FMcase 18

Case 18
24-year-old female with headaches - Ms. Payne

Author: Rachel Franklin, M.D., University of Oklahoma College of Medicine
Learning Objectives:
Student will identify the typical presenting signs and symptoms of migraine
headache and contrast these with the typical signs and symptoms of the
most common and most serious causes of headache (tension, cluster, brain
tumor, intracranial hemorrhage, medication use).
1.
Student will obtain an appropriately focused history on a patient who
presents with headache.
2.
Student will perform a reliable focused neurologic exam on a patient who
presents with headache.
3.
Student will identify appropriate indications for ordering imaging tests on a
patient who presents with headache.
4.
Student will counsel a patient who presents with headache on the
appropriate prevention and treatment of the headache.
5.
Student will understand the importance of continuity of care when treating a
patient who presents with chronic headache.
6.
Student will demonstrate the use of point-of-care technology when
uncertainty regarding diagnosis, appropriate evaluation, and/or treatment of
a patient arises during the course of an office visit.
7.
Summary of Clinical Scenario: Sarah is a 24-year-old female with a past
history of headaches, previously controlled with ibuprofen, who is here today
because her headaches have worsened and because she is anxious about missing
a more serious problem before her insurance runs out next month. Upon further
questioning, we discover that her severe headaches are primarily unilateral and
throbbing, with associated photo- and phonophobia. She also has tension-type
headaches with associated occipital tenderness. An appropriately thorough
neurological exam is performed. The student considers and rules out each of the
three most troublesome potential diagnoses: bacterial meningitis, increased
intracranial pressure, and brain tumor. After comparing and contrasting the key
features of the most common types of headaches, using the International
Headache Society's classification system, the student decides that the patient is
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most likely suffering from both migraine headache and tension headache. The
preceptor, student, and patient discuss a functional goal and negotiate a
management plan that involves non-pharmacological strategies, acute-treatment
medications, and prophylactic therapy. During this discussion, the student learns
about classification, mechanism of action, and side effects of commonly used
medications.
Key Findings from History
Unilateral, throbbing
headaches
Headaches last one to two
days
Increased life stressors
Key Findings from Physical
Exam
Tenderness over occiput
Normal neurological exam
Differential Diagnosis
Migraine headache
Tension headache
Medication-overuse headache
Anxiety disorder/depression
Key Findings from Testing Not applicable
Final Diagnosis
Migraine headache
Tension headache
Case Highlights: Despite lack of history of head trauma, fever, or focal
neurological findings, the patient insists on a STAT MRI. This provides the
student with an opportunity to identify gaps in his knowledge, search for
appropriate evidence-based answers, and understand how to recommend
radiographic studies appropriately. Furthermore, the student learns how to deal
with a situation in which a patient demands a specific and expensive test that the
history does not warrant. The patient has been using her fathers hydrocodone,
which provides an opportunity to review the appropriate use of narcotics for
chronic pain and learn how to identify narcotic abuse and misuse (including
DSM-IV criteria for dependence, addiction, and tolerance). There is also a
discussion of how narcotic use is managed in the practice via a narcotic contract.
Key Teaching Points
Knowledge
Headache: May be primary or secondary.
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Primary headaches (International Headache Society criteria):
Migraine Tension Cluster
Number
needed for
diagnosis
5 episodes 10 episodes 5 episodes
Pain
Moderate to
severe
Mild to moderate Severe
Character Pulsating Pressing
Associated
symptoms
Nausea
Vomiting
Photophobia
Phonophobia
Photophobia
Phonophobia
Autonomic
features:
Rhinorrhea
Lacrimation
Facial
sweating
Miosis
Eyelid edema
Conjunctival
injection
Ptosis
Location Unilateral
Bilateral
Occipital
tenderness
possible
Unilateral
Orbital
Periorbital
Supraorbital
Temporal
Aura Possible No No
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Duration 4 to 72 hours
30 minutes to 7
days
15 to 180
minutes
Aggravated
by physical
activity
Yes No No
Secondary headaches
Headaches as a result of another underlying medical or psychological
diagnosis, such as anxiety or depression.
High rate of comorbidity between depression or anxiety and primary
headaches.
Features of the more common secondary headaches may be exactly like
those of tension headaches, so other aspects of historysuch as sleep
disturbance or feelings of sadness or anxietyprovide vital clues to the
actual diagnosis.
Appropriate neurological exam is essential. Observe for:
Papilledema
Altered mental status
Signs of meningeal irritation (Kernigs or Brudzinskis signs)
Focal neurologic deficits
Medication overuse (analgesic rebound)-induced
Reflect a rebound of a primary headache following chronic use of any
analgesic (opioids, acetaminophen, aspirin, analgesic-codeine, analgesic-
barbiturates, NSAIDs, ergotamies, triptans).
Present similarly to primary headaches, only they occur daily, frequently
present on awakening, and are refractory to treatment.
Tolerance develops to abortive medications, and there is decreased
responsiveness to preventive medications.
Associated with restlessness, nausea, forgetfulness, and depression
Criteria for diagnosis includes:
> 15 headaches per month
Regular overuse of an analgesic for > three months
Development or worsening of a headache during medication overuse
Main treatment is stopping the overused medication.
Chronic Pain:
Chronic pain is defined as pain that persists beyond the usual course of disease
or injury, and which may or may not be associated with a pathologic process.
May be nociceptive (due to tissue injury), neuropathic (a neurologic response to
either neural or nonneural injury) or a combination.
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Differential diagnosis
Potentially life-threatening diagnoses to consider with headache:
Bacterial meningitis:
Symptoms include:
Acute headache
Fever
Chills
Stiff neck

