Resident Headache Clinic
Goals: To learn to care for patients that have been referred from the general clinic for a
diagnosis of a rare primary headache disorder, or management of a refractory
primary headache disorder. As part of management, you will learn interventional
techniques including Botox PREEMPT protocol, occipital and trigeminal nerve blocks,
and trigger point injections. A good resource for the diagnosis of headache disorders is:
rd
The International Classification of Headache Disorders. 3 edition, (beta version).
Cephalalgia 2013; 33: 629-808.
Referring patients to the clinic/what patients should expect at their first
appointment: Patients should be referred for an initial assessment during which a full
history will be obtained and reviewed with a headache attending. Patients should not
expect procedures on the first day of assessment. If it is deemed appropriate at the initial
visit, Botox therapy or other interventional treatments will be scheduled for follow-up.
Rarely a nerve block may be performed at the initial visit.
Assessing headache features: The HPI at initial visit should include a detailed
headache/facial pain history, including at least the following:
-pain location, radiation, quality, severity
-temporal features: how quickly pain starts, how long it lasts, frequency of headaches,
evolution of frequency over years
-associated features: migrainous symptoms (photophobia, phonophobia, osmophobia,
movement sensitivity, nausea/vomiting), cranial autonomic symptoms (lacrimation,
conjunctival injection, periorbital edema, eye grittiness, ptosis, pupillary changes, nasal
congestion, rhinorrhea, facial flushing/pallor, aural fullness, tinnitus); aura (visual,
sensory, dysphasic, motor, brainstem)
-assessment of red flags for dangerous headache, some of which include positional pain,
worsening headache pattern, vision changes, focal deficits and atypical aura symptoms,
pregnancy
-assessment of common secondary causes of headache – medication overuse, OSA
Headache exam: In addition to a general neuro exam, include a fundoscopic exam; when
appropriate, assessment of temporal arteries, tenderness over facial sinuses, occipital
nerve tenderness, assessment of TMJ dysfunction, examination of cervical and trapezius
muscle spasm.
Plan for headache management includes:
1. laboratory and imaging workup for any secondary headache etiologies that may have
not been addressed
2. preventive treatment strategy -this may include referral for Botox
3. acute treatment strategy
4. bridge treatment - some patients will require a 1-2 week course of NSAIDs or steroids
or a nerve block to address medication overuse, status migrainosus, or onset of cluster
headache. Intravenous therapies (e.g,. DHE, valproic acid) may be considered as well.
5. education about healthy habits for headache and about keeping a headache calendar