1. Headache (HA) JHL Module
Dr. Kenisha J Evans PGY1

2. What of the following is the most appropriate next step in management?
A 35 y.o M is eval. for recurrent HA. For the past 5 yrs., he has had weekly episodes of HA lasting 6-8 hrs. The patient describes the pain as a steady pressure affecting the frontal and maxillary regions that is exacerbated by physical activity. When severe, the pain radiates to the temples and occiput. He also experiences nasal congestion and sensitivity to light, noise, & odors with the HA but has had no gastrointestinal or other neurologic sx. Potential HA triggers include weather changes, strong odors, & stress. Current meds include acetaminophen and fexofenadine, which have been ineffective in relieving HA and their associated Sx.
On Physical Exam, blood pressure 114/72 mmHg, and pulse is 66/min. Other physical examination findings unremarkable.
What of the following is the most appropriate next step in management?
CT of the HEAD
CT of the Sinuses
Naproxen
Pseudoephedrine
Sumatriptan

3. Objectives Recognition of Migraines Recognition of Migraine Triggers
Abortive Migraine Treatment
Prophylactic Migraine Treatment
Other Primary Headaches
Medication Overuse Headaches
Secondary Headaches

4. Headache Classification

5. Headache Classification
Primary Headache
Migraine w/o Aura
Migraine w/ Aura
Migraine w/ typical aura
Migraine w/ brainstem Aura
Hemiplegic migraine
Retinal Migrain
Chronic Migraine
Complicated Migraine
Tension-type Headache
Infrequent Episodic
Frequent Episodic
Chronic
Trigeminal Autonomic Cephalalgias
Cluster Headache
Chronic Paroxysmal Hemicrania
Short-Lasting Neuralgiform Headache Attacks
Other Primary Headache Disorder
Secondary Headache
Posttraumatic Headache
Headaches attributed to cranial or cervical vascular disorder
Ischemic Stroke or TIA
Parenchymal or subarachnoid hemorrhage
Headache attributed to nonvascular intracranial disorders
Intacranial Hypotension or Hypertension
Brain Neoplasia
Noninfectious inflammatory Disorders
Headache attributed to substance use or withdrawal
Headache attributed to infection
Headache attributed to disorder of homeostasis
Headache attributed to disorder of neck, eyes, ears, nose, sinuses, teeth, or mouth
Cranial Neuralgias

6. What will your H & P Look Like ?
Focus on ruling out secondary causes and Red Flags
3 Question Headache (PIN) ~93% PPV
Photophobia
Incapacitating
Nausea

8. What will your H & P Look Like ?

9. What will your H & P Look Like ?

10. An otherwise health 19 y/o W present to clinic for a yearly physical
An otherwise health 19 y/o W present to clinic for a yearly physical. She reports unilateral, pounding headache over the past year with associated nausea. You suspect she is suffering from migraine.
Which of the following symptoms would not be consistent with migraines?
She has headache more frequently on weekends
Her vision becomes clouded like “barbed wire” just before the headache onset
Her Left Lower Leg was numb for 2 weeks after a headache but has since resolve
She has numbness on her right face during migraine

11. Objectives Recognition of Migraines Recognition of Migraine Triggers
Abortive Migraine Treatment
Prophylactic Migraine Treatment
Other Primary Headaches
Medication Overuse Headaches
Secondary Headaches

12. Migraine without Aura
Most common Primary HA causes individual to seek medical attention
Characteristic acute onset of a throbbing unilateral headache that is disabling and known triggers
Peak onset Adolescence
Highest prevalence 4th Decade
Women:Men —> 3:1
Family History
~80% of all Migraines

13. Migraine without Aura H & P with no other disease etiologies and
Diagnostic Criteria
H & P with no other disease etiologies and
5 Attacks
At least 1 of Following Symptoms During Headache
nausea
vomiting
Photophobia
Phonophobia
At least 2 of Following Characteristics
Duration between 4-72hrs if untreated
Unilateral
Pulsating Quality
Moderate -Severe Intensity
Aggravation by Routine Physical Activity

