Headaches

Headache

• DDX:
  • – Migraine (complicated)
    
  • – Tension headache
    
  • – Cluster headache
    
  • – Pseudotumor cerebri
    
  • – Trigeminal neuralgia
    
  • – CNS vasculitis – Temporal Arteritis
    
  • – Subarachnoid hemorrhage (SAH)
    
  • – Partial seizure
    
  • – Intracranial neoplasm
    
  • – Sinusitis
• Physical Exam:
  • – VS – state or say wnl (wnl except…)
  • – General: Patient is in no acute distress
  • – HEENT: Inspect Nose (Noses, mouth, teeth, and throat) and Palpate entire head (including sinuses (ENT) and temporomandibular joints (Jaw)), Fundoscopic Exam – NC/AT, nontender to palpation, PERRLA, EOMI, no papilledema, no nasal congestion, no pharyngeal erythema or exudate, good dentition
  • – Neck: Inspect/Palpate – Supple, No lymphadenopathy
  • – Chest: Auscultate – Clear breath sounds bilaterally
  • – Heart: Auscultate – RRR, S1, S2 wnl, No murmurs, rubs or gallops (distal pulses intact bilaterally, 2+)
  • – Neuro Exam: MSE, CN, Motor, DTR – Mental Status: Alert and oriented x 3, good concentration; Cranial Nerves (CN) 2 – 12 grossly intact; Motor Strength 5/5 throughout; DTR: 2+ intact, symmetric
• Work-up:
  • – CBC with diff
    – ESR
    – CT—head
    – MRI—brain/MRA—brain
    – Lumbar Puncture (LP)
    – XR-sinues

Migraine

• Presentation:
  • – Unilateral throbbing
    
  • – Photophobia
    
  • – Sonophobia
    
  • – Aura
    
  • – Recurrent
• Physical Exam
  • – No fever
    
  • – No weakness in extremities
• DDX:
  • – Migraine (complicated)
  • – Tension headache
  • – Cluster headache
  • – Pseudotumor cerebri
  • – Trigeminal neuralgia
  • – CNS vasculitis – Temporal Arteritis
  • – Subarachnoid hemorrhage (SAH)
  • – Partial seizure
  • – Intracranial neoplasm
  • – Sinusitis
• Work-up:
  • – CBC with diff
  • – CT—head
  • – MRI—brain
  • – LP
  • – X-Ray of Sinuses
• Treatment:
  • Self Care
    • Avoid migraine triggers (caffeine, alcohol), Stress management improved sleep habits and Diet modification
  • Medication:
    • Antipsychotic
      • Chlorpromazine
    • Analgesic
      • Treximet (Naproxen/Sumatriptan)
      • Cafergot (Caffeine/Ergotamine)
      • Acetaminophen
      • Excedrin (Acetaminophen/Aspirin/Caffeine)
    • Nonsteroidal anti-inflammatory drug
      • Ibuprophen
      • Naproxen
    • Stimulant
      • Caffeine
    • Nerve pain medication
      • Topiramate
      • Amitriptyline
    • Triptan
      • Sumatriptan
      • Frovatriptan
      • Rizatriptan
      • Zolmitriptan
      • Naratriptan
      • Almotriptan
    • Neurotoxin
      • Botulinum Toxin Type A
  • Therapy:
    • Progressive muscle relaxation and Acupuncture

Tension Headache

• Presentation:
  • – recurrent episodes of bilateral squeezing headaches that occur 3-4 times a week, typically toward the end of her work day. experiencing significant stress in her life.
  • – Usually bilateral (bandlike) and squeezing
    
  • – Last hours to days
    
  • – Recurrent
    
  • – Constant, not throbbing
    
  • – Associated with stress
    
  • – Gets worse as the day progresses
    
  • – Better with massage
• Physical Exam:
  • – Normal Vital Signs
  • – Normal Neuro Exam
• DDX:
  • – Tension headache
    
  • – Migraine
    
  • – Depression
    
  • – Caffeine or analgesic withdrawal
    
  • – Hypertension
    
  • – Cluster headache
    
  • – Pseudotumor cerebri
    
  • – Intracranial neoplasm
• Work-up:
  • – CBC with diff, Electrolytes, ESR
    
  • – CT—head
    
  • – LP
• Treatment:
  • Self Care – Ice packs, Physical exercise, Stress management, and Relaxation techniques
  • Medication
    • NSAID – Ibuprofen, Naproxen, Ketoprofen, Ketorolac
    • Analgesic – Acetominophen
  • Therapy – Biofeedback, Joint manipulation, Chiropractic treatment techniques, Behavior therapy, Massage, and Acupuncture

