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My Patient has a Headache

Clin Med competencies in the form of an algorithm. The really basic stuff like anatomy was left out.
by

Ali Mc

on 21 December 2015

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Transcript of My Patient has a Headache

This Q is asked to differentiate from primary and secondary HAs.
Primary HA are usually benign in the sense that they wont directly kill you. They can still be severe and debilitating, and cluster headaches may cause you to kill yourself, but the HA itself wont do you in. Primary HAs are usually "old" in that they start before 40 and affect the Px for years.
Secondary HA are out to kill you directly. They are caused by some other disease process like a brain tumor or stroke. There are many forms of secondary HA. They are often new or different from the patients usual HA pattern. You detect these HA by looking for red flags...

WHO suggests doing the following PEx on ALL HA
Fundoscopy. (Acute Glaucoma and migraine)
Neurological examination including cognitive function.
Blood pressure.
Additional physical examination may be suggested from the history...
Fever and neck stiffness (meningitis).
Scalp tenderness (giant cell arteritis).
Painful red eye with dilated pupil (primary closed-angle glaucoma).
Papilloedema (intracranial tumours, adult idiopathic intracranial hypertension).
Fever (infections, systemic illness).
Features of hypothyroidism.
Careful head and neck examination (temporomandibular joint (TMJ) disease).
Is this an old headache or a new/changed headache.
My Patient has a Headache
What the f**k do I do!

S- Systemic Symptoms- The main 2 are Fever and weight loss but also include night sweats
S- Systemic disease- HIV patients are more likely to develop cancer and infections like meningitis so refer for a CT or lumbar puncture. Cancer patients with a HA may have metastasis to the brain and need to be seen ASAP. Aggressive cancers can spread and kill quickly.
N- Neurological symptoms- Disequilibrium can be very serious (LR49), as can an abnormal neurological exam (LR5), unilateral weakness (LR3.7) and focal neurological Sx (LR3) --> Refer to ER
N- Head or neck trauma- there could be a hemorrhage. If a new headache occurs after recent trauma, send to ER for observation.
O- Onset is Sudden- could be a stroke, if sudden and severe (thunderclap) it could be a GCA
O- Onset after 40- stroke, cancer and GCA are more likely
P- Assess previous headaches (is this the 1st time or the worst time?)
The details on these emergent conditions and diagnostic criteria
New or changed headaches are more likely to be secondary headaches and emergent.
The top priority will be to assess red flags and refer to ER or call 911 if present.

DDX list:
Stroke
Giant cell arteritis
tumour
acute glaucoma
meningitis, sinusitis, viral infection
New Headache or an Old headache that has changed
Our main DDx's are now
Tension HA
Cluster HA
Migraine- w/ or w/o aura
Narcotic or medication induced (see new HA section for details on medication HA)
Old HA's are less likely to be Emergant
Red Flag Symptoms
Alarm Symptoms are Present:
Refer to ER or 911
Alarm Symptoms are Absent! Good sign
Is there a fever?
Stroke
Giant Cell (Temporal) Arteritis
Tumour
Acute Glaucoma
NO
YES
Meningitis
Sinusitis
Viral Syndrome
No Fever, consider other causes.
Review your DDX, maybe add less likely causes
Consider Narcotics and Medication, esp. SSRIs, oral contraceptives, analgesic overuse, caffeine, triptans
path: the medication provides pain relief initially but then a tolerance is developed which requires a progressively higher dose to get relief. May also be a side effect of some medications.
presentation:
more often affects women than men and often 30-40 yo.
variable HA often worse on waking and with exercise
may occur with nausea, anxiety, depression, concentration difficulty, asthenia
Diagnosis clues:
Px may describe using drugs preemptively in anticipation of HA.
will use meds on a nearly daily basis and often an excessive dose
Tx: complete withdrawal
Are HA triggered by cough, sex or emotions- R/Out CNS aneurism by imaging. If negative in imaging the HA is considered benign
Px over 50? Re-assess for possible stroke, GCA or tumour.
New HA
Old HA
If there are no red flags and you still suspect a secondary HA, refer anyways. Trust your intuition!
Path: Two kinds of stroke:
1. Ischemic- usually caused by a thrombus but atherosclerotic plaques may cause this as well. In the atherosclerotic Px, the blood vessels typically narrow and the walls develop plaque further narrowing the lumen. If a plaque or clot in the vasculature should dislodge, it will likely get trapped in a smaller vessel blocking blood flow distally. Lack of blood for long enough will cause cell death. Blood thinners are given to dissolve a thrombus.
2. Hemorrhagic- a cerebral artery has burst. Blood will accumulate in the skull causing compression and thus damage of brain tissue. The direct contact of the blood on the brain will cause injury and the blood that is causing this pressure had a destination it is no longer reaching and thus there will be necrosis of the starved tissue. Blood thinners will worsen the bleeding and make survival less likely. Sub arachnoid hemorrhage is associated with a thunderclap HA. 10-15% never make it to the hospital though the prognosis is low regardless.
An intracerebral hemorrhage (w/in the brain) is usually caused by chronic hypertension, a vascular defect or the result of medication. Sub arachnoid hemorrhages are usually caused by injury or aneurism.