14. Migraine with Aura Referred as “Classic Migraine”
Classification of 1 or more fully reversible Auras
Require 2 Attacks with Aura + H & P without underlying disease
Associated with increase risk of ischemic stroke, MI, and Claudication
Aura
Develops > 4 minutes and last no longer than 60 minutes
Start of the headache within 60 minutes

15. Migraine with Aura Sub-classification
Typical migraine aura followed by headache
Typical migraine aura without headache
Aura followed by non-migraine headache
Basiliar-type Migraine
Hemiplegic Migraine

16. Migraine with Aura Sub-classification
Complicated migraine - neurologic deficit from migraine last >24hrs
Migrainous infarction- neurologic deficit that doesn’t resolve
Ddx 2/2 sustained metabolic disturbance
Migraine associated Symptoms - Autonomic symptoms during Headache
Retinal Migraine - monocular blindness

17. Recognition of Migraine Triggers
Presentation variable
classic presentation neuromuscular headache secondary to throbbing pain and vasodilation
Pathophysiology - no completely understood
Pain likely begins brainstem
Inflammation + Distention of meningeal vessels
release of inflammatory substances via abnormal impulses to periphery
Involvement of Trigeminal Vascular system

18. Recognition of Migraine Triggers
Migraine Prodrome
~60% of Patients have an usual feeling 24 hrs before onset of Migraine
Euphoria
Depression
Dizziness
Food Craving
Hypomania
Fatigue
Cognitive Slowing
Usual yawning behavior

19. Migraine Triggers

20. Objectives Recognition of Migraines Recognition of Migraine Triggers
Abortive Migraine Treatment
Prophylactic Migraine Treatment
Other Primary Headaches
Medication Overuse Headaches
Secondary Headaches

21. Management of Migraine

22. Management of Migraine
Goal of Therapy is to Reduce headache frequency and intensity
Abortive Headache Treatment
Treatment when headache is occurring
Prophylactic Headache Treatment
Preventing future Headaches

23. Abortive Migraine Treatment
First Line : ASA, Acetaminophen, NSAIDs
Avoiding Triggers
First Line + Caffeine
Alleviate complicated Migraines
Patients with Chronic Long-standing Migraines not relieved by First line agents
Start with Triptans 5-hydroxtryptamine receptor agonist
Quick Onset Acting
Almotriptan
Eletriptan
Rizatrpitan
Long Acting —> Eletriptan
Parenteral Route —> Sumatriptan, Zolmitriptan

24. Abortive Migraine Treatment

25. Abortive Migraine Treatment
When Triptans are ineffective / Contraindicated
Poorly controlled Hypertensive Patient + Migraine
related to vasoconstrictive properties
Ergotamine
MAO Inhibitors
Compazine
Droperidol

26. Prophylactic Migraine Treatment
Reduce frequency of headaches per month by ~10% within 1st month & by 90% by the 6th month of Prophylactic therapy
Consider when
Migraines occur twice a week
If abortive therapy doesn’t work
If abortive therapy not tolerated
Presence of features such as
Hemiplegia
Migrainous infarction

27. Prophylactic Migraine Treatment
Min-Prophylaxis
Predictable migraine/ Menstrual Migraine
Migraines fall in Estrogen
Migraines occur 2 days before menses
Prophylactic therapy NSAIDS, Triptans