Cluster Headache

• Presentation:
  • – Unilateral periorbital pain (behind the eye pain), often accompanied by ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of the eye, and/or Horner’s syndrome
  • – Episodes of daily pain occur in clusters
  • – Sudden and intense
  • – Last a couple of hours and gone
  • – Recurrent same time of day
  • – Often awaken patients at night
  • – Rarely occurs in women (similarity seen in women is termed “chronic paroxysmal hemicrania”)
• Physical Exam
  • – Lacrimation
  • – Blushing of Face
• DDX:
  • – Cluster headache
    
  • – Migraine
    
  • – Tension headache
    
  • – Sinusitis
    
  • – Pseudotumor cerebri
    
  • – Trigeminal neuralgia
    
  • – Intracranial neoplasm
• Work-up:
  • – CBC with diff, ESR
    
  • – CT—head
    
  • – MRI—brain
    
  • – LP
• Specialist:
  • Primary care provider (PCP)
  • Neurologist 
• Treatment:
  • Supportive Care
    • Oxygen therapy
  • Medication
    • Triptan – Sumatriptan
    • CCB – Verapamil
    • Steroid – Prednisone
    • Nerve Pain – Topiramate

Temporal Arteritis

• Presentation:
  • – Throbbing one-sided headache
    
  • – Fevers
    
  • – Jaw pain 
    
  • – Visual changes
    
• Physical Exam
  • – Tender over temporal artery
    
  • – Jaw pain when opening Jaw
    
  • – Age over 50 years
    
  • – May present with Polymyalgia Rheumatica (syndrome with pain or stiffness, usually in the neck, shoulders, and hips. The pain can be very sudden, or can occur gradually over a period.)
• DDX:
  • – Temporal arteritis (giant cell arteritis)
  • – Migraine
  • – Cluster headache
  • – Tension headache
  • – Meningitis
  • – Carotid artery dissection
  • – Pseudotumor cerebri
  • – Trigeminal neuralgia
  • – Intracranial neoplasm
• Work-up:
  • – CBC with diff, ESR, CRP
  • – Temporal Artery Biopsy
  • – Doppler U/S – carotid
  • – MRI—brain
  • – LP
• Specialist:
  • Primary care provider (PCP)
  • Neurologist
  • Ophthalmologist
• Treatment:
  • Steroid
    • Prednisone
    • Methylprednisilone 
  • NSAID – Aspirin

Chronic Paroxysmal Hemicrania (CPH) (aka Sjaastad syndrome)

• Presentation:
  • – Debilitating unilateral headache (usually around eye)
  • – Multiple severe, yet short, headache attacks affecting only one side of the cranium
  • – Women >> Men
  • – No neurological symptoms associated with it.
• Diagnosis with CPH: ≥ 20 attacks filling the following criteria:
  • – Attacks of severe unilateral orbital, supraorbital, or temporal pain lasting between 2 and 30 minutes.
• Headache needs to take place w/ 1 of the following:
  • – Ipsilateral conjunctival injection and/or lacrimation
  • – Ipsilateral nasal congestion and/or rhinorrhoea
  • – Ipsilateral eyelid edema
  • – Ipsilateral forehead and facial sweating
  • – Ipsilateral miosis and/or ptosis
• – Attacks need to occur > 5 x day for more than half of the time
• – Attacks can be prevented completely by therapeutic doses of indomethacin
• – Symptoms not due to another disorder and neuropathy of the supraorbital area in the temporal branch of facial nerve r/p

Depression 

• Presentation:
  • – Headaches may be worse on waking up in morning
  • – Associated with other depression symptoms

Intracranial Mass Lesion

• Presentation:
  • – 1/3 of patients with brain tumors present with primary complaint = headache
    
  • – Headache = non-specific => mimics migraine
    
  • – Certain brain tumors may have familial basis
    
• Physical Exam
  • – Mental status changes
    
  • – Ataxia
    
  • – Focal weakness
    
  • – Visual Changes
• Treatment:
  • antibiotics
  • brain surgery
  • radiation therapy
  • chemotherapy
  • combination 

Meningitis (bacterial)

• Presentation:
  • – high fever
  • – severe headache
  • – confusion
  • – photophobia
  • – nuchal rigidity
  • – Kernig’s and Brudzinski’s signs are positive.
• DDX:
  • – Meningitis (bacterial)
    
  • – Meningitis (HSV)
    
  • – Migraine
    
  • – Subarachnoid hemorrhage
    
  • – Sinusitis/Encephalitis
    
  • – Intracranial or epidural abscess
• Work-up:
  • – CBC with diff
    
  • – CT—head
    
  • – MRI—brain
    
  • – LP— CSF analysis (cell count, protein, glucose, gram stain, PCR for antigens, culture)
• Treatment:
  • Supportive Care
    • Hospitalization and Oxygen therapy
  • Antibiotics
    • Vancomycin
    • Cephalosporins
      • Claforan (cefotaxime)
      • Rocephin (ceftriaxone)
      • Ceftazidime
      • Cefepime
    • Meropenem
  • Steroid
    • Dexamethasone
  • Penicillin – Ampicilin

