mastering the headache history · 2018. 4. 4. · mastering the headache history rebecca erwin...
TRANSCRIPT
Mastering the Headache HistoryRebecca Erwin Wells, MD, MPH
Assistant Professor, Neurology
Associate Director-Clinical Research, Center for Integrative Medicine
Wake Forest Baptist Medical Center
Wake Forest Baptist Medical Center
@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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