Headache – nanoxia ncore

Contents

• 1 more specific terms

• 2 classification

• 3 etiology

• 4 epidemiology

• 5 history

• 6 physical-examination

• 7 clinical-manifestations

• 8 radiology

• 9 complications

• 10 management

• 11 more general terms

• 12 additional terms

• 13 references

More specific terms

• chronic daily headache

• cold-stimulus headache (brain freeze)

• cough headache

• drug-induced headache

• migraine headache

• nummular headache; coin-shaped cephalgia

• orthostatic headache

• post-traumatic headache

• postural headache

• tension headache (stress headache)

• thunderclap headache

• trigeminal autonomic cephalgia

Classification

• primary headache

• migraine headache

• tension headache

• trigeminal autonomic cephalgia

• cluster headache, paroxysmal hemicrania, SUNCT syndrome

nanoxia ncore retro

• primary stabbing, cough, exertion, sexual headaches

• external pressure headache

• thunderclap headache

• hemicrania continua

• hypnic headache

• nummular headache

• new daily persistent headache

• secondary headache

• headache associated with head trauma or neck trauma

• headache associated with vascular disorders

• headache associated with non-vascular intracranial disorder

• headache associated with toxins, drugs or withdrawal

• headache associated with infection

• headache associated with disorder of homeostasis

• headache or facial pain associated with extracranial head neck structures

• headache associated with psychiatric disorder

• cranial neuralgias: trigeminal neuralgia

• unclassified headache

• international headache society

nanoxia ncore retro

Etiology

• primary headache

• migraine headache

• tension headache

• trigeminal autonomic cephalgia

• cluster headache, paroxysmal hemicrania, SUNCT syndrome

• primary stabbing, cough, exertion, sexual headaches

• external pressure headache

• thunderclap headache

• hemicrania continua

• hypnic headache

• nummular headache

• new daily persistent headache

• also see chronic daily headache

• secondary headache

• head trauma or neck trauma

• postconcussion syndrome, subdural hematoma

• whiplash injury

• vascular disorders

• stroke, subarachnoid hemorrhage, arterial dissection

• vascular malformation, cerebral aneurysm

• arteritis, intracranial or extracranial, temporal arteritis

• venous thrombosis, dural sinus thrombosis, cavernous sinus thrombosis

nanoxia ncore retro

• non-vascular intracranial disorders

• intracranial hypertension, intracranial hypotension

• brain neoplasm or other CNS mass lesion, arachnoid cyst

• non- infectious inflammatory disorder, sarcoidosis

• chiari malformation

• toxins, drugs or withdrawal

• nitrates, alcohol, caffeine

• carbon monoxide

• heavy metals: lead, cadmium?

• mushrooms

• monosodium glutamate ( MSG)

• ergotamine ( withdrawal)

• hydralazine

• indomethacin

• numerous others (see pharmaceutical agents associated with headache)

• analgesic rebound headache

• infections

• meningitis, encephalitis, cerebral abscess

• extracranial infections

• opportunistic infections

• cryptococcal meningitis

• progressive multifocal leukoencephalopathy ( PML)

• generalized sepsis

nanoxia ncore retro

• disorder of homeostasis

• hypercapnia, hypoxia, dialysis,

• hypertensive crisis, malignant hypertension

• endocrinopathy: hypothyroidism, pheochromocytoma

• hyponatremia, uremia, hyperglycemia/ hypoglycemia

• headache or facial pain associated with extracranial head neck structures

• sinusitis

• eye pain: acute angle closure glaucoma

• cutaneous allodynia

• psychiatric disorders

• depression, anxiety disorder

• cranial neuralgias

• trigeminal neuralgia

• facial neuralgias

• occipital neuralgia

• environmental factors

• video display terminal (eyestrain)

• cold exposure ( brain freeze)

• altitude ( acute mountain sickness)

• lumbar puncture

• psychosocial stress

• purely psychogenic headaches are rare

• anorexia

nanoxia ncore retro

• acute exertional headaches

• coughing; b) sneezing; c) straining; d) running; e) orgasm

• obstructive sleep apnea (morning headaches)

• also see etiology of headache not apparent on noncontrast CT

Epidemiology

• 93% of the population reports headache within the last 12 months

• 42,000,000 patient visits/year occur with headache as a chief complaint

• in children, occurs most frequently at age 13; 10% of children have recurring headaches [4]

History

• pulsating?

• without medications, duration 4-72 hours?

• unilateral?

• nausea?

• disturbance of daily activities?

• POUNDING ( pulsatile, one day, unilateral, nausea, disturbing)

• 3/5 positive responses suggests migraine

Physical-examination

• sensorimotor testing

nanoxia ncore retro

• reflex testing

• cranial nerve assessment

• assessment of eye movements

• cognitive assessment

• fundoscopy

• visual field examination [3]

Clinical-manifestations

• WARNING signs in patients with headaches

• headache during exertion or straining

• berry aneurysm

• increased intracranial pressure

• headache with fever

• meningitis

• encephalitis

• headache with nuchal rigidity

• meningitis

• encephalitis

• headache with drowsiness confusion

• increased intracranial pressure

• meningitis

• encephalitis

• metabolic

• headache with abnormal physical exam ( pupil size, facial asymmetry, extraocular muscle abnormalities, abnormal fundoscopic exam, abnormal reflexes)

• subdural hematoma

• headache in a patient who looks ill

nanoxia ncore retro

• new WARNING signs from MKSAP17 [3]

• first or worst headache [3]

• abrupt-onset or thunderclap headache

• progression or change in headache pattern

• neurologic symptoms lasting 1 hour

• new headache in a patient 50 years

• new headache in pregnant women, cancer patients or immunocompromised patients

Radiology

• routine imaging in patients without WARNING signs* not indicated [3,14]