28. Prophylactic Migraine Treatment

29. Prophylactic Migraine Treatment

30. Which of the following is the most appropriate next step?
A 44 y/o Male, 20 pack -year smoker, is eval for a 1-week history of severe, recurrent, left periorbital headaches. The patient has experienced a 10- to 12-week period of similar headaches every spring for the past 3 years. Headaches occur once or twice daily, last 2-3 hrs. if untreated, and are accompanied by nausea, photophobia, and ipsilateral tearing but no aura or vomiting. Resting during headache episodes brings no relief; he instead paces the floor. Simple analgesics and prednisone have been ineffective. Although subcutaneous sumatriptan generally relieves symptoms within minutes, his headache frequency & dosing limitations preclude his using this drug every time he has symptoms. Physical Exam blood pressure 134/82 HR 78 remaining exam including neurologic exam unremarkable
Which of the following is the most appropriate next step?
Amitriptyline
Indomethacin
Propranolol
Topiramate
Verapamil

31. Objectives Recognition of Migraines Recognition of Migraine Triggers
Abortive Migraine Treatment
Prophylactic Migraine Treatment
Other Primary Headaches
Medication Overuse Headaches
Secondary Headaches

32. Other Primary Headaches
Trigeminal Autonomic Cephalagia “Tears of Pains”
1. Cluster Headaches
2. Paroxysmal Hemicrania
3. Short-Lasting Unilateral
Neuralgiform Headache Attacks
Tension-Type Headache

33. Trigeminal Autonomic Cephalalgia
Cluster Headaches “Suicide Headaches”
Occurs in Batches
Agitation
Causes Head-Banging
Lacrimation
Age of Onset 20-50y/o
Man to Woman 5:1
Triggers EtOH,
Associated with Tobacco use

34. Trigeminal Autonomic Cephalalgia
Cluster Headaches “Suicide Headaches”
Headache Profile
Rapid onset of non-throbbing, unilateral lasting <3hrs
Occurs 1-2x/ day
Circadian association
Episodic form of cluster - daily for 4-8 weeks
Headache free period for at least 2 weeks

35. Trigeminal Autonomic Cephalalgia
Cluster Headaches “Suicide Headaches”
Therapy Aim
Simultaneous Abortive & Prophylactic
Oxygen inhalation ~7 L/min for 10minutes + subcutaneous /nasal inhalation triptans
DHE lidocaine
Prophylactic
Verapamil Topiramate
Lithium Methysergide
Corticosteroid Taper

36. Trigeminal Autonomic Cephalalgia

37. Trigeminal Autonomic Cephalalgia
Paroxymsal Hemicrania
Autonomic Symptoms
short bouts of severe unilateral pain in orbital or temple region
Trigeminal Autonomic Cephalalgia

38. Which of the follow do you suspect
A 62 y/o M who is a government worker describes longstanding intermittent quick stabbing pain on the Left temple that causes tearing of the left eye. He already been to the ophthalmologist and was told his eyes are healthy .
Which of the follow do you suspect
SUNCT syndrome
SUNA
Tension -type Headache
Retinal Migraine

39. Trigeminal Autonomic Cephalalgia
Unilateral Neuralgiform Headaches
SUNA- Short-lasting Unilateral Neuralgiform Headaches with cranial Autonomic Symptoms
SUNCT Syndrome - Short-lasting Unilateral Neuralgiform headache with Conjuntival injection & Tearing
Both syndromes are characterized by many short- lasting (1-600 secs) unilateral headache attacks ~200/day

40. Trigeminal Autonomic Cephalalgia
Unilateral Neuralgiform Headaches
Pain occurs as single stab, series of stabs, or a saw-tooth pattern
Drug of choice Indomethacin
Antiepileptic therapy
Trigeminal Autonomic Cephalalgia

41. What is the most likely diagnosis ?
A 32 y/o M present with a moderate intensity dull occipital headache that occurs intermittently and last for one hour at a time. He denies any photophobia or phonophobia. He has not missed work, and the pain has been adequately controlled Tylenol. Physical exam is otherwise normal.
What is the most likely diagnosis ?
Tension-Type Headache
Migraine without Aura
Cluster Headache
Low Pressure Headache
SUNA

42. Tension -Type Headache
“Annoying” Headaches
Absence of associated features
mild to moderate intensity
non debilitating
Headache Profile
Dull (non-throbbing )
bilateral (band-like)
Persistent last up to one week
Not Aggravated by Physical Activity

