Headache Shalin

8/3/2019 Headache Shalin

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Acute Headache

An Overview

DR SHALIN SHAH MD, DM Neurology

SGPGI, Lucknow


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Most of the time he seemed to see something shiningbefore him like a light, usually in part of the right

eye; at the end of a moment, a violent pain

supervened in the right temple, then all of the head

and neck, where the head is attached to thespinevomiting, when it became possible, was able

to divert the pain and render it more moderate.

Hippocrates


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The Burden of Headache

4% of visits to the physicians office

1-2% of visits to the emergency department

Lifetime prevalence for any type of headache >90% for men & 95% for women

Most have primary headache disorders

In patients with the worst ever headache oftheir life, and normal neurological exam, 12%

will have SAH


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Working classification of headache

Primary Headache

Migraine (10% prevalence)

Tension-type headache(30-80% prevalence)

(CTH-2%)

Cluster headaches

Secondary Headache


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Secondary headache disorders

Vascular Disorder - Stroke, SAH

Tumour

Trauma

Infection

Temporal arteritis

Ophthalmological (glucoma) and ENT causes. Systemic disorders- thyroid disease, HT,

pheochromocytoma


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Danger signals

First or worst headaches

Headache on exertion, early morning, ornocturnal

Progressive headache

New onset headache in adult >50 years old

Abnormal physical or neurological findings(fever, stiff neck)


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History

Onset /Duration/Progress

Age of onset > 50 years

Headache characteristics Precipitating/Reliving factors

Quality

Region

Severity (0-10)

Timing

Past history of headaches first, worst, different, progressive, persistent


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History

Associated Symptoms Fever/Chills/Nightsweats

Nausea/Vomiting Photophobia & Phonophobia

Neck pain or stiffness

Alterations in level of consciousness

Focal neurologic symptoms

Family History


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Physical Examination

General ExamVital Signs / HEENT (Trauma, dentition,

sinus/temples)

Neck /Skin /Lymph Nodes

Neurologic Exam Mental Status: LOC, Orientation,Language,mood

Cranial Nerves-Fundus, EOM, V,VII Motor / Sensory/ Reflex/Gait


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Subhyaloid hemorrhage


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Laboratory Studies

Blood CBC

Chemistry panel ESR

PT/PTT (Consider hypercoagulable profile)

TSH

ABG (if clinically indicated)

Drug screen

Urinalysis


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Imaging

X-rays

CXR

Cervical Spine X-ray

Cranial computed tomography (CT) preferred initial imaging study for acute headache

Cranial magnetic resonance imaging (MRI)

Magnetic resonance angiography (MRA) Cerebral angiography


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Indications for neuroimaging

First or worst headache

Progressive or CDH

Side-locked headache

Headaches not responding to treatment

New onset headache in patients with cancer,

HIV infection, or age >50 yrs Associated fever, stiff neck, neurological

deficits


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CT Vs MRI

Preferred in

SAH

ICH

Posterior fossa lesions

CVT

SDH, EDH

Meningeal disease

Cerebritis and abscess

Pituitary pathology


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Imaging in pts with headache and

normal neurological exam

Benefits- CT MRI

Migraine 0.3% 0.4%

Any HA 2.4% 2.4%

Relief of anxiety 30%

Harms-iodine reaction

Mild 10%

Death 0.002% Claustrophobia

CostFrishberg 1994


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Probability of detection of SAH

on CT after the initial event Day 0 95%

Day 3 75%

1 week 50% 2 weeks 30%

3 weeks almost 0%

Evans RW 1999


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Other Studies

Lumbar puncture (LP)

indicated if acute or chronic meningitis, SAH,

pseudotumor cerebri (IIT) or low CSF pressureheadache suspected

preferable to perform CT before LP

Electroencephalogram (EEG)indicated if seizures are suspect


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Angiography

In proven SAH- 4 vessel angio(DSA)to identify source and r/o multipleaneurysms

Initial arteriogram negative in upto16% of SAH

MRA detects 90% of saccularaneurysms of >5mm

Spiral CT angio detects 85% ofsaccular aneurysms


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Differential Diagnosis

Primary headache

Migraine

Tension-type headache

Cluster headache

Indomethacin-responsive headache syndromes

Secondary headache


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Migraine Headache

IHS Classification Migraine without aura (common migraine)