Pseudotumor Cerebri

• Presentation:
  • pulsatile headache, vomiting, and blurred vision for the past 2-3 weeks. taking OCPs
  • – Headaches can be focal but usually accompanied by diplopia and other visual symptoms
• Physical Exam:
  • – Should reveal papilledema (but can be normal during the first few days after onset of illness)
• DDX:
  • – Pseudotumor cerebri
    
  • – Tension headache
    
  • – Migraine
    
  • – Cluster headache
    
  • – Meningitis
    
  • – Intracranial venous thrombosis
    
  • – Intracranial neoplasm
• Work-up:
  • – Urine B-HCG
    
  • – CBC with diff
    
  • – CT—head
    
  • – LP—opening pressure and CSF analysis
• Specialist:
  • Primary care provider (PCP)
  • Neurologist
  • Ophthalmologist
• Treatment:
  • Self Care
    • Weigth loss
  • Medication
    • Diuretics
      • Acetozolamide
      • Furosemide

Sinusitis

• Presentation:
  • frontal headache, fever, and nasal discharge.
  • pain on palpation of the frontal and maxillary sinuses.
  • history of sinusitis.
  • – Recent upper respiratory infection
    
  • – Pain in cheek below eye
    
  • – Dull, constant ache, worse leaning over
    
  • – Nasal discharge and stuffiness
    
  • – Rare cause of headache (w/o other symptoms)
    
• Physical Exam:
  
  • – Tenderness to palpation of maxillary sinus
    
  • – No weakness in extremities
• DDX:
  • – Sinusitis
    
  • – Migraine
    
  • – Tension headache
    
  • – Meningitis
    
  • – Intracranial neoplasm
• Work-up:
  • – CBC with diff
    
  • – XR—sinus
    
  • – CT—sinus
    
  • – LP
• Treatment:
  • Self Care
    • Nasal washing
  • Medication
    • Decongestant – Xylomethazoline, Phenylephrine, Oxymethazoline, Pseudoephedrine
    • Penicillin antibiotic – amoxicillin, amox/clav
    • Antibiotics – Clarithromycin, Ciprofloxacin, Erithromycin, Azithromycin, Ceftriaxone, Moxifloxacin
    • Steroid – Nasonex (mometasone) 
    • Cough medicine – Guaifenesin
    • Antihistamine – Loratadine
    • NSAID – Ibuprophen
    • Analgesic – Acetominophen

Subarachnoid Bleed/Hemorrhage

• Presentation:
  • – sudden severe headache, vomiting, confusion, hemiplegia, and nuchal rigidity.
  • – Headache
    
  • – Syncope
    
  • – Very severe intensity
    
  • – First episode
    
  • – Vomiting
• Physical Exam:
  • – Mental status change
  • – Stiff neck
• DDX:
  • – Subarachnoid hemorrhage
  • – Migraine
  • – Meningitis/Encephalitis
  • – Intracranial hemorrhage
  • – Vertebral artery dissection
  • – Intracranial venous thrombosis
  • – Acute hypertension
  • – Intracranial neoplasm
• Work-up:
  • – Noncontrast CT – head
  • – LP
  • – CBC with diff
  • – PT/PTT/INR
  • – MRI/MRA of brain
• Treatment:
  • Supportive Care
    • IV fluids
  • Endovascular coiling and Clipping
  • Medication
    • Antihypertensive drug – Nimodipine, Nicardipine
    • Diuretic – Furosemide, Mannitol
    • Anticonvulsant – Levetiracetam, Phenytoin
  • Surgery
    • Ventriculostomy and Craniotomy

Subdural Hematoma

• Presentation:
  • – History of Trauma
    
  • – On warfarin
    
  • – Headache
    
• Physical Exam
  • – Mental status changes
    
  • – Ataxia
    
  • – Focal weakness
    
  • – Visual Changes
• Specialist:
  • Neurosurgeon, Critical care doctor, and Neurologist
• Treatment:
  • Anticonvulsant – Levetiracetam
  • Procedure – Surgical drain
  • Surgery
    • Craniotomy and Decompressive craniectomy

Trigeminal Neuralgia (TN) (aka tic douloureux)

• Presentation:
  • – Pain accompanied by brief facial spasm or tic
    
  • – Pain distribution unilateral, follows branch of CN V (maxillary (V2) or mandibular (V3)) sensory distribution
    
  • – P/E eliminates alternative diagnoses
• DDX:
  • – Trigeminal neuralgia
    
  • – Tension headache
    
  • – Migraine
    
  • – Cluster headache
    
  • – TMJ dysfunction
    
  • – Intracranial neoplasm
• Work-up:
  • – CBC with diff, ESR
    – MRI—brain
• Specialist: – PCP, Pain management, Neurologist
• Treatment:
  • Anticonvulsant
    • Carbamazepine
    • Oxcarbazepine