Headaches
Jonathan Rochlin, MD
January 9, 2008
Outline
 Epidemiology
 Pathophysiology
 Differential Diagnosis and Work-Up
 Algorithmic Approach
 A Closer Look at Migraine Headaches
2
Outline
 Epidemiology
 Pathophysiology
 Differential Diagnosis and Work-Up
 Algorithmic Approach
 A Closer Look at Migraine Headaches
3
Epidemiology
 Headaches are common complaints
 Most headaches are cared for at home
 Headaches are usually one in a number of
complaints
 Headache as a chief complaint: 1% of patients
4
Outline
 Epidemiology
 Pathophysiology
 Differential Diagnosis and Work-Up
 Algorithmic Approach
 A Closer Look at Migraine Headaches
5
Pathophysiology of Pain Sensation
 Extracranial structures: all sensitive to pain
 Intracranial structures: some sensitive, some not
• Insensitive to pain: brain, ependymal lining,
choroid plexus, dura mater, arachnoid, pia mater
• Sensitive to pain: proximal portions of cerebral
arteries, venous sinuses and the cerebral veins
 Attempting to locate the anatomic site of the pain
source is difficult
6
Pathophysiologic Classification
 Vascular Headaches:
• Due to Vasodilation
• Include Headaches Due To:
 Migraines
 Hypertension
 Hypoxia
 Fever
 Muscle Contraction Headaches:
• Tension
7
Pathophysiologic Classification
 Headaches Due To Inflammation:
• Intracranial Infections:
 Bacterial Meningitis
 Encephalitis
 Orbital Cellulitis
 Cerebral Abscess
• Extracranial Infections:
 Strep Throat
 AOM/Otitis Externa
 Sinus Infections
 Dental Infections
8
Pathophysiologic Classification
 Headaches Due To Compression/Traction:
• Brain Tumor
• Intracranial Hemorrhage
• Pseudotumor Cerebri
• Hydrocephalus
• Post-LP Headache
9
Pathophysiologic Classification
 Headaches Due To Other Causes:
• Psychogenic Headaches
• Ocular Headaches
10
Outline
 Epidemiology
 Pathophysiology
 Differential Diagnosis and Work-Up
 Algorithmic Approach
 A Closer Look at Migraine Headaches
11
Another Word About Epidemiology
 Causes of headache in the pediatric emergency department:
Viral Illness
39.2%
Sinusitis
16.0%
Migraine
15.6%
Post-traumatic Headache
6.6%
Strep Throat
4.9%
Tension Headache
4.5%
Total of benign causes

12
86.8%
Burton LJ et al. “Headache etiology in a pediatric emergency department.” Pediatric
Emergency Care 1997. Feb; 13 (1): 1-4.
Differentiating the Benign From the Bad
 History
 Physical Exam
 Laboratory and Radiology Testing
13
History
 Temporal Pattern:
• Acute:
 Localized:
–
–
–
–
–
14
Dental Infections
Sinus Infections
Otitis Media/Externa
Post-Traumatic
First Migraine
History
 Temporal Pattern:
• Acute:
 Generalized:
–
–
–
–
Intracranial Hemorrhage
Hypertension
Hypoxia
Systemic Infections:
» Bacterial Meningitis
» Encephalitis
» Febrile Illnesses
– First Migraine
15
History
 Temporal Pattern:
• Acute and Recurrent:
 Migraine Headaches
 Tension Headaches
16
History
 Temporal Pattern:
• Chronic But Non-Progressive:
 Tension Headaches
 Psychogenic Headaches
 Medication Overuse Headaches
• Chronic And Progressive:
 Brain Tumor
 Cerebral Abscess
 Hydrocephalus
 Intracranial Hemorrhage
 Pseudotumor Cerebri
17
History
 Characteristic Historical Findings of Brain Tumor
Headaches in Children:
• Headaches that wake the patient up
• Headaches that are present when waking up in
the morning
• Headaches that worsen over time (chronic and
progressive)
• Headaches associated with vomiting
• Behavioral changes
• Polydipsia/polyuria (craniopharyngioma)
• History of neurologic deficits
Honig PJ, Charney EB. “Children with brain tumor headaches: distinguishing
features.” American J Dis Child 1982. 136: 121-141.