Other signs that might make you consider this include:
Symptoms of upper respiratory infection
A new rash
Recent exposure to infections
Abnormal thinking
Abnormal neurologic exam
1.
Intracranial hemorrhage: Consider this if you discover a recent history
of trauma or an acute change in the pattern or severity of headaches. Red
flags that accompany intracranial hemorrhage include:
Findings of a first or worst headache
A change in an existing headache
Hypertension
History of recent trauma to the head
2.
Brain tumor: Brain tumors rarely cause headache as the only presenting
symptom. A brain tumor will, by definition, not cause head pain unless the
tumor affects the dura mater, since the brain itself does not contain fibers
that detect painful stimuli. Red flags that accompany brain tumors include:
First headache in a patient over 50 years old
Abnormal thinking
oWeight loss or other systemic symptoms
3.
Skills
History:
Evaluation of pain: Visual analog scales are a useful tool for gauging pain and
the success of treatment.
Screening for depression: Patient Health Questionnaire 2 (PHQ-2):
"During the past month, have you been often bothered by feeling down,
depressed or hopeless?"
1.
"Have you, in the last month, been bothered by being uninterested or 2.
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unable to find pleasure in the things you do?"
Identifying narcotic abuse and misuse:
Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision
(DSM-IV-TR), criteria:
Dependence: A syndrome characterized by a maladaptive pattern of opioid use
causing clinically significant impairment or distress manifested by at least three of
the following:
Tolerance
Withdrawal
Increasing doses
Desire or inability to cut down
Significant amount of time spent in search of drug
Interference with social, occupational, or recreational activities
Continued use despite persistent/recurrent physical or psychological
problems due to the drug.
Addiction: Persistent drug craving, loss of control over drug use, compulsive use,
and a strong tendency to relapse after withdrawal.
Tolerance: The need for increasing doses of medication to achieve the initial
effect of the drug.
Physical exam:
Mental status exam: It is particularly important to note any change in mental
status in patients with a headache, as this could indicate increased intracranial
pressure.
Appearance/attitude
Psychomotor behavior
Speech/language
Affect
Mood
Thought process
Thought content
Level of awareness
Attention
Memory
Insight/Judgment
Musculoskeletal exam: Be sure to palpate for areas of tenderness in the head
and neck.
Neurological exam:
Examine cranial nerves (CNs):
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CN II and III: Pupils should be equal, round, and reactive to light.
CN III, IV, VI: Extraocular movements. Ask patient to refrain from moving her
head while following your finger movements with her eyes. Make a wide H in the
air, leading her gaze (1) to her extreme right, (2) to the right and upward, and
(3) down on the right; then (4) without pausing in the middle, to the extreme left,
(5) to the left and upward, and (6) down on the left.
Test for convergence by asking patient to follow your fingertip with her eyes as
you move it toward the bridge of her nose.
CN II: Test visual fields with confrontation. Ask patient to look with both eyes into
your eyes. While you return her gaze, place your hands about 2 feet apart, lateral
to her ears, and instruct her to point to your fingers as soon as they are seen.
Then slowly, while wiggling the fingers of both hands, move your hands along an
imaginary bowl encircling patients head toward the line of gaze until she identifies
them. Do this in the upper and lower temporal quadrants.
CN IX, X, XII: Evaluate clarity of speech and look to see if tongue is midline.
CN VII: Ask patient to, in sequence, (1) raise her eyebrows, (2) frown, (3) close
both eyes tightly while you try to open them, (4) show both upper and lower
teeth, (5) smile, (6) puff out both cheeks.
CN V: Ask patient to close her eyes and then ask if the 2 stimuli feel the same
when you lightly touch her right then left forehead; right then left cheek; right
then left chin.
Visualize fundi to look for papilledema (indicating increased intracranial
pressure).
Note sensation to light touch, motor strength, and symmetry in all
extremities; deep tendon reflexes and plantar responses.
Coordination: Observe for accuracy and tremor during the following
maneuvers:
Finger-to-nose: Ask patient to use the tip of her index finger to touch
the tip of your index finger, then the tip of her nose, then your finger
again, and so forth.
Heel-to-shin: Have patient extend her left leg, place the right heel on
the left knee, and then move the heel smoothly down the shin to the
ankle. Repeat using the left heel on the right shin.
Gait: Have patient walk toward you while walking on her heels, then walk
away from you on her tiptoes. Also have her walk in tandem, placing one
foot directly in front of the other as if walking on a tightrope. Note
steadiness and symmetry.
Studies
Neuroimaging:The American Academy of Neurology and the U.S. Headache
Consortium guidelines recommend neuroimaging only if:
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Patient has migraine with atypical headache patterns or neurologic signs
Patient is at higher risk of a significant abnormality
Study results would alter the management of the headache
Symptoms that increase the odds of positive neuroimaging results include:
Rapidly increasing frequency of headache
Abrupt onset of severe headache
Marked change in headache pattern
History of poor coordination, focal neurologic signs or symptoms, and a
headache that awakens patient from sleep
Headache that is worsened with use of a Valsalva maneuver
Persistent headache following head trauma
New onset of headache in a person age 35 or over
History of cancer or human immunodeficiency virus (HIV)
Lumbar puncture: Indicated in presence of meningeal signs.
Management
Non-pharmacologic:In a headache diary, patient keeps daily notes of presence
of headache, severity, treatment, and alleviation. This helps to monitor triggers
and daily stressors that may be modified.
Physical or environmental triggers include:
Intense or strenuous exercise
Sleep disturbance
Menses, ovulation, pregnancy
Acute illness
Fasting
Bright or flickering lights
Emotional stress
Medications or substances that act as triggers include:
Progesterone (birth control/hormone replacement)
Tobacco
Caffeine
Alcohol
Aspartame and phenylalanine (found in diet colas)
Dietary triggers include:
Ripened cheeses
Cured meats
Organ meats
Pickled or fermented foods
Monosodium glutamate (MSG)
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Yeast-based products
Chocolate
Legumes and beans
Onions
Citrus fruits
Bananas
Stress reduction:
Meditation, prayer, or scheduled moment of stillness
Relaxation audio programs
Setting limits on other people's expectations
Moderate, regular exercise
Eight to nine hours of restful sleep each night
Pharmacologic: Resource to help patients get low-cost medications RxOutreach
(http://www.rxoutreach.org/medications/ ).
Acute-treatment (abortive) medications: An attempt to stop the headache as
soon as it starts. The key to treating a migraine is to catch it at the first sign of
pain.
Migraine-specific:

