18: 24-year-old woman with headaches

Question 1

Common types of headache seen in the outpatient setting:

Answer 1

1. Tension-type
2. Migraine
3. Medication overuse

Question 2

Serious causes of headache:

Answer 2

1. Meningitis
2. Brain tumor
3. Intracranial hemmorhage
4. Traumatic brain injury (concussion)

Question 3

Causes of Serious Secondary Headaches

Answer 3

Meningitis
Headache with fever, mental status changes, or stiff neck.

Intracranial hemorrhage
Sudden onset of headache, severe headache, recent trauma, elevated blood pressure.

Brain tumor
Cognitive impairment, weight loss or other systemic symptoms, abnormal neurologic examination.

Traumatic brain injury (concussion)
Head injury with subsequent confusion and amnesia. Loss of consciousness sometimes occurs. Subsequent headache, dizziness, and nausea and vomiting. Over hours and days: mood and cognitive disturbances, sensitivity to light and noise, and sleep disturbances.

Question 4

1. Headache due to depression or anxiety

Answer 4

Similar to tension-type headache:
Bilateral, pressing, and/or tight
Last from 30 minutes to seven days

Some experts feel that depression or anxiety can trigger tension-type headaches. In those cases tension-type headaches are considered secondary, not primary headaches.

Question 5

2. Medication overuse headache (also called analgesic rebound headache)

Answer 5

Mild to moderate in severity
Diffuse, bilateral headaches that occur almost daily and are often present on first waking up in the morning.
Often aggravated by mild physical or mental exertion.
Can be associated with restlessness, nausea, forgetfulness, and depression.
Headaches may improve slightly with analgesics but worsen when the medication wears off.
Tolerance develops to abortive medications and there is decreased responsiveness to preventive medications.
Medication overuse headache can occur at varying doses for different types of medication; it may occur with as low as an average of 18 doses of triptans per month, but may require as high as an average of 114 doses of analgesics per month.

Question 6

2. Medication overuse headache (also called analgesic rebound headache)….diagnostic criteria

Answer 6

Diagnostic criteria

More than 15 headaches per month.
Regular overuse of an analgesic for more than three months.
Development or worsening of a headache during medication overuse.
Headache resolves or reverts to its previous pattern within 2 months after discontinuation of overused medication.

Question 7

Important Physical Exam Findings with Headache

Answer 7

Signs of increased intracranial pressure:
Papilledema
Altered mental status

Other important findings to look for:
Signs of meningeal irritation such as Kernig’s sign or Brudzinski’s sign
Focal neurologic deficits such as unilateral loss of sensation, unilateral weakness, or unilateral hyperreflexia.

Question 8

Physical or environmental triggers for Tension & Migraine Headaches

Answer 8

1. Intense or strenuous exercise
2. Sleep disturbance
3. Menses
4. Ovulation
5. Pregnancy (though for many women, headaches actually improve during pregnancy)
6. Acute illness
7. Fasting
8. Bright or flickering lights
9. Emotional stress

Question 9

Medications or substances that act as triggers for Tension & Migraine Headaches

Answer 9

1. Estrogen (birth control/hormone replacement)
2. Tobacco, caffeine or alcohol
3. Aspartame and phenylalanine (from diet soda)

Question 10

When to Initiate Prevention of Migraines

Answer 10

The American Migraine Prevalance and Prevention Study outlines recommendations as to when daily pharmacological treatment should be initiated:
At least six headache days per month
At least four headache days with at least some impairment
At least three headache days with severe impairment or requiring bed rest.

Prevention should be considered:
Four to five migraine days per month with normal functioning
Two to three migraine days per month with some impairment
Two migraine days with severe impairment.

Question 11

DSM-5 Substance Use Disorder

Answer 11

The DSM-5 substance use disorder criteria combine the DSM-4 criteria for dependence, addiction, and tolerance. There is now one term, “substance use disorder,” that encompasses a continuum of problems with substances from mild to severe. Each specific substance use disorder is diagnosed in similar fashion, using a list of 11 symptoms to determine the severity of illness.
For opioid use disorder, the 11 symptoms are:
-opioids taken in larger amounts than intended
-unsuccessful efforts to control use
-significant time spent in opioid-related activities
-craving
-use results in unmet obligations at work, school, or home
-continued use despite significant interpersonal problems related to use
-other activities neglected due to use
-use in physically hazardous situations
-continued use despite physical or psychological problems related to use
-tolerance
-withdrawal
Note: The last two symptoms do not apply to patients taking opioids solely under appropriate medical supervision.

