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

• Pattern change/progressive - Different or new

• Papilledema

• Postural aggravation

• Precipitated by valsalva (cough, sneeze)

• Secondary risk factors- HIV, malignancy, 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

• Consider Gepants (Ubrogepant and Rimegepant) for patients with cardiovascular disease (for whom triptans are contraindicated)

• 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