs (meningismus,
  encephalopathy, seizures)

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Chiari I Malformation

• Protrusion of cerebellar tonsils below the
  foramen of Monro
• Red flags
• Location (posterior)
• Postural, pain with
• neck movements
• Focal Neurologic signs
• (ataxia)
• Worse with cough,
• sneezing, valsalva

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Post-traumatic or Post-concussiveHeadache

• Red flags See hemorrhage
• Will get better, may take months
• Cognitive changes are common, will also improve

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Headache Evaluation
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Do I order LABS?
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Headaches in children younger than seven years
of ageChu ML, Shinnar S. Arch Neurol, 491992
79-82

• Study of 104 children referred to Child Neurology
• Studies performed prior by the pediatrician
• Studies included
• Cell counts
• Basic electrolytes
• Tranaminases
• Urinalysis
• Uniformly unrevealing
• Similar prospective study in adults of 193
  patients showed same results

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Do I order a SCAN?
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American Academy of Neurology Practice
Parameter Evaluation of children and adolescents
with recurrent headaches 2002

• Neuroimaging
• Combined 6 studies
• 605 of 1275 had imaging (CT in 116, MRI in 483,
  both in 75)
• 97 children with imaging abnormalities (16)
• 79 considered incidental
• 14 surgically treatable
• 4 medically treatable

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American Academy of Neurology Practice
Parameter Evaluation of children and adolescents
with recurrent headaches 2002

• Of the 14 surgical lesions
• 10 tumors
• 3 symptomatic vascular malfomations
• 1 significant arachnoid cyst
• All had an abnormal neurologic examination
• Papilledema
• Abnormal eye movements
• Motor dysfunction
• Gait dysfunction

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American Academy of Neurology Practice
Parameter Evaluation of children and adolescents
with recurrent headaches 2002

• Parameters which distinguish headache patients
  with space occupying lesions
• Headache of less than one month duration
• Absence of a family history of migraine
• Abnormal neurological examination
• Gait abnormalities
• Seizures
• Those patients with headaches for less than 6
  months and at least one of the above symptoms are
  considered high-risk
• High-risk 4 chance of space occupying lesion

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CT vs. MRI?
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Primary Headache Disorders
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Migraine Diagnosis and Treatment Results From
the American Migraine Study IIHeadache
200141638-645

• Survey mailed to 20,000 homes, identified 3577
  individuals who met criteria for migraine
• 48 had previously received a physician diagnosis
• 24 of those undiagnosed had missed at least one
  day of work or school in the previous three
  months
• Those missed were
• Lower income
• Younger age (18-29)
• Male

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Migraine epidemiology

• Headache prevalence
• Tension type HA 78
• Migraine 16
• Children
• 3-8 by age 3
• 37-52 by age 7
• 57-82 in 7-15 year olds
• Peak incidence
• Women age 12-13 (aura), 14-17 (without)
• Men age 5 (aura), 10-11 (without)

Comprehensive Review of Headache Medicine Levin
M Ed Oxford 2008
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• If nothing is wrong with me, doctor, why do I
  have these headaches?

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Migraine pathophysiology

• Primarily a NEUROGENIC process
• We think
• For now

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Migraine pathophysiology

• Aura
• Cortical spreading depression
• Front of profound depolarization
• Moves across cortex 3mm/min
• Following by suppression of neural activity
  lasting minutes

A.P. Leão.
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Cortical Spreading Depression
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Migraine pathophysiology
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Migraine without aura Pediatric diagnostic
criteria

• At least five attacks fulfilling criteria B-D
  (below)
• Headache attacks lasting 1 to 72 h
• Headache having at least two of the following
  characteristics
• Unilateral location, may be bilateral,
  frontotemporal (not occipital)
• Pulsing quality
• Moderate or severe pain intensity
• Aggravation by or causing avoidance of routine
  physical activity (eg, walking, climbing stairs)
• During the headache, at least one of the
  following
• Nausea or vomiting
• Photophobia and phonophobia, which may be
  inferred from behavior
• Not attributed to another disorder

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Migraine with aura Pediatric diagnostic criteria

• At least two attacks fulfilling the criteria B-D
  (below)
• Aura consisting of at least one of the following,
  but no motor weakness
• Fully reversible visual symptoms, including
  positive features or negative features (e.g.,
  flickering lights, spots, or lines)
• Fully reversible sensory symptoms, including
  positive features (i.e., pins and needles) or
  negative features (ie, numbness)
• Fully reversible dysphasic speech disturbances
• At least two of the following
• Homonymous visual symptoms or unilateral sensory
  symptoms
• At least one aura symptom develops gradually over
  5 min or different aura symptoms occur in
  succession over 5 min
• Each symptom lasts between 5 min and 60 min
• Not attributable to another disorder

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And
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Chronic Daily Headache
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Chronic Daily Headache

• Transformed (or chronic) migraine
• History of migraine
• Progresses to chronic, low level headache with
  periodic migraines
• Chronic tension type headache
• Lack significant migranous features
• Less severe intensity
• Tightening more than pulsating
• New daily persistent headache

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Chronic daily headaches - evaluation

• Look for red flags
• Ask about analgesic overuse
• Especially in New Daily Persistent Headache

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Practice Parameter Pharmacologicaltreatment of
migraine headache in children and adolescents

• D. Lewis, MD S. Ashwal, MD A. Hershey, MD D.
  Hirtz, MD M. Yonker, MD and S. Silberstein, MD
• NEUROLOGY 2004 63 22152224