Question 12

Patient Management of Migraine and Tension-Type Headaches

Answer 12

1. HA diary
2. caffeine
3. sleep

Question 13

triptans

Answer 13


sumatriptan (Imitrex, Imigran), naratriptan (Amerge, Naramig), rizatriptan (Maxalt), zolmitriptan (Zomig), frovatriptan (Frova, Migard), almotriptan (Axert), eletriptan (Relpax)

contraindications:
Concurrent use of ergotamine, MAOIs; history of hemiplegic or basilar migraine; significant cardiovascular, cerebrovascular, or peripheral vascular disease; severe hypertension; pregnancy; in combination with SSRI’s, may cause serotonin syndrome.

SE: Dizziness, sleepiness, nausea, fatigue, paresthesia, throat tightness/closure, chest pressure.

Question 14

ergot alkaloids

Answer 14

ergotamine (Ergostat), ergotamine/caffeine (Cafergot), dihydroergotamine (DHE)

contradindication: Concurrent use of triptans, many possibly serious drug interactions; heart disease or angina, hypertension, peripheral vascular disease, pregnancy, renal insufficiency, breastfeeding.

SE: Severe reactions possible. MI, ventricular tachyarrhythmias, stroke, hypertension, nausea, vomiting, diarrhea, dry mouth, rash.

Question 15

Patients who have migraines more frequently than twice weekly are at risk for medication overuse headache. Migraine prophylaxis should be considered in these patients if the lifestyle changes aren’t effective .

Answer 15

Beta-blockers
First line:
Metoprolol (47.5- 200 mg)
Propranolol (20- 160mg)
Timolol (10- 30mg)
Second line:
Atenolol Nadolol
FDA approved: Yes
Cost: Good- excellent/cheap
Asthma, depression, severe COPD, DM requiring insulin, Raynaud's disease
Fatigue, bronchospasm, lightheadedness, insomnia, bradycardia, depression, sexual dysfunction

Tricyclic Antidepressants
First line:
Amitriptyline (10- 150mg)
FDA approved: No (off- label)
Excellent/cheap and also work for fibromyalgia and tension-type headache
Cardiac conduction defects, MAOI
Drowsiness, weight gain, dry mouth

Neurostabilizers
Second line:
Divalproex sodium (500- 1500mg); Topiramate (25- 200mg
FDA approved: Yes
Good/expensive
Pregnancy/risk of pregnancy Divalproex: hepatic disease
Divalproex: birth defects, weight gain, alopecia, pancreatitis, ovarian cysts
Topiramate: abdominal pain, change in tastes, renal stones, weight loss

Herbal
Butterbur (100- 150mg)
No
Cheap
hepatotoxicity, allergic reactions in patients with plant allergies, safety not established for long-term use
belching, headache, itchy eyes, GI issues, asthma, fatigue

Question 16

The 2000 US Headache Consortium defined the following goals for HA preventive treatment:

Answer 16

(1) decrease attack frequency by 50% and decrease intensity and duration;
(2) improve responsiveness to acute therapy; (3) improve function and decrease disability; (4) prevent the occurrence of a medication overuse headache (MOH) and chronic daily headache.

Question 17

Don’t do imaging for uncomplicated headache.

Answer 17

Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.

Question 18

The American Academy of Neurology and the U.S. Headache Consortium guidelines recommend neuroimaging only if:

Answer 18

1. The patient has migraine with atypical headache patterns or unexplained abnormalities on neurological examination
2. The patient is at higher risk of a significant abnormality
3. The results of the study would alter the management of the headache

Question 19

Symptoms that increase the odds of positive neuroimaging results include:

Answer 19

Rapidly increasing frequency of headache
Abrupt onset of severe headache
Marked change in headache pattern
A history of poor coordination, focal neurologic signs or symptoms, and a headache that awakens the patient from sleep.
A headache that is worsened with use of Valsalva’s maneuver Persistent headache following head trauma
New onset of headache in a person age 35 or over
History of cancer or HIV

Question 20

Defining Characteristics of Primary Headaches

Answer 20

Migraine
Tension HA
Cluster

Severity of pain
Moderate to severe.
Mild to moderate.
Severe.

Associated symptoms
Often occur with nausea and vomiting, photophobia, or hyperacusis. May occur with aura.
May occur with photophobia or hyperacusis.
Associated with rhinorrhea, lacrimation, facial sweating, miosis, eyelid edema, conjunctival injection, and ptosis.

Quality of pain
Pulsating and can be unilateral.
Pressing, tightening, and bilateral.
Severe unilateral orbital, periorbital, supraorbital, or temporal pain.

Aggravating factors
Worsened with physical activity.
Typically not worsened with physical activity.
Duration of symptoms
Last from 4-72 hours.
Last from 30 minutes to 7 days.
Last 15-180 minutes.

Number of episodes
5 episodes needed for diagnosis.
10 episodes needed for diagnosis.
5 episodes needed for diagnosis.