Headache

Eye Strain and hypertension are uncommon causes of headaches

If a headache has been present continuously for 4 weeks in the abscence of

neurological signs, it is probably psychogenic in origin

If patient over age 55 have an acute onset of an unrelenting headache that

lasts for hours or days, significant disease such as TUMOR, MENINGITIS,
ENCEPHALITIS, OR TEMPORAL ARTERITIS should be suspected.

A change in pattern of a patient's headache is a new development.

RED FLAGS for Organic brain disease

1. intermittent or continuous headache that is progressively increases in
frequency and severity
2. Headache that is exacerbated by coughing or straining at stool
3. Headache that is worse in the morning (Sinus and hypertensive
headaches are also worse in the morning)
4. Headache that distrubs sleep
5. Vomiting
6. Inequality of pupils
7. Fever
8. Seizures
9. Confusion
10. Recent onset of neurological deficit
11. Papilledema
12. Onset of severe headaches after age 50

Nature of Patient
1. Females - Tension, vascular (migraine), temporal arteritis, pseudo tumor
cerebri, and subaracnoid hemoorhage

2. Males - Cluster headaches

3. Children and Adults - Most common - Muscle contraction (tension

headaches)- usually of psychogenic orgin

4. Sinus headaches are uncommon in children, but may be associated with

persistent rhinorrhea, cough, otitis media, or allergies. Maxillary sinus most
frequently involved in children.

5. Increased intracranial pressure should be suspected for a child who

complains of headache and has neurologic dysfunction or projectilve vomiting
without nausea. Headaches can be exacerbated by coughing or straining.
Examples: pseudotumor cerebri, hydrocephalus, subdural hematoma, and
brain abscess

6. Classic Migraine (migraine with aura) prodrome are prominent, and the
headaches are throbbing and UNILATERAL. Often sleep and wakes with
relief.

7. Common Migraine (migraine without aura): More frequent than Classic

Migraines. Prodrome may be vague: personality change, malaise, nausea,
and vomiting. Not as UNILATERAL as Classic Migraine.

8. Cluster Headaches - uncommon in children. Highest frequencies in the

40's to 60's. No family history associations like Migraine patients.

9. Fewer than 2% of patients over age 55 experience NEW, SEVERE

HEADACHES.

10. Patients over 50: few conditions that cause chronic headaches: temporal
arteririts, cluster headaches, mass lesions, post traumatic headaches,
cervical arthritis, Parkinson's disease, medications, and depression.

11. Temporarl arteritis: suspected in elderly patients over 60 who have

unilateral chronic head pain, unexplained low grade fever, proximal myalgia,
a greatly elevated ESR, or an unexplained decrease in visual acuity.

12. Less common causes of headache: CHF, glaucoma, trigeminal neuralgia,

TMJ dysufnction.

Nature of Pain
1. Tension headaches - DULL, not throbbing, steady, and of moderate but
persistent intensity. IF WAKEN UPON with headache, it will worsen
throughout the day and improve by evening. Presist all day.

2. Migraine - severe, initially throbbing, and later boring. Pain increases

rapdily and steadily. Classic migraine lasts 2 to 8 days. Common migraines
4 hours to several days.

3. Cluster headache - much more severe, MORE STABBING AND BURNING in

quality.

4. Sinus headache - severe, throbbing, and pressure like.

5. Common Migraine - more bilateral than unilateral. LOCATED

FRONTOTEMPORAL OR SUPRAORBITAL.

6. Cluster headaches: unilateral and PERIORBTIAL in any given cluster; PAIN

DESCRIBED AS IN THE EYE AND RADIATING TO THE THE FRONT OF THE FACE
OR THE TEMPROAL REGIONS. Lasts 20 to 60 minutes.

7. Tension headaces: OCCIPITAL, subocciptial, and bilateral. Tight band

across head. RADIATES down the back of ehad and neck.

8. Sinus headaches: involved sinus maxillary, ethmoid, and/or frontal.

Ethmoid sinuitis=preent of pain behind the eye that intensifies with coughing
or sneezing.

9. Trigeminal neuralgia- facial pain, usually short, sharp, severe, and

stabbing. Each episodes last less than 90 seconds. repeated pain persists
for 2 to 3 minutes.

10. Mass lesions: presistent but intermittent vs intracranial infectiosn are

usually constant.

Headache Patterns
1. Migraine headaches recur at irregular internals and have no specific
pattern. recur once or twice weakly or once a year. OFTEN occur around the
MENSTRUAL PERIOD.
Classic migraine - prodrome occurs 15 to 30 minutes before the headache.
Abrupt in onset, lasts for 10 to 15 minutes and is often contralateral to the
headache.
Visual aura: scotomata, transietn blindness, blurred vision, and
hemianopsia
nonvisual aura: weakness, aphasia, mood disturbances, and
photophobia
Common migraine- often has no specific aura

2. Tension headaches: occur daily but may also occur several times a week.
Chronic tension headaches may awaken in the morning with a headache but
rarely at night. Bruxism is a specific type of tension headache.

3. Hypertensive headaches: occur in the morning after nighttime

recumbency and usually described as throbbing.

4. Cluster headache - occurs in close succession. Often occur at the same

time of day for 3 to 8 weeks and may recur one to three times a day.

5. Sinus headache- often begin in the morning and progressively worsen but
tend to improve toward evening.

Associated Symptoms
1. Classic Migraine: anorexia, nasua, vomiting, sonophobia, photophobia,
and irritability. Less common: dizziness, fluid retention, abdominal pain, and
sleepiness.
2. Common Migraines: above as well as fatigue, chills, diarrhea, and
urticaria. CYCLIC ABDOMINAL PAIN or vomiting in children and motion
sickness in adults are typically seen in patiens with migraine headaches.