• if neuroimaging is needed, magnetic resonance imaging is preferred modality [12]

• reserve computed tomography for emergency situations

• * see clinical manifestations

Complications

• chronic headache /or migraine associated with risk of suicide ( hazzard ratio = 1.5-1.6) [9]

Management

• see specific type

• nsaids generally more effective than tricyclic antidepressants for tension headache

nanoxia ncore retro

• tricyclic antidepressants more useful than SSRI in patients with migraine or tension headaches [10]

• for chronic daily headache with characteristics of both tension headache migraine, gabapentin (up to 2400 mg QD) may be useful [5]

• acupuncture may be of benefit for chronic headache [6]

• mirtazapine may be useful chronic tension headaches in patients without depression [7]

• do not use bultalbital-containing analgesics ( fioricet) or opiates as 1st line therapy for recurrent headache [3,12]

• opiates* may be useful for chronic headaches [7]

• limit OTC analgesic use to 2 days/week [12]

• * structured, monitored program

More general terms

• pain [odyn-]

Additional terms

• etiology of headache not apparent on noncontrast CT

nanoxia ncore retro

• pharmaceutical agents associated with headache

References

• harrison’s principles of internal medicine, 13th ed. Companion handbook, isselbacher et al (eds), mcgraw-hill inc. NY, 1995, pg 829-39

• saunders manual of medical practice, rakel (ed), WB saunders, philadelphia, 1996, pg 1028-31

• medical knowledge self assessment program (MKSAP) 11, 16, 17. American college of physicians, philadelphia 1998, 2012, 2015

• journal watch 21(13):104, 2001 fearon P hotopf H relation between headache in childhood and physical and psychiatric symptoms in adulthood: national birth cohort study. BMJ 322:1145, 2001 PMID: [1]

• journal watch 24(3):23, 2004 spira PJ et al gabapentin in the prophylaxis of chronic daily headache: a randomized, placebo-controlled study.Nanoxia ncore retro neurology 61:1753, 2003 PMID: dopt=abstract

– silberstein SD, neurology 61:1637, 2003

• journal watch 24(11):91, 2004 vickers AJ, rees RW, zollman CE, mccarney R, smith CM, ellis N, fisher P, van haselen R. Acupuncture for chronic headache in primary care: large, pragmatic, randomised trial. BMJ. 2004 mar 27;328(7442):744. Epub 2004 mar 15. PMID: [2] [3]

• journal watch 24(14):116, 2004 bendtsen L, jensen R. Mirtazapine is effective in the prophylactic treatment of chronic tension-type headache. Neurology. 2004 may 25;62(10):1706-11. PMID: [4]

– saper JR, lake AE 3rd, hamel RL, lutz TE, branca B, sims DB, kroll MM. Daily scheduled opioids for intractable head pain: long-term observations of a treatment program.Nanoxia ncore retro neurology. 2004 may 25;62(10):1687-94. PMID: [5]

• bigal ME, ashina S, burstein R, reed ML, buse D, serrano D, lipton RB; AMPP group. Prevalence and characteristics of allodynia in headache sufferers: a population study. Neurology. 2008 apr 22;70(17):1525-33. PMID: [6]

• veterans administration memorandum dec 24, 2009 recent VHA findings regarding chronic pain conditions and suicide risk

• jackson JL et al. Tricyclic antidepressants and headaches: systematic review and meta-analysis. BMJ 2010 oct 20; 341:c5222 PMID: [7] [8]

• de luca GC, bartleson JD. When and how to investigate the patient with headache. Semin neurol. 2010 apr;30(2):131-44 PMID: [9]

• choosing wisely: american headache society five things physicians and patients should question [10]

nanoxia ncore retro

• torelli P, allais G, manzoni GC. Clinical review of headache in pregnancy. Neurol sci. 2010 jun;31 suppl 1:S55-8. PMID: [11]

• callaghan BC et al. Headaches and neuroimaging: high utilization and costs despite guidelines. JAMA intern med 2014 mar 17 PMID: [12]

• martin VT the diagnostic evaluation of secondary headache disorders. Headache. 2011 feb;51(2):346-52. PMID: [13]

– dodick DW pearls: headache. Semin neurol. 2010 feb;30(1):74-81 PMID: [14]

• loder E, weizenbaum E, frishberg B et al choosing wisely in headache medicine: the american headache society’s list of five things physicians and patients should question. Headache. 2013 nov-dec;53(10):1651-9 PMID: [15]

• nagy AJ, gandhi S, bhola R, goadsby PJ.Nanoxia ncore retro intravenous dihydroergotamine for inpatient management of refractory primary headaches. Neurology. 2011 nov 15;77(20):1827-32. PMID: [16]

• NIH institute center resources [17]

– NINDS headache information page [18]

• national guideline clearinghouse

– headache. (american college of radiology) ngc-guideline: [19]

– headache — child. American college of radiology ngc-guideline: [20]

– diagnosis and treatment of headache. Institute for clinical systems improvement ngc-guideline: [21]

– diagnosis and management of headache singapore ministry of health ngc-guideline: [22]

– clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache american college of emergency physicians ngc-guideline: [23]

nanoxia ncore retro

– diagnosis and management of headache in adults. A national clinical guideline. Scottish intercollegiate guidelines network ngc-guideline: [24]

– headache – child. (american college of radiology) ngc-guideline: [25]

– headaches: diagnosis and management of headaches in young people and adults. National institute for health and clinical excellence (NICE) ngc-guideline: [26]

Headache