Headaches

Headaches are defined as pain originating anywhere in the head or neck. They are a common presenting complaint in primary care and carry a high level of morbidity. The most common type of headache is tension HA, whereas, the most common presenting HA to primary care is migraine. Headaches can subdivided into primary or secondary based on etiology.

Primary Headaches are benign, recurrent headaches that are not caused by underlying medical disorder.

Secondary Headaches are the result of an underlying medical disorder

History

 * History is key. It guides the physical examination and further investigations
 * Age of onset
 * ChLORIDE FPP (characteristic, location, onset, radiation, intensity, duration, events associated, frequency, palliating/provoking factors)
 * Triggers (valsalva, menstrual cycle)
 * Previous treatment
 * Constitutional symptoms
 * Associated symptoms (aura, neurological symptoms, N/V, photo/phonophobia, visual changes)
 * History of head trauma
 * Past medical history: immunosuppression, HIV, malignancy, HTN, sinusitis
 * Medications: anti-coagulants, OCP, anti-platelet, corticosteroids, analgesics
 * SHx: substance use
 * FamHX: migraines

Physical exam

 * Depends on history
 * Vitals
 * MSK (C-spine, shoulders)
 * Neuro exam
 * Meningeal signs
 * Temporal and neck arteries
 * Bruits in the neck/eye/head for AV malformations

Investigations

 * Depend on history and physical
 * Blood work: CBC, ESR, TSH, tox screen, septic w/u
 * Imaging: CT/ MRI
 * Lumbar puncture
 * Temporal artery biopsy

Red Flags of Headaches

 * 1) Change in LOC
 * 2) Focal Neurological findings
 * 3) Fever, neck stiffness, meningeal signs
 * 4) New onset HA or progressive HA > 50 years old or <5 years old
 * 5) Sudden onset, severe HA, intensity 10/10
 * 6) Signs/symptoms increased intracranial pressure (morning HA, wakes you from sleep, N/V, worse with exercise/valsalva, papilledema)
 * 7) History of cancer, immunosuppressions
 * 8) HA associated with head trauma
 * 9) HA increasing in frequency and severity (change in pattern)
 * 10) Jaw claudication, scalp tenderness, visual loss
 * 11) HA associated with pregnancy/postpartum period
 * 12) Severe eye pain, halos around light, decreased visual acuity, N/Vm cilliary flush, fixed mid dilated pupil (think acute angle closure glaucoma)

History

 * bilateral, mild-moderate intensity, band-like characteristic
 * Non-pulsatile
 * 40 minutes - 7 days in duration
 * No associated N/V
 * No associated photo/phonophobia
 * Not aggravated by physical activity
 * Often has triggers
 * Not caused by underlying medical disorder

Physical

 * Normal physical examination

Investigations

 * None required

Classification

 * Infrequent < 1 day/month
 * Frequent 1-14 days/month
 * Chronic 15+ days/month

Management

 * May not require treatment
 * Non-pharm
 * avoid triggers, stress management, physiotherapy, CBT
 * Pharmacotherapy
 * Acute: first line - tylenol, NSAIDS
 * Chronic: Effexor, amitriptyline
 * Muscle relaxants have NO evidence for mngt

History

 * Unilateral, pulsating, moderate-severe intensity
 * Worse with physical activity
 * Duration 4-72 hours
 * Associated with N/V
 * Associated with photo/phonophobia
 * +/- aura
 * +/- family history
 * Often associated with triggers: food, exercise, sexual activity, weather changes, sleep changes, substance use, emotional stress, hormone therapy, menstrual cycle, lights
 * Not caused by underlying medical disorder

Physical

 * Migraine variants may show focal neurological signs

Investigations

 * NO CT if >4/5 POUND (pulsatile, onset 4-72 hours, unilateral, nausea, disabling)

Classification

 * Classic Migraine: migraine with aura
 * Common Migraine: migraine without aura

Management

 * Migraine diary
 * Avoid triggers
 * Stress reduction, regular exercise/sleep/meals
 * Acute:
 * NSAIDs - naproxen
 * Tylenol
 * Triptans: avoid in HTN/CVD. Expect relief in 2 hours
 * Lidocaine 4% nasal 0.4-0.5ml IN for 30 seconds
 * Severe: prochlorperazine, DHE, ketorolac IM
 * Prophylaxis:
 * B-Blockers (propranolol, metoprolol)
 * Anti-epileptics (valproic acid, topiramate)
 * Anti-depressants (amitriptyline, Effexor)
 * OTC vitamins
 * Riboflavin 400mg PO/day
 * Magnesium Citrate 600mg PO/day

History

 * >5 attacks lasting 15-180 minutes
 * Severe intensity, unilateral orbital/supraorbital/temporal
 * Frequency every 2-8 days
 * Unable to lie down
 * Males>Females
 * Autonomic dysfunction (e.g. lacrimation, rhinorrhea, facial swelling, ptosis)

Physical

 * Often normal. May have autonomic dysfunction signs

Investigations

 * None required

Management

 * Acute
 * Start prophylactic medications and bridging medications at the same time
 * 100% oxygen - non-rebreather 12 L/min for 15 minutes
 * Triptan (subcutaneous, intranasal)
 * sumatriptan 6mg SC or zolmitriptan 5mg Intranasal (contraindications: cardio d/o or cerebrovascular d/o)
 * Bridging
 * Steroids
 * Ergotamine
 * Occipital nerve block
 * Maintenance
 * Verapamil (#1)
 * Steroids
 * Lithium
 * Topiramate

Secondary Headaches
***NOTE: This is not an exhaustive list**** * IPH: intra-parenchymal hemorrhage

** Features of Increase ICP: morning HA, N/V, ocular palsies, altered LOC, seizures, papilledema, Cushings triad (bradycardia, hypertension and irregular breathing pattern)

*** Kernigs: pain with passive extension of flexed knee

***Brudzinski's: flexion of neck --> involuntary flexion of knee + hip

***Jolt accentuation: turn head horizontally at rate of 2-3/second = increase in HA

Common cancers that metabolize to brain: LUNG>breast>GU> Bone> Melanoma

Other differentials for HA that should be considered
TMJ dysfunction/ dental issues, substance intoxication/withdrawal, carotid/vertebral artery dissection, AVM, post-traumatic, psyche, cerebral abscess, encephalitis, metabolic (hypoxia, hypercapnia, hypoglycemia), cavernous sinus thrombosis, HTN, fever, Chiari malformation, normal pressure hydrocephalus (triad: dementia, urinary incontinence and gait instability)

References/Resources
1. International Headache Society

2. Migraine Diary