18
History
 Other Historical Findings Worrisome For Intracranial
Pathology:
• Headache worsened by cough, urination or defecation
• Headache < 6 months duration
• Pulsatile tinnitus
• “Worst headache”/thunderclap headache
• Growth abnormalities
• PMedHx risk factors for intracranial pathology:
 VP Shunt
 Neurocutaneous syndromes
 Coagulopathic patients
 Sickle cell patients
• Absence of family history of migraines
19
History
 Other Key Points To Address:
• Fever
• Mental Status Changes
• Past Medical History
• Family History
• Trauma
• Environmental Exposure
• Headaches Worse With Bending Over
• Visual Changes
20
Physical Exam
 General Appearance
 Vital Signs:
• Temperature
• BP
• O2 Sats
21
Physical Exam
 Head and Neck Exam:
• Signs of Trauma
• Otitis Media/Externa
• Strep Throat
• Teeth and Gingiva
• TMJ and Masseter Muscles
• Nuchal Rigidity
• Sinus Tenderness
• Head Circumference
• Muscle Tenderness
22
Physical Exam – The Skin
23
Physical Exam – The Skin
24
Physical Exam – The Skin
25
Physical Exam – The Skin
26
Physical Exam – The Skin
27
Physical Exam – The Skin
28
Physical Exam – The Skin
29
Physical Exam – The Skin
30
Physical Exam – The Skin
31
Physical Exam – The Skin
32
Physical Exam
 The Neurologic Exam:
• Funduscopic Examination
• Extraocular Muscle Movement
• Pupillary Light Reflex
• Other Cranial Nerves
• Gait
• Motor Examination
33
Studies
 CT
 LP
 Bloodwork
 Most Patients Do Not Need Any of These
• Based on Lewis DW et al. “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.
34
CT Evaluation of Headaches
 1 fatal cancer for every 1,000 CTs performed
• Rice HE et al. “Review of radiation risks from computed
tomography: essentials for the pediatric surgeon.” J Pediatric
Surgery 2007. Apr; 42(4): 603-7.
35
CT Evaluation of Headaches
 Each year, 500 children will ultimately die from
cancer due to CT scans
• Brenner D et al. “Estimated risks of radiation-induced fatal cancer
from pediatric CT.” American J Roentgenol 2001. Feb; 176(2):
289-96.
36
CT Evaluation of Headaches
37
CT Evaluation of Headaches
38
 Who Should Get a CT:
• Points on the History Concerning For Intracranial
Pathology:
 Headaches that wake the patient up
 Headaches that are present when waking up
in the morning
 Headaches that worsen over time (chronic and
progressive)
 Headaches associated with vomiting
 Behavioral changes
 Polydipsia/polyuria (craniopharyngioma)
 History of neurologic deficits
CT Evaluation of Headaches
 Who Should Get a CT:
• Points on the History Concerning For Intracranial
Pathology:
 Headache worsened by cough, urination or defecation
 Headache < 6 months duration
 Pulsatile tinnitus
 “Worst headache”/thunderclap headache
 Growth abnormalities
 PMedHx risk factors for intracranial pathology:
–
–
–
–
VP Shunt
Neurocutaneous syndromes
Coagulopathic patients
Sickle cell patients
 Absence of family history of migraines
 Altered mental status
39
CT Evaluation of Headaches
 Who Should Get a CT:
• Points on the Physical Exam Concerning For
Intracranial Pathology:
 Abnormal Neurologic Exam
 Abnormal Skin Findings Suggestive of
Neurocutaneous Disorder
 Macrocephaly
40
CT Evaluation of Headaches
 Who Does NOT Need a CT:
• Most Patients With Migraines
• Those With Chronic But Non-Progressing
Headaches
41
MRI Evaluation of Headache
 Usually this is not practical in the ED
 For some lesions, MRI is better
 However, do not delay the CT in order to get an
MRI later
42
LP for Evaluation of Headache