Generic and
trade names
Contraindications Side effects
Triptans
sumatriptan
(Imitrex)
naratriptan
(Amerge)
rizatriptan
(Maxalt)
zolmitriptan
(Zomig)
frovatriptan
(Frova)
almotriptan
(Axert)
eletriptan
(Relpax)
Use of ergotamine
MAOI use
History of hemiplegic
or basilar migraine
Pregnancy
Heart disease/history
of stroke/
uncontrolled
hypertension
In combination with
selective serotonin
reuptake inhibitors
(SSRIs) may cause
serotonin syndrome
Dizziness
Sleepiness
Nausea
Fatigue
Paresthesias
Throat tightness or
closure
Chest pressure
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Ergot
alkaloids
ergotamine
(Ergostat)
ergotamine and
caffeine
(Cafergot)
dihydroer-
gotamine
(DHE)
Triptans
Many possibly
serious drug
interactions
Heart disease or
angina
Hypertension
Peripheral vas- cular
disease
Pregnancy
Renal insufficiency
Breastfeeding
Severe reactions
possible
MI
Ventricular tachyar-
rhythmias
Stroke
Hypertension
Rash
Nausea
Vomiting
Diarrhea
Dry mouth
Non-specific:
Aspirin,
butalbital,
caffeine (Fiorinal)
History of por- phyria
History of peptic
ulcers
Allergy to aspirin
Renal/hepatic
insufficiency
Caution in drug
abuse
Anaphylaxis
Toxic
epidermal
necrolysis
Stevens-
Johnson
syndrome
Myelo-
suppression
Thrombo-
cytopenia
GI bleed
acetaminophen
/butalbital/
caffeine
(Esgic,
Fioricet,
History of por- phyria
Allergy to aspirin
Renal/hepatic
insufficiency
Dizziness
Drowsiness
Dyspnea
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Phrenilin
[lacks caffeine])
Caution in drug
abuse
Nausea
Vomiting
Abdominal pain
Intoxication
Agranulocytosis
Thrombocytopenia
Respiratory
depression
Stevens-Johnson
syndrome
acetaminophen/
dichloralphenazone
(Midrin)
Hepatorenal
insufficiency
Diabetes
Hypertension
Glaucoma
heart disease
MAOI use
Hypertension
Dizziness
Rash
acetaminophen/
aspirin/
caffeine
(Excedrin)
Pregnancy
Sensitivity to aspirin
Nausea
GI bleed
Hypertension
Prophylactic therapies:Prophylactic therapies prevent overuse of the acute-
treatment (abortive) medicines and development of resistant headaches.
Drug (daily
dose range)
FDA
approved
Efficacy/
cost
Contra-
indications
Side
effects
Beta-blockers
Propranolol
(20160 mg)
Yes
Good-
Asthma
Depression
Fatigue
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Timolol
(1030 mg)
excellent/
cheap
Severe
CAD
DM
requiring
insulin
Reynauds
disease
Light-
headed-
ness
Insomnia
Brady-
cardia
Depres-
sion
Sexual
dysfunc-
tion
Neuristabilizers:
Divalproex
sodium
(500 1500
mg)
Topiramate
(25200 mg)
Yes
Good/
expensive
Pregnancy
Risk of
pregnancy
Divalproex:
Birth
defects
Weight
gain
Alopecia
Pancre-
atitis
Ovarian
cysts
Topiramate:
Renal
stones
Weight
loss
Tricyclic anti-depressants:
Amitriptyline
(10150 mg)
No
(off-
label)
Excellent/
cheap
Also works
for
fibro-
myalgia
and
Cardiac
conduction
defects
Drowsiness
Weight
gain
Dry
mouth
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tension-
type
headache
Calcium-channel blocker:
Verapamil
(240320 mg)
no (off-
label)
Fair/
moderately
expensive

