1. Headache CME Dave Martin MPAS, PAC Idaho State University
Assistant Clinical Professor

2. Objectives Review alarm symptom & signs for serious HA’s
Discuss patient evaluation and treatment
Discuss more common headache syndromes
Recall headache syndromes that are truly emergent and how evaluate for them

3. Headaches Your next patient today has a headache
They are lying in a dark room laying on the exam table with an emesis basin
What are you thinking and what are your emotions?
Headaches account for 9th most common reason to consult a physician
Headaches account for 1-4% of ER visits

4. Intracranial Lesion Concern & HA Alarms
Morning HA or awakens pt
Worst HA of pt’s life
Thunderclap HA – max in 1 minute
Abrupt onset
Worse with posture change or exertion or straining
Nausea
New onset HA or change from usual or progressive
Onset of HA <5yo or >50yo
New HA with history cancer or immunosuppression
Hx of medication or ETOH

5. Intracranial Lesion Concern & HA Alarms
Papilledema
Aura >1hr
Focal neurological sx’s or deficits on exam
Vague neuropsychiatric sx’s
Personality change
Trouble thinking or remembering
Fever
Nuchal rigidity
Syncope or seizure
Altered consciousness

6. Alarm Clock Headache Hypnic Headache REALLY
Alarm Clock Headache Hypnic Headache REALLY!! I just wanted info on HA alarms – internet
Usually involves pts >65yo
Cause unknown = related to REM sleep?
Awakened at night by HA
Intense dull or throbbing
Unilat or bilat
Usually occurs
Lasts minutes
Tx: lithium

7. Headache Differential
Migraine
Meningitis/encephalitis
Cluster
Temporal arteritis
Tension
Tumor
Trauma
Psychological
Sinus
Drugs/toxins
Musculoskeletal
Viral illness
Stroke
Vascular

8. Evaluation History and PE to include what?
Lab for temporal arteritis, infection, metabolic causes
CBC
ESR & CRP
CMP
Imaging for intracranial bleed or lesion CT
MRI
With or without contrast
Angiography imaging – CTA/MRA
LP for infection and SAH
Angiography for vascular lesions

9. Imaging Recommendations = Who?
First/worst HA
Subacute HA with increasing frequency/severity
Progressive or new daily persistent HA
Chronic daily HA
HA always on same side
HA not responding to tx

10. Imaging Recommendations = Who?
New HA
>50yo
Hx of cancer or HIV
Fever, stiff neck, N&V
Aura and focal neuro sx’/signs in non-migraine HA
Papilledema, cognitive impairment or personality changes
Seizures

11. Tension HA Very common at 20.8% of population
Episodic or chronic
Pt’s don’t typically present for care
Pain classically mild to moderate
Pressure/tightness
Steady
Neck/occipital
Bilateral
Tx: OTC
Rx NSAIDs
Muscle relaxants don’t typically help

12. Migraine HA Neurovascular syndrome
Trigeminovascular reflex – altered central neuronal processing
Neurochemical activation, irritation, inflammation
Sensory sensitivity
Vascular constriction then dilation – OLD theory
30 million in US with at least one migraine per year
Female:Male 3:1
Inherited  70% plus with positive FH

13. Migraine HA Signs and symptoms Pain moderate to severe
Lasting hours to days
Commonly improved by sleep
Unilateral (classic) or bilateral
Frontotemporal area
Aching/squeezing/throbbing
N&V
Photophobia

14. Migraine HA Signs and symptoms Phonophobia/hyperacusis/sonophobia
Osmophobia/hyperosmia
Reduced concentration
Physical activity aggravates
Commonly people like to lie in a dark quiet room
Frequency quite variable
Symptoms or intensity may vary

