medicine 5th year, 1st lecture (dr. mohammed tahir)
DESCRIPTION
The lecture has been given on Feb. 26th, 2011 by Dr. Mohammed Tahir.TRANSCRIPT
Evaluation of HeadacheEvaluation of Headache
Dr. Mohammed Tahir Kurmanji Neurologist FICMS
University of SuleimaniaDepartment of Neurology
Pain Sensitivity of Cranial StructuresPain Sensitivity of Cranial Structures
Cranial venous sinuses with afferent veins
Arteries at base of brain and their major branches
Arteries of the dura Dura near base of brain and large
arteries Dural, Cranial and extracranial
nerves All extracranial structures
Brain parenchyma
Ependyma
Choroid
Pia
Arachnoid
Dura over convexity
Skull
Pain-Sensitive Pain-Insensitive
Overall ApproachOverall Approach
Chief Complaint: Headache
Headache AlarmsEvidence of serious headache disorder
by history or physical exam
Diagnosis ofPrimary Headache Disorder
Work-up to identify/exclude secondary headache etiology
Treat Primary Headache
NO YES
YES NO
Consider work-up for secondary headache
General Mechanisms of HeadacheGeneral Mechanisms of Headache
Traction on major intracranial vessels
Distention, dilation of intracranial arteries
Inflammation near pain sensitive structures
Direct pressure on cranial or cervical nerves
Sustained contraction of scalp or neck muscles
Stimulation from disease of eye, ear, nose and sinuses (referred pain)
EpidemiologyEpidemiology
60-75% of adults have at least one headache/year
5-10% will seek physician evaluation
Less than 10% of ED patients with chief complaint of headache will have emergent secondary cause
EpidemiologyEpidemiology
Tension Migraine Cold Stimulus Headache Cluster
69% 15%15%
0.1%
Primary Headache Lifetime Prevalence
Hangover Fever Metabolic disorder Disorders of nose/sinuses Head trauma Disorders of eyes Vascular disorders
72% 63%22%15%
4%3%1%
Secondary Headache
Headache in the EDHeadache in the ED
Tension Migraine Cluster
32 %22 %
< 1 %
Primary Headache
Subarachnoid Hemorrhage Meningitis Temporal Arteritis Subdural Hematoma CNS tumor Miscellaneous illness No specific diagnosis
< 1 %< 1 %< 1 %< 1 %
3 %33 %
7 %
3%
Secondary Headache
Leicht M, Ann Emerg Med 1980;9:404
Primary HeadachePrimary Headache
Migraine
TensionCluster
Tension HeadacheTension Headache
Duration 30 min to 7 days
Pain characteristics (at least 2) Pressing/tightening quality Mild to moderate severity Bilateral location No aggravation by routine physical activity
Associate symptoms (Must have both) No vomiting No more than one of: nausea, photophobia, phonophobia
H&P and diagnostic tests do not suggest underlying organic disease
International Headache Society Diagnostic Criteria
Migraine Without AuraMigraine Without Aura
At least 6 or more periodic attacks Duration
4-72 h if untreated or unsuccessfully treated Pain characteristics (at least 2)
Unilateral location Pulsating quality Moderate to severe intensity Aggravation by walking stairs or similar physical activity
Associated symptoms (at least 1) Nausea, vomiting, or both Photophobia or phonophobia
H&P and diagnostic tests do not suggest underlying organic disease
International Headache Society Diagnostic Criteria
Migraine With AuraMigraine With Aura
At least 3 periodic attacks
Aura characertistics (At least 3 )
One or more fully reversible aura symptoms indicating focal cerebral cortical or brain-stem dysfunction
At least 1 aura symptom develops gradually over >4 minutes or 2 or more symptoms occur in succession
No single aura symptom lasts > 60 minutes
Headache begins within 60 minutes of aura onset
History, physical, and diagnostic tests do not suggest underlying organic disease
International Headache Society Diagnostic Criteria
Cluster HeadacheCluster Headache
Duration 15 to 180 minutes untreated
Pain characteristics Severe unilateral orbital, supraorbital, or temporal pain
Associated symptoms (at least 1, ipsilateral to pain) Conjunctival injection, Lacrimation Nasal congestion, Rhinorrhea Forehead and facial swelling Miosis, Ptosis Eyelid Edema
Frequency: between 1 every other day to 8/day
International Headache Society Diagnostic Criteria
Secondary HeadacheSecondary Headache
Intracranial hemorrhage
– Subarachnoid Hemorrhage
– Intracerebral hemorrhage
– Subdural/epidural hematoma
Meningitis/encephalitis
Hypertensive encephalopathy Ischemic stroke Venous sinus thrombosis
Hypoxia, hypercarbia, carbon monoxide
Secondary HeadacheSecondary Headache
Temporal arteritis
Mass lesions
Tumor, abscess, arteriovenous malformation
Altitude sickness
Metabolic
Hypoglycemia, fever, hypothyroid, anemia
Glaucoma
Pseudotumor cerebri (benign intracranial hypertension)
Secondary HeadacheSecondary Headache
Trigeminal Neuralgia
Post-concussion syndrome
Sinusitis without complication
Post-lumbar puncture
Diet
Medications
Fatigue, postexertion, postcoital
Overall ApproachOverall Approach
Chief Complaint: Headache
Headache AlarmsEvidence of serious headache disorder
by history or physical exam
Diagnosis ofPrimary Headache Disorder
Work-up to identify/exclude secondary headache etiology
Treat Primary Headache
NO YES
YES NO
Consider work-up for secondary headache
HistoryHistory
Why did this headache bring you to the Emergency Department?
