Approach to Headaches
AIMGP Seminar
April 2004
Gloria Rambaldini
Case 1
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A 28 y.o. woman is referred to you for
management of her headaches
Headaches are described as right-sided
pounding, with associated nausea and
photophobia
Aggravated by activity
ASA and Tylenol have not provided relief
What next?
Case 2
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A 72 y.o. woman presents with a four
month history of a bitemporal headache
with aching and morning stiffness of her
shoulders
She has noted a low grade fever and
some weight loss
What next?
Case 3
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A 62 y.o. man is referred for new onset
headaches
For the last 4 weeks he has awoken with a
diffuse headache and nausea
What next?
Objectives
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To learn about the major types of
headaches
To understand the difference between
primary and secondary headaches
Be familiar with the ‘RED FLAGS’
Treatment and prophylaxis of primary
headaches
Origins of Pain in the Head
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Extra-cranial pain
sensitive structures:
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Sinuses
Eyes/orbits
Ears
Teeth
TMJ
Blood vessels
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Intra-cranial pain
sensitive structures:
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Arteries
Veins
Meninges
Dura
Classification of Headaches
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PRIMARY - NO
structural or metabolic
abnormality:
 Tension
 Migraine
 Cluster
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SECONDARY –
structural or metabolic
abnormality:
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Extracranial: sinusitis,
otitis media, glaucoma,
TMJ ds
Inracranial: SAH, vasculitis,
dissection, central vein
thrombosis, tumor,
abscess, meningitis
Metabolic disorders: CO2
retention, CO poisoing
HISTORY
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Headache Characteristics:
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Temporal profile: acute vs chronic, frequency
Location and radiation
Quality
Alleviating and exacerbating factors
Associated symptoms
Constitutional symptoms
PMH: HTN, DM, hyperlipidemia, smoking
RED Flags
RED Flags
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New onset headache in a patient >50 y.o.
Sudden, worst headache of one’s life
Morning headache associated with N/V
Fever, weight loss
Worsens with valsalva maneuvers
Focal neurologic deficits, jaw claudication
Altered LOC
Hx of trauma, cancer or HIV
Physical Exam
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Blood pressure
Fundoscopy
Auscultation for bruits in H/N
Temporal artery inspection and palpation
Meningismus
Neurologic exam: motor, sensory,
coordination and gait
MIGRAINE Headaches
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Affects 15% of the general population
Female > Males
Family History present in 70%
Pathophysiology: vascular vs neurologic
Precipitants: caffeine, chocolate, alcohol,
cheese, BCP/HRT, menses, stress
MIGRAINE Headaches
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Diagnostic criteria:
1. 5 attacks in 6 months
2. Headaches lasting 4-72 h with >/= 2:
- unilateral
- pulsatile
- moderate to severe in intensity
- aggravated by activity
3. Associated with >/= 1:
- nausea/vomiting
- photophobia/phonophobia
MIGRAINE Headaches
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Subtypes:
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Auras – visual or sensory
Scintillating scotoma
Fortification spectra
Ophthalmoplegic
CN III palsy
Vertbrobasilar
hemiplegic
Visual Auras: Patient drawings
Scintillating Scotomas
Progression of a typical aura
over 30 minutes
BMJ 2002; 325:881-6
MIGRAINE: Acute Treatment
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Mild attacks: NSAIDS +/- dopamine
antagonists
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eg. ASA 650-1300 mg q4h + metoclopromide
10 mg PO/IV
Moderate attacks:
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NSAIDS (ibuprofen 400-800 mg PO q2-6h)
5-HT1 receptor agonists
Selective – sumatriptan 50-100 mg PO
 Nonselective – ergot 1-2 mg PO q1h x 3
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CMAJ 1997; 156: 1273-87
MIGRAINE: Acute Treatment
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Severe & Ultra-severe attacks:
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First line:
DHE 0.5-1 mg q1h IM/SC/IV
 sumatriptan 50-100 mg PO or 6 mg SC
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Second line:
chlorpromazine 50 mg IM
 Prochlorperazine 5-10 mg IV/IM
 dexamethasone 12-20 mg IV
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CMAJ 1997; 156: 1273-87
MIGRAINE: Prophylaxis
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Consider if >/3 attacks/month, impaired
quality of life:
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B-blockers
Calcium channel blockers
TCA (amitriptyline)
NSAIDS
Valproic acid
5HT2 Antagonists (methysergide, pizotyline)
CMAJ 1997; 156: 1273-87
TENSION Headaches
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Most common type, typically brought on by
stress, lasting 30 min to 7 d
Diagnostic Criteria >/= 2:
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Pressing/tightening, non-pulsating
Mild-moderate
Bilateral
Not worsened by ADLs
Photo or phonophobia (not coincident)
Not associated with N/V
Treatment: reassurance, NSAIDS
CLUSTER Headaches
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Age of onset 25-50 y.o., M>F
Features:
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Attacks clustered in time (>5)
Severe unilateral, orbital or temporal pain
Lasting 15 min – 3 h
Ipsilateral conjunctival injection, lacrimation, nasal
congestion, rhinorrhea, forehead/facial swelling,
miosis, ptosis
Treatment:
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Acute: O2, 5HT1 antagonists, DHE
Prophylaxis: Calcium Channel Blockers, ergots, Li
Medication Induced Headaches
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Rebound headaches due to overuse of
analgesics or prophylactic meds
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25% of patients referred to neurologists for
‘intractable’ headaches have medicationoveruse or medication-induced headaches
Giant Cell Arteritis
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Chronic granulomatous vasculitis affecting the
arteries originating from the aortic arch
18/100 000 persons >50 y.o.
Features:
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Headache 2/3 of patients (LR 1.2)
Fever, weight loss, malaise
Scalp tenderness
Jaw claudication (LR 4.2)
Diplopia (LR 3.4)
PMR related Sx (50% of GCA patients have PMR)
Giant Cell Arteritis
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Physical Exam:
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BP and pulse deficits in arms
Fundoscopy
Temporal Artery: beaded (LR 4.6), prominent (LR
4.3), tender (LR 2.6)
H/N and subclavian bruits
MSK exam
Investigations:
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Normocytic normochromic anemia
ESR (typically > 50)
TA biopsy
JAMA 2002; 287(1): 92-101
Giant Cell Arteritis
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Diagnostic Criteria – 3/5 (Sn 94%, Sp 91%)
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Age > 50 y.o.
New onset headache
TA tender +/- decreased pulse
ESR > 50
Bx: necrotizing granulomatous arteritis
Giant Cell Arteritis
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Treatment:
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Prednisone 40-80 mg PO od until symptoms
resolve and ESR normalizes
Once in remission decrease dose by 10% q12w
Osteoporosis prevention: vitamin D and
calcium +/- bisphosphonate
AIM 2003; 139:505-515
Case 1





A 28 y.o. woman is referred to you for
management of her headaches
Headaches are described as right-sided
pounding, with associated nausea and
photophobia
Aggravated by activity
ASA and Tylenol have not provided relief
What next?
Case 2



A 72 y.o. woman presents with a four
month history of a bitemporal headache
with aching and morning stiffness of her
shoulders
She has noted a low grade fever and
some weight loss
What next?
Case 3



A 62 y.o. man is referred for new onset
headaches
For the last 4 weeks he has awoken with a
diffuse headache and nausea
What next?