Presentation: Consider the possibility of stroke in anyone with an acute neurological defect or altered LOC. May see hemiparesis (unilateral weakness), hemisensory defects, vision loss or duplication, dysarthria (can't articulate), facial droop, ataxia, vertigo (w/ other Sxs), aphagia (can't , sudden change in LOC.

Use FAST to assess for stroke.
F- Facial paralysis. Ask the Px to smile and one side lags.
A- Arm drift. Have Px raise both arms. One may drift down.
S- Speech abnormalities. Have Px repeat a phrase and listen for slurring.
T- Time, don't waste any--> Call 911 Must be diagnosed via imaging, usually CT scan or s/t lumbar puncture though neither is great are for hemorrhagic stroke

Even one of these Sx is cause for concern (LR5) and Px should be referred.


Path: Inflammation in branches of the carotid artery cause narrowing and ischemia. The process is T-cell mediated and AG driven but the exact etiology remains unknown. GCA is a systemic vasculitis predominantly effecting the extra cranial large and medium arteries of the head, causing damage to the media and internal elastic layer. This will lead to intima proliferation which adds material to the lumen eventually occluding the lumen. The granulomatous infiltrate consists of mostly CD4+ T cells and macrophages. Many of these lesions, have giant cells clustered near the disrupted elastic lamina. [summary- immune driven, intima proliferation occludes the lumen of large and medium sized cranial arteries. Forms lesions full of t cells and giant cells in the elastic luminal layer]
Significant findings that may rule in GCA
HA (may last 2-3 months continuous or intermittent, worse at night and with cold. Pain is sharp, throbbing, boring, aching)
Beading of the temporal artery (5)
Prominent/enlarged temporal artery (4)
Jaw claudation (4) (d/t vascular insufficiency to mm)
Diplopia (3)
Findings that suggest a possible GCA are
an abnormal temporal artery that doesn't have a pulse or is tender on palpation.
transient blindness. aka amaurosis fugax
Being a Caucasian or male
Tooth, sinus or tongue pain
should test visual acuity, fields and fundoscopy
fever, anorexia, UWL.
Stiff achy muscles (PMR Sx), pain in large proximal joints which is worse in morning and better w/ movement
A normal ESR may rule GCA out (0.2). Also this condition is highly unlikely in a Px under 50 yo.
Labs:
-normocytic, normochromic anemia. On a lab this would show as a normal MCV but a decr RBC count.
-Very high ESR, elevated CRP, liver function abnormalities, thrombocytosis
-ultimately Dx with biopsy of temporal artery
PEx: systemic Sx like low fever, anorexia/WL, malaise, depression
If untreated: can cause amaurosis fugax (temp blindness) then, irreversible blindness
Red Flags:
A-agg by positional changes
R- Ralphing- vomiting
N- Neurological Sx
O- Ongoing /persistant
L
D- different pattern to their HA
S- Seizures
Top Presenting Sx in Order
HA (most common) usually worsening progressively over weeks or months.
Memory loss
Cog changes
Motor defect
Seizures
Change in personality, vision, LOC
Nausea/vomiting (projectile)
Sensory defect
Classic Triad: Disturbed sleep, severe pain, nausea and vomiting.
**Pain alleviating from drugs does not indicate the HA is non-emergent
The classic Sx triad is...
stiff neck
fever (>38)
HA [some sources say altered mental state instead but most say HA so that is what I am going with here]