43. Tension- Type Headaches
Therapy first line Analgesics limited to 2-3 days per week
Avoid medication -overuse headaches
Therapy Consists of
Acetaminophen
Aspirin
NSAIDS
Anti-Anxiety
Antidepressant TCAs
Biofeedback technique

44. Which of the follow should you recommend?
A 30 y/o M with a history of Migraines since adolescence has been having daily headaches over the past few months despite taking Exedrin on a daily basis. He drinks two can of Jolt energy drink every day
Which of the follow should you recommend?
continue Excedrin, discontinue Jolt
Taper Excedrin to less than 3 times/ week, Jolt is okay
Switch to Naproxen only
Taper Excedrin to less than 3 times/week, discontinue Jolts
Discontinue Excedrin, Discontinue Jolt

45. Medication- Overuse Headaches
Category of Chronic Daily headache
Presence of a headache > 15 days per month for > 3 months
frequency of use vs quantity of use
any analgesic use more than 15 days/month
Ergotamine
Triptan
Opioid
Combination of analgesic use > 10 days/month

46. Medication- Overuse Headaches
Category of Chronic Daily headache
Ddx Transformed Migraine- Patient headache persistent after removal of medication
Analgesic or Ergotamine overuse
Therapy is STOP medication
Taper for Barbituates or Opioids
Behavioral therapy (biofeedback, relaxation therapy_
Life modifications
Consider short course of Prednisone for sever headaches

47. Which of the following is the most appropriate next step?
A 65 y/o W is eval in the emergency department for a 2-day history of nausea and vomiting and a 3-week history of increasingly persistent and severe morning headaches. Breast Cancer was diagnosed 8 months ago and treated with lumpectomy, radiation therapy, and chemotherapy, which she recently completed. On physical examination, T 36.7 C bp 110/70, HR 95 RR 18. The patient is alert & oriented x3. Difficulty with tasks requiring attention, such as stating months of year backward. Mild bilateral papilledema is present. Increase tone of the left upper and lower extremities is noted. Left toe exhibits a plantar extensor response.
Which of the following is the most appropriate next step?
PET scan of body
MRI Brain
Lumbar Puncture
Whole-Brain Radiation
PET Brain

48. Which of the following is the most appropriate next step?
Women receive MRI of brain shows a 3 x 2 x2 cm ring-enhancing lesion at the gray-white junction of the Right frontal lobe surrounding edema
A Recent PET scan of the body showed no evidence of metastatic disease
Which of the following is the most appropriate next step?
Brain PET
Surgical Resection of the brain lesion
Lumbar Puncture
Whole-Brain Radiation

49. Objectives Recognition of Migraines Recognition of Migraine Triggers
Abortive Migraine Treatment
Prophylactic Migraine Treatment
Other Primary Headaches
Medication Overuse Headaches
Secondary Headaches

50. Secondary Headaches

51. Secondary Headaches

52. Secondary Headaches Subarachnoid Hemorrhage
-“the worst Headache” of the patient life
Acute Ischemic Cerebrovascular Events
Brain Tumors
- Tension-type headache increasing frequency
Low Pressure Headache
-“Orthstatic Headache”
Idiopathic Intracranial Hypertension
Symptoms of increase intracranial pressure
Signs of increase pressure papilledema, possible facial palsy
LP opening pressure>250mmH2O + normal CSF

53. Secondary Headaches Subdural Headaches
gradual onset & associated with hx of trauma or fall
episodic headaches
Cerebral Venous Thrombosis
increase intracranial pressure
Gold standard MRI & MR Venogram
Giant Cell Arteritis or Temporal Arteritis
Vasculitis of large & medium blood vessel
Typical patient >50y/o with + Polymyalgia Rheumatica

54. Summary Headaches

55. References MKSAP Neurology Internal Medicine JHL