15. Migraine HA Defined as w/o aura
Chronic episodic HA typically lasting 4-72 hours
Five episodes required for diagnosis
Presence of episodic severe HA is 93% predictive of a migraine diagnosis
Criteria
2 pain qualities
Unilateral
Throbbing/pulsating
Worse with movement – routine physical activity
Moderate to severe pain
1 associated sx
Nausea and/or vomiting
Photophobia or phonophobia

16. Migraine HA Defined with aura At least two attacks for diagnosis
Aura consisting of at least one of:
Fully reversible visual sx’s
Positive and/or negative features
Fully reversible sensory sx’s
Fully reversible dysphasic speech

17. Migraine HA Defined with aura At least two of: Homonymous visual sx’s
Unilateral sensory sx’s
At least one aura sx develops gradually over >5min and/or different aura sx’s occur in succession over >5min
Sx’s last ≥5min but ≤60min
Migraine occurring during or within 60 min of aura
Migraine aura w/o HA can occur – visual most common

18. Hemiplegic Migraine Neuro deficit with HA Clears as HA improves
Sensory
Motor – hemiparesis or hemiplegia
Speech – aphasia/dysphagia
Altered LOC possible
Clears as HA improves
Controversy using Triptans
“contraindicated” but probably safe

19. Basilar Migraine HA with N&V and photosensitivity and hyperacusis
Two or more of following fully reversible auras
Vertigo
Hypacusia and/or tinnitus
Ataxia
Visual field loss or diplopia
Bilateral paresthesias
Dysarthria
Altered LOC – obtundation, amnesia, syncope
Common

20. Migraine OTC Tx Percentage of Responders at 2 hr (% Placebo)
Medication and Dose
Mild or No Pain
Ibuprofen, 400 mg
42 (28)
49 (32)
Acetaminophen, 1,000 mg
58 (39)
77 (46)
Acetaminophen, 500 mg, plus aspirin, 500 mg, plus caffeine, 130 mg
59 (33)
79 (52)
Aspirin, effervescent, 1,000 mg
55 (37)
Not assessed

21. Maximum Daily Dose (mg)
Migraine Triptans
Drug (Brand Name)
Formulation
Doses* (mg)
Maximum Daily Dose (mg)
Almotriptan (Axert)
Tablet
6.25, 12.5 25
Eletriptan (Relpax)
20, 40 80
Frovatriptan (Frova)
2.5 5
Naratriptan (Amerge)
1, 2.5
Rizatriptan (Maxalt)
Orally disintegrating preparation (Maxalt MLT)
5,10 5, 10
30 30
Sumatriptan (Imitrex)
Tablet with 500 mg naproxen sodium (Treximet)
Nasal spray
Subcutaneous injection
25, 50, , 20 4, 6
Zolmitriptan (Zomig)
Orally disintegrating preparation (Zomig ZMT)
2.5, 5 2.5, 5 5

22. Migraine ER Tx
Evidence-based guidelines recommend the first-line use of DHE, subcutaneous sumatriptan, dopamine antagonists (metoclopramide, prochlorperazine, and chlorpromazine), and ketorolac, which have response rates of up to 70% Narcotic analgesics, recommended as rescue drugs, are still widely used first line.

23. Migraine ER Tx
Migraine pain persists or recurs in over half of patients within 24 hours of discharge from the emergency
Not treatment dependent
Intravenous dexamethasone (10 to 24 mg) has a modest effect (the number needed to treat is nine) on preventing recurrence
Not effective for acute treatment of migraine pain

24. Migraine Tx
Parenteral medication options for persistent or recurrence:
Imitrex - Sumatriptan, 4 or 6 mg SC
DHE, 0.5 to 1 mg by SC, IM, IV (DHE and triptans should not be used within 24 hours of each other).
Reglan - Metoclopramide 10 IV
Zofran - Ondansetron 4 to 8 mg IV
Compazine - Prochlorperazine, 5 to 10 mg IV
Thorazine – Chlorpromazine, 25 mg IV, 25 to 50 mg IM
Toradol - Ketorolac, 30 mg IV, 30 to 60 mg IM
Inapsine - Droperidol (2.5 mg IM or IV)
Parenteral narcotics, which may be combined with promethazine
Depakote - Valproate sodium, 500 to 1,000 mg IV
Decadron - Dexamethasone, 10 mg IM or IV