Path:Meningitis is an infection of the meningies. HA is a result of meningeal irritation, increased intracranial pressure, a reaction to fever or toxic substances produced by the infection.
Presentation:
bac --> HA is severe and "bursting" of increasing intensity, stiff neck, (likely +ve Brudzinski, Kernig and Jolt), higher fever.
viral--> HA is severe , stiff neck, slower progression than bacterial
-Meningitis is a serious condition and must be ruled out. For this we have three tests: the Kernig, Brudzinski and Jolt acceleration. Kernig and Brudzinski are classically used but each used on it's own is not sufficient to R/O meningitis. The Jolt acceleration test however is. It boasts a 0.05 -LR it consists of simply shaking the head back and forth at a rate of 2 per second.
-All Px with a fever and recent onset HA should have their CSF checked for signs of infection. Especially if they are immunocompromised, alcoholics, had recent surgery or injury to the head or abdomen, newborns, college students and aboriginals [or have a systemic disease]. We prefer sensitive tests with more false positives so as to not miss a diagnosis.
-If bacterial meningitis is suspected, refer for ABx IV urgently w/ complete evaluation. Dxing bacterial meningitis takes time and a CT scan is needed before lumbar puncture so it is best to start the IV while these values are being obtained. Sx of viral and bacterial are often the same and the two are often undifferentiatable even with lumbar puncture.
-Work up: Lumbar puncture to isolate bacteria from CSF, show low glucose (bac), high protein and decreased neutrophils (viral). Blood neutrophils will be high in bact infection. Presence of seizures will increase likelihood of meningitis. CT scan may be preformed to ensure Px is a candidate for lumbar puncture.
Cllinical Decision Rule:
4 or more of the following indicates likely sinusitis (6). 3 may still indicate the pathology (3)
Maxillary toothache
poor/no response to nasal decongestants
Hx of coloured discharge
Purulent nasal discharge
Abnormal transillumination (though this test is difficult to perfect)
Cluster HA
Path: not completely known but likely involves the hypothalamus and central disinhibition of the trigeminal nocioceptive pathways
Cluster HA are quite rare (1% prevalence) but they can have a large impact on quality of life. They are defined as...
severe, unilateral and affecting the orbit or temporal regions though a number of spots on the head may be affected (jaw, teeth, neck or anywhere reached by the trigeminal nerve. Cluster HAs only occur in the area of the trigeminal nerve).
pain will last 15min-3 hours
frequency ranges from every other day to 8/day during active times for 6-12 weeks, with remission periods lasting up to a year.
must have one of these autonomal Sx: (conjuctival injection, red eye or lacrimation (tearing), nasal congestion or rhinorrhea, eyelid edema, sweating of face and forehead, myosis/ptosis, restlessness, agitation
Cluster HA are often not properly diagnosed.

Presentation:
Px appears agitated/anxious, pacing, rocking, rubbing the head.
The attack disappears randomly leaving the Px tired.

Cluster HA are considered benign because they don't directly kill you but they are liked to depression and 2% of affected Px commit suicide. Ask about depression and suicide.
Risk factors: young to middle-aged adult male, smoking.
Triggers: Alcohol, stress, climate changes
Depression Screening
-the purpose of screening is to R/out. If there is a +ve finding you can't r/in but you can investigate further.

Two Q Screening Test
1. In the last 2 weeks have you often been bothered by feeling down, depressed or hopeless?
2. In the past 2 weeks have you often been bothered by having little interest in doing things.

If positive, investigate further...SIGECAPS
1. Sleep disorders?
2. Loss of interest? (anhedonia)
3. Feelings of guilt, hopelessness
4. Energy deficit
5. Concentration deficit
6. Appetite deficit
7. Psycomotor retardation/agitation
8. Suicidality
Any 4 of these Sx's with a depressed mood or anhedonia, for over 2 weeks can be diagnostic of depression.

Tension-Type HAs (TTH)
This is the most common type of HA in adults and is likely caused by stress (and thus often start in the afternoon) or MSK problems like TMJ syndrome or cervicogenic tightness but yet to be proven. Regardless many PEx find tenderness on scalp and neck..
Triggers: Stress, sleep loss

Traits of TTH...
may last 30 min to a week
there will be no nausea or vomiting and no more than one of photophobia or phonophobia [though headache, nech stiffness and photo/phonophobia sounds a lot like meningitis- but this is an old HA with no fever]
will have 2 of the following traits
bilateral
non-pulsating, feels more pressing or tight (like a band)
mild-moderate intensity
not aggrivated by regular activities.
Differentiate from a migraine: TTN does not worsen w/ exercise and does not usually involve vomiting, nausea, photo/phonophobia.
Migraines
Path: Once thought to be of vascular origin it is now believed migraine is a neurological event with vascular effects. The trigeminal nerve is abnormally activated which leads to pain and sensitization of the higher order neurons of the brain stem and the thalamus.
Migraines can affect anyone but they seem more frequent in women. Though the prevalence of migraines in women in the general population is only 15%, it is 33% in the population of women seeking primary care. 50% of female migraine sufferers notice a a correlation to their menses. They often start in the 20s and peak in the 40s. Migraines are usually unilateral.