Migraine with aura (classic migraine)

Migraine with typical aura Migraine with prolonged aura

Familial hemiplegic migraine

Basilar migraine

Migraine aura w/o headache

Migraine with acute onset aura

Opthalmoplegic migraine

Retinal migraine


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Acute Treatment

Mild - NSAID+Anti emetic

ModerateNSAID/Ergot/Triptan-

Sumatriptan/Rizatriptan + Anti emetic

SevereErgot +Antiemetic (rectal),

Sumatriptan-nasal/Subcu ,Rizatriptan oral

Very severe- Ketorolac IM /DHE IV

+Antiemetics, Opiods


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Preventive Treatment

Proven or well accepted

B Blockers-Propanolol, metoprolol

Amitryptyline / Divalproex / Flunarizine /Methysergide.

Widely used with poor evidence

Verapamil/SSRIPromising

Topiramate/Gabapentin


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Tension-type headache

IHS Classification Episodic Tension-type headache

Chronic (Daily) Tension-typeheadache


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Cluster Headache

IHS Classification 5 or more attacks with the following:

Severe unilateral supraorbital or temporal pain lasting 15-180minutes, pain has boring quality

One of the following ipsilateral autonomic signs conjunctival injection

eyelid edema

tearing

nasal congestion/rhinorrhea

forehead/facial sweating

miosis or ptosis

Frequency of attacks qod to 8x/day, occur atsimilar time of day and often awaken pt from

sleep


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Indomethacin-Responsive

Headache Syndromes Paroxymal Hemicrania

Onset second-third decade

Females > males (3:1) Unilateral orbit or occipital pain

20 minute attacks, 5 attacks/day on average

Hemicrania Continua Prolonged unilateral headache lasting days-weeks


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Secondary Headache DDx

Subarachnoid Hemorrhage (SAH)

first or worst headache

Chance of misdiagnose in SAH high

pts with the greatest potential tx benefits are most

often misdiagnosed

early complications develop in patients with an

incorrect dx

Meningitis

associated with fever, neck stiffness, confusion


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Subdural hematoma

recent trauma (+/-)

Stroke (Ischemic or Hemorrhagic)

occurs with focal neurologic sx

Cervicocephalic arterial dissection

trauma hx (+/-), neck pain, ipsilateral Horners

Giant cell arteritis

> 50 yrs, visual loss, temporal pain, ESR


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Cerebral venous thrombosis

diffuse headache from increased ICP, may see sz orfocal neurologic symptoms

Idiopathic intracranial hypertension young obese women, blindness may develop

Unruptured vascular malformation (AVM)

can result in migraine like headaches

Cerebral tumors/abscesses

progressive headache over weeks to months


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Dental: abscesses/TMJ oral or jaw pain initially

Sinusitis overdiagnosed, dx more likely with fever/purulent nasal discharge

Trigeminal neuralgia sharp unilateral pain usually over maxillary distribution

Low CSF pressure headache sx resolve in supine position and recur when upright

Acute Glaucoma periorbital pain, conjuntival injection, lens clouding


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Case Study #1

28 year-old female presents with acute headachesince 4 days and one episode of confusional state2days back.On examination no focaldeficit.History of episodic headaches that occur

four to five times a month since 4 years. Havesince increased in severity. The headache itself inusually on the left side, throbbing in nature andsevere. It lasts 4-6 hours.

CT Brain /CSF done. Persistent headache.Next day MR angio done


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Case Study #2

42 year-old femalepresented with history of acute very

severe headache since 2 days. Associated with nausea and

photo/phonophobia.No significant past history.Physical

examination including fundus normal.

Patient CT Brain was done. Treated with analgesics,beta

blockers and flunarizine.No response. Was given

suatriptan nasal spray. Patient felt better for 24

hours.Again patient had severe headache.


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Case Study #3

78 year-old female presented with acute right frontal-

temporal headaches associated with nausea and vomiting.

H/O similar headache 4 months back for 1 day.

She was HT with h/o CV stroke 2 years back.

Neurologic examination normal except bilateral

diminished vision due to mature cataract.


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Thank You

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Headache Shalin