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Migraine treatment - Abortive

• Ibuprofen, acetaminophen, ketorolac,
  indomethacin, ASA
• Combinations (Acetaminophen/ASA/caffeine)
• Antiemetics (promethazine, chlorpromethazine
• Opiates, barbituates (no, no, never)
• Corticosteroids
• Triptans
• 5HT1b, 1d, and 1f agonists
• Contraindications include cardiovascular disease
  or risk factors, Reynauds, hemiplegic migraine
• Side effects include nausea, dizziness, chest and
  throat tightness

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Migraine treatment - Abortive
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Migraine treatment - Prophylactic

• When to use prophylaxis
• Headaches frequent
• Headaches severe
• Headaches disruptive
• Side effects and burden of taking a daily
  medicine lt the life disruption caused by
  (appropriately treated) headaches

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Migraine treatment - Prophylactic

• Antihistamines
• Beta-blockers
• Tricyclics
• Anticonvulsants
• Calcium channel blockers

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Migraine treatment - Prophylactic

• Antihistamines
• Cyproheptadine
• Little studied, often used
• Reduce headaches from 8.4 to 3.7 per month
• Somnolence, weight gain
• Initial dose 1-2 mg QHS, max 4 mg BID

Lewis D, Diamond S, Scott D, et al. Prophylactic
treatment of pediatric migraine. Headache
200444230237.
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Migraine treatment - Prophylactic

• Beta-blockers
• Propranolol most studied
• Three small, prospective class II studies with
  conflicting results
• Exercise intolerance
• Contraindicated in asthma, depression
• Initial dose 20 mg, up to 160 mg

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Migraine treatment - Prophylactic

• Tricyclics
• Amitriptyline most studied
• Anticholinergic effects, somnolence
• Black box warning re suicidality
• Baseline EKG and monitor for QT prolongation
• Initial dose 10 mg up to 100 mg
• Give at dinner

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Migraine treatment - Prophylactic

• Anticonvulsants
• Topiramate (or zonisamide)
• Best studied
• Valproate
• Effective but side effects can be significant
• Levetiracetam/ Lamotrigine
• Limited (poor) data

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Migraine treatment - Prophylactic

• Calcium channel blockers
• Conflicting data
• Familial hemiplegic migraine
• Abdominal discomfort
• Monitor EKG and blood pressure

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Chronic Daily Headache - Treatment

• Preventative medications
• Evidence is spotty at best
• Topiramate is best studied, anecdotally all
  migraine medications may work
• Transformed migraine or for medication overuse
  early prophylactic treatment
• Chronic tension type headache late medical
  treatment
• New daily persistent headache doesnt matter

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Non-pharmacologic Treatment

• Lifestyle! Lifestyle! Lifestyle!
• Analgesic overuse
• Sleep
• Diet
• Psychiatric

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Non-pharmacologic Treatment

• Analgesic overuse
• Opiotes/ barbiturates gt triptans gtgtNSAIDS
• Any used over 15 days/month, some over 10
  days/month
• Can treat by a period of elimination or by
  moderation
• Headaches may take 4-6 weeks to improve

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Non-pharmacologic Treatment

• Sleep
• Snoring
• Movements
• Quality
• Quantity
• Continuity

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Non-pharmacologic Treatment

• Diet
• Meats (Iron, B12)
• Vegetables (Folate?)
• Skipping meals
• Hydration
• Caffeine

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Non-pharmacologic Treatment

• Psychiatric evaluation
• Anxiety
• Depression
• Obsessive-compulsive disorder
• Non-pharmocologic management
• Biofeedback
• Self-hypnosis
• Relaxation

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Take home points

• Red flags
• Progressive time course
• Postural
• Worse in the morning
• Any neurologic sign or symptom
• Worse with valsalva
• Practice your fundoscopic and cranial nerve exam

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Closing thoughts

• Watch for red flags
• Know when to image
• If unsure whether to image, refer
• Know helpful lifestyle modifications
• Know when to start or refer for prophylactic
  medications
• Remember Your patient does not want to have a
  headache

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References

• Sargent JD, Solbach P. Medical evaluation of
  migraineurs review of the value of laboratory
  and radiologic tests Headache 1983 2362-65
• Chu ML, Shinnar S. Headaches in children younger
  than seven years of ageArch Neurol, 49 1992
  pp79-82
• Maytal J, Robert S. Bienkowski, Patel M and
  Eviatar L. The Value of Brain Imaging in Children
  With Headaches. Pediatrics 199596413-416
• Levin M Ed Comprehensive Review of Headache
  Medicine Oxford 2008
• Lewis D, Ashwal, S Hershey A Hirtz D Yonker,
  M and Silberstein S, Practice Parameter
  Pharmacological Treatment of migraine headache in
  children and adolescents. Neurology
  20046322152224
• Ludvigsson J. Propranolol used in prophylaxis of
  migraine in children. Acta Neurol
  197450109115.
• Forsythe WI, Gillies D, Sills MA. Propranolol
  (Inderal) in the treatment of childhood migraine.
  Dev Med Child Neurol 198426737741.
• Olness K, MacDonald JT, Uden DL. Comparison of
  self-hypnosis and propranolol in the treatment of
  juvenile classic migraine. Pediatrics
  198779593597.
• D.W. Lewis, MD S. Ashwal, MD G. Dahl, BS D.
  Dorbad, MD D. Hirtz. 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 200259490498