Headache for the PCP:
Evaluation and Initial
Management
Chris Jackman, MD
Assistant Professor of Neurology
Child Neurology of Riley Hospital
Director, Riley Headache Center
Objectives
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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
Initial Evaluation
1. Shoulder shrug and look to parents
2. “I don’t know”
3. “Headaches?”
It’s in the history
• Time course
• Time course
• Time course
• Pain description
– Location
– Severity
– Quality
• Associated
symptoms
Other questions:
• Pain description
– Location
– Severity
– Quality
• Associated symptoms
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Aura
Nausea, vomiting
Photophobia, phonophobia
Light-headedness, vertigo
Autonomic features
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
Physical exam
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Eyes / Fundus
TMJ
Face
Muscles
Skin
Neurologic
Secondary Headaches
Non-neurologic causes of
secondary headaches
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Dental/ TMJ
Allergies/ congestion
Sinus inflammation/ infection
Ear infection/ Mastoiditis
Hypothyroidism
Pheochromocytoma (Hypertension)
Eye-strain
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…
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
It is a tumor
• Key features
– Time course (Progressive)
– Timing (On awakening)
– Postural (Supine)
– Focal Neurologic signs
– Seizures
If it’s not a tumor, what is it?
Intracerbral Hemorrhage
• Features
– Time course (Acute)
– History of trauma
– Focal Neurologic signs
• Types of hemorrhage
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Subdural
Epidural
Subarachnoid
Paranchymal
Interventricular
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
Ideopathic intracranial hypertension
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Mechanism unknown
More female, more obese
Headache with visual loss
Red Flags
– Time course (Progressive or static)
– Postural
– Neurologic signs
• Papilledema
• 6th nerve palsies
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
Meningitis / Encephallitis
• Red flags:
– Systemic signs (fever)
– Focal Neurologic signs (meningismus,
encephalopathy, seizures)
Chiari I Malformation
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Protrusion of cerebellar tonsils below the
foramen of Monro
Red flags:
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Location (posterior)
Postural, pain with
neck movements
– Focal Neurologic signs
(ataxia)
– Worse with cough,
sneezing, valsalva
Post-traumatic or Post-concussive
Headache
• Red flags: See
hemorrhage
• Will get better, may
take months
• Cognitive changes
are common, will
also improve
Headache Evaluation
Do I order LABS?
Headaches in children younger than
seven years of age
Chu ML, Shinnar S.
Arch Neurol, 49:1992; 79-82
• Study of 104 children referred to Child
Neurology
• Studies performed prior by the pediatrician
• Studies included:
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Cell counts
Basic electrolytes
Tranaminases
Urinalysis
• “Uniformly unrevealing”
• Similar prospective study in adults of 193
patients showed same results
Do I order a SCAN?
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
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
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Papilledema
Abnormal eye movements
Motor dysfunction
Gait dysfunction
American Academy of Neurology
Practice Parameter: Evaluation of children
and adolescents with recurrent headaches
2002
– Parameters which distinguish headache patients
with space occupying lesions
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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
CT vs. MRI?
Primary Headache Disorders
Migraine Diagnosis and Treatment: Results
From the American Migraine Study II
Headache 2001;41:638-645
• 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
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
“If nothing is wrong with me, doctor, why do I
have these headaches?”
Migraine pathophysiology
• Primarily a NEUROGENIC process
• We think
• For now
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.
Cortical Spreading Depression
Migraine pathophysiology
Migraine without aura
Pediatric diagnostic criteria
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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
Migraine with aura
Pediatric diagnostic criteria
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At least two attacks fulfilling the criteria B-D (below)
Aura consisting of at least one of the following, but no
motor weakness:
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At least two of the following:
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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
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
And…
…Chronic Daily Headache…
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
Chronic daily headaches evaluation
• Look for red flags*
• Ask about analgesic overuse
* Especially in New Daily Persistent Headache
Practice Parameter:
Pharmacological
treatment 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: 2215–2224
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, Reynaud’s, hemiplegic migraine
– Side effects include nausea, dizziness, chest and throat
tightness
Migraine treatment - Abortive
Migraine treatment Prophylactic
• When to use prophylaxis
– Headaches frequent
– Headaches severe
– Headaches disruptive
• Side effects and burden of taking a daily
medicine < the life disruption caused by
(appropriately treated) headaches
Migraine treatment Prophylactic
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Antihistamines
Beta-blockers
Tricyclics
Anticonvulsants
Calcium channel blockers
Migraine treatment Prophylactic
• Antihistamines
– Cyproheptadine
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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 2004;44:230–237.
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
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
Migraine treatment Prophylactic
• Anticonvulsants
– Topiramate (or zonisamide)
• Best studied
– Valproate
• Effective but side effects can be significant
– Levetiracetam/ Lamotrigine
• Limited (poor) data
Migraine treatment Prophylactic
• Calcium channel blockers
– Conflicting data
– Familial hemiplegic migraine
– Abdominal discomfort
– Monitor EKG and blood pressure
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 – doesn’t
matter
Non-pharmacologic Treatment
• Lifestyle! Lifestyle! Lifestyle!
– Analgesic overuse
– Sleep
– Diet
– Psychiatric
Non-pharmacologic Treatment
• Analgesic overuse
– Opiotes/ barbiturates > triptans
>>NSAIDS
– 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
Non-pharmacologic Treatment
• Sleep
– Snoring
– Movements
– Quality
– Quantity
– Continuity
Non-pharmacologic Treatment
• Diet
– Meats (Iron, B12)
– Vegetables (Folate?)
– Skipping meals
– Hydration
– Caffeine
Non-pharmacologic Treatment
• Psychiatric evaluation
– Anxiety
– Depression
– Obsessive-compulsive disorder
• Non-pharmocologic management
– Biofeedback
– Self-hypnosis
– Relaxation
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
Closing thoughts…
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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”
References
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Sargent JD, Solbach P. Medical evaluation of migraineurs: review of the value of
laboratory and radiologic tests; Headache 1983; 23:62-65
Chu ML, Shinnar S. Headaches in children younger than seven years of age
Arch 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 1995;96;413-416
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 2004;63:2215–2224
Ludvigsson J. Propranolol used in prophylaxis of migraine in children. Acta Neurol
1974;50:109–115.
Forsythe WI, Gillies D, Sills MA. Propranolol (Inderal) in the treatment of childhood
migraine. Dev Med Child Neurol 1984;26:737–741.
Olness K, MacDonald JT, Uden DL. Comparison of self-hypnosis and propranolol in
the treatment of juvenile classic migraine. Pediatrics 1987;79:593–597.
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 2002;59:490–498