Headache

  1. Given a patient with a new-onset headache, differentiate benign from serious pathology through history and physical examination.
  2. Given a patient with worrisome headache suggestive of serious pathology (e.g., meningitis, tumour, temporal arteritis, subarachnoid bleed):
    1. Do the appropriate work-up (e.g., biopsy, computed tomography [CT], lumbar puncture [LP], erythrocyte sedimentation rate).
    2. Make the diagnosis.
    3. Begin timely appropriate treatment (i.e., treat before a diagnosis of temporal arteritis or meningitis is confirmed).
    4. Do not assume that relief of symptoms with treatment excludes serious pathology.
  3. Given a patient with a history of chronic and/or relapsing headache (e.g., tension, migraine, cluster, narcotic-induced, medication-induced), treat appropriately, and avoid narcotic, barbiturate dependence.
  4. In a patient with a history of suspected subarachnoid bleed and a negative CT scan, do a lumbar puncture.
  5. In a patient suffering from acute migraine headache:
    1. Treat the episode.
    2. Assess the ongoing treatment plan. (referral when necessary, take a stepwise approach).

Red Flags

  • Systemic - fever, weight loss, HTN, myalgias, scalp tenderness
  • Neuro - confusion, decreased LOC, papilledema, visual field defect, CN asymmetry, extremity drift/weakness, reflex asymmetry, seizure
  • Onset - Sudden
  • Older - New onset or progressive >50yo
  • Previous/Pattern - Different or new
  • Secondary risk factors- HIV, malignancy, precipitated by valsalva (cough, sneeze), trauma, early morning/nocturnal

Differential

  • Primary:
    • Migraine
      • 4-72h (untreated)
      • 2 of unilateral, pulsatile, moderate-severe pain, worse with or avoid routine physical activity
      • 1 of nausea/vomiting, photo/phonophobia
    • Tension
      • 2 of Bilateral, non-pulsating (pressing), mild-moderate intensity, not worse with or avoid routine physical activity
      • No N/V, no more than one of photo/phonophobia
    • Cluster
      • Severe unilateral orbital, supraorbital and/or temporal pain, 15-180mins (untreated)
      • One symptom/sign ipsilateral (Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, sweating, flushing, ear fullness, miosis, ptosis)
      • Sense of restlessness or agitation
    • If ≥15d/mo for ≥3mo
      • Chronic migraine
      • Chronic tension
      • Medication overuse headache (usually present on wakening)
        • ≥15d/mo simple analgesics (acetaminophen, aspirin, NSAID)
        • ≥10d/mo ergotamine, triptan, opioids
      • Hemicrania continua
        • Strictly unilateral, persistent with exacerbations, cranial autonomic symptoms, restlessness, responsive to indomethacin
      • New daily persistent headache
        • Abrupt onset, daily, unremitting from onset (or within 3d of onset) typically in patients without history of headache
  • Secondary:
    • Infection: Meningitis, sinus, mastoid, dental
    • Hypertension: Preeclampsia
    • Systemic illness
      • Carbon monoxide
  • Intracranial:
    • Vascular: Subarachnoid hemorrhage (thunderclap), Temporal arteritis, Venous Sinus Thrombosis, SDH (worsening over time), Cervical artery dissection (TIA/neuro deficit in young)
    • Nonvascular: Increased/decreased (eg. CSF leak) ICP, Tumor, Chiari malformation (Valsalva)
  • Extracranial:
    • Eye disorder (refractory errors, glaucoma), Carotid dissection, TMJ

Physical Exam

  • Vitals including BP
  • Neurological exam
    • Mental status
    • Cranial nerve (including fundoscopy)
    • Unilateral limb weakness, reflex asymmetry, coordination in arms
    • Gait, heel-toe walking
  • Consider neck and oropharynx exam

Investigation

  • Neuro exam, fundoscopy r/o increased ICP
  • CT if red flags or risk of intracranial pathology
  • Lumbar puncture if symptoms of secondary cause
      • Valsalva/exercise, systemic illness (fever/rash/neck stiffness/meningismus), neuro sign (papilledema/seizure)
  • Consider ESR/CRP if suspect temporal arteritis
  • Consider CT/LP to rule out subarachnoid hemorrhage (SAH)
    • Ottawa SAH Rule (100% sensitive, 15% specific - if negative helpful to rule out, excluded neuro deficits, brain tumors, chronic recurrent headache)
      • Age≥40, Neck Pain/Stiffness, LOC, Onset during Exertion, Thunderclap, Limited Neck Flexion on exam
    • CT (diagnosis 90% SAH within 24h)
      • Lumbar Puncture (If negative CT)
        • Elevated opening pressure, elevated RBC count that does not significantly diminish, Xanthochromia (hemoglobin degradation if blood in CSF >2h)
        • If diagnosed SAH, proceed to angiography to rule out aneurysmal

Treatment

  • Keep headache diary, record frequency, intensity, triggers, medication
  • Lifestyle changes
    • Reduce caffeine
    • Regular aerobic exercise
    • Avoid irregular/inadequate sleep or meals
    • Avoid triggers
    • Fluids
  • Stress management
    • Relaxation training
    • CBT
    • Pacing activity
    • Biofeedback therapy
  • Acupuncture
  • Transcutaneous electrical nerve stimulation

Migraine

  • Ibuprofen 400mg, ASA 1000mg, Naproxen 500mg, Acetaminophen 1000mg
  • Second Line: Triptans (eg. Sumatriptan 100mg PO)
    • Sumatriptan 6mg subcutaneous if vomiting or resistant to oral triptans
    • Contraindicated in CV diseases, pregnancy, ergots
  • Prophylaxis if 4+/month, or >12h, or increased in frequency or rebound (trial of at least 2 months needed, treat for 6-12 months then taper to reassess need)
    • Betablocker (Propranolol, Metoprolol, Timolol), Antidepressants (Amitriptyline, Venlafaxine), Anticonvulsants (Valproate, Topiramate)
    • Less evidence:
      • Calcium channel blockers (Verapamil)
      • Melatonin 3mg (as effective as amitriptyline in one RCT)
      • Riboflavin (Vit B2) 400mg/d after three months
  • ER IV cocktail: 1L bolus NS, Prochlorperazine 10mg, Diphenhydramine 25mg , Ketorolac 30mg, Dexamethasone 10mg

Tension-type

  • Ibuprofen 400mg, ASA 1000mg, Naproxen 500mg, Acetaminophen 1000mg
  • Prophylactic: TCA (Amitriptyline, Nortriptyline)

Cluster

  • 100% oxygen 12L/min x 15 mins through non-rebreather mask
  • Sumatriptan 6mg subcutaneous, Zolmitriptan 5mg intranasal
    • Triptans contraindicated in Cardio/Cerebrovascular disorders
  • Bridge with Corticosteroids (prednisone), Ergotamine, Occipital nerve block
  • Prophylactic Verapamil 240-480mg/d or steroids
  • Early specialist referral

Medication overuse

  • Stop offending medication
    • Can bridge with NSAID (naproxen) or prednisone

Hemicrania Continua or Daily Persistent Headache

  • Indomethacin
  • Specialist referral
  • Consider MRI Brain

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