25. Migraine Tx Magnesium 1 gm IV – some sources Adjunct Tx
IV fluids
Rest in quite dark room
Antiemetics
Hydroxyzine
Metoclopramide
Prochlorperazine
Promethazine
Caffeine
Trigger point injections neck/trapezius can be very effective

26. Migraine Prophylaxis Prophylaxis  most efficacious listed first
Start low and titrate over 8-12 weeks
Beta blockers
Metoprolol, propranolol, timolol
Others – atenolol, nadolol
Antidepressants
Amitriptyline
Others – nortriptyline, protriptyline, venlafaxine
Anticonvulsants
Divalproex/valproic acid, topiramate
Others – gabapentin
Menstrual migraine may respond to estrogen

27. Case #1 38 yo female presents with migraine HA
Maxalt didn’t help after 2 doses
What questions do you want to ask
What physical exam are you going to do
What are you going to give pt for tx
What will you give if the first med doesn’t work

28. Cluster HA Uncommon: US 0.4% in men & 0.08% in women
Clusters = QOD to several per day & remission times
Severe – unilat – orbital/temporal
Lasts 15 min to 3 hours
Ipsilateral
Conjunctival injection and lacrimation 80%
Nasal congestion and coryza 75%
Miosis
Ptosis
Hyperhidrosis face
N&V, photophobia, hyperacusis – 50%

29. Cluster HA Evaluation: MRI with pituitary views – r/o mimics Treatment
100% O2 with NRB 7-15L for minutes  70-80%
Imitrex injection 6mg SQ – 75%
DHE 1mg IV works faster than subQ
Lidocaine 4% nasal drops – modestly effective
Zomig or Imitrex nasal spray – less effective
Prednisone as transitional med for prophylaxis

30. Temporal Arteritis >50yo with female>male 3:1
Giant cell arteritis
Polymyalgia rheumatica
Jaw claudication
Throbbing severe HA – usually unilat
Constitutional sx’s
Visual changes possible – on to blindness
Scalp tender over temporal artery – diminished pulse
Brushing hair or laying on pillow = tender

31. Temporal Arteritis 3 of 5 criteria for dx Dx lab and bx
1) >50yo
2) new onset HA
3) temporal artery tenderness
4) ESR >50
5) abnormal temporal artery bx
Dx lab and bx
Elevation ESR & CRP
Both elevated specificity 97%
Tx steroids 40-80mg QD
Avoid blindness – start tx as soon as suspicion

32. Case #2 64 yo female presents with unilateral throbbing HA
Pt reports muscle pain and stiffness in shoulder, hips and back muscles for a number of weeks
Stiffness in am
They feel weak but PE w/o weakness
Pt has been feeling: malaise, poor appetite
Reports temps to 100
What do you expect on PE
What tests would help
What is the tx

33. Headaches Your next pt today is complaining of a “sinus HA”
They have a long hx of sinus infections
They are requesting and abx because this is what clears up their sinus HAs

34. Sinus HA
How many have heard the pt say “I have a sinus headache and I need antibiotics”
Pt typically has a hx of recurrent sinus HA’s
By hx antibiotics typically start to clear the sinus problem within a day or two
Why is that?