A HA can be diagnosed as a migraine if it occurs with either
1. Just nausea
2. 2 of Nausea, photophobia, pulsing quality.
3. 2 of nausea, photophobia, agg with physical activity
Chocolate or cheese triggers may also indicate migraine. May R/O if neither nausea or photophobia is present.

Alternatively you may use the POUND rule. 3 Sx suggests migraine, 4+ is very clear (24)
Pulsitile quality
one day duration (4-72 hours)
Unilateral
Nausea/ vomiting
Disabling intensity

Migraines can be classified as either having an aura or not. Most don't have an aura.
Auras last less than one hour by definition. They include...
fully reversible visual Sx like flickering lights, spots, lines, vision loss.
pins and needles, weakness or numbness, unilateral on the face or hand.
Dysphasic speech (send for imaging to establish this is a HA pattern and not a TIA)

Never assume that a focal neurological defect is caused by a migraine without ruling out more serious pathologies and establishing that the Sx is part of a pattern.

Migraines are typically both treated and prevented with drugs. The Acute Migraine Tx Principles are as follows... (americanheadachesociety.org)
Treat early in an attack to reduce intensity, duration and associated Sx.
Use the correct dose and formulation for the individual Px and ensure they use the acute remedy for a maximum of 3 days.
Stratify Tx: preventative Tx with an acute Tx in case Ha overpowers preventative.
Must treat two attacks with the medication before it is determined effective
If Tx is ineffective...
reconsider Dx
treat early
change formula, drug or method of delivery
check for interfering medication (this should be earlier on the list!) or overuse
add adjunct (ie. treat associated Sx)

Stepwise Tx Plan
Px are typically given and initial therapy to take in the event of an attack based on their profile. If the initial therapy fails, they take a back up therapy which may be more of the initial drug. Failure here indicates the rescue therapy should be used (often a potent opioid) and failure again necessitates a follow up visit.

How to Assess a Tx Plan...is it successful?
-severity of disability: you can assess the impact the illness has had on the Px using the MIDAS or HIT questionnaire. Alternatively you can ask about days of work missed, reduced leisure activities or productivity.
-duration, intensity, frequency of attacks
-use of medications and how often are second doses, rescue meds or emergent care needed
-how quickly is pain relieved and for how long
-incidence of adverse effects
-patient satisfaction, return to normal function.



Most Likely Causes of HAs
Primary and secondary tension-type headaches are the most common (69%).
Headache from systemic infection is second in frequency (63%).
Migraine is next (16%).
Headache after head injury (4%).
Exertional headache (1%).
Vascular disorders (1%).
Sub arachnoid haemorrhage (<1%).
Brain tumours (0.1%).
-WHO
Path: there is a congenital narrowing of the anterior chamber that may close for a variety of reasons causing a significant rise in intraocular pressure. Episodes may occur after entering an area of low light as the pupils dilate which may obscure the canal of schlem. May also be caused by some medications.
Sx:
Sudden, severe localized pain of the eye that may radiate to the ear, sinuses, teeth, forehead {very similar to a cluster headache which can also have pain, nausea and red eye but cluster HA don't have a vision change}
visual Sxs: blurring, halos, scotomas with nausea or vomiting. {just like a migraine}
PEx: Red-eye, fixed mid-dilated pupil, cloudy cornea and shallow anterior chamber
Refer to ophthalmologist promptly to reduce risk of blindness
Path: Most common cancers metastasizing to the brain are lung, breast, melanoma, then GI. Pain may be caused by many mechanisms including traction or involvement to pain sensitive structures like the meninges or large vessels, or simply increased intracranial pressure. Anyone with a history of any cancer and a new or changed HA should be imaged.
Diagnosis: Early Sx may include only HA and intact neurological exam. Eventually most will exhibit a focal neural defect.
Use CT or MRI to image for Dx.