– First or Worst– Accompanied by new or frightening features– Last straw
How did this headache start?
Have you had previous similar headaches; if so when did this headache type start?
HistoryHistory
Where does it hurt?– Unilateral/bilateral– Frontal/occipital/facial
What is the character of the pain?– Pulsatile, steady, shocklike, tightness
What other symptoms do you experience? – Nausea, vomiting, LOC, flushing,
lacrimation, drop attack, neck stiffness, photophobia, dizziness
HistoryHistory
Precipitating/aggravating factors– Trauma, exertion, noise, position, foods, drugs,
weather, anxiety, menstration
Relieving factors– Darkroom, position, pressing on scalp, medication
Medical history– HIV, Cancer, HTN– Recent procedure (LP)– Change in medications
HistoryHistory
Family History– Migraine headaches, subarachnoid hemorrhage
Environment– Carbon monoxide
Physical ExamPhysical Exam
Vital signs– fever, hypertension, hypoxia
Head/face– trauma, bruits, tenderness
Eyes– conjunctiva, cornea, pupils,
fundi:papilledema Ears
– OM or hemotympanum Mouth
– Teeth, TMJ
Neck– pain/stiffness/tenderness– Carotid and/or vertebral
bruits Skin
– rash Neurologic
– Mental status– Pupils, EOM, Visual fields– Focal deficits– Horner's syndrome– Ataxia
Diagnostic AlarmsDiagnostic Alarms
Onset after age 50
Sudden onset
Increased frequency and severity
New onset with risk factors for HIV or cancer
Associated with systemic illness (HT,DM,fever, meningismus, rash)
Altered consciousness or focal neurologic deficits
Papilledema
Significant trauma
Overall ApproachOverall Approach
Chief Complaint: Headache
Headache AlarmsEvidence of serious headache disorder
by history or physical exam
Diagnosis ofPrimary Headache Disorder
Work-up to identify/exclude secondary headache etiology
Treat Primary Headache
NO YES
YES NO
Consider work-up for secondary headache
ED Treatment of Primary HeadacheED Treatment of Primary Headache
Tension Oral Analgesics (NSAIDS, Acetaminophen)
Migraine Serotonin agonists
ie, Sumitriptan 50 mg PO or 6.0 mg SQ Narcotics IV or IM
Cluster 100% oxygen Intranasal lidocaine ? NSAIDS Migraine specific therapies
Prophylaxis Treatment of Primary Prophylaxis Treatment of Primary HeadacheHeadache
Tension Reassurance Antidepressant &/or Anxiolytic drugs (Tricyclic antidepressant or/& SSRI)
Migraine Betablockers: Proponolol Ca channel blocker: Verapamile Antidepressant: (Tricyclic antidepressant or/& SSRI) Anticonvulsant: Na valproate, topiramate, Methysergid. Pizotifine.
Cluster Steroid Lithium carbonate Verapamile
Overall ApproachOverall Approach
Chief Complaint: Headache
Headache AlarmsEvidence of serious headache disorder
by history or physical exam
Diagnosis ofPrimary Headache Disorder
Work-up to identify/exclude secondary headache etiology
Treat Primary Headache
NO YES
YES NO
Consider work-up for secondary headache
Diagnostic StudiesDiagnostic Studies
Computerized tomography
– Hemorrhage, tumor, abscess, AVM
Lumbar puncture
– Hemorrhage, infection, increased CSF pressure
Limited indications for MRI, MRA, or Angiography
Laboratory studies based on suspected etiologies
– ESR: Temporal arteritis
– Carboxyhemoglobin: Carbon monoxide
Subarachnoid HemorrhageSubarachnoid Hemorrhage
Approximately 50% of have "sentinal bleed" 50% with "sentinal bleed" will rebleed within 2-6 wks Rebleed
– 50% mortality– > 50% of survivors have significant neurologic deficits
Head CT negative in 1-10% of cases– Sensitivity decreases with time from onset of sx
LP if head CT negative (RBC's 3 hrs, xanthochromia 12 hrs) Angiography if postive CT or LP
Temporal ArteritisTemporal Arteritis
Rare before age 50 Temporal artery tenderness, swelling, redness, nodularity Visual disturbance
– Visual loss in 7-60% if untreated Jaw claudication Systemic symptoms
– fever, wt loss, anorexia, malaise Polymyalgia rheumatica (prox muscle pain/tend./stiffness) ESR usually > 50 (mm/hr) Temporal artery biopsy
– multinucleated giant cells / inflammation Therapy: High dose steroids
Overall ApproachOverall Approach
Chief Complaint: Headache
Headache AlarmsEvidence of serious headache disorder
by history or physical exam
Diagnosis ofPrimary Headache Disorder
Work-up to identify/exclude secondary headache etiology
Treat Primary Headache
NO YES
YES NO
Consider work-up for secondary headache