Other treatments:
Feverfew
Magnesium
(400800 mg)
Vitamin B2
(riboflavin)
No (off-
label)
Fair/cheap None known Unknown

Treatment of chronic pain:
Emphasize function over pain relief
Set realistic goals for his pain relief, while optimizing social, occupational,
psychological and interpersonal functions
Improve sleep patterns and mood
Appropriate use of narcotics for chronic pain:
Understand underlying cause of pain.
Use as many non-pharmacologic remedies as possible.
Discuss with patients that you cannot take the pain away but will try to
improve the patients functional abilities and help them live with their pain.
When you use medicines, first select those non-narcotic options that work
for the cause of pain (anti-epileptic drugs for neuropathic pain,
anti-inflammatories for musculoskeletal pain, and so on).
Most short-acting narcotics such as acetaminophen/hydrocodone (Lortab)
and acetaminophen/oxycodone (Percocet) are indicated for use only in acute
pain or for breakthrough pain when long-acting agents are insufficient to
control symptoms.
These drugs are to be used cautiously, since they cause effects like euphoria
that are not related to their ability to control pain. It is because of these
effects that narcotics are frequently overused or diverted for other
purposes.
When you must use narcotics, the goal is to use long-acting agents along
with the other agents and use the lowest possible dose that improves
patients function.
Once patients have started narcotics, the nature of their care changes. In
addition to office visits for their other conditions, like diabetes, they are
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required to keep separate office visits just for the pain.
Have patient sign a narcotic contract. Expect compliance; check urine drug
screens, check with the states reporting system whether patient has
received drugs from other providers.
Keep an open line of communication and prescribe the medicines
consistently.
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Case 18

24-year-old female with headaches - Ms. Payne

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