mastering the headache history · 2018. 4. 4. · mastering the headache history rebecca erwin...

Mastering the Headache HistoryRebecca Erwin Wells, MD, MPH

Assistant Professor, Neurology

Associate Director-Clinical Research, Center for Integrative Medicine

Wake Forest Baptist Medical Center

rewells@wakehealth.edu

Wake Forest Baptist Medical Center

rewells@wakehealth.edu

@RebeccaWellsMD

Disclosures

• No disclosures

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Objectives• Identify headache red flags to differentiate primary

from secondary headaches

• Apply the 5 key histories important for headache

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• Apply the 5 key histories important for headache

• Recognize important nuances in a headache history

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Primary or Secondary?

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Primary Headaches

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SNOOP4 Red Flags• Systemic symptoms

• Neurologic symptoms/signs

• Onset sudden

• Older age of onset (>50)

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• Older age of onset (>50)

• Postural aggravation

• Precipitated by valsalva

• Pregnancy

• ProgressiveDodick, Semin Neurol 2010.

5 Key Histories

• Life History

• Attack History

• Medical History: Comorbidities

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• Medical History: Comorbidities

• Medication History

• Family History

Kathleen Digre, MD

Life History• Age of 1st Headache Ever

• Childhood episodic syndromes

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• When worse/better

• Pregnancy, children, high school, college

• Menarche, menopause, menses

• Changed over time?

What if our 19 yo patient told you..

Prior history of HA NO prior history of HA

Versus

• As a child, frequent headaches

• Got worse as a young adolescent

• Then went away

• Until now…

Monthly HA History since 2004

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Attack History• New vs. old

• More than 1 type?

• Frequency (HA-free days?)

• Warning: aura vs. prodrome

• Location

• Quality

• Severity

• Duration• Warning: aura vs. prodrome

• Triggers

• Duration

• Timing

• Context

• Associated symptoms

• Ipsilateral autonomic

What if our patient told youHA wakes him from sleep:

Versus

• Awakens every day 2am

• Pain is unilateral, R eye

• Right eye lacrimation, injection

• Awakes with tongue biting,

incontinence

• Unexplained fever

Additional Tools

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Medical History

• HTN, HLD, DM

• Hypothyroidism

• Fibromyalgia

• Irritable bowel

• Depression

• Anxiety

• Bipolar

Medical Psych Chronic Pain

• Thyroid

• Sleep Apnea

• TMJ

• Head/neck trauma

• Menopause, PMS

• Endometriosis

• Chronic fatigue

• Interstitial cystitis

• Arthritis

• Uterine fibroids

• Bipolar

• Insomnia

• Abuse

Tietjen G, Headache 2007.

Ask directly about:• Caffeine

• Sleep; snoring

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• ER/urgent care visits

• Head/neck trauma

• Abuse

Medication History• Current, past, works

• Prescription, non-prescription

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• Prescription, non-prescription

• Drug abuse

Medications: Circle those you have been on

Family History

• Anyone with ““““headaches””””

• Pro-thrombotic conditions

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• Pro-thrombotic conditions

• Cerebral aneurysms

Nuances of Headache History• Open ended vs. directed

• Insightful questions

• Do, Fears, Impact, Goals

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• Compassion

• Initial visit, Follow-ups

• Use template

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Reversible Cerebral Vasoconstriction Syndrome (RCVS)

• Recurrent thunderclap headaches

• Segmental constriction-cerebral arteries, reversible

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• Normal CSF protein

• Must rule out other causes

• Consider Precipitants

• Postpartum, vasoactive drugs, catecholamine tumorsDucros A, Lancet Neurology 2012.

Final Tips and Pearls• Approach: primary vs. secondary

• Life, attack, medical, meds, family histories

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• Recognize nuances

• Refractory? Return to the history

• Use template

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