Management:
If Sx of ICP (bilateral pain, worsening w/ cough, sneeze, bending forward, defication, sex) referral must be very immediate. All suspected tumours should be referred to oncologist

Other Intercranial Infections
Encephalitis
Presentation: depends on virus involved, Mumps causes a mild HA, HSV caused an abrupt/severe HA with confusion, fever, altered LOC, seizures and focal neurological signs

Brain Abscess
Presentation: HA progressing to vomitting, focal neuro defects, and decreased LOC

HIV Px are more susceptible to infection with opportunistic pathoges as T cells decline, particularily Cryptococcal Meningitis
Mastoiditis
Path: The middle ear connects to the mastoid air cells via the adits ad antrum, an opening between the two. If this canal should become blocked d/t infection (OM) an abscess can develop followed by bone destruction (coalescent mastoiditis). The puralent discharge resulting may spread to a variety of nearby structures. Sterp. pneumoniae is the usual cause.
Presentation: Fever, HA, otalgia (ear pain) and erythema
Diagnostic: No specific rule but you will often find...
post-auricular erythema and tenderness
auricular protrusion
abnormal TM (similar to AOM)
be suspicious if OM has lasted more than 2 weeks
Tx: Usually ABx is enough, in severe cases surgical drainage to mastoidectomy
Complications: Recurrent infections (difficult the ABx to penetrate that far), hearing loss, vertigo, facial palsy (if it spreads to the facial nerve), numerous brain infections like meningitis. Depends where it spreads.

Path: may be caused by...
a narrow sinus ostia sets the stage for obstruction. May be narrowed by inflammation, mechanical obstruction or trauma. An obstruction will cause a negative pressure in the sinus cavity as O2 is depleted which will facilitate introduction of bacteria during nose blowing. Mucus secretion continues filling the sinus.
Mucociliary dysfunction occurs during viral infection. There is a progressive decline in ciliated cells which hinders the clearance of materials.
Mucus has two layers, a thin layer that can be moved by cilia and a thick layer over top. Allergy and CF can alter this layer composition making mucus difficult to move
Presentation/PEx Findings:
Sinus pain/tenderness to pressure, may refer to vertex, occiput, temple. Facial pain.
Red nose, cheeks, eyelids
post nasal discharge, blocked nose, reduced sense of smell.
persistent cough

Labs not typically used. Typically treated as outpatient.

Complications: boney erosion beyond sinuses, osteomylitis w/ local edema "puffy tumour", orbital erosion, subdural abscess, organ failure if seeded throughout body.
Path: HA often accompanies a viral infection due either to fever, interferon or other immune elements, nasal congestion or blockages.

There is little about this, I suppose you would just diagnose it as you would a cold or flu?

Colds typically last 1-2 weeks with Px feeling better after week 1. Most resolve spontaneously and complications are rare unless immunocompromised. Labs are unnecessary.
Sx include rhinorrhea, nasal obstruction, laryngitis, cough with normal chest exam, low fever.
Can be treated as outpatient.

The Flu can be differentiated from a cold in that it has a faster onset, higher fever w/chills, aches, and more typically cause a HA. Labs are s/t available but often unnecessary unless there is something weird going on like an outbreak of a more dangerous form or in an immunocomp Px
Consider Referred Pain:
Referred pain can contribute to tension HA and migraine, see OLD HEADACHES for details.
Muscular disorders- facial and masticating mm are very susceptible to stress and overuse usually from clenching or grinding teeth, which cause spasms and pain. Pain is often felt when chewing and can be referred to head, neck, ears, teeth.
Disk/Cartilage disorders- the cartridge disk in the TMJ can become displaced causing the jaw pain, clicking or locking (either open or closed).
Inflammatory disorders- inflammation. degradation or arthritis of the TMJ can cause pain and reduced ROM. The jaw will seem like a rusty hinge (creaking).
Other- Pain can be caused by irritated nerves and neck stiffness.

Consider Dental Reasons (contributed by my Mom)
Red Flags:
An abscess is a medical emergency. Pain extending from the jaw to the ear can be an abscess. Presentation is variable depending on age. In an adult it will cause the face to swell and may affect the eye. In kids, there may be a pea sized lump on the gum or something resembling a pimple which may or may not leak. Or the cheek may be swollen. The Px will require urgent ABx, possibly IV ABx and must be referred to a dentist or ER immediately (same day). An abscess beside a tooth likely means the tooth is dead and will need extraction once the infection is cleared.
If all or half of the teeth are in pain, the Px is likely clenching the jaw or grinding their teeth at night which can contribute to HA. This is often seen in women and is usually stress induced. Oil of oregano may help but Px should be fitted for a mouth guard for sleeping.
Based on the algorithm in The Patient History
Augmented by Ali McMillan
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