35. Sinus HA Recurrent sinus HA 2nd to infection essentially NOT
Think of migraine with complaint of episodic “sinus” HA
Migraine can have sinus like sx’s
Sinus pain and pressure -- 82% & 84%
Nasal congestion -- 63%
Rhinorrhea -- 40%
Watery eyes -- 38%
Itchy nose -- 27%
Big majority of pt’s with “sinus HA” do NOT have real sinus disease on CT ~ 88%

36. Sinus HA Descriptors for migraine
Pulsing/throbbing 89%
Worse with physical activity 85%
Sinus pressure 84%
Sinus pain 82%
Nasal congestion 63%
Photophobia 79%
Nausea 73%
Phonophobia 67%
Sinusitis dx criteria: purulent discharge, nasal obstruction, facial pain/pressure/fullness
American Academy of Otolaryngology-Head and Neck Surgery

37. Chronic Daily HA 15 or more HA’s per month
50% are rebound/medication overuse headaches (MOH)
Chronic migraine (CM)
Multiple other etiologies
What are original HA’s like
Cause: more than 2 acute med doses per week – any meds
OTC’s
Rx’s – narcotics – triptans

38. Chronic Daily HA MUST stop meds including OTC’s for MOH & CM
Endure for a few weeks until back to baseline
Start prophylactic drugs
Will help accelerate improvement
Will not work well if con’t pain meds
May take 1-3 months to work
VERY difficult to manage

39. Case #3 44 yo female presents with “severe” migraine for 3 days
Headaches occur 4-5 days a week
Imitrex isn’t helpful or minimally helpful
OTC’s commonly used – Tylenol and ibuprofen
Vicodin using 2-4 times daily when has the HA and not helping – given by PCP
Commonly gets Demerol and Phenergan which provides relief for a couple days
What is dx
What is tx

40. Brain Tumors 70% report HA Similar to tension HA Usually bilat
Neuro exam may be normal
New onset or progressive HA
Morning HA’s are worst – 20%
HA with
Seizure
Confusion
Focal neuro findings
Prolonged N&V
Mental changes
Dx: imaging CT with contrast

41. Subarachnoid Hemorrhage
Sudden onset severe/worst HA
May be improving by time of presentation
Onset with exertion
N&V
Focal neuro sx’s or findings on PE
May be non focal
Meningeal signs
May have changes in consciousness to LOC to coma
Dx: CT without contrast
LP may help if CT neg and still suspect

42. Case #4
45 yo male JHS teacher presents with mild HA for 2 days and mild neck stiffness
2d ago while splitting wood passed out – uncertain time frame – woke with saw dust on clothing
Unwitnessed
No prodromal sx’s
Ate lunch 2 hours previous
Denies injury and no focal neuro sx’s
No hx consistent with seizure
Negative PMH
SH: married with kids, mod ETOH use, denies drugs

43. Case #4
What is your differential
What is your w/u
What is your tx

44. Pseudotumor Cerebri Idiopathic intracranial hypertension Increased ICP
CSF analysis nl
1:100,000 (normal wt) & 20:100,000 (obese)
Common in women of child bearing age
Idiopathic usually
Occasionally drugs or systemic conditions
Daily HA freq with nausea
Worse with straining

45. Pseudotumor Cerebri May have visual changes Papilledema
Abducens palsy common – lateral gaze – diplopia
Papilledema
May be present in asx pt
Dx -- MRI with contrast normal
Elevated CSF pressure on LP
Tx with Diamox, steroids, wt loss and LP’s
Lumboperitoneal or ventriculoperitoneal shunt for failure of conservative measures

46. Papilledema – mild, mod, severe

47. Case #5
50 yo male presents to a rural Idaho town with 1 day severe HA with N&V
No CT capability
No hx of HA like this
Negative PMH and SH
Further hx and PE all normal
IV fluids and parenteral narcotics/antiemetics w/o help
By the way pt has a hx of a brain tumor dx’d many years ago but forgot to mention anything about it
Pt life flighted to referral hospital – 2 days later dx of meningitis

48. HA Info Sources http://www.icsi.org http://www.ihs-headache.org
Copy and paste into browser
Click on guidelines then search for headache
Click on guidelines then down to classification guidelines
Medscape
Merck Manual 19th Edition
AAFP
American Academy of Otolaryngology-Head and Neck Surgery