3. Tension Headaches: Pain in the posterior cervical region and is

exacerbated by neck extension. frequently tense, anxious, significantly
depressed, and fatigued. connected with their emtoions.

4. Sinus headaches: pain in the eye - ethmoid sinusitis. Tender to palpation

indicate URI. NASAL OR SINUS NEOPLASM may be present if the physician
suspects a sinus headache that does not improve after approximately 2
weeks of appropriate theraphy antibiotics and nasal decongestants.

5. Cluster headaches: compalin of injection of the involved eye, a block nose

with rhinorrhea, and mrked ipsilateral lacrimination. May have ipsilateral
Hroner's syndrome. 25% of patients with cluster headaches have PUD.

Precipitating and Aggravating Factors

1. Migraine headaches: precipitated by menstruation (when estrogen levels
fall)
b)emtotional stress NOT AS FREQUENT (hypoglycemia, fasting, bright lights,
fatigue, foods in tyramine, odors, exercise, weather changes, and high
altitude

2. Foods: MSG, nitrites, alcohol, caffeine. CAFFEINE WITHDRWAL.

3. Medications: reserpine, vasodilators, H2-blockers, indomethacin, ACEI,
beta blockers, CCB, sildenafil, OCP - may cause headaches. Taper off Ergots.
4. Tension headaches: EMOTIONS/STRESS/PHysical stress/long mental
concentration. Poor fitting dentures.
5. Cluster Headaches: preciptated with short naps, alcohol ingestion,
nitroglycerin, tyramine, and emotional stress
6. Sinus headache: coughing sneezing.
7. Gluacoma: headaches with visual halo or worsen in the dark

Amerliorating Factors
1. Ergot-containing drugs - vascular nature headaches
2. Aspirin or indomethacin- trigeminal autonomic cephalgia.
3. Nasal decongestants and antibotics - sinus cause
4. Headache that is severe; associated with nausea, vomiting, scotomata, or
aura with relief with sleep - probable migraine.
5. medication-overuse headaches are relieved with cessation of medications

Physical Findings
1. Tension or Migraine - seldom contribute to the differential diagnosis
2. Trigeminal neuralgia - have a trigger point.
3. True nuchal rigidity, neck stiffness throughout the arc as the examiner
flexes it but not in extension or lateral rotation.
4. TMJ dysfunction

Diagnostic Studies
1. CT may confirm acute sinusitis
2. ESR greatly elevated with temporal arteritis
3. SAH - lumber puncture/CT scan
4. MRI - for intracranial disease
5. Arteriograms may show vascular abnormalites and mass lesions.

Treatment of Headaches

1. Menstrual migraines: drop in estrogen with increase in prostaglandins

Estrogen. Supplemental estrogen is useful for women taking oral contraceptives.
Recommend Premarin 0.9 mg/day or a 0.1 mg/day estradiol patch during the placebo
week.
Oral contraceptives. Recommend switching to Seasonale or an extended cycle of another
pill so periods occur less frequently. Or suggest Mircette...it has a shorter placebo period
than other OCs.
Advise avoiding oral contraceptives in patients who have migraines with
aura...smokers...or over 35 years of age.
NSAIDs. Recommend naproxen sodium 550 mg BID for thirteen days....starting 7 days
before menses.
Triptans. Naratriptan (Amerge) or frovatriptan (Frova) are sometimes used for
prevention...not just treatment.
Suggest Amerge 1 mg BID or Frova 2.5 mg BID...starting 2 or 3 days before the start of
menses and for 3 days afterwards.
New sumatriptan generics are raising questions about which triptan to use for migraines.
Payors will encourage starting with generic sumatriptan...but it's not the best triptan for
everyone.
Efficacy. If sumatriptan doesn't work well, try a different triptan. Tell patients who fail
their first triptan that the next one might work better. Explain that it requires some trial
and error.
Faster onset. Sumatriptan injection starts working in 10 to 15 minutes...sumatriptan and
zolmitriptan nasal sprays in 15 minutes.
Orally disintegrating tabs (Maxalt-MLT, Zomig-ZMT) DON'T work faster than other oral
tabs. Explain that they dissolve in the mouth, but are then swallowed and absorbed in the
GI tract.
Route. Use the nasal spray or injection for patients who can't take the oral tabs due to
nausea and vomiting. Or try the orally disintegrating tabs for patients who are not
vomiting.
Longer duration. Frova (frovatriptan) and Amerge (naratriptan) are the longest-acting
triptans...but they also have the slowest onset.
Use these when PREVENTING a recurrence is more important than a fast onset. Also
consider using these to prevent menstrual migraines...their longer duration means less
frequent dosing.
Combo therapy. Combining a triptan and an NSAID often works better than either one
alone.
But there's no proof that Treximet (sumatriptan/naproxen) is better than a triptan plus a
separate NSAID...and it costs more.
Medication overuse headaches can occur with any of the acute migraine drugs...triptans,
analgesics, caffeine. If patients need an acute drug more than two days a week, consider
prophylactic therapy.

Acute Migraine Management

1. First line - NSAIDs
2. Triptans - Selective H1 agonists -contraindicated heart diease, uncontrolled
hypertension. SC Imitrex -very rapid onset
3. Ergots - Intransal dihydroergotamine (DHE) monotherapy - constricts cranial and
peripheral blood vessels
4. Opiods - butorphanol nasal spray -Stadol NS
5. Antiemetics: Reglan (anti-dopamine)