4 - Case Study 1 · Dodick DW. Adv Stud Med . 2003;3:550–555. Pitfalls in This Case • Remember SNOOP 4: –Systemic features oGeneralized weakness oFatigue oNausea –Change in

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Case Study 1 and Q & AContent developed by:

Lawrence C. Newman, MD, FAHS

Donna Gutterman, PharmD

Faculty Disclosures

LAWRENCE C. NEWMAN, MD, FAHS

Dr. Newman has received consulting fees and/or honoraria from Allergan, Inc., Labrys Biologics, NuPathe, and Zogenix. Dr. Newman

is on the speaker bureaus for Allergan, Inc. and Zogenix.

DONNA GUTTERMAN, PHARMD

Dr. Gutterman has received consulting fees and/or honoraria from

NuPathe, Teva Pharmaceuticals, Dr. Reddy Pharmaceuticals.

Learning Objectives

At the conclusion of this talk, participants will be able to:

1. Screen for secondary headache disorders using the SNOOP4 paradigm

2. Evaluate the need for ancillary testing in patients presenting with headache

3. Order and analyze appropriate test results in

patients in whom headache patterns have changed

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Terri, Age 30

15-year history of migraine without aura

Stress and changes in weather

are triggers

Typically associated with her

menstrual cycle

Daily headache

Increasing in frequency for the last 4 months

Terri Presents with…..

Headache Frequency: September–December

X

X X X

XX

X X

X

XX

X X

X X X

X X X

X X X

X X XX X X

X X X

XX X X

X X X X

September October

November December

X

X XX

X X X

XX XX

X

XX

X

X

X

X

X X X

X

XX

X

X

XX

XX

X

X

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What else would you like to know?

What Else Would You Like To Know?

Is this different than her prior attacks?

What Else Would You Like To Know?

• Pain is generalized, dull, and associated with nausea

• Awakens with headache every morning for past 2 months

• Only pain-free time was during a ski trip 2 weeks ago

• Medical and neurological exams (while pain-free) are normal

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What Else Would You Like To Know? cont.

Is this different than her prior attacks? Yes

Are there other features associated with

these “new” attacks. . .

Photo-, phono-, or osmophobia? No

Autonomic signs? No

Weakness, numbness, speech disturbances?

Generalized weakness

Systemic signs/symptoms? Fatigue

Symptoms of allodynia? Hurts to brush hair

Do the HAs remit spontaneously? “I don’t know; I always treat them”How does she treat the HA?

Sumatriptan 6 mg sc almost every morning for the past 2 months

Previously used OTC aspirin/acetaminophen/caffeine tablets

Next Steps?

Diagnose Chronic migraine with MOH*

Limit acute treatment Sumatriptan ≤2 days/week

Begin preventionTopiramate 25 mg hs and titrate up to 100 mg hs

Follow-up 1 month

*Medication Overuse Headache

1-Month Follow-Up

• No improvement

• Daily headache persists

• On days without sumatriptan notes that headache spontaneously remits while at work

• Fatigue, nausea, and weakness persist all day

• Exam still normal

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Terri’s Headache Diary

ARS Question

What is the most appropriate next step with this patient?

A. More history

B. Imaging

C. Blood work

D. All of the above

More History and Investigations

MRI with and without contrast

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MRI with and without contrast Normal



CBC / Routine Labs



CBC / Routine Labs Normal

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Sed rate




Sed rate 30 mm/hr




Sed rate 30 mm/hr

EKG

8




Sed rate 30 mm/hr

EKG Sinus tachycardia at 120 bpm




Sed rate 30 mm/hr


More history




Sed rate 30 mm/hr


More history Boyfriend, with whom she lives, has

same symptoms

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Sed rate 30 mm/hr



same symptoms

Consultation was called. . .with a plumber




Sed rate 30 mm/hr



same symptoms





Sed rate 30 mm/hr



same symptoms


Hot water heater has a leak

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Sed rate 30 mm/hr



same symptoms



Carboxyhemoglobin level




Sed rate 30 mm/hr



same symptoms



Carboxyhemoglobin level 10%

Carbon Monoxide Toxicity

• Carbon monoxide (CO) is a colorless, odorless gas

• CO binds to hemoglobin >200 times higher affinity than oxygen so even small

concentrations can result in significant levels of carboxyhemoglobin (HbCO)

Ernst A et al. NEJM. 1998;339:1603–1608.

• CO toxicity causes impaired cellular oxygen delivery and utilization

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CO Toxicity

• CO has its most profound impact on the organs with the highest oxygen requirement

• Brain

• Heart

• Kidney

• Headaches occur at levels around 10%

• Levels of 50–70% may cause:

– Seizure

– Coma

– Death

Ernst A et al. NEJM. 1998;339:1603–1608.

HbCO levels often

do not reflect the clinical picture

Symptoms of Acute CO Poisoning

Malaise, flulike symptoms,

fatigueAgitation

Dyspnea on exertion Nausea, vomiting, diarrhea

Chest pain, palpitations Abdominal pain

Lethargy Headache, drowsiness

Confusion Dizziness, weakness, confusion

Depression Visual disturbance, syncope, seizure

Impulsiveness Fecal and urinary incontinence

Distractibility Memory and gait disturbance

Hallucination, confabulation Bizarre neurologic symptoms, coma

Ernst A et al. NEJM. 1998;339:1603–1608.

Physical Findings of CO Poisoning

Heart • Tachycardia• Hypertension or hypotension

• Hyperthermia• Tachypnea

Skin • Classic cherry red skin is rare (ie, "When you're cherry red,

you're dead”)• Pallor is present more often

Eyes • Flame-shaped retinal hemorrhages• Bright red retinal veins (a sensitive early sign)

• Papilledema• Homonymous hemianopsia

Lungs • Noncardiogenic pulmonary edema

Neurologic /Psychiatric

• Memory disturbances (most common), including retrograde and anterograde amnesia with amnestic confabulatory

states• Emotional lability

• Stupor, coma, gait disturbance, movement disorders, rigidity

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Exclude Secondary Headache

History and examination

Assess for worrisome signs and symptoms Look for atypical features

SNOOP4

S Systemic symptoms (weakness, fatigue, nausea)

N Neurologic symptoms or signs

O Onset: abrupt, peak <1 min

O Older: >50 (GCA; glaucoma, cardiac cephalalgia)

P Previous headache history (symptoms changed over the past 4 months)

P Postural, positional

P Precipitated by Valsalva, exertion

P Papilledema (pulsatile tinnitus, diplopia, transient visual obscurations)

P Progressive (intractable)

Screen forRed Flags

Evaluate for Secondary HeadacheYes?

Dodick DW. Adv Stud Med. 2003;3:550–555.

Pitfalls in This Case

• Remember SNOOP4:

–Systemic features

o Generalized weakness

o Fatigue

o Nausea

–Change in headache pattern/history

• Don’t be fooled by response to treatment

• Medication overuse doesn’t always cause

Medication Overuse Headache

Lipton RB et al. Headache. 1997;37:392–395.

Documents

4 - Case Study 1 · Dodick DW. Adv Stud Med . 2003;3:550–555. Pitfalls in This Case • Remember SNOOP 4: –Systemic features oGeneralized weakness oFatigue oNausea –Change in