 Who Should Get an LP:
• Suspected Meningitis/Encephalitis
• Suspected Pseudotumor Cerebri
• Suspected Subarachnoid Hemorrhage
 With Abnormal Neurologic Exam, Do a CT First
43
Bloodwork for Evaluation of Headache
 Rarely Indicated
 Exceptions Include:
• Serious Infectious Process (Meningitis Or
Encephalitis):
 CBCD
 BCx
• Elevated BP:
 BMP
 UA
44
Outline
 Epidemiology
 Pathophysiology
 Differential Diagnosis and Work-Up
 Algorithmic Approach
 A Closer Look at Migraine Headaches
45
Algorithm
History of acute and recurrent headaches
No
Yes
Typical pattern with no
new findings
Abnormal neuro exam or Hx/PE findings
concerning for intracranial pathology
No
Yes
Yes
No
Migraine
Tension
Go to CT scan algorithm
Fever
Yes
No
Go to fever algorithm
Other abnormalities on Hx/PE
Yes
History of trauma
46
Posttraumatic
headache
Hypoxic
Hypoxic
headache
Exposure
CO
poisoning
No
Increased BP
Focal tenderness
Hypertensive
headache*
Sinusitis
Dental infection
TMJ dysfunction
Tension headache
Migraine
Tension
Psychogenic
Med Overuse
Fever Algorithm
Patient has fever
Meningeal signs
Yes
No
LP*
LP abnormal
Yes
Bacterial meningitis
Encephalitis
47
No
Consider CT to rule
out bleed or tumor
Viral syndrome
Sinusitis
Dental infection
Otitis Media/Externa
Strep Throat
CT Scan Algorithm
Patient has abnormal neuro exam or Hx/PE
findings concerning for intracranial pathology
CT scan
CT scan abnormal
No
Yes
Brain tumor
Intracranial bleed
Hydrocephalus
Cerebral abscess
Orbital cellulitis
Malfunctioning VP shunt*
Extremely severe headache
or stiff neck
Yes
No
Neuro findings abnormal
for >60 minutes
LP with opening pressure
Pleocytosis
No
Yes
Increased RBCs
Subarachnoid
hemorrhage
48
Yes
Elevated opening
pressure
Increased WBCs
Bacterial meningitis
Encephalitis
Yes
Pseudotumor cerebri
No
Migraine
Stroke
Todd’s paralysis (after
unwitnessed seizure)
Pseudopapilledema
No
Migraine
Outline
 Epidemiology
 Pathophysiology
 Differential Diagnosis and Work-Up
 Algorithmic Approach
 A Closer Look at Migraine Headaches
49
Migraine Diagnosis
 International Headache Society Criteria:
• A. At least 5 attacks fulfilling B - D
• B. Headache lasts 1 - 72 hours
• C. Headache with at least 2 of following:
 Bilateral or unilateral (but not occipital)
 Pulsating
 Moderate to severe pain intensity
 Aggravated by or causing avoidance of routine
physical activity (walking, climbing stairs)
• D. At least 1 of the following during headache:
 Nausea and/or vomiting
 Photophobia and phonophobia (can infer)
50
Migraine Diagnosis
 Often Positive Family History
 Aura in 15-40% of Patients
 Characteristic Pattern
51
Tension Headaches
 Characteristics of Tension Headaches:
• Duration 30 minutes - 7 days
• No aura
• 2 out of 4 of following:
 Pressing, tightening, band-like, dull
 Nonpulsatile
 Mild or moderate
 Bilateral, often frontal
 Not aggravated by physical activity
• Both of following:
 No nausea or vomiting
 Photophobia or phonophobia (but not both)
52
Migraine Treatment
 Ask: What Usually Works
 Goal: Break the Headache Quickly
 First-Line Treatment:
• No Emesis:
 Ibuprofen PO:
– 10mg/kg q6hrs; max=800mg/dose
 Acetaminophen PO:
– 15mg/kg q4hrs; max=1,000mg/dose
 Naproxen PO:
– 5-7mg/kg q8hrs; max=1,250mg/day
 Some evidence that ibuprofen is better than
acetaminophen
53
Migraine Treatment
 First-Line Treatment:
• Emesis:
 Pain Medications:
– Acetaminophen PR:
» 15mg/kg q4hrs; max=1,000mg/dose
– Toradol IV:
» 0.5mg/kg q6hrs; max=30mg
 Antiemetics:
– Phenergan PR/IM/IV:
» 1mg/kg/dose q4-6hrs; max=25mg
» Only for children >2 years old
– Consider Reglan/Zofran/Compazine
54
 IV Hydration
Migraine Treatment
 Second-Line Treatment:
• Triptans:
 5HT1 Receptor Agonists
 Promote Vasoconstriction
 Sumatriptan (Imitrex)
55
Migraine Treatment
 Intranasal Sumatriptan (Imitrex):
• Does Not Work If Under 6 Years Old
• Dosage:
 6-12 Years Old:
– 5mg
– If This Is Not Effective, Try 10mg in 2 Hours
 > 12 Years Old:
– 20mg
– If This Is Not Effective, Try Again in 2 Hours
 Do Not Give More Than Twice/24hrs
• Usually There is Some Effect Within 30 Minutes
• This Has a Bad/Salty Taste
56
Migraine Treatment
 Third-Line Treatment: Ergotamines
• Contraindications:
 Pregnancy
 Use of Triptans Within 24hrs
• Dihydroergotamine (DHE):
 Alpha-Adrenergic Blocker
 Vasoconstrictor
 Dosage:
– 0.5mg IV or 1mg SQ
– Only in Children > 10 Years Old
57
Migraine Treatment
 Attempt to Induce Sleep
• Place in a Quiet and Dark Room
 Avoid Precipitating Factors
 Avoid Opioids
58
Key Points
 Most Headaches Have Benign Causes
 Remember The Uncommon But Serious Causes
 Address The Temporal Pattern
 Always Get Temperature and BP Readings
 Do a Complete Neurologic Exam, Including Fundi
 Only Patients With Abnormal Neurologic Exams or
Findings Suggestive of Intracranial Pathology Need
a CT
59
References
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BEIR V (Committee on the Biological Effects of Ionizing Radiations). Health
effects of exposure to low levels of ionizing radiation. Washington, DC:
National Academy Press, 1990.
Brazis PW, Lee AG. “Approach to the child with headache.”
www.uptodate.com.
Brenner D et al. “Estimated risks of radiation-induced fatal cancer from
pediatric CT.” American J Roentgenol 2001. Feb; 176(2): 289-96.
Burton LJ et al. “Headache etiology in a pediatric emergency department.”
Pediatric Emergency Care 1997. Feb; 13 (1): 1-4.
Burton LJ et al. “Headache in the Pediatric Patient.” The Clinical Practice
of Emergency Medicine, 5th Edition. Draft.
Cruse RP. “Classification of migraine in children.” www.uptodate.com.
Cruse RP. “Management of migraine headache in children.”
www.uptodate.com.
Cruise RP. “Tension headache in children.” www.uptodate.com.
Honig PJ, Charney EB. “Children with brain tumor headaches:
distinguishing features.” American J Dis Child 1982. 136: 121-141.
International Commission on Radiological Protection. 1990
recommendations of the International Commission on Radiological
Protection. Oxford, England: Pergamon, 1991. ICRP publication 60.
References
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King C. “Emergent evaluation of headache in children.”
www.uptodate.com.
King C. “Headache.” Textbook of Pediatric Emergency Medicine, 5th
edition. Fleisher GR et al Editors. Lippincott Williams & Wilkins:
Philadelphia. 2006. 511-518.
Lewis DW et al. “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.
Lewis D et al. “Practice parameter: pharmacological treatment of migraine
headache in children and adolescents: report of the American Academy of
Neurology Quality Standards Subcommittee and the Practice Committee of
the Child Neurology Society. Neurology 2004. 63: 2215-2224.
Olsen J. “The International Classification of Headache Disorders.”
Cephalagia 2004. 24; Suppl 1: 23-44.
Rice HE et al. “Review of radiation risks from computed tomography:
essentials for the pediatric surgeon.” J Pediatric Surgery 2007. Apr; 42(4):
603-7.
The End
62