Headache resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo, M.D. Niloofarsadaat Eshaghhosseiny, MD[2]

Synonyms and Keywords: Approach to headache, Headache management, Headache workup

Main article: Headache

Headache Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

The first step in headache diagnosis is to determine what kind of headache the patient has, primary or secondary headache disorder. Primary headaches such as migraine,tension-type, cluster are not caused by another underlying disease, despite secondary headaches are caused by another underlying disorder such as trauma, tumors. For differentiating these two types of headache, history and physical examination are necessary, although neuroimaging and other tests may be needed as well.

Causes

Primary	Migraine
	Tension- type headache
	Cluster headache
Secondary	Extracranial disorders	Carotid or vertebral artery dissection
		Temporomandibular joint dysfunction
		Glaucoma
		Sinusitis
	Intracranial disorders	Brain space-occupying lesion
		Chiari Type 1 malformation
		CSF leak with low-pressure headache
		Hemorrhage
		Meningitis
		Vascular malformations
		Venous sinus thrombosis
	Systemic disorders	Acute severe hypertension
		Pheochromocytoma
		Fever
		Vasculitis
		Viral infections
		Hypercapnia
	Drugs	Analgesic overdose
		Proton pump inhibitors
		Caffeine withdrawal
		Hormones (estrogen)
	Toxins	Carbonmonoxide
		Nitrates

Life-threatening causes: Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Brain abscess
• Cerebral aneurysm
• Encephalitis
• Hydrocephalus
• Hypertensive encephalopathy
• Increased intracranial pressure
• Intracerebral hemorrhage
• Meningitis
• Subarachnoid hemorrhage
• Subdural hemorrhage

FIRE

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Headache according the American Academy of Neurology guidelines:

Red flags •Headache beginning after 50 years old •Increased severity and frequency of headaches •Sudden onset of headache •New onset of headache in cancer and HIV patients •Headache with sign of systemic illness(fever,rash,neck stiffness) •Focal neurological symptoms •Papilledema •Headache subsequent to head trauma

Yes

Refer and investigate

Possible indicators of secondary headache •Unexplained focal signs •Atypical headaches •Unusual headache precipitatnts •Unusual aura symptoms •Onset after after age 50 •Agravatting by neck movement: abnormal neck examination findings (consider cervicogenic headache) •Jaw symptoms (consider temporomandibular joint dysfunction)

Yes

No

Migraine •Acute medications •Monitor for medication overuse •Prophylactic medication if: -Headache >3 d/mo and acute medications are not effective OR -Headache >8 d/mo (risk of overuse) OR -Disability despite acute medication

Headache with >2 of the following: •Nausea •Light sensitivity •Interference with activities Practice points: •Migraine has been historically underdiagnosed •Considere migraine diagnosis for recurring "sinus" headaches

Yes Migraine

Medication overuse Assess •Ergots, triptans, combination analgesics, or codeine or other opioids >10 d/mo OR •Acetaminophen or NSAIDs >15 d/mo Manage •Educate patient •Considere prophylactic medication •Provide an effective acute medication for severe attacks with limitations on frequency of use •Gradual withdrawal of opioids if used, or combination analgesic with opioid or barbiturate •Abrupt (or gradual) withdrawal of acetaminophen, NSAIDs or triptans

Behavioral management •Keep headache diary: intensity, triggers, frequency, medications •Adjust lifestyle factors: reduce caffeine, ensure regular exercise, avoid irregular or inadecuate sleep or meals •Develope stress management strategies: relaxation training, CBI, pacing activity, biofeedback

No

Tension type headache •Acute medications •Monitor for medication overuse •Prophylactic medication disability despite medication

Headache with no nausea but >2 of the following: •Bilateral headache •Nonpulsating pain •Not worsened by activity

Yes Tension type headache

No

Uncommon headache syndromes

All of the following: •Frequent headache •Severe •Brief <3 h per attack) •Unilateral (always same side) •Ipsilateral eye redness, tearing or restleness during attacks

All of the following: •Unilateral (always same side) •Continuous •Dramatically responsive to indomethacin

Headache continuous side onset

Yes

Yes

Yes

Cluster headache or another trigeminal autonomic cephalalgia •Management primarly pharmacologic •Acute medication •Prophylactic medication •Early specialist referral recommended

Hemicrania continua •Specialist referral

New daily persistent headache •Specialist referral

Treatment

Shown below is an algorithm summarizing the treatment of headache:

Patient with headache

Rule about secondary causes and emergency conditions

Treat secondary causes and emergency conditions

Patient education and assessment of severity

Mild to moderate

Associated with nausea, vomiting, and diarrhea

Severe

Simple analgesics: NSAIDs, acetaminophen

Add an antiemetic

Triptans, DHE nasal spray

Combination of analgesics and caffeine

Inadequate response

Opioid analgesics Butorphanol

Inadequate response

Considere preventive therapy

Corticosteroids IV valproate

Manage as sever migraine

Do's

• Be aware of patients who describe a sudden severe thunderclap headache, described as the worst headache of their lives. Perform a non-contrasted CT scan of the head to rule out subarachnoid hemorrhage; if negative, perform a lumbar puncture.
• Rule out secondary headache when diagnosing a primary headache disorder.
• Distinguish migraine from meningitis if in addition of photophobia and phonophobia, neck stiffness and fever coexist.
• Perform an MRI or CT scan of the head, if intracranial hypertension is suspected. Morning predominant headache accompanied by vomiting supports the diagnosis of intracranial tumors.

Don'ts

• Do not perform neuroimaging in patients with recurrent headache, normal neurologic examination findings, and absence of red flags.
• Do not administer Drospirenone and Ethinyl estradiol or Norelgestromin and Ethinyl Estradiol in patients older than 35.
• Do not administer NSAIDs more than 15 days straight do to